Sacral reflex staging differences between 51 healthy subjects and 134 patients with pudendal neuralgia: methodology and normal values
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https://www.eduzhai.net Clinical M edicine and Diagnostics 2012, 2(4): 21-26 DOI: 10.5923/j.cmd.20120204.01 Differential Staged Sacral Reflexes: Methodology and Normal Values from 51 Healthy Subjects and 134 Patients with Pudendal Neuralgia Eric de Bisschop1,2, Rajeshree Nundlall2,* 1Department of surgery, Casamance Clinic, 33, Boulevard des Farigoules, 13400, Aubagne, France 2Angiolo gy, p rivate office, 55 avenu e des Goums, 13400, Aubagne, France Abstract Objective: to develop a reproducible method for electrophysiological study of pudendal nerves which can explore the different risk areas: sacral spinal, infrap iriformis area and ischiorectal fossa. This method is called "differential staged sacral reflexes (DSSR) ". 51 patients not suffering fro m pudendal neuralgia and 134 patients with pudendal neuralgia have been selected. The sacral reflexes (SR) are made at the ventral and dorsal quadrants of the anal sphincter and at the pubococcygeus muscle. Considering the values of the DSSR obtained on healthy subjects and on patients with pudendal neuralgia, maximu m threshold values have been established: a significant difference between ventral and dorsal quadrant of the anal sphincter: da mage orientation at the level of the ischiorectal fossa; significant diffe rence between dorsal quadrant of the anal sphincter and pubococcygeus muscle: damage orientation at the level of the infrapiriformis area. SR delayed uniformly at the three afore-mentioned muscles: damage orientation at the level of the sacral spinal. The DSSR allow in a reproducible way to investigate the pudendal nerve in all areas suitable to entrap this nerve, which is impossible with the method of pudendal nerve terminal motor latency (PNTM L). Keywords Diffe rential Staged Sacral Re fle xes, Pudendal Nerve, Elevator Ani Nerve, Piriformis Area, Ischiorectal Fossa 1. Introduction staged sacral reflexes can also direct the co mpressive site to the infrapiriformis area and/or to the ischiorectal fossa. The conventional technique of electrophysiology of the pudendal nerve is to measure the distal motor latency (PNTM L) by endocavitary stimulation, rectal and / or vaginal, at the level of the ischial spine with collection at the anal sphincter This method sins however due to the lack of reproducibility and of sensibility[2-5]: PNTM L can be lengthened without corresponding to a pudendal neuropathy and being normal without eliminating it. Several factors can interfere with nervous time conductions: vascular, synaptiques distales endings, vegetative reactivities, variability of the answers in the time and according to the operator. The sacral reflexes[6-8] studied on the ventral and dorsal quadrants of the anal sphincter and on the pubococcygeus muscle (staged sacral reflex) showed significant differences in responses to establish normal values, beyond and which according to the responses, a truncal compression (TC) or an intra-spinal conflict may be mentioned. In case of TC, these * Corresponding author: rajeshree@free. fr (Rajeshree Nundlall) Published online at https://www.eduzhai.net Copyright © 2012 Scientific & Academic Publishing. All Rights Reserved 2. Anatomical Recall (Fig. 1) The PN is a mixed nerve taking its origin at the S2, S3 and S4 roots, with a possible contribution of S1. Then, the PN cross the infrapiriformis area limited fro m the lower edge of the piriformis muscle to the sacrospinous ligament (SSL). The PN then passes beneath the SSL. The inferior rectal nerve (IRN), the first collateral PN, born before the coming of the ischiorectal fossa (IRF), does not go under the falciform process (FP) or in the A lcock canal (A C). It will innervate the dorsal quadrant of the anal sphincter (AS). The PN truncal pathway, became perineal nerve (PEN), continues under the FP and the AC (duplication of the fascia of the Obturator internus). It will innervate the ventral quadrant of AS. The levator ani nerve (LAN) runs up the anterior coccygeal muscle. It thus does not pass under the SSL or under the FP and thus avoids the AC. It innervates, among other things, the pubococcygeus muscle (PCM). Note that the PN has many anatomical variat ions: After dissection of the body 