By O. Treslott. Wichita State University. 2019.
The ultrasound transducer is then slowly moved in a inferomedial direction along the course of the inguinal ligament until the hyperechoic honeycombed appearing lateral femoral cutaneous nerve appears lying beneath the fascia lata and on top of the sartorius muscle (Fig purchase fildena 25mg. Medial to the lateral femoral cutaneous nerve is the femoral nerve fildena 100 mg otc, artery discount fildena 25 mg free shipping, and vein which can be easily visualized with color Doppler (Fig buy 25mg fildena otc. B: Oblique placement of the ultrasound transducer placed in a plane perpendicular with the inguinal ligament with the superior aspect of the transducer lying over the anterior-superior iliac spine and the inferior aspect of the transducer pointed directly at the pubic symphysis. Oblique ultrasound image demonstrating the hyperechoic anterior-superior iliac spine and its acoustic shadow and the inguinal ligament. Oblique ultrasound image demonstrating the hyperechoic honeycombed appearing lateral femoral cutaneous nerve appears lying beneath the fascia lata and on top of the sartorius muscle. Oblique color Doppler image demonstrating the femoral nerve artery and vein which lie medial to the lateral femoral cutaneous nerve. When these classic honeycombed, triangular, sonographic signature of the lateral femoral cutaneous nerve is identified on ultrasound scan, the nerve is evaluated for compression, enlargement, and tumor (Fig. The course of the nerve is traced both superiorly and inferiorly to identify abnormalities (Figs. Meralgia paresthetica caused by hip-huggers in a patient with aberrant course of the lateral femoral cutaneous nerve. Meralgia paresthetica caused by hip huggers in a patient with aberrant course of the lateral femoral cutaneous nerve. Therapeutic lateral femoral cutaneous nerve blocks with local anesthetic and steroid are extremely beneficial when treating meralgia paresthetica. However, if a patient presents with pain suggestive of meralgia paresthetica and lateral femoral cutaneous nerve blocks are ineffectual, a diagnosis of lesions more proximal in the lumbar plexus or L2-L3 radiculopathy should be considered. Electromyography and magnetic resonance imaging of the lumbar plexus are indicated in this patient population to help rule out other causes of lateral femoral cutaneous pain, including malignancy invading the lumbar plexus or epidural or vertebral metastatic disease at L2-L3. Meralgia paresthetica: a result of tight new trendy low cut trousers (‘taille basse’). The nerve fibers enter the psoas muscle where they fuse together within the muscle body and leave the medial border of the psoas at the brim of the pelvis (Fig. The nerve passes behind the common iliac arteries to run adjacent to the lateral wall of the pelvis where it joins the obturator artery and vein. Along with the obturator artery and vein, the obturator nerve enters the obturator canal to pass into the proximal thigh (Fig. At this point the obturator nerve divides into four branches: (1) an anterior branch which provides sensory innervation to the hip joint and motor branches to the superficial hip adductors; (2) a cutaneous branch which provides sensory innervation to the medial aspect of the distal thigh; (3) a posterior branch which provides motor innervation to the deep hip adductors; and (4) an articular branch to the posterior knee joint. At this point the obturator nerve divides into four branches: (1) an anterior branch which provides sensory innervation to the hip joint and motor branches to the superficial hip adductors; (2) a cutaneous branch which provides sensory innervation to the medial aspect of the distal thigh; (3) a posterior branch which provides motor innervation to the deep hip adductors; and (4) an articular branch to the posterior knee joint. The nerve may be compressed and entrapped by retroperitoneal and pelvic cysts, tumors, hematoma and callus formation from healing pelvic fractures as well as by implantable mesh and tapes used for surgical correction of urinary incontinence and uterine prolapse (Figs. The nerve may be injured by penetrating injuries as well as from pelvic fractures, tumor, crush injuries, mid forceps deliveries, and from surgical misadventures during groin, pelvic, and medial thigh surgeries. A: Laparoscopic view showing that the nerve appeared to be compressed in the region of the obturator canal by the internal obturator muscle. B: Laparoscopic view after the neurolysis and the incision of the internal obturator muscle and the obturator membrane. The nerve was free to pass the obturator canal without any macroscopic sign of compression and with room to slide freely. Obturator nerve entrapment: diagnosis and laparoscopic treatment: technical case report. Plain radiograph demonstrating a chondrosarcoma invading the superior and inferior pubic ramus. Patients with significant obturator neuropathy lose the ability to abduct and