词条 | Draft:Neuropelveology |
释义 |
Neuropelveology is the branch of medicine dealing with the pathologies of the pelvic nerves and plexuses. The word "neuropelveology" comes from the oblique stem (νεûρον) of Greek: neuron, nerve, pelveo- from Latin: "pelvis" and –logia, "study". HistoryThis academic discipline began with the work and research of a gynecologist, Marc Possover, who in 2005 first chronicled the use of laparoscopy for the exploration of the pelvic nerves to treat various neuropathic conditions..[1][2][3][4][5][6]Marc Possover is unanimously considered to be the father of neuropelveology: it was in 2010 that he first named the discipline "neuropelveology" and described the methods and techniques of this emerging specialty field of medicine[7][8][9] He presented and described in detail in several scientific publications, the method for neuropelveological diagnoses, in the process identifying previously unnamed conditions such as "vascular entrapment of the pelvic nerves" responsible for pelvic neuropathic pain syndrome[10][11][12][13][14][15][16], as well as developing several innovative laparoscopic procedures to the pelvic nerves, to treat a range of pathologies[17][18][19][20][21][22][23][24][25], including the LION procedure[26][27] This latest technique for the Laparoscopic Implantation of Neuroprothesis, also called "The Possover Procedure", enables the selective placement of electrodes in direct contact with the nerves under direct visualization. The LION procedure to the pelvic somatic nerves allows for the management of neurogenic pain syndromes and pelvic organ dysfunction and may also represent a potent alternative to current methods for neuromodulation in the treatment of visceral pain mediated by the autonomous nervous system[28][29][30][31][32]. Recent studies have demonstrated that pelvic nerve stimulation might also induce changes that affect the central nervous system to engage residual spinal and peripheral pathways for recovery of voluntary motion of the legs in chronic paraplegics[33][34][35][36] Due to growing interest from the wider medical community for this new specialty, Prof. Possover was inspired in 2014 in Belgium, along with several colleagues, to found the International Society of Neuropelveology (ISoN) with the major objective of providing universal access to education in neuropelveology. TrainingThe International Society Of Neuropelveology, also called the ISoN, encourages the study and advancement of both the science and practice of neuropelveology. This is done through postgraduate medical education and training development and the publication of clinical reports on aspects of the specialty and service provision. The International Society Of Neuropelveology certifies Neuropelevologists at three levels:
Medical applicationSymptomsPelvic pain can be categorized as visceral pain (the sympathetic plexus is affected) or somatic pain (the somatic nerves and sacral plexus are affected). Autonomic nerve irritation will produce combined visceral pain (low abdominal and/or low back pain) and vegetative symptoms, such as urinary frequency or urgency, dysuria, rectal pain, suprapubic pain, and/or abdominal cramps and chills/nausea/vomiting/fatigue/anxiety/malaise/depression or even fainting spells. The resulting pain can be described as unspecific, non-localized in the entire lower abdomen with radiation to the lower back, and dull in nature. Pathologies of the somatic pelvic nerves will produce pain on the affected nerve's dermatomes with symptoms such as burning pain (allodynia), tingling, electric shock–like pain, numbness, and muscle weakness, along with urinary and bowel dysfunctions. The main symptoms of pelvic somatic nerve irritation are as follows:
The symptoms of pelvic neuropathic pain syndrome can include tingling, numbness and loss of feeling, weakness in the lower back, buttocks and legs, which has not been pinpointed to any traceable spinal cause. The location of the pain can be described very specifically. Patients may report feeling "burning pain" with distal radiation to the corresponding dermatome(s). Due to the fact that somatic nerves are mixed nerves, somatic pain is usually associated with functional problems in the pelvic organs, and sometimes in the legs. Vegetative symptoms are absent, except as side effects of painkillers. Pelvic neuropathic pain syndromes are often accompanied by negative cognitive, behavioural, sexual or emotional consequences with an important impact on the quality of life. Management of pelvic nerve pathologies requires good integration and knowledge of all pelvic organ systems, neuro-functional pelvic anatomy and the musculoskeletal, neurological and psychological aspects, which no current specialty thus far had been able to address. As a result of the stigma and social isolation of these patients, it