7[7-8]: The origin of the IRN is in all cases before entering the ischiorectal fossa (IRF) with a direct path to the posterior of the anal canal, can 22 Eric de Bisschop et al.: Differential Staged Sacral Reflexes : M ethodology and Normal Values from 51 Healthy Subjects and 134 Patients with Pudendal Neuralgia passes under/throught or above the SSL. Then it runs in the lateral space of the ischiorectal fossa nerve. It never passes in the AC (duplication of the fascia o f the Obturator internusl). After dissection of 37 bodies, it is found from a trunk under the SSL in 56.2%, 11% in two trunks, 2 trunks with 1 IRN perforating the SSL in 11%, 3 t runks with a IRN does not pierce SSL in the 9.5% and 12.3% in three trunk. spinal cord (S2-S4) located in the nucleus of Onuf. All of the reflex arc takes about 35 ms (N <44 ms). Muscle response can be recorded at all perineal pelvic mu s cles . Figure 1. Nerve supply pelvic floor anatomy Figure 2. Sacral reflex S: Stimulation; NPA: afferent way of PN; M: medullar level S2, S3 and S4; TM:transfer module; NPE efferent way of PN; NEA: elevator ani nerve 3. Sacral Reflex[13-14] (Fig. 2) The afferent way consists of sensory fibers of PN stimulated electrically at the dorsal nerve of the clitoris / p en is . It is essential to consider that the nerve is made up of many nerve fibers (NF). Increasing the intensity of stimu lation has the effect a gradual increase in the number of NF recruited (spatial summat ion). The rece iver corresponds to a sensitive current-transducer number, fro m which the stimu lation intensity (I) is converted to a number (N) of activated NF[N = f (I)]. On a normal subject, the threshold intensity is the minimu m number of NF whose action potentials arriving phase have a resultant intensity sufficient to trigger the ref le x. But if on the afferent way the individual nervous conductions are desynchronized or if a denervation is important, the reflex is absent or requires a higher stimulat ion intensity. In this case, D. Vodusek shown we can get the reflex with 2 or many coupled stimu lations. We get the same effect by recording the reflex during voluntary contraction force of the anal sphincter (personal method). The afferent message will be articulated relat ing to a transfer module located at S2-S4 spinal cord with a systemof interneurons. This message, via the transfer module, will excite the outflow tract at the start of the ventral horn o f the 4. Materials a. For the puncture of the ventral and dorsal quadrant of the anal sphincter, is used a disposable concentric needle electrode 25 mm X 30 G b. For the puncture of the pubococcygeus muscle, is used a disposable concentric needle electrode 50 mm X 26 G. c. 51 healthy subjects divided into 38 wo men and 13 men were selected. These subjects are free of pain pelvic -perineal and / or functional sign pelvic-perineal and / o r pelvic viscera of ptosis. Carriers of blemishes that may be associated with neuropathy were eliminated fro m the study. The 13 men were investigated for evaluation before treatment by finasteride (9 for alopecia and 4 for benign prostatic hyperplasia). 38 wo men were investigated for stress incontinence by cervico-urethral hypermobility (staged sacral refle xes made before the urodynamic investigations) Patient age is between 26 and 83 years, with an average of 58 years. d. 134 patients, included 83 wo men and 51 men suffering fro m pudendal neuralgia with a positive response to the infiltrat ion of truncal PN. 5. Methods a. Location of the pubococcygeus muscle (fig. 3) Clinical M edicine and Diagnostics 2012, 2(4): 21-26 23 Obturator crest Figure 3. location of the pubococcygeus muscle Figure 4. Schematic representation of DSSR with-drawn type of example: damage orientation at the level at the entire route IPA/IRF nerve of clitoris/penis stimulations : Dorsal For the puncture of the pubococcygeus muscle, we use a disposable concentric needle electrode 50 mm X 26 G. Women and men, the needle is introduce at 4 to 5 cm. * Women: Puncture just below the obturator crest, lateral to the lower part of the labia majora. Inclination of the needle at 15-20 ° upwards * Men: punture 1 cm lateral to the raphe of perineu m. Inclination of the needle at 15-20° upwards b. Staged sacral refle xes (fig. 4) Based on the general princip le of the sacral reflex, the staged sacral refle xes use the