externally rotate the hip. The patient will exhibit a typical gait abnormality that consists of an externally rotated foot. Wasting of the adductor muscles of the thigh and numbness of the distal medial thigh may also be identified. Deep, aching groin pain is often present which is often centered on the attachment of the adductor muscles to the pubic bone. Exercise will often exacerbate the pain and may cause paresthesias to radiate into the distribution of the anterior division of the obturator nerve on the medial thigh. These symptoms may often be reproduced by active external rotation of the hip against resistance. The inguinal crease on the affected side is identified and a linear high-frequency ultrasound transducer is placed in an oblique plane perpendicular with the inguinal ligament (Fig. An ultrasound survey scan is obtained and the iliacus muscle is identified with the femoral nerve lying between the muscle and the pulsatile femoral artery (Fig. The femoral vein lies medial to the femoral artery and is easily compressible by pressure from the ultrasound transducer (Fig. Color Doppler can be used to aid in the identification of the femoral artery and vein (Fig. When these anatomic structures are clearly identified on oblique ultrasound scan, the ultrasound transducer is moved medially until the pectineus muscle, which looks like a “breaching whale” is visualized (Fig. Just medial to the medial aspect 749 of the pectineus muscle lie the adductor longus, brevis, and magnus muscles which are stacked on top of one another like a like a double decker sandwich (Fig. The anterior branch of the obturator nerve lies in the fascial cleft between the adductor longus and brevis muscles and the posterior branch of the obturator nerve lies between the fascial cleft between the adductor brevis and magnus muscles (Fig. When the adductor muscles and the anterior and posterior branches of the obturator nerve are identified, the nerves are assessed by changes in the neurofibular pattern, enlargement, tumor, compression, and entrapment. Oblique placement of the ultrasound transducer placed in a plane perpendicular with the inguinal ligament with the inferior aspect of the transducer lying over the anterior-superior iliac spine and the superior aspect of the transducer pointed directly at the umbilicus. Oblique ultrasound image demonstrating the iliacus muscle, the fascia iliacus, the femoral nerve, artery, and vein. Oblique ultrasound image demonstrating the compressibility of the femoral vein which lies medial to the pulsatile femoral artery. A: Probe is moved medially until the pectineus muscle which looks like a “breaching whale” is identified. Just medial to the medial border of the pectineus muscle lie the adductor longus, brevis, and magnus muscles which are stacked on top of one another like a like a double decker sandwich. The anterior branch of the obturator nerve lies in the fascial cleft between the adductor longus and 751 brevis muscles and the posterior branch of the obturator nerve lies between the fascial cleft between the adductor brevis and magnus muscles. Polymyxin B-immobilized fiber hemoperfusion in a high school football player with septic shock caused by osteitis pubis. Electromyography and magnetic resonance imaging of the lumbar spine, retroperitoneum, groin, and pelvis—combined with the clinical history and physical examination—help sort out the etiology of pain thought to be mediated via the obturator nerve. The avascular interpubic fibroelastic cartilage connects the two opposing articular surfaces of the pubic bones (Fig. The interpubic fibroelastic cartilage is wider anteriorly, narrowing toward the back of the joint space. This asymmetrical shape gives the joint space and its adjacent pubic bodies their characteristic heart-shaped appearance on transverse ultrasound scan (see below). These articular surfaces have thin layers of hyaline articular cartilage that are subject to damage or inflammation. In health, the joint can be moved forward and backward approximately 2 mm with a minimal amount of rotation. The range of motion of the joint increases dramatically in women during childbirth. The joint is relatively avascular, which accounts for the difficulty in treating joint space infections of the symphysis pubis. The joint is strengthened by a variety of ligaments, including the superior pubic ligament, which connects the top of the joint and the arcuate ligament, which strengthens the joint from below. These ligaments are subject to disruption from blunt trauma to the pelvis, including seat-belt injuries (Fig. The symphysis pubis is a nonsynovial amphiarthrodial joint that provides articulation between the two pubic bones.
