前后挤压型骶骨Ⅱ区骨折与骶丛神经损伤的关系

目的 探讨前后挤压致骶骨Ⅱ区骨折造成骶丛神经损伤的机制。方法 经甲醛短期（1年内）浸泡固定的国人尸体6具，12侧。解剖保护骶丛神经，制成前后挤压型暴力致骶Ⅱ区骨折模型，定量测量不同骨折移位时骶丛神经被拉长的距离。另外，利用X线片观察骶从神经受压情况。结果 随耻骨联合分离逐渐增大，骶丛神经张应变呈直线相关逐渐加大，以S1，S4为最显著，且可造成神经的刺伤，多见于L5和S1，X线未发现骶丛神经受压表现。结论 前后挤压型暴力致骶骨Ⅱ区骨折神经损伤以牵拉伤为丰，以S1，S4为主，且与骨折移位程度成正相关关系。神经的刺伤，多见于骨折移位较大的L5和S1。     

骶骨肿瘤的分区切除与重建方式的选择

目的：探讨对骶骨肿瘤按其发生部位进行分区切除，选择相应重建方式的方法及疗效。方法：1988年2月-2005年1月手术治疗43例骶骨肿瘤患者，按肿瘤侵及部位（即上段骶骨、骶髂关节及骶髂关节水平向外的髂骨是否被破坏）对骶骨肿瘤进行分区切除并重建，相应的手术及重建方式包括单纯切除、钢针加塑形骨水泥（CPC）重建骶骨、钢板螺钉固定或骶骨螺钉固定重建骶髂关节、不同长度的Luque棒或髂骨棒加钢丝缠扎或TSRH或Isola或CGWS腰椎骨盆内固定。并给予相应的放疗与化疗。结果：术后出现脑脊液漏2例，切口感染及延期愈合3例，切口皮肤边缘坏死1例，下肢深静脉血栓形成1例，经积极处理后均治愈。随访1-17年，平均75个月，43例患者中39例（90．7％）术后疼痛得到缓解，视觉模拟疼痛评分由术前平均8．5分降低到术后3.4分（P〈0．01）。14例有神经功能损害的患者中，11例术后症状改善，3例无改善。20例行自体和或异体植骨的患者术后1年16例获得骨性融合。3例脊索瘤、3例恶性纤维组织细胞瘤和4例骨巨细胞瘤患者于术后1年因复发而进行1次或多次手术，其中有5例和1例骨髓瘤、1例转移癌患者于术后17-50个月因肺部和全身转移死亡。发生断棒2例，均再次手术更换断棒。结论：按肿瘤部位进行分区切除，选择相应的重建方式，达到尽可能广泛切除肿瘤组织和维持脊柱及骨盆稳定性的目的．是取得良好疗效的重要保证。     

Exploration simplifiée des atteintes plexiques par réduction aux atteintes nerveuses et radiculaires connues

The anatomic complexity of the brachial plexus makes its electrophysiological exploration difficult. Electrodiagnosis nevertheless plays a crucial role in assessing brachial plexopathies, particularly in the perspective of post-traumatic surgical reconstructions. The evaluation aims to locate as precisely as possible injuries within the plexus, as well as to determine their severity and capacity for recovery. This requires various sensory nerve conduction studies and needle EMG recordings of “marker” muscles. Plexopathies differ from radiculopathies by altered sensory nerve responses and unaltered functional innervation of paracervical muscles. We propose to simplify the exploration of brachial plexopathies by following some practical rules derived from a reanalysis of the brachial plexus anatomic sketch. Two main simplification rules can be deduced from an analysis of the anatomic sketch. First it would be judicious to associate the plexopathies involving a single element of the brachial plexus with distinct etiological and symptomatic patterns according to the altered element, as one does for peripheral nerve and root pathologies. The second proposal relies on the observation that each supraclavicular “truncal” element (upper, middle, or lower) of the brachial plexus results from reunion of cervical root nerves and behaves like a “super-root” for the upper limb, while each infraclavicular “cord” element (posterior, lateral, or medial) is the sum of two or more peripheral nerves and behaves like a “super-nerve”. Accordingly, the motor and sensory abnormalities associated with the lesion of a single plexus branch may occupy a clinical and electrophysiological territory that recovers those of its constituants. Except the unaltered paracervical muscles, it is useful to reduce the topographical semiology of truncal lesions to well-known cervical radiculopathies (upper trunk neuropathy to C5 and C6 associated radiculopathies, middle trunk neuropathy to C7 radiculopathy, lower trunk neuropathy to C8 and T1 associated radiculopathies); and that of cord lesions to well-known mononeuropathies of the upper limb (for example, a posterior cord neuropathy may be considered as a full radial mononeuropathy associated with an axillary one). This method of simplification allows to demystify the brachial plexopathies and to facilitate their comprehension and exploration.     

Five‐Year Follow‐up After Sacral Neuromodulation: Single Center Experience

Objective. We studied long‐term clinical efficacy of sacral neuromodulation (SNM) therapy in patients with refractory urgency incontinence (UI), urgency/frequency (UF) and voiding difficulty (VD), together with urodynamic data at baseline and six   months postimplant. Materials and Methods. Twenty‐two patients were implanted with a neurostimulator after a positive response to a percutaneous nerve evaluation test defined as a greater than 50% improvement in symptoms. Results. At five‐year follow‐up, the number of incontinent episodes and pad usage per day decreased significantly in 10 out of 15 UI patients. Two of five UF patients were successfully treated with SNM; the number of daily voids for all UF patients decreased from 25 to 19 and average voided volume increased from 98 to 212 mL. One of the two VD patients was able to void to completion. Mean first sensation of filling at the six‐month urodynamic investigation for the UI and UF patients increased from 78 to 241 mL and 141 to 232 mL, respectively, and the maximum bladder capacity increased from 292 to 352 mL and 223 to 318 mL, respectively. Five of 22 patients underwent device explant and one patient still has an inactive stimulator implanted. Conclusion. SNM is an effective treatment modality that offers sustained clinical benefit in the majority of patients with refractory UI, UF, and VD that do not respond to other, more conservative therapies.     

