lumbosacral plexus surgery
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Dr. Héctor Giócoli's own methods and results for lumbosacral plexus surgeryTRANSCRIPT
Lumbosacral Lumbosacral PlexusPlexus SurgerySurgery
Hector Giocoli, MDHector Giocoli, MDBuenos Aires - ArgentinaBuenos Aires - ArgentinaHector Giocoli, MDHector Giocoli, MDBuenos Aires - ArgentinaBuenos Aires - Argentina
CharacteristicsCharacteristics Low incidence:Low incidence: Rarely reported lesions, witch, Rarely reported lesions, witch,
if posttraumatic, may remain undiagnosed if posttraumatic, may remain undiagnosed because of the variable destination of the patients because of the variable destination of the patients in emergency in emergency
Difficult level diagnosis:Difficult level diagnosis: Patients witch Patients witch different parenchimal or visceral lesions, with different parenchimal or visceral lesions, with different problems witch hinder motility (And different problems witch hinder motility (And frequently affected by severe pain)frequently affected by severe pain)
Difficult surgical treatment:Difficult surgical treatment: Analogous lesions in the brachial plexus are Analogous lesions in the brachial plexus are
normally treated, and results are quite well normally treated, and results are quite well known.known.
In this anatomical district surgical approach is In this anatomical district surgical approach is not so comfortable and familiar not so comfortable and familiar
Low incidence:Low incidence: Rarely reported lesions, witch, Rarely reported lesions, witch, if posttraumatic, may remain undiagnosed if posttraumatic, may remain undiagnosed because of the variable destination of the patients because of the variable destination of the patients in emergency in emergency
Difficult level diagnosis:Difficult level diagnosis: Patients witch Patients witch different parenchimal or visceral lesions, with different parenchimal or visceral lesions, with different problems witch hinder motility (And different problems witch hinder motility (And frequently affected by severe pain)frequently affected by severe pain)
Difficult surgical treatment:Difficult surgical treatment: Analogous lesions in the brachial plexus are Analogous lesions in the brachial plexus are
normally treated, and results are quite well normally treated, and results are quite well known.known.
In this anatomical district surgical approach is In this anatomical district surgical approach is not so comfortable and familiar not so comfortable and familiar www.hgiocoli.com
EtiologyEtiology
Traumatic EventsTraumatic Events
Obstetrical traumaObstetrical trauma
Surgery Surgery Abdominal surgeryAbdominal surgery Gynecological proceduresGynecological procedures
TumorsTumors IntrapelvicIntrapelvic Terminal branchesTerminal branches
Traumatic EventsTraumatic Events
Obstetrical traumaObstetrical trauma
Surgery Surgery Abdominal surgeryAbdominal surgery Gynecological proceduresGynecological procedures
TumorsTumors IntrapelvicIntrapelvic Terminal branchesTerminal branches
• HerniorrhaphyHerniorrhaphy• AppendectomyAppendectomy• HysterectomyHysterectomy• Lumbar sympatectomyLumbar sympatectomy• Lateral approach to the Lateral approach to the
spinespine
• HerniorrhaphyHerniorrhaphy• AppendectomyAppendectomy• HysterectomyHysterectomy• Lumbar sympatectomyLumbar sympatectomy• Lateral approach to the Lateral approach to the
spinespine
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AnatomyAnatomy
Lumbar PlexusLumbar Plexus Spinal roots L2, L3, and L4 Spinal roots L2, L3, and L4
(L1 and L5)(L1 and L5) Located in the corner Located in the corner
between vertebral bodies between vertebral bodies and lateral apophisisand lateral apophisis
Covered byCovered by Ascending iliac and cava Ascending iliac and cava
veins, and by psoas veins, and by psoas musclemuscle
By aorta and common iliac By aorta and common iliac arteries on the right side arteries on the right side
By iliac arterial and By iliac arterial and venous plexuses on the venous plexuses on the leftleft
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AnatomyAnatomy
Lumbar PlexusLumbar Plexus Subserved Muscle are:Subserved Muscle are: AbdominalAbdominal PsoasPsoas IliacIliac PectineusPectineus SartoriusSartorius Quadriceps femorisQuadriceps femoris Adductors of the thigh Adductors of the thigh
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AnatomyAnatomySacral PlexusSacral Plexus Spinal roots L5, S1, Spinal roots L5, S1,
and L2 (L4) and L2 (L4) Lies on the sacro iliac Lies on the sacro iliac
junction junction Medial to psoas muscle Medial to psoas muscle
between it and the column between it and the column Hypogastric artery Hypogastric artery
intermigles the nerve intermigles the nerve trunks and asending veins trunks and asending veins cover the plexuscover the plexus
The lumbosacral trunk is The lumbosacral trunk is given by components from given by components from L4 and from L5L4 and from L5
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AnatomyAnatomy
Sacral PlexusSacral Plexus Subserved Muscle are:Subserved Muscle are: GluteiGlutei ObturatorObturator PiriformPiriform GemelliGemelli QuadratusQuadratus Muscle or posterior thighMuscle or posterior thigh Anterior tibialAnterior tibial Peroneal foot abductors Peroneal foot abductors