collateral dichotomy of PN and the innervation of the EAN. The EAN does not pass through areas likely to co mpress the PN, serves as a reference minimu m conduction delay. The perineal nerve, passing through all the areas likely to compress the PN, serves as a reference maximu m conduction delay. By co mparing the sacral reflex obtained on the ventral quadrant of the anal sphincter (perineal nerve), and those obtained in the dorsal quadrant of the anal sphincter (IRN), never passing through the IRF, we study nerve conduction in the IRF and the same in the Alcock canal By co mparing the sacral reflex obtained on the dorsal quadrant of the anal sphincter (IRN), and those obtained in the pubococcygeus muscle (EAN), we study nerve conduction in the infrap iriformis area. Reporting results in anatomical d iagram: •Ventral quadrant (Q1) of the anal sphincter (perineal nerve): in forms on the overall conduction of PN: the neural pathway will go through all the areas likely to conflict with the PN: spinal sacral roots, IPA, IRF and AC •Dorsal quadrant of the anal sphincter (IRN) fro m the ventral quadrant of the anal sphincter: this path does not pass 24 Eric de Bisschop et al.: Differential Staged Sacral Reflexes : M ethodology and Normal Values from 51 Healthy Subjects and 134 Patients with Pudendal Neuralgia through the IRF, the falciformis process and AC. It therefore informs the distal nerve conduction PN (IRF and AC). Subtracting the value of SR obtained at the ventral quadrant to that obtained at the dorsal quadrant. If the NRI forward pass of SSL (anatomical variation), the difference of the values obtained informat ion on all of the truncal motor conduction PN (IPA, IRF and AC). •Pubococcygeus muscle (Q3) (PCM ) fro m the dorsal quadrant: information on nerve conduction of the PN at the IPA. Subtracting the value of SR obtained at the dorsal quadrant to that obtained at the pubococcygeus muscle. If the IRN forward pass of SSL, the value obtained will be similar (not significant) than that obtained on the dorsal quadrant. 6. Results By studying the values obtained on the sacral reflexes on pelvic floor muscles with the study exp lored the d ifferences recorded between each of these muscles in all healthy subjects and patients with pudendal neuralg ia (Table 1), detailing the wo men (Table 2 ) and men (Table 3), we defined the min imu m and maximu m nervous time conduction between the quadrant ventral Q1 and dorsal quadrant Q2 and between Q2 and pubococcygeus muscle Q3 of 51 healthy subjects (table 4) and the 134 patients with pudendal neuralgia (table 5) Table 1. Sacral reflexes values obtained on the perineal muscles explored on the healthy subjects and on the patients with pudendal neuralgia Max (ms) Min (ms) Moy (ms) Q1 S 43,6 32,6 38,3 51 healthy subject s (S) 134 patients with pudendal neuralgia (NP) Q1 NP Q2 S Q2 NP 55,6 42,6 55,6 42,6 30,2 32,6 50,2 36,9 40,4 Q3 S 41,8 29,4 36,1 Q3 NP 42,2 28,8 35,6 Table 2. Sacral reflexes values obtained on the perineal muscles explored on the healthy women and on the women with pudendal neuralgia Max (ms) Min (ms) Moy (ms) Q1 S 43,6 32,6 38,6 38 healthy women (S) 83 women with pudendal neuralgia (NP) Q1 NP Q2 S Q2 NP 55,6 42,6 55,6 42,8 30,2 34,8 52,4 37,1 42,2 Q3 S 41,8 29,4 36,3 Q3 NP 41,8 29,4 36,3 Table 3. Sacral reflexes values obtained on the perineal muscles explored on the healthy men and on the men with pudendal neuralgia Max (ms) Min (ms) Moy (ms) Q1 S 41,8 33 38 13 healthy men (S) 51 men with pudendal neuralgia (NP) Q1 NP Q2 S Q2 NP 53,4 40 53,2 38,6 31,8 32,6 46,8 36,7 39,8 Q3 S 39,8 31 35,9 Q3 NP 42,2 28,8 35 Table 4. Nerve conduction time between ventral quadrant Q1 and dorsal quadrant Q2 and between Q2 and pubococcygeus muscle Q3 on the 51 healthy subject s Femmes t emps max en ms Women max time in ms Femmes t emps min en ms Women min time in ms Hommes t emps max en ms Men max time in ms Hommes t emps min en ms Men min time in ms Q1 – Q2 3 0 2 0 Q2 – Q3 2.2 0 1.4 0 Table 5. Nerve conduction time between ventral quadrant Q1 and dorsal quadrant Q2 and between Q2 and pubococcygeus muscle Q3 on the 134 patients with pudendal neuralgia 83 Women with pudendal neuralgia - 51 Men with pudendal neuralgia Q1 – Q2 Women max time in ms 17,6 Women min time in ms 3,2 Men max time in ms 14,2 Men min time in ms 2,2 Q2 – Q3 10,2 2,4 8,8 1,6 Table 6. Normal nerve conduction time between ventral quadrant Q1 and dorsal quadrant Q2 and between Q2 and pubococcygeus muscle Q3 Women in ms Men in ms Q1 – Q2 N ≤3 N ≤2 Q2 – Q3 N ≤ 2.2 N ≤ 1.4 Clinical M edicine and Diagnostics 2012, 2(4): 21-26 25 Table 7 Q2-Q3 ♀ > 2.2 ms - ♂ > 1.4 ms Q2-Q3 ♀ ≤ 2.2 ms - ♂ ≤ 1.4 ms Table 7. compressive topographic orientation Q1-Q2 ♀ > 3 ms - ♂ > 2 ms CIP + FIR RS <> N CIP +/- FIR RS <> N Q1-Q2 ♀ ≤ 3 ms - ♂ ≤ 2 ms CIP RS <> N sacral spine RS > N We were able to define maximu m normative values between these muscles (Table 6) provide guidance and topographic compressive (Table 7).  