Menstrual disorders are more common may afect the outcome of pregnancy and there are increased risks among women with epilepsy purchase fildena 50mg on line, occurring in one-third compared of obstetric complications discount 100 mg fildena free shipping. Seizure control can change during preg- with 12–14% in the general population  fildena 25mg with visa. Enzyme-inducing drugs such as carbamazepine purchase fildena 50 mg amex, phe- ible causes for reduced fertility rates among people with epilepsy. In a cross-sec- epilepsy or risks to the fetus incurred by seizures or the drug treat- tional study, monotherapy with carbamazepine was associated with ment. However, some studies suggest that concurrent disabilities and ment in doses of at least 900 mg/day was associated with similar en- comorbidities (e. Fertility rates among people with epilepsy in 12 out of 21 men treated with valproic acid for generalized or were essentially normal in two population-based studies from focal seizures . No diference was observed in linear growth ment , whereas a cross-sectional study of men and women with and sexual maturation . When 41 girls on valproic acid were epilepsy found no diference in levels of reproductive hormones compared with 54 healthy controls, hyperandrogenism was ob- between those taking levetiracetam, carbamazepine or lamotrigine served more frequently among the valproic acid-exposed girls, but . A long-term follow-up of these cohorts revealed normal endo- esis or sperm function. A small cross-sectional study As suggested in a recent comprehensive review, women with epi- of men with epilepsy suggested that all investigated drugs, carba- lepsy should be monitored for signs and symptoms of reproductive mazepine, oxcarbazepine and valproic acid, were associated with an dysfunction in conjunction with their clinical visits. This includes increase in abnormal sperm morphology , although the clinical assessment of menstrual cycles, occurrence of hirsutism, acne, relevance of these fndings remains to be shown. In addition to the com- mental factors can contribute to the development of this syndrome. In these studies, 30–40% of patients treated and an increased frequency of unplanned pregnancies . However, whether this dose is 26 years (44% and 23%) but was similar if treatment was started at sufcient is uncertain. Taken to- Estradiol-containing oral contraceptives induce the elimination of gether, these observations confrm that valproic acid can indeed lamotrigine. This can lead as important as reported in the initial cross-sectional studies from to breakthrough seizures unless the lamotrigine dosage is adjusted. Tese changes occur rapidly and hence lamotrigine levels rise during Withdrawal of carbamazepine in seizure-free male and female the pill-free week if sequential pills are used . This may induce patients has also been associated with normalization (increase) toxic symptoms. Preliminary data suggest that estradiol can have a of serum testosterone and free androgen index . Pure proges- sectional studies assessed endocrine function in a younger female tagen-containing pills do not seem to afect lamotrigine serum con- population with epilepsy [18,19]. A cohort of 77 girls, 8–18 years centrations, and concomitant use of valproic acid appears to block of age, under treatment with valproic acid (n 40), carbamazepine the estradiol-induced efects on lamotrigine kinetics . Howev- (n = 19) or oxcarbazepine (n = 18) were compared with 49 healthy er, as lamotrigine can reduce the bioavailability of gestagens , Reproductive Aspects of Epilepsy Treatment 313 Table 23. Drugs in which the clearance is Drugs that increase the clearance Drugs that do not affect the induced by estradiol-containing of oral contraceptives clearance of oral contraceptives oral contraceptives Carbamazepine Ethosuxumide Lamotrigine Eslicarbazepine acetate Gabapentin Valproic acid Felbamate Lacosamide Lamotriginea Levetiracetam Oxcarbazepine Pregabalin Phenobarbital Retigabine Perampanel Tiagabine Primidone Valproic acid Phenytoin Vigabatrin Rufnimide Zonisamide Topiramate (at dosages >200 mg/day) a Lamotrigine does not affect estradiol concentrations but has a modest effect (18% reduction in plasma concentration) on the norgestrel component of the combined oral contraceptive. It has therefore been suggested that for women taking lamo- a few such reports have been published. In contrast, prolonged sei- trigine, the combined contraceptive pill can be used with tricycling zure activity, such as status epilepticus, may be a serious threat to or continuous use to avoid fuctuations in lamotrigine serum con- the fetus as well as to the woman. Given the choice of two drugs similar in all other women with status epilepticus (12 of whom were convulsive) . The possibility of using com- nancy are not associated with an increased risk of birth defects. Generalized tonic–clonic seizures during labour can cause fetal Pregnancy in women with epilepsy asphyxia. Focal seizures that impair consciousness may also impose In the treatment of epilepsy during pregnancy, maternal and fetal risks because the mother’s ability to cooperate during the delivery risks associated with uncontrolled seizures need to be weighed is lost. Nevertheless, Effects of