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During a routine cadaveric dissection of the posterior abdominal wall, variations of the bilateral lumbar plexus and a variant saphenous nerve originating in the lower abdomen were noted and documented. The description of a saphenous nerve originating at the level of the lumbar plexus is, to the best of our knowledge, the first of its kind. Further study revealed more variations at the root of the lumbar plexus and bilateral branching patterns. A variant iliacus muscle entrapping the superior portion of the femoral nerve was also observed on the right side within the abdominal cavity. These variations are discussed in the context of risk of clinical intervention in this anatomical region..

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El dolor abdominal es una de las sintomatologías que afectan con frecuencia la cavidad abdomino-pélvica. Dicha cavidad posee una inervación somática en la que intervienen del séptimo a doceavo nervios intercostales, ramos colaterales y terminales del plexo lumbar y el nervio pudendo; siendo objetivo de este trabajo la descripción anatómica del dolor abdominopélvico a través del plexo lumbar, nervios intercostales y nervio pudendo, sus diferentes patrones y variaciones de conformación, y las implicancias de éstas últimas en las distintas maniobras clínico-quirúrgicas. Se realizó un estudio descriptivo, observacional y morfométrico de la inervación somática de la cavidad abdomino-pélvica, en 50 preparaciones cadavéricas, fijadas en solución de formaldehído, de la Tercera Cátedra de Anatomía, Facultad de Medicina, Universidad de Buenos Aires, entre Agosto/2017-Diciembre/2019. La descripción clásica del plexo lumbar se encontró en 35 casos; la presencia del nervio femoral accesorio en ningún caso; así como también la ausencia del nervio iliohipogástrico en ningún caso; el nervio obturador accesorio se halló en 2 casos; el nervio genitofemoral dividiéndose dentro de la masa muscular del psoas mayor en 6 casos; el nervio cutáneo femoral lateral emergiendo únicamente de la segunda raíz lumbar en 6 casos y por último se encontró la presencia de un ramo del nervio obturador uniéndose al tronco lumbosacro en un caso. Los nervios intercostales y el nervio pudendo presentaron una disposición clásica en todos los casos analizados. Es esencial un adecuado conocimiento y descripción del plexo lumbar, nervios intercostales y nervio pudendo para un adecuado abordaje de la cavidad abdomino-pélvica en los bloqueos nerviosos.

SUMMARY: Abdominal pain is one of the symptoms that affect the abdominal-pelvic cavity. The abdominal-pelvic cavity has a somatic innervation involving the seventh to twelfth intercostal nerves, collateral and terminal branches of the lumbar plexus and the pudendal nerve. The objective of this work is the description of the lumbar plexus, intercostal nerves and pudendal nerve, its different patterns and structure variations, as well as its implications during pain management in patients. A descriptive, observational, and morphometric study of patterns and structure variations of the lumbar plexus, intercostal nerves and pudendal nerve was conducted in 50 formalin-fixed cadaveric dissections of the Third Chair of Anatomy at the School of Medicine in the Universidad de Buenos Aires from August 2017 to December/2019. The standard description of the lumbar plexus was found in 35 cases; accessory femoral nerve was not present in any of the cases; absence of the iliohipogastric nerve was also not found in any case, while the accessory obturating nerve was found in 2 cases; genitofemoral nerve dividing within the muscle mass of psoas in 6 cases; lateral femoral cutaneous nerve emerging only from the second lumbar root in 6 cases and finally, presence of a branch of the obturating nerve was found joining the lumbosacral trunk in one case. The pudendal and intercostal nerve patterns presented a typical pathway in all cases. Adequate knowledge and description of the lumbar plexus, intercostal nerves and pudendal nerve is essential for an adequate approach of the abdominal-pelvic cavity in nerve blocks.

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Background: Lumbar plexus schwannomas are a rare occurrence in neurosurgery, with few reported cases and no standard surgical approach. This study describes a successful surgical resection with no complications using the Wiltse approach. Methods: Patient presented with an intra-psoas tumor suggesting schwannoma. We described the surgical technique involved step by step. Results: The patient recovered from the surgery with no complications. The anatomopathological examination confirmed the schwannoma diagnosis. The post operatory magnetic resonance imaging showed complete resection. Conclusion: This study shows that the use of Wiltse approach, mainly used for classical herniated disc extraforaminal, can be used successfully on Lumbar plexus schwannomas.