Treatment of fecal incontinence by temporary sacral nerve stimulation

Summary BACKGROUND: Sacral nerve stimulation (SNS) is an option for the treatment of fecal incontinence in patients with morphologically intact, but weak external anal sphincter. METHODS: In ten patients a percutaneous test-SNS was performed. Two patients suffered from fecal incontinence after surgery, one patient after incomplete leg palsy after traumatic spine injury and seven patients from idiopathic incontinence. Incontinence score, anorectal manometry and patient diary were performed before and after test-SNS. RESULTS: Intraoperative response (Bellows action) could be achieved in 90% of patients. Test-SNS was successful in 50% of patients. In these patients, resting pressure was increased by 100.1% and squeeze pressure by 84.5%. CONCLUSIONS: SNS is an effective therapy in a subset of patients with fecal incontinence. Fifty percent of patients tested are eligible for implantation of a permanent stimulation device.      

原发性骶骨肿瘤病理及影像学表现

目的:分析原发性骶骨肿瘤的病理学分型及影像学表现特点。方法:48例原发性骶骨肿瘤均经手术病理证实,术前均行常规X线平片、CT和/或MR检查,结合病理回顾分析了其影像学表现。结果:原发性骶骨肿瘤以脊索瘤(21例)最多见,其次是巨细胞瘤(7例)、神经源性肿瘤(6例)、软骨肉瘤(4例)、滑膜肉瘤(3例),囊肿(3例),其它相对少见,包括纤维组织细胞癌1例,尤文氏肉瘤1例,梭形细胞癌1例,节细胞神经瘤1例。影像表现包括软组织肿块、骶孔扩大、瘤灶内钙化、骨嵴形成等不同特点。常见原发骶骨肿瘤常有其特征性影像学表现。结论:原发骶骨肿瘤病理分型相对复杂,影像表现多样化,诊断常需综合不同影像检查手段。     

The subdivisions of the intermediolateral nucleus in the sacral spinal cord of the cat

The subdivisions of the sacral intermediolateral nucleus (IML) of the cat have been studied by using a double-labeling technique of retrograde Fluoro-gold (FG) and wheat germ agglutinin-conjugated horseradish peroxidase (WGA-HRP) tracing. The parasympathetic preganglionic neurons (PGNs) that were labeled by the FG injected into the pelvic nerve formed a ‘V’-shaped column known as the sacral parasympathetic nucleus (SPN) in the sacral IML. The neurons that were labeled by the WGA-HRP applied to the lateral parabrachial nucleus (PBL) formed an elongated spindle-shaped column extending throughout the IML of the sacral segments. We designated it by the name of sacral visceral sensory nucleus (SVSN). These findings indicate that the sacral IML of the cat contain two distinct subdivisions, SPN and SVSN.     

Time-dependent changes of insufficiency fractures of the sacrum: intraosseous vacuum phenomenon as an early sign

Sacral insufficiency fractures develop over a period of time and show time-dependent changes. We report on 15 CT examinations of 5 patients with early-stage insufficiency fractures of the sacrum. In 4 patients only irregular sclerosis without distinct fracture lines was present in 7 of 8 fractures. Of these 4 patients; 3 exhibited intraosseous gas inclusions in a ventral part of a lateral mass; 5 of 8 fractures disclosed a ventral cortical break. When distinct fracture lines had developed in 1 patient, intraosseous vacuum phenomenon had disappeared. Fracture lines evolve over weeks to months and show central bone absorption. The fractures can heal as demonstrated in 4 of 6 fractures in 3 patients, can persist over 1 year without significant changes or can progress to pseudoarthrosis with bone destruction similar to neuropathic joint disease. Intraosseous vacuum phenomena can persist to this stage. Intraosseous vacuum phenomenon is recognized as a potential finding in the early stage of sacral insufficiency fracture, which also is true for irregular sclerosis and ventral cortical disruption. Correspondence to: A. Stäbler     

Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps

PURPOSES: In this study we present our experience with treating persistent sacral and perineal defects secondary to radiation and abdominoperineal resection with or without sacrectomy. METHODS: Fifteen consecutive patients were treated with an inferiorly based transpelvic rectus abdominis muscle or musculocutaneous flap. RESULTS: Fourteen of the 15 patients achieved healing, and 7 patients had no complications. The remaining eight patients required one or more operative debridements and/or prolonged wound care to accomplish a healed wound. Our technique for the dissection and insetting of the transpelvic muscle flap is presented. CONCLUSION: The difficult postirradiated perineal and sacral wounds can be healed with persistent surgical attention to adequate debridement, control of infections, and a well-vascularized muscle flap. The most satisfying aspects for patients are the discontinuance of foul-smelling discharge, discontinuation of multiple, daily dressing changes, and reduction in the degree of chronic pain.Read at the meeting of the Midwestern Association of Plastic Surgeons, Bismarck, North Dakota, June 15 to 18, 1992.