maternal seizures on the fetus there is a general consensus among physicians that generalized ton- Epileptic seizures in a pregnant woman may have adverse efects ic–clonic seizures in particular should be avoided during pregnancy on the fetus, in addition to risks for the woman. With respect to for the sake of the well-being of the fetus as well as the mother. Maternal risks with uncontrolled seizures Tonic–clonic seizures are associated with transient lactic acidosis, Epilepsy is a serious condition and uncontrolled seizures occasion- which is likely to be transferred to the fetus. This concern appears to be fetal heart rate, which is a common response to acidosis, has been particularly relevant during pregnancy. Fourteen deaths were epilepsy-related, of which afects uterine blood fow and thus the fetus. An estimated 1 in ternal abdominal trauma could also, theoretically, cause injury to 1000 women with epilepsy died during or shortly afer pregnancy the fetus or placental abruption. Despite these efects, intrauterine compared with 1 in 10 000 in the general population. This appears to be mainly because of a decrease Seizure control during pregnancy and delivery in drug binding to plasma proteins and/or an increase in drug me- The largest prospective study of seizure control in pregnancy to tabolism and elimination. A decrease in protein binding will result date reported that 59% of 1736 women remained seizure-free in lower total drug levels but leave unchanged the unbound, active throughout pregnancy . Earlier studies, mainly from special- concentration of the drug, which is the relevant concentration in ized epilepsy centres, indicated that approximately one-third of the treated mother as well as for exposure to the fetus. Prospective studies of fewer selected women with phenobarbital decline by up to 50% . Total concentrations of epilepsy suggest that the proportion of women who deteriorate is carbamazepine decline to a lesser extent and the changes in un- smaller . Some of the observed changes in seizure frequency bound concentrations are insignifcant . Marked decreases in are likely to be explained by the normal spontaneous fuctuations total phenytoin concentrations to about 40% of prepregnancy levels in seizure occurrence, but it appears that some periods of pregnan- have been reported , whereas free concentrations decreased to cy are associated with a signifcant increase in seizures. For valproic acid, no signifcant changes were alized tonic–clonic seizure occurs during labour in about 1–2% noted in unbound concentrations despite a fairly marked decrease of pregnancies of women with epilepsy and within 24 hours afer in total concentrations . Taking all seizure types together, such as valproic acid and phenytoin, total plasma concentrations roughly 5% of women with epilepsy will experience seizures during can be misleading during pregnancy, underestimating the pharma- labour, delivery or immediately thereafer. In some patients, serum concentrations decline in late carbamazepine, lamotrigine, phenobarbital or valproate . Of pregnancy to 30% of prepregnancy levels, with normalization all cases, 67% remained seizure-free throughout pregnancy. Such alterations in serum con- eralized tonic–clonic seizures occurred in 15% of the pregnancies. Recent data suggest a similar decline in likely to remain seizure-free (74%) than women with focal epilep- serum concentrations of the active moiety of oxcarbazepine  sy (60%). Worsening in seizure control from the frst to second or and a fall in serum concentrations of levetiracetam of up to 50% third trimesters occurred in 16% of pregnancies. The fgures quoted represent average changes for groups of pa- Status epilepticus occurs in less than 1% of all pregnancies of tients, while the efect of pregnancy varies among individuals. The women with epilepsy and does not seem to occur more frequently decline in plasma concentration is insignifcant in some patients during pregnancy than in other periods of life. A single drug level is of limited value cated that poor compliance with the drug treatment, ofen because because the optimal concentration difers in diferent individuals. If seizures occur for the frst time during the last The literature on rates of obstetric complications in pregnant wom- 20 weeks of pregnancy, eclampsia needs to be excluded. Earlier studies suggest cerebral venous thrombosis also occur at a higher frequency during that induction of labour and instrumental deliveries are more fre- pregnancy. This may be a consequence of fear of treatment also apply for women in pregnancy, although treatment seizures and unfamiliarity with epilepsy among obstetricians rath- is ofen withheld during the frst trimester unless the risk is high for er than a refection of an increased rate of obstetric complications. Caesarean section might be needed if frequent seizures greatly im- pair cooperation in the forthcoming labour and delivery or if a gen- Pharmacokinetics of antiepileptic drugs during eralized tonic–clonic seizure occurs during labour . For these pregnancy reasons, pregnant women with epilepsy should be counselled by The pharmacokinetics of many drugs changes signifcantly during obstetricians who are familiar with epilepsy-related problems and pregnancy, and this can have consequences for maternal seizure delivery should take place in well-equipped obstetric units. Reproductive Aspects of Epilepsy Treatment 315 While some studies suggest that, with modern management, controls and criteria for malformations can account for the varia- there is no signifcant increase in common obstetric complications tion in outcome .