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INTRODUCTION: joint replacement is a highly effective intervention that significantly improves the patient's quality of life, relieves symptoms, restores joint function, and improves mobility and independence. The optimal pain control after total hip replacement has become an important goal of postoperative management. The purpose of this paper is to compare periarticular infiltration (PAI) and lumbar plexus nerve block (LPNB) for the management of post-operative pain in primary total hip arthroplasty because we believe that LPNB provides better analgesic management and lower opioid consumption. We evaluated the opioid usage during hospitalization and the complications derived from either technique. MATERIAL AND METHODS: we randomized 45 patients who underwent elective total hip arthroplasty between January 2019 and January 2020. Two groups were evaluated based on the association of PAI or LPNB. Both as part of a multimodal analgesic regimen. RESULTS: a total of 45 patients were evaluated (22 PAI group, 23 LPNB group). Block group required less opioid administration (p = 0.069). Most of the patients in both groups reported mild/moderate pain. The LPNB group had lower pain scale with physiotherapy. We did not have complications derived from either technique. CONCLUSION: lumbar plexus nerve block (LPNB) in patients undergoing total hip arthroplasty provides better pain management and reduced opioid consumption compared to PAI. The performance of this technique does not delay the beginning of physiotherapy and there were not any issues with the patient's recovery.

INTRODUCCIÓN: la artroplastía es una intervención altamente eficaz que mejora de manera significativa la calidad de vida del paciente, alivia los síntomas, restaura la función articular y mejora la movilidad e independencia. El control óptimo del dolor después de la artroplastía total de cadera se ha convertido en un objetivo importante del tratamiento postoperatorio. El propósito de este trabajo es comparar la infiltración periarticular (IPA) y el bloqueo nervioso del plexo lumbar (BNPL) para el manejo del dolor postoperatorio en la artroplastía total de cadera primaria, ya que creemos que la BNPL proporciona mejor manejo analgésico y menor consumo de opioides. Se evaluó el uso de opioides durante la hospitalización y las complicaciones derivadas de cada técnica. MATERIAL Y MÉTODOS: fueron aleatorizados 45 pacientes tratados con artroplastía total de cadera electiva entre Enero de 2019 y Enero de 2020 en dos grupos: IPA o BNPL. Ambos como parte de un régimen analgésico multimodal. RESULTADOS: veintidós en el grupo IPA y 23 en el grupo BNPL. El grupo de bloqueo requirió menos administración de opioides (p = 0.069). La mayoría de los pacientes de ambos grupos reportaron dolor leve/moderado. El grupo de BNPL tuvo menor escala de dolor al realizar fisioterapia. No tuvimos complicaciones derivadas de ninguna de las técnicas analgésicas. CONCLUSIÓN: el BNPL en pacientes sometidos a artroplastía total de cadera proporciona mejor manejo del dolor y una reducción del consumo de opioides en el postoperatorio en comparación con la IPA. La realización de esta técnica no retrasa el inicio de la fisioterapia y no hubo problemas con la recuperación del paciente.