Kiff E, Swash M . Slowed conduction in the pudendal nerves in idiopathic (neugenic) faecal incontinence. Br J Surg 1984;71:614-16 In the particular case of a conflict purely root S2, S3 or S4  Bussen D, Sailer M , Fuchs K-H, Thiede A. Reliability of kind Tarlov cyst, it will most often neurogenic signals without focal slowing of nervous conductions. Pudendal Nerve Terminal M otor Latency. Coloproctology 2003;5:261-265 Legend:  de bisschop E, Bautrant E. EM G: which one and why?. SR > N: the SR are h igher than normal on all the muscles Considerations regarding Pudendal Nerve Terminal M otor explored, with no significant difference in terms of Q1, Q2 and Q3 SR <> N: The SR is higher or lowe r than norma l but in all Latencies (PNTM L). 31st meeting of the International Urogynecologycal Association (IUGA 2006). September 6-9. 2006. Athens cases with significant differences between Q1 and Q2 and /  Le Tallec de Certaines H, Veillard D, Dugast J, Estèbe J-P, or Q2 and Q3. Kerdraon J, Toulouse P et al. Comparaison entre la latence distale motrice du nerf pudendal, la topographie de la douleur périnéale et le résultat d'infiltrations. Analyse pour 53 patients. 7. Discussion Annales de réadaptation et de médecine physique 50 (2007) 65-69 a. Advantage of the differentia l staged sacral refle xes: • Reproducible method • Allow to exp lore the PN, fro m the sacral spine to the distal part via the sacral roots. • A llo w to act out a TC at the IPA, can not be accessed with the PNTM L • Directs the head injury (sacral spine, IPA, IRF) • Few false positives • No false negatives b. Disadvantages: Appears to have 7.8% false positives. Note that 80% of these false positives have shown clinical signs of PN contralateral side to evoke electrophysiological within 2 years that follo wed exp loration EM G. Study conducted on unilateral 64 pudendal neuralgia. 5 false positive contralateral side. 4 pudendal neuralg ia have their b ilateralized in two years that have followed. Can thus be estimated at 1.6% real rate of false positives. 8. Conclusions Co mpared to the motor latency of the pudendal nerve (PNTM L), the differential staged sacral reflexes can, reproducibly, explore the whole pathway of the pudendal nerve and sacral spine. A PN entrap ment compression located in the infrapiriformis area (70-80% of cases) may be evoked, which is technically impossible with the PNTM L.  Altomare D, Rinaldi M , Petrolino M , Ripetti V, M asin A, Ratto C and Al. Reliability of electrophysiologic anal tests in predicting the outcome of Sacral nerve modulation for fecal incontinence. American Society of Colorectal Surgeons. 2004;47:853-857  de Bisschop E, Bautrant E. Nouveaux concepts d’explorations électrophysiologiques du nerf pudendal dans le cadre de la névralgie pudendale. Electrophysiologie de diagnostic. Electrophysiologie per-opératoire. Pelvimag 2006;55:12-4  Spinosa J-P, de Bisschop E, Laurençon J, Kuhn G, Dubuisson J-B, Riedederer B-M . Les réflexes sacrés étagées dans l’étude anatomique de la névralgie pudendale : validation anatomique. Rev M ed Suisse 2006;2:2416-2421  Spinosa J-P, de Bisschop E, Laurençon J, Kuhn G, Riedederer B-M . Differential staged sacral reflexes allow a localization of pudendal neuralgia. 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Clin Anat. 2005 Apr;18(3):200-5  de Bisschop G, Spinosa J-P, de Bisschop E, Nundlall R. Considérations anatomophysiologiques à propos du réflexe sacré. Rev M ed Suisse 2008;4:546-549  Uher E-M , Swash M . Sacral reflexes Physiology and clinical application Diseases of the Colon & Rectum. 1998;41(9)  Vodusek D.B., Janko M . Lokar J. Direct and reflex responses in perineal muscles on electrical stimulation. J. Neurol Neurosurg Psychiatry 1983; 46:67-71
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