Because the brain is pain insensitive cheap fildena 100 mg overnight delivery, the patient is is not to say that inhibitory networks are not important in modu- not aware of whether stimulation is activated or not fildena 150 mg fast delivery, and controlled lating human brain activity buy 25mg fildena overnight delivery, just that inhibition may not be neces- blinded studies are feasible buy cheap fildena 50 mg. In some neurostimulation trials, one sary for seizure termination, either spontaneous or triggered. The investigator is unblinded to allow for adjustment of stimulation pa- human brain and hippocampus comprise predominantly (80–90%) rameters. This investigator needs to be careful to ‘preserve the blind’ excitatory connections . Stimulation of the cerebellum was the frst site of attempted ther- Recurrent seizures from single seizure focus in a patient have apeutic neurostimulation for epilepsy. This is apparent with visual inspection and utilized two eight-contact strip electrodes, placed on the upper sur- is supported by the application of time–frequency analyses . In face of the anterior lobe of the cerebellum through a burr hole or addition to somewhat stereotyped patterns of frequency, the onset craniotomy. Stimulus intensities of 1–9 mA, at 10 cycles per second, of a seizure is characterized by an increase in signal complexity were used. The fact that these seizure-onset patterns recorded from in- lar stimulation was used in attempts to reduce spasticity in patients tracranial electrodes in a given patient are very similar facilitates with cerebral palsy . Cerebellar tient and their seizures so that seizure detection can be very sensi- stimulation had been shown to shorten trains of hippocampal dis- tive. The fact that artefacts are markedly reduced with intracranial charges induced in humans  and to provide inhibition of corti- electrodes also facilitates accurate detection. Two double-blind trials of chronic cerebellar stimulation in the treatment of epilepsy comprised a total of 17 patients . In the study by Wright and colleagues , 11 out of 12 patients subjec- tively reported improvement, but there was no signifcant quan- tifable reduction in seizures shown for any patient. The safety of chronic implantation of intracranial strips was demonstrated with these studies. One might speculate that a potential reason for fail- ure is that the resting fring rate of Purkinje cells is already quite high (e. A more recent, very small double-blind study of fve patients with drug-resistant motor seizures employed bilateral stimulation of the superomedi- an surface of the cerebellum . The patients served as their own controls, but only two patients were randomized to no stimulation. Analyses showed a signifcant reduction in tonic and tonic–clonic seizures, increasing with time in the three patients followed long term. Whether larger blinded studies would have provided diferent results is not known, but cerebellar stimulation in humans for the treatment of epilepsy is presently inactive. Chronic stimulation of the thalamus The extensive application of thalamic stimulation for the treatment of tremor and Parkinson disease has provided considerable experi- (a) ence with long-term implantable devices for chronic, programmed stimulation. The thalamus is an important relay for aferents to the cortex and midline thalamic nuclei have strong connections with limbic regions [41,42]. Animal models have provided some ev- idence for medial thalamic involvement early in seizures . A study in kindled rats demonstrated that seizures were prolonged when drugs that either enhanced excitation (e. Tese studies illustrated that pharmacological manipulation of midline thalamic regions could infuence hippocampal seizure discharges, although typically the changes in duration were less than 50%. Electrical stimulation of the reticular nucleus in the rat suppresses kindled limbic seizures . The patient intensity (500 μA was better than 1000 μA) may be more impor- did not beneft signifcantly from the stimulation and the stimulator was tant than stimulus frequency . As with cerebellar (with or without secondary generalization, and patients could have stimulation, whether clinical trials with larger patient populations multiple seizure foci) and included an initial 3-month period when would have