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Resumen: Introducción: La artroplastía es una intervención altamente eficaz que mejora de manera significativa la calidad de vida del paciente, alivia los síntomas, restaura la función articular y mejora la movilidad e independencia. El control óptimo del dolor después de la artroplastía total de cadera se ha convertido en un objetivo importante del tratamiento postoperatorio. El propósito de este trabajo es comparar la infiltración periarticular (IPA) y el bloqueo nervioso del plexo lumbar (BNPL) para el manejo del dolor postoperatorio en la artroplastía total de cadera primaria, ya que creemos que la BNPL proporciona mejor manejo analgésico y menor consumo de opioides. Se evaluó el uso de opioides durante la hospitalización y las complicaciones derivadas de cada técnica. Material y métodos: Fueron aleatorizados 45 pacientes tratados con artroplastía total de cadera electiva entre Enero de 2019 y Enero de 2020 en dos grupos: IPA o BNPL. Ambos como parte de un régimen analgésico multimodal. Resultados: Veintidós en el grupo IPA y 23 en el grupo BNPL. El grupo de bloqueo requirió menos administración de opioides (p = 0.069). La mayoría de los pacientes de ambos grupos reportaron dolor leve/moderado. El grupo de BNPL tuvo menor escala de dolor al realizar fisioterapia. No tuvimos complicaciones derivadas de ninguna de las técnicas analgésicas. Conclusión: El BNPL en pacientes sometidos a artroplastía total de cadera proporciona mejor manejo del dolor y una reducción del consumo de opioides en el postoperatorio en comparación con la IPA. La realización de esta técnica no retrasa el inicio de la fisioterapia y no hubo problemas con la recuperación del paciente.

Abstract: Introduction: Joint replacement is a highly effective intervention that significantly improves the patient's quality of life, relieves symptoms, restores joint function, and improves mobility and independence. The optimal pain control after total hip replacement has become an important goal of postoperative management. The purpose of this paper is to compare periarticular infiltration (PAI) and lumbar plexus nerve block (LPNB) for the management of post-operative pain in primary total hip arthroplasty because we believe that LPNB provides better analgesic management and lower opioid consumption. We evaluated the opioid usage during hospitalization and the complications derived from either technique. Material and methods: We randomized 45 patients who underwent elective total hip arthroplasty between January 2019 and January 2020. Two groups were evaluated based on the association of PAI or LPNB. Both as part of a multimodal analgesic regimen. Results: A total of 45 patients were evaluated (22 PAI group, 23 LPNB group). Block group required less opioid administration (p = 0.069). Most of the patients in both groups reported mild/moderate pain. The LPNB group had lower pain scale with physiotherapy. We did not have complications derived from either technique. Conclusion: Lumbar plexus nerve block (LPNB) in patients undergoing total hip arthroplasty provides better pain management and reduced opioid consumption compared to PAI. The performance of this technique does not delay the beginning of physiotherapy and there were not any issues with the patient's recovery.

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SUMMARY: The aim of this study was to clarify the diverse spinal compositions of the branches of the lumbar plexus in terms of their prevalence rates and thicknesses. Thirty lumbar plexuses extracted from Korean adults were used in this study. The nerve fascicles were separated and traced with the aid of a surgical microscope. The thickness of each spinal nerve component was calculated based on the mean of the largest and smallest diameters using digital calipers under the surgical microscope. The most common patterns of the spinal composition of the branches of the lumbar plexus were as follows: The iliohypogastric nerve (IHN) and the ilioinguinal nerve (IIN) arose from the ventral ramus of the first lumbar nerve (L1), the genitofemoral nerve (GFN) arose from the anterior division of the ventral ramus of the second lumbar nerve (L2), and the lateral femoral cutaneous nerve (LFCN) arose from the posterior division of the ventral ramus of theL2, the femoral nerve (FN) arose from the posterior division of the ventral ramus of L2-the fourth lumbar nerve (L4), with the thickest spinal component derived from the third lumbar nerve (L3), and the obturator nerve (OBN) arose from the anterior division of the ventral ramus of L2-L4, with the thickest spinal component derived from L3. However, when L5 constituted the FN and OBN, the thickest spinal components of the FN and OBN was L4. This morphometric study has measured the thicknesses of diverse spinal components that constitute the branches of the lumbar plexus after separating the nerve fascicles. The thicknesses of the various spinal components of these branches can be compared in order to understand which make the main and minor contributions to the lower limb.

