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Ростовский Государственный Медицинский Университет

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study. Although targeted patching seems to provide higher symptom relief rate, in cases of indeterminateleaklocation,traditionalblindpatchinginthelumbarspineisgenerallyapplied. In addition,the lumbar epidural space can accommodate a larger volume of blood without

concernforcompressiveeffectsonthespinalcord.

FIGURE6-4.Themajorarteriessupplyingthespinalcordandtheassociatedveins(FromMooreKL,AgurAM,

DalleyAF.ClinicallyOrientedAnatomy.7thed.Philadelphia,PA:WoltersKluwer;2009,withpermission).

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FIGURE6-5.Thespinalvenousplexusesrelativetothelumbarspine(FromMooreKL,AgurAM,DalleyAF.

ClinicallyOrientedAnatomy.7thed.Philadelphia,PA:WoltersKluwer;2009,withpermission).

Theprocessofepiduralpuncturecanitselfinjurethevertebralvenousplexus,around6%

incidence,leadingtorepeatprocedurehalfthetime,21andsometimesepiduralhematomas.In thesecases,themajoritywereassociatedwithanticoagulantuseorclottingdisorder.Patients frequentlypresentwithmotorweakness(46%)andbackpain(38%).Notably,backpaincan

bemaskedincasesofcontinuousanesthesia.

LumbarPuncture

Headacheafterlumbarpunctureisverycommon;roughlyone-thirdofpatientsexperienceit.

Theseheadachesaretypicallyassociatedwithrapidremovalofroughly15%(20mL)oftotal CSFvolume,provokedbysittingorstanding,andrelievedbyrecumbence.24Themechanism

involvesacombinationofmeningealtractionfromintracranialhypotensionaswellasdilation ofcerebral veinsandvenoussinuses.25 Spontaneous intracranial hypotension has a similar

presentation; however, its pathophysiology and diagnostic criteria differ (see Table 6-1). Conservativetreatmentwithhydrationandintravenouscaffeineoftenofferssymptomaticrelief, butinrefractorycases,bloodpatchingisrequired.

The infection rate from lumbar puncture is low (1 to2 per 10,000), the most common

organismisStreptococcustwo-thirds ofthetime.26Bleedingis asignificantcomplicationin coagulopathic and thrombocytopenic patients and can lead to paraplegia. The diagnosis is oftendelayed,withabout50% of lumbar puncture–inducedhematomas discovered after 12

hours ofparaplegia.27 Complication rates are significantlyhigher in anticoagulatedpatients whoundergolumbar puncture.28 Guidelinesforanticoagulation andlumbar punctureare the

sameasthoseofESIandotherepidural/duralpunctureprocedures.Notably,clearCSFdoes not preclude risk of hematoma formation, as up to half of patients who later develop

hematomashaveinitiallyclearCSF.

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Table6-1.

A.

1.

2.

3.

4.

5. B. C. D.

1.

2.

A.

1.

2.

3.

4.

5.

B.

1.

2.

3.

C.

D.

DegenerativeDiscDiseaseandSpinalStenosis

The cause of degenerative disc disease is multifactorial and includes lifestyle (smoking, occupation),mechanicalloading,nutrition,andgenetics(aggrecangenepolymorphism),which

all lead to degenerative changes beginning in the 20s to early 30s.29 Symptomatic lumbar diseasecontributestoanestimated60%to80%oflowbackpaincasesandismostcommonly

causedbylumbardischerniations.

Sciaticaisacommoncomplicationofdegenerativediscdisease.Thehallmarkpresentation isradiatingpaindownthebuttock,followingthecourseofthesciaticnerve.Disccompression ofthenerverootsatL4–S1canproduceunilateralsciaticasymptoms.However,compression ofthe pelvic plexus or cauda equina andlumbar stenosis canproduce bilateral symptoms. Clinically,worseningpainwithcoughing,sneezing,orValsalva is indicativeofdiscdisease

rather than otheretiologies such as spondylolisthesis or piriformis syndrome.31 Fortunately, sciaticaself-resolvesin75% ofpatientsafter3months.32The mainstay oftreatmentis with

nonopiateanalgesicstoallowforphysicaltherapy.Discsurgeryisanotheroption,butinterms ofpainordisability,thereseemstobelimitedbenefitcomparedwithconservativemeasuresat

1year.