is not surprising that other associated problems may co-exist alongside, such as depression, anxiety and drug addiction amongst others. Chronic pain syndromes present a major challenge to healthcare providers due to their unclear etiology, complex natural history and poor response to therapy. These patients often approach several new physicians with a combination of unrealistic hopes for a cure and at the same time may be highly suspicious due to incorrect past diagnosis and treatment failures. Patients are often sidelined and have to accept medical pain management and antidepressants, with their known side effects and risk of dependency development for the rest of their lives. Neuropelveological diagnosisFor a proper neuropelveological diagnosis, it is essential to adopt a "neurological way of thinking" reported by Possover. Standard medical training imparts the concept that the location of the pain and its etiology correspond to the same area. In pathologies of the pelvic nerves, however, the location of the patient's pain (dermatomes) and the senso-motor dysfunctions of the pelvic organs and the lower extremities reveal which nerves are involved in pain process, whereas the etiology is mostly located on the path from the dermatome to the brain. A neuropelveological workup aims to determine which nerves, at which level, are involved in pain generation and always follows four steps in the following subsection:
Steps 1 to 3 are achieved by studying the patient's history while the neurological examination with the direct transvaginal/rectal digital palpation of the pelvic somatic nerves is used to confirm the diagnosis. Modern imaging and/or laparoscopic visualization may offer an effective etiological diagnosis and, in most cases, the corresponding etiological treatment as well. TherapiesAs with all surgical specialties, neuropelveologists may employ medical or surgical therapies, depending on the exact nature of the problem and the accessibility of the nerves for diagnostic or therapeutic medical infiltrations. In neuropathic pain, medical management will often employ many standard drug therapies, such as neuroleptics, antidepressant drugs and analgesics. It is the goal in a neuropelveological approach of course to seek to reduce pain and others symptoms but ultimately the aim is to find an etiological treatment, or surgical solution. Considering the number of pelvic pathologies and invasive procedures in proximity to the pelvic nerves that could potentially induce neuronal compression, entrapment or damage, reports in the scientific literature are still extremely rare. The incidence of pelvic nerve pathologies seems widely underestimated, mainly because of lack of awareness that such lesions may exist, a lack of diagnosis and acceptance, as well as declaration and reporting of such lesions. Neurosurgical procedure techniques are well established in nerve lesions of the upper limbs but surgical exploration of the pelvic retroperitoneal area and the pelvic nerves are still most unusual for neurosurgeons. The only pelvic nerve pathology that has been widely explored is pudendal neuralgia (Alcock's Canal Syndrome) as the nerve is easily accessible for neurophysiological explorations, infiltrations and surgical decompression. By contrast, the endopelvic nerves are difficult to access and have been less well investigated in the past. Laparoscopy plays a key role not only in diagnosis but also in the operative phase in neuropelveology. Advances in video endoscopy as well as microsurgical instruments, have enabled good accessibility to all areas in the retroperitoneal pelvic space, providing the necessary visibility with magnification of the structures and possibility to work with appropriate instruments for adequate neurofunctional procedures, such as nerve decompression and neurolysis. Laparoscopy is also the only technique that enables selective placement of electrodes to all the pelvic nerves and plexuses. This technique of Laparoscopic Implantation of Neuroprothesis, also called the "LION procedure", enables the selective placement of electrodes in direct contact with the nerves under direct visualization. The LION procedure to the pelvic somatic nerves allows for control of neurogenic pain syndromes and pelvic organ dysfunction and may also represent a potent alternative to current methods for neuromodulation in the treatment of visceral pain mediated by the autonomous nervous system. Recent studies have demonstrated that pelvic nerve stimulation might also induce changes that affect the central nervous system to engage residual spinal and peripheral pathways for recovery of voluntary motion of the legs in chronic paraplegics. ConditionsConditions treated by neuropelveologists include, but are not limited to:
See also
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