RESUMEN: El objetivo de este estudio fue evaluar las diversas composiciones espinales de los ramos del plexo lumbar en cuanto a sus tasas de prevalencia y grosor. Se utilizaron treinta plexos lumbares extraídos de individuos adultos coreanos. Se separaron y trazaron los fascículos nerviosos por medio de un microscopio quirúrgico. El grosor de cada componente del nervio espinal se calculó con base en la media de los diámetros mayor y menor utilizando calibradores digitales bajo el microscopio. Los patrones más comunes de la composición espinal de los ramos del plexo lumbar fueron los siguientes: el nervio iliohipogástrico (NIH) y el nervio ilioinguinal (NII) surgieron del ramo ventral del primer nervio lumbar (L1). El nervio genitofemoral (NGF) surgió de la división anterior del ramo ventral del segundo nervio lumbar (L2). El nervio cutáneo femoral lateral (NCFM) surgió de la división posterior del ramo ventral L2. El nervio femoral (NF) surgió de la división posterior del ramo ventral de L2. El cuarto nervio lumbar (L4), con el componente espinal más grueso derivado del tercer nervio lumbar (L3) y el nervio obturador (NOB) surgieron de la división anterior del ramo ventral de L2-L4, con el componente espinal más grueso derivado de L3. Sin embargo, cuando L5 constituía el NF y NOB, los componentes espinales más gruesos del NF y NOB eran de L4. Este estudio morfométrico analizó los espesores de diversos componentes espinales que constituyen las ramas del plexo lumbar después de separar los fascículos nerviosos. Es posible comparar los espesores de los diversos componentes espinales de estos ramos para comprender las contribuciones principales y menores al miembro inferior.

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BACKGROUND AND OBJECTIVES: The lumbar plexus block (LPB) is a key technique for lower limb surgery. All approaches to the LPB involve a number of complications. We hypothesized that Chayen's approach, which involves a more caudal and more lateral needle entry point than the major techniques described in the literature, would be associated with a lower rate of epidural spread. METHOD: We reviewed the electronic medical records and chart of all adult patients who underwent orthopedic surgery for total hip arthroplasty (THA) and hip hemiarthroplasty due to osteoarthritis and femoral neck fracture with LPB and sciatic nerve block (SNB) between January 1, 2002, and December 31, 2017, in our institute. The LPB was performed according to Chayen's technique using a mixture of mepivacaine and levobupivacaine (total volume, 25 mL) and a SNB by the parasacral approach. The sensory and motor block was evaluated bilaterally during intraoperative and postoperative period. RESULTS: A total number of 700 patients with American Society of Anesthesiologists (ASA) physical status I to IV who underwent LPB met the inclusion criteria. The LPB and SNB was successfully performed in all patients. Epidural spread was reported in a single patient (0.14%; p <0.05), accounting for an 8.30% reduction compared with the other approaches described in the literature. No other complications were recorded. CONCLUSIONS: This retrospective study indicates that more caudal and more lateral approach to the LPB, such as the Chayen's approach, is characterized by a lower epidural spread than the other approach to the LPB.

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Abstract Background and objectives: The lumbar plexus block (LPB) is a key technique for lower limb surgery. All approaches to the LPB involve a number of complications. We hypothesized that Chayen's approach, which involves a more caudal and more lateral needle entry point than the major techniques described in the literature, would be associated with a lower rate of epidural spread. Method: We reviewed the electronic medical records and chart of all adult patients who underwent orthopedic surgery for Total Hip Arthroplasty (THA) and hip hemiarthroplasty due to osteoarthritis and femoral neck fracture with LPB and Sciatic Nerve Block (SNB) between January 1, 2002, and December 31, 2017, in our institute. The LPB was performed according to Chayen's technique using a mixture of mepivacaine and levobupivacaine (total volume, 25 mL) and a SNB by the parasacral approach. The sensory and motor block was evaluated bilaterally during intraoperative and postoperative period. Results: A total number of 700 patients with American Society of Anesthesiologists (ASA) physical status I to IV who underwent LPB met the inclusion criteria. The LPB and SNB was successfully performed in all patients. Epidural spread was reported in a single patient (0.14%;p < 0.05), accounting for an 8.30% reduction compared with the other approaches described in the literature. No other complications were recorded. Conclusions: This retrospective study indicates that more caudal and more lateral approach to the LPB, such as the Chayen's approach, is characterized by a lower epidural spread than the other approach to the LPB.

Resumo Justificativa e objetivos: O bloqueio do plexo lombar (BPL) é uma técnica fundamental para a cirurgia de membros inferiores. Todas as abordagens do BPL são associadas a uma série de complicações. Nossa hipótese foi de que a abordagem de Chayen, que envolve um ponto de entrada da agulha mais caudal e mais lateral do que as principais técnicas descritas na literatura, estaria associada a menor incidência de dispersão peridural. Método: Revisamos os prontuários médicos eletrônicos e em papel de todos os pacientes adultos submetidos à artroplastia total do quadril (ATQ) e hemiartroplastia do quadril devido a osteoartrite ou fratura do colo do fêmur empregando-se BPL associado ao bloqueio do nervo ciático (BNC), entre 1 de janeiro de 2002 e 31 de dezembro de 2017 em nossa instituição. Realizamos o BPL usando a técnica de Chayen e uma mistura de mepivacaína e levobupivacaína (volume total de 25 mL) e o BNC pela abordagem parassacral. Testes sensorial e motor bilaterais foram realizados no intra e pós-operatório. Resultados: Os critérios de inclusão foram obedecidos pelo total de 700 pacientes classe ASA I a IV submetidos ao BPL. Os BPL e BNC foram realizados com sucesso em todos os pacientes. A dispersão peridural foi relatada em um único paciente (0,14%; p < 0,05), representando uma redução de 8,30% quando comparada às outras abordagens descritas na literatura. Nenhuma outra complicação foi registrada. Conclusões: Este estudo retrospectivo indica que a abordagem mais caudal e mais lateral do BPL, como a técnica de Chayen, é caracterizada por menor dispersão peridural do que outras abordagens do BPL.

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Lower limb blocks are described with emphasis on distribution according to sensitive distribution and its sonoanatomy.

Se describen los bloqueos de la extremidad inferior haciendo énfasis en la distribución de acuerdo a distribución sensitiva y a su sonoanatomia.

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Abstract Background Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. Methods Patients older than 60 years, ASA II-III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring. Results Thirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p = 0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores. Conclusions Using continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Resumo Justificativa A isquemia miocárdica perioperatória é comum em pacientes submetidos à cirurgia de fratura de quadril. Nosso objetivo foi avaliar a eficácia do bloqueio perioperatório contínuo do plexo lombar na redução do risco de eventos cardíacos isquêmicos em pacientes idosos submetidos à cirurgia para fraturas de quadril, expresso como uma redução de eventos isquêmicos por indivíduo. Métodos Pacientes com mais de 60 anos de idade, ASA II-III com fatores de risco para ou com doença coronariana conhecida foram incluídos neste estudo controlado e randomizado. Os pacientes foram aleatorizados para analgesia convencional usando analgésicos opioides para administração de analgesia intravenosa controlada pelo paciente (Intravenous Patient-Controlled Analgesia - IVPCA) ou analgesia contínua com o bloqueio do Plexo Lombar (PL), ambas iniciadas no pré-operatório e mantidas até o terceiro dia de pós-operatório. Monitoração contínua de ECG com análise do segmento ST foi registrada. Enzimas cardíacas seriadas e escores de dor foram registrados durante todo o período. Medimos a incidência de eventos isquêmicos por indivíduo registrados com monitoração contínua do segmento ST via Holter. Resultados Trinta e um pacientes (IVPCA 14, PL 17) foram incluídos. Não houve eventos cardíacos sérios durante o período de observação. O número de eventos isquêmicos registrados por sujeito durante o período de observação foi de seis no grupo PL e três no grupo IVPCA. Essa diferença não foi estatisticamente significativa (p = 0,618). Não houve diferenças estatisticamente significativas no número de casos com aumento dos valores de troponina no perioperatório (três casos no grupo LP e um caso no grupo IVPCA) ou em termos de escores de dor. Conclusões O uso da analgesia perineural contínua comparado ao da analgesia sistêmica convencional não modifica a incidência de eventos isquêmicos cardíacos no período perioperatório de pacientes idosos com fratura de quadril.

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