and extensorsand extensors Triceps surae and plantar Triceps surae and plantar
flexorsflexorswww.hgiocoli.com
Surgical TechniquesSurgical Techniques
Anterior:Anterior: extraperitoneal extraperitoneal Lateral:Lateral: extraperitoneal extraperitoneal Anterior:Anterior: transperitoneal transperitoneal Posterior:Posterior: sacrectomy sacrectomy
In some cases is impossible to access to the In some cases is impossible to access to the more proximal sciatic nerve, the bony and more proximal sciatic nerve, the bony and ligamentous rim of the greater sciatic notch ligamentous rim of the greater sciatic notch can be nibbled or drilled away to gain accesscan be nibbled or drilled away to gain access
In some cases is impossible to access to the In some cases is impossible to access to the more proximal sciatic nerve, the bony and more proximal sciatic nerve, the bony and ligamentous rim of the greater sciatic notch ligamentous rim of the greater sciatic notch can be nibbled or drilled away to gain accesscan be nibbled or drilled away to gain access
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Surgical TechniquesSurgical Techniques
Intraoperative electrophysiological recording Intraoperative electrophysiological recording
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Surgical Approach Surgical Approach
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Surgical Approach Surgical Approach
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Surgical Approach Surgical Approach
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Surgical Approach Surgical Approach
Sciatic nerve Sciatic nerve
Neurolysis Neurolysis
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Surgical Approach Surgical Approach
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Surgical Approach Surgical Approach
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Intrabdominal Graft Intrabdominal Graft
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Surgical Approach Surgical Approach
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Surgical Approach Surgical Approach
Psoas Psoas
Femoral nerve Femoral nerve
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Neurolysis Neurolysis
30 days later30 days later
Results Results
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3 months later 3 months later
Results Results
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Posterior Approach Posterior Approach
Sacrectomy Sacrectomy
Nerve graftingNerve grafting
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Sciatic NerveSciatic Nerve
Classic Technique Classic Technique
Our ApproachOur Approach
Surgical Approach Surgical Approach
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Sciatic Sciatic NerveNerve
Surgical Approach Surgical Approach
Neurolysis Neurolysis
Aesthetic results Aesthetic results www.hgiocoli.com
Sciatic Nerve TumorSciatic Nerve Tumor
Surgical Approach Surgical Approach
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Follow-upFollow-up
Sciatic Sciatic NerveNerve
Surgical Approach Surgical Approach
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Pelvis TumorPelvis Tumor
Tumor Tumor
Incision Incision
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Pelvis TumorPelvis Tumor
Tumor Tumor
Extirpation Extirpation
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Pelvis TumorPelvis Tumor
Tumor Tumor
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Femoral nerve Femoral nerve
Anterior ApproachAnterior Approach
Total extirpation Total extirpation
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Posterior ApproachPosterior Approach
Sciatic nerve Sciatic nerve
Tumor Tumor
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Pelvis TumorPelvis Tumor
Total extirpation Total extirpation
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5 months later 5 months later
ResultsResults
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Femoral SurgeryFemoral Surgery
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Femoral SurgeryFemoral Surgery
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Femoral SurgeryFemoral Surgery
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Distal and Proximal Stump Distal and Proximal Stump Common Peroneal NerveCommon Peroneal Nerve
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Common Peroneal NerveCommon Peroneal Nerve
ResultsResults
Grafts Grafts
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Tibial Nerve Palsy Tibial Nerve Palsy
Incision Incision
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Tibial Nerve Palsy Tibial Nerve Palsy Neuroma Neuroma
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Tibial Nerve Palsy Tibial Nerve Palsy
Nerve Grafting Nerve Grafting
Results Results
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PosteriorPosterior Tibial NerveTibial Nerve
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NeurolysisNeurolysis
PosteriorPosterior Tibial NerveTibial Nerve
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PosteriorPosterior Tibial NerveTibial Nerve
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GraftsGrafts
PosteriorPosterior Tibial NerveTibial Nerve
StumpsStumpswww.hgiocoli.com
Results After 29 patientsResults After 29 patients
GoodGood FearFear BadBadMaleMale FemaleFemale
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Thank you !! Thank you !! www.hgiocoli.com