InternalHeadacheSocietyDiagnosticCriteriaforHeadaches RelatedtoIntracranialHypotension

DiagnosticCriteriaforPostdural(Postlumbar)Puncture Headache

DiagnosticCriteriaforHeadacheAttributedto Spontaneous(orIdiopathic)LowCSFPressure

Headachethatworsenswithin15minaftersittingor standingandimproveswithin15minafterlying,withat leastoneofthefollowingandfulfillingcriteriaCandD:

neckstiffness tinnitus hyperacusis photophobia

nausea Duralpuncturehasbeenperformed Headachedevelopswithin5dafterduralpuncture Headacheresolveseither:

spontaneouslywithin1wkor

within48haftereffectivetreatmentofthespinalfluid

leak(usuallybyepiduralbloodpatch)

Diffuseand/ordullheadachethatworsens within15minaftersittingorstanding,withat leastoneofthefollowingandfulfillingcriterion D:

neckstiffness tinnitus hyperacusis photophobia nausea

Atleastoneofthefollowing:

evidenceoflowCSFpressureonMRI(e.g., pachymeningealenhancement) evidenceofCSFleakageonconventional myelography,CTmyelography,or cisternography CSFopeningpressure<60mmH2Oin

sittingposition Nohistoryofduralpunctureorothercauseof CSFfistula Headacheresolveswithin72hafterepidural bloodpatching

Spinalstenosistypicallydevelopsinthe50sto60s. Thestenosis canoccur centrallyor laterally. Aside from discogenic causes, central stenosis often develops from ligamentum flavum hypertrophy,whichcanbefromagingormechanicalinstabilityofthespine.Patients withcentralstenosisoftenpresentwithneurogenicclaudication:radiatingpaindownbothlegs

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while standingorwalking, relieved withsittingdownandbendingforward, thekyphosisof which increases the spinal canal diameter. In contrast, lateral spinal stenosis produces radiculopathies, with weakness or sensory decrease along the corresponding myotome and dermatomeanddecreasedreflexescorrespondingtothelevelsofstenosis.Asidefromdirect disc compression, foraminal stenosis from articular hypertrophy, pedicular kinking, and uncinatespurcan compress the nerve root as itenters, passes through, andexits the neural

foramen.34 Conservative treatment for lumbar spinal stenosis includes a combination of physicaltherapy,intermittentpelvictraction,oralanalgesics,andepiduralsteroids.Depending

on the degree of stenosis, 70% of patients can have symptom improvement.35 For severe stenosisorrefractorycases,decompressivesurgeriessuchaslaminectomies,foraminotomies, andspinalfusionincasesofinstability canbetried,and whensuccessful,patientscan have completeresolutionofsymptoms.

CaudaEquinaSyndrome

CESconsists oflow backpain,including radicular pain or numbness, tingling orelectrical sensationtravelingdowntheleg,aswellassensationchangeintheperinealregion,or“saddle anesthesia,”andbowelorbladderdysfunction.Inpractice,manypatientspresentwithapartial

syndrome.

3,36

Compression, whether by trauma, disc herniation, abscess, hematoma, or tumors, is the main etiology of CES. The degree and timing of compression affect clinical presentation, because patients with chronic mild compression are largely asymptomatic and show only changesinelectrodiagnosticstudies,whereasthosewithacutesignificantcompression,suchas fromahematoma,canmanifesttheentireCESsyndrome.

WhenCESis suspected,imaging confirmationisrequired. Although magnetic resonance imaging (MRI) is the study of choice, CT with myelography canbe useful for determining pathology that requires immediate surgical intervention. Intervention should be urgent, as patientshavesignificantsymptomimprovement withdecompressionwithin48hours, though

earlierisoftenpreferredinpractice.37Morethanhalfofpatientswhoundergodecompression within48hourscanhavecompleterecoveryofurinaryincontinenceversusonlyonethirdin

patients outside of 48 hours.38 Overall, surgery is very effective, with 43% of patients eventuallygainingcompleterecoveryand87%gainfunctionalrecovery.

THELUMBOSACRALPLEXUS

LumbosacralPlexusNeuroanatomy

All spinal nerves exit the intervertebral foramen and divide into anterior (ventral) and posterior (dorsal)rami.The anteriorramiofL1–S4form the lumbosacralplexus,whichhas threecomponents:(1)thelumbarplexus(L1–L4),(2)thesacralplexus (S1–S4),and(3)the lumbosacraltrunk(L4–L5)thatconnectsthelumbarandsacralplexus(Fig.6-6).

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Table6-2.

FIGURE6-6.Thelumbosacralplexusandtheirassociatedrootsandnerves(FromAgurAM,DalleyAF.Grant’s

AtlasofAnatomy.13thed.Philadelphia,PA:WoltersKluwer;2012,withpermission).

Thelumbarplexusforms onthepsoasmajormusclealongthe posteriorabdominalwall, makingitpronetocompressionfrompsoasmuscledamageorretroperitoneal(RP)hematoma. It then branches into an anterior and posterior division. The anterior division forms the obturatornerve,whichgoesintothemedialcompartmentofthethigh.Theposteriordivision forms thefemoral nerve, which innervatesthe legextensors, and, owing tomedial rotation duringdevelopment, ends up in the anterior compartment of the thigh. The lumbar plexus nerve,roots,andfunctionsaresummarizedinTable6-2.

The roots of thesacral plexus lie on the piriformis muscle and form thesciatic nerve, whichalso divides intoan anterior and posterior division.The anterior divisionforms the tibialbranchofthesciaticnerve,whichismoremedial,whiletheposteriordivisionformsthe peronealbranchofthesciaticnerve,whichismorelateral.Thesacralplexusnerve,roots,and functionsaresummarizedinTable6-3.

LumbarPlexus,Nerves,Roots,andTheirFunctions

Nerve Root Motor Sensory

Iliohypogastric T12,L1 Internalobliqueandtransversus

abdominis(supports abdominalwall)

Posterolateralglutealskin

Ilioinguinal L1 None Medialthigh,pubis,andexternal

genitalia

Genitofemoral L1,L2 Genitalbranch:cremasteric

reflex

Femoralbranch:none

Genitalbranch:externalgenitalia Femoralbranch:upperanterior

thigh-femoraltriangle

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■

Table6-3.

■

Lateralcutaneousnerveof

thethigh

L2,L3 None Anteriorandlateralthightothe

knee

Obturator(medial

compartmentofthe thigh)

L2–L4 Anteriordivision:

Adductorlongusandbrevis (adducts) Gracilis(adductship,internally rotatesandflexesknee)

Posteriordivision:

Adductormagnus(adducts) Obturatorexternus(laterally rotatesknee)

Cutaneousbranchofobturator

nerve:

Comesofftheanteriordivision afteritpiercesthefascialata. Itsuppliestheinferomedial thigh

Femoral(anterior

compartmentofthe thigh)

L2–L4 Pectineus,psoas(hipflexors)

Iliacus(hipflexor,internal rotatorthigh) Quadriceps(rectusfemoris, vastuslateralis,medialisand intermedius)—(kneeextensor) Sartorius(hipflexor,abductor, externalrotator)

Anteriorcutaneous:supplies anteromedialthigh Saphenous(terminalbranch): suppliesanterior/medialleg andfoot

SacralPlexusNerves,Roots,andTheirFunctions

Nerve Root Motor Sensory

Superiorgluteal L4–S1 Gluteusminimusandmedius

(abductthigh) Tensorfascialatae(medial rotationthigh)

None

Inferiorgluteal L5–S2 Gluteusmaximus(extendhip) None

Sciatic(posterior

compartmentofthigh)

L4–S3 Hamstringmuscles:

semitendinosus, semimembranosus,short headofbicepfemoris(extend thehipandflextheknee)

Onemuscleinmedial

compartmentofthigh:

Hamstringportionofadductor magnus(adductsthethigh)

Terminatesastibialandfibular

nerve

Nodirectinnervations,but

indirectlyinnervatesviaits terminalbranches(tibialand fibularnerve)

Posteriorfemoral

cutaneous

S1–S3 None Posteriorthigh,posteriorleg,

perineum

Pudendal S2–S4 Externalanalsphincter

Internalurethralsphincter Musclesofperineum

Clitoris,penis,skinofperineum

Nervetothepiriformis,nervetotheobturatorinternus,nervetothequadratusfemorisalsocomeoffthesacral

plexusanddirectlyinnervatethemusclesthatsharethesamenameasthenerve.

DiagnosingLumbosacralPlexopathy

Diagnosis

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Clinical features of a lumbosacral plexopathy (LSP) dependon location andthe underlying etiology.OneshouldconsiderLSPifapatient’ssymptomscannotbelocalizedtoaperipheral nerveorasinglenerveroot.Ifthelumbarplexusisdamaged,therewillbeweaknessofhip flexion,kneeextension(femoral),andhipadduction(obturator).Sensorylossandparesthesia tendtooccuroverthelateral,anterior,andmedialthigh,butmayextenddowntothemedial calf.Ifpainispresent,itismostoftenlocatedinthepelvis,withradiationtotheanteriorthigh. Lesionsofthesacralplexustendtopresentwithweaknessofhipextensors(gluteusmaximus), adductors, and internal rotators (gluteus medius and tensor fasciae latae), and hamstring muscles or distal foot muscles. Sensory symptoms are seen over the posterior thigh, and

posteriorlateralcalfandfoot.40Painmaybepresentinthepelvis.

ThefirststepindiagnosinganLSPistheexam.Thephysicianshouldassessforweakness andsensorylossinthedistributionsdiscussedabove.Lossofreflexes,ordiminishedreflexes, may indicate specific nerve root involvement (adductor [L3], patellar [L4], Achilles [S1]). One should also palpate the inguinal region tofeel for hematoma or mass, andpalpate the greatertrochanterofthehipforbursitis.Straightlegraise(L5,S1)canalsohelpdistinguishan LSPfrom a radiculopathy(acommon mimic).Maneuvering thehip canalso helpdetermine whetherthepainisrelatedinsteadtosacroiliitis.

The imaging of choice is an MRI. If abscess, neoplasm, or inflammatory changes are suspected,theMRIshouldbeorderedwithcontrast.Morerecently,MRneurographycanmore

closelyexamineattheplexusnerveroots.40Electrodiagnosticstudieshelplocalizealesionto thelumbosacralplexus,andexcluderadiculopathiesorneuropathiesthatmayclinicallymimic an LSP. Nerve conduction studies (NCS) should be performed to look for specific nerve abnormalities, andelectromyogram(EMG) oflower extremitiesandparaspinalmuscles can aid in localizing weakness or muscle denervation. Specificallyon NCS, decreased sensory nerveactionpotentialsimplythatthelesionisatordistaltothedorsalrootganglion,butnotat thelevelofthenerveroots.ImportantmusclestotestonEMGincludegluteal,thighadductor muscles, and paraspinal muscles. Testing the gluteal muscles can distinguish a sciatic neuropathy from a lower LSP. Abnormalities in the adductor muscles (obturator nerve) in additiontofemoralinnervatedmusclesindicateanupperLSP,ratherthananisolatedfemoral neuropathy. Abnormalities in the paraspinal muscles localize the lesion to the nerve root, ratherthantheplexus.AnupperlimbEMGshouldbeusedifthereisbilateralinvolvement,to helpexcludepolyneuropathy.

TheclinicianshouldconsiderhemoