Obturator nerve damage

Introduction Closed-hole sputum has the symptoms of obturator nerve damage. The peritoneal viscera protrudes through the hip-obturator tube in the triangle region, which is called obturator. The obturator tube is a fibrous bony tube with a length of 2 to 3 cm and is inclined forward, inside and below. The upper part of the tube is composed of a closed sulcus under the pubic symphysis, and the lower part is formed by the connection of the pelvic sarcolemma and the obturator membrane covering the upper edge of the muscle in the closed hole. The obturator membrane is a fibrous diaphragm, the fibers are arranged in an irregular cross, and the outer membrane and the inner membrane are covered. The inner mouth (pelvic mouth) is covered with peritoneal and extraperitoneal tissues, and the outer mouth is open to the internal femoral and femoral arteries. The triangular area formed by the pubic bone. There are obturator nerves and obturator veins in the obturator tube to reach the inner side of the thigh, so when there is sputum prolapse, there are often symptoms of obturator nerve compression. The obturator artery is from the internal iliac artery, but a small part is from the inferior abdominal artery. It passes through the edge of the ligament of the sac, and accidentally injures the inside of the inguinal ligament during operation. Uncontrolled bleeding can occur.

Cause

(1) Causes of the disease

1. Local weakness: Closed-hole tube provides a potential channel for the occurrence of obturator, but it does not necessarily occur. Only local tissue is weak, such as rupture of the obturator muscle, displacement to the caudal side, or abnormal obturator membrane. It is possible to form sputum under the action of intra-abdominal pressure. The hernia sac can be directly protruded through the ruptured obturator muscle, or the obturator nerve and the obturator vessel can be worn out of the obturator or the obturator vessel, and can also protrude under the obturator muscle.

2. Degeneration of pelvic floor tissue: This sputum occurs in elderly patients, mostly in the 70 to 80 years old, and Larrieu et al reported that the average age of onset is 67 years. This may be related to the degeneration of the elderly tissue leading to physiological pelvic fascia relaxation, pelvic floor muscle atrophy and so on.

3. Closed-tube widening: Closed-hole sputum is more common in female patients, which is related to the female obscuration tube being wider and flatter than male. Physiologically, due to multiple pregnancies and increased intra-abdominal pressure, the female perineum can be too loose and wide.

4. Weight loss: multiple illnesses, malnutrition, weight loss, and any wasting disease can cause the perforation of the peritoneal fat tissue to be lost in the closed mouth. The peritoneum covering the upper part of the peritoneum is easily depressed to form the hernia sac.

5. Increased intra-abdominal pressure: diseases that lead to increased intra-abdominal pressure include chronic bronchitis, long-term cough, and habitual constipation.

(two) pathogenesis

1. Formation process: The formation of closed-hole defects is divided into three stages:

1 There is extraperital fat at the obturator.

2 There is a shallow peritoneal depression, and gradually deepens to form the hernia sac.

3 The sac is full of contents.

The sputum content of the obturator is mainly the small intestine, and it may be part of the intestinal wall (Richter's sputum) or all of the intestinal tract. The contents of the sputum may also be bladder, ovary, fallopian tube, appendix, colon, and Meckel diverticulum.

2. Ways to take out: There are 3 ways to highlight:

1 The sac is passed through a closed-cell tube and is removed under the pubic muscle.

2 The sac is in the middle and upper muscle bundles of the obturator muscle, and travels along the obstructed nerve and the lower branch of the artery.

3 The sac is moved downwards and out of the closed hole and between the outer membrane. But in either case, the site is very deep, and unless the hernia sac is large, it is not easy to lick and swollen in the thigh.

3. Pathophysiology: The closed hole is a narrow fibrotic duct, the surrounding tissue is hard and tough, and the obturator nerve (waist 2~3) passes through it. When the viscera or tissue is released from the obturator, due to the crowding of the sac and the contents, the obturator nerve is inevitably pressed, and intermittent pain, soreness, numbness, and the like on the inside of the thigh and the knee joint occur. Most of the sputum contents of the obturator are small intestine, and the ankle ring is small and inelastic, so the invaded intestinal tube is prone to incarceration, and blood circulation disorder occurs in a short period of time, and intestinal narrowing and necrosis occur. Therefore, the symptoms of small bowel obstruction appear after clinical knee pain. If the contents of the sputum are partially incarcerated, there is no obvious intestinal obstruction in the early stage, and the sputum is small, and it is located deep in the pubis muscle, so that it is difficult to find.

an examination

Related inspection

CT examination of gastrointestinal CT examination

Therefore, clinically, patients with obturator fistula should be examined:

First, physical examination

Taking a medical history gives us a first impression and revelation, and also guides us to a concept of the nature of the disease.

1. Characteristics of medical history:

(1) Older women, weight loss, patients who may have a history of similar episodes, multiple pregnancy and childbirth, and habitual constipation should be highly vigilant.

(2) In the early stage of the attack, knee pain, soreness and other signs of intestinal obstruction, but also have the characteristics of general sputum, that is, the sudden onset of intra-abdominal pressure, sudden relief after supine or rest.

2. Signs:

(1) The Howship-Romberg sign is the earliest and most characteristic sign of the disease, and it is also the main basis for making a diagnosis before surgery. Especially in elderly and frail women with intestinal obstruction and Howship-Romberg sign, this disease should be considered.

(2) The inside of the fossa ovalis under the inguinal ligament can be combined with a round mass with mild tenderness. However, only some patients can find this sign.

(3) When rectal or vaginal examination, there may be a cord-like mass on the anterior wall of the pelvis, and there is tenderness, but when the tumor is not obvious, the disease cannot be ruled out.

Second, laboratory inspection

Laboratory examinations must be summarized and analyzed based on objective data learned from medical history and physical examination, from which several diagnostic possibilities may be proposed, and further consideration should be given to those examinations to confirm the diagnosis. For example, the abdominal and pelvic X-ray films show the shadow of the inflatable bowel fixed in the upper edge of the pubic bone or the gas in the closed hole or an inflated bowel, and the blind end points to the closed hole. Closed-port hernia sac can be observed during the interstitial sac angiography, and CT can sometimes help to confirm the diagnosis.

Differential diagnosis

The comprehensive literature of obturator is often misdiagnosed as the following diseases, which need to be carefully identified.

1. Intestinal obstruction: small, deep, severe abdominal pain in the obturator is easy to cover up other symptoms. The main points of identification of intestinal obstruction caused by non-obturator sputum are: 1 No Howship-Romberg sign. 2 rectal or vaginal finger examination on the pelvic side wall without cords and tenderness. 3 Abdominal and pelvic X-ray examination, no visible obscuration with enhanced transmittance in the anterior pubic branch. CT examination, there is no pedicle shadow on the outer mouth of the obturator tube.

2. Peritonitis: It is often easy to diagnose Richter's sputum as peritonitis. Since the sputum is partially invaded by the intestinal wall, there is no obvious intestinal obstruction. The bottom of the sac is far from the body surface, the lumps are small, easy to delay diagnosis, resulting in narrowing and necrosis of the intestinal wall, and easily misdiagnosed as peritonitis. But peritonitis: 1 no Howship-Romberg sign. 2 There is no tender cord-like mass at the inner mouth of the closed wall of the pelvic wall of the rectum or vaginal. 3 imaging findings without obturator sputum.

3. Rheumatoid arthritis, sciatica, lumbosacral pain, obturator sputum: The initial symptom of obturator is obturator neuralgia, often misdiagnosed as rheumatoid arthritis, sciatica, lumbosacral pain. However, the latter disease has no Howship-Romberg sign and intestinal obstruction symptoms, combined with rectal or vaginal finger examination, X-ray examination, etc. can be distinguished.

4. Femoral hernia: the sacral mass protrudes from the fossa ovalis on the inner side of the femoral vein, and the obturator sac is protruded through the obturator tube in the deep part of the pubic plexus and the lower end of the femoral triangle. Combined with rectal or vaginal finger examination, the anterior wall of the affected pelvis touches the cord or block with tenderness, the abducted limb, the mass is prominent, and the tenderness is aggravated, which is helpful for diagnosis.

5. Acute appendicitis: Richters in the small intestine part of the intestine wall incarceration, the patient still has deflation, defecation, incarceration of intestinal necrosis, inflammatory exudation stimulated right lower quadrant tenderness with elevated body temperature, easily misdiagnosed as acute appendicitis. However, acute appendicitis often has metastatic right lower abdominal pain, positive colonic inflation test, early no intestinal obstruction, no Howship-Romberg sign, rectal or vaginal finger examination of the anterior pelvic wall without cords with tenderness.

6. Ureteral stones: abdominal cramps and radiation pain, hematuria, B-ultrasound, CT, IVU can show renal pelvis, ureteral hydrops and ureteral calculi. However, there is no intestinal obstruction and Howship-Romberg sign, rectal or vaginal finger examination, abdominal and pelvic X-ray film also have no relevant manifestations of this disease.

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