demonstrated improved efcacy is not known. The tients who had been implanted and were not receiving stimulation subgroup of patients with temporal lobe epilepsy had somewhat also appeared to beneft [61,65], notably in the immediate postim- greater seizure reduction (44%) during the blinded period, which is plant period. Median stimulation frequencies have been typically not surprising based on the known thalamic projections . At 13 months there was a 41% 49% in four patients, with one patient having ≥50% reduction in median seizure frequency reduction, increasing to 56% at 2 years seizures; however, some patients in this study also experienced ben- long-term follow-up and 68% at 5 years . The best results sponder rates (patients with >50% reduction in seizures) revealed from pilot studies were in the series of Osorio et al. This study, though trial designs may use seizure counts or responder rates as as noted by the authors, had a higher mean stimulus frequency the primary outcome measures, most trials show similar results for (157 Hz) than other studies (~100 Hz). During the 3-month blinded evaluation period the patients receiving anterior thalamic stimulation had a signifcant reduction in seizures. In contrast, in the neu- and 800 Hz stimulation actually lowered seizure threshold . During the blinded pe- riods the control group gradually began to have more seizures. Although approved in the European Un- al temporal onset seizures have seizures that remain refractory to ion, Canada, Taiwan, Australia, New Zealand and Israel, it is not yet medical therapy. Patients with mesial temporal onset seizures, espe- approved in the United States. Many of these patients regions, other studies have used regularly cycling stimulation par- are those who had become less responsive to dopaminergic agents adigms. It is thought that the substantia nigra plays an im- dling in the rat or suppress already kindled rats . The group considerable previous experience in the population with Parkinson that has been most active in human studies has also reported that disease. A more recent re- imal studies suggest that absence and clonic seizures beneft most. In the seven animals studied there was a 90% reduction in seizure Tese experimental studies have prompted several small uncon- frequency. Stimulation of An early report of beneft (80% seizure reduction) in a single patient the hippocampus has been shown to suppress local feld potentials appeared in 2002 . One preliminary report of three patients and other measures of network excitability in a large animal model with refractory focal seizures found a mean reduction in seizures of of epilepsy . The mechanism of action of any benefcial efects of 49% with all three patients benefting . Brain stimulation for epilepsy 973 Stimulation reduced both seizures and interictal spike activity and contrast to the non-lesional patients who beneftted from low-in- did not appear to produce any pathological changes in this limit- tensity stimulation. Chronic stimulation of hippocampal structures has the high stimulation intensities. The group in Ghent described their experience with  that suggested the potential for memory enhancement with 12 patients with refractory mesial temporal-onset focal seizures stimulation of the entorhinal regions. Although unblinded, the 12 patients were consecu- Tese results are similar to those of the unblinded reports of tive. Two pa- seizure reduction, with another three patients having a 40–70% sei- tients proceeded to selective amygdalohippocampectomy, one early zure reduction. Overall, 10 of the 11 remaining patients had a >50% re- A recent assessment of the safety and efcacy of deep brain and duction in interictal spikes of sampled epochs. The one patient who cortical stimulation, which included the Cochrane Central Register did not have a reduction in interictal spikes proceeded to successful and the above studies, concluded that there was moderate quality resective surgery. The other 10 patients entered a long-term stimu- evidence supporting the efcacy and safety of chronic hippocampal lation period with an implanted pulse generator. The authors, however, said that there was insufcient typically at 130 Hz but with one patient stimulated at 200 Hz. Mean evidence to make conclusive statements and larger, well-designed follow-up was 31 (range 12–52) months and mean monthly seizure trials are needed . Including these two patients, eight out of 11 had >50% reduction Clinical studies of responsive in disabling (i. The only stim- The idea that electrical stimulation could terminate epileptic sei- ulus parameter altered was stimulus intensity; although this may zures (rather than cause them) was one that initially was questioned. No increases in seizure frequency or aferdischarg- for responsive closed-loop therapy to provide meaningful beneft, es were observed; stimulation was well tolerated. The investigators patients would need to have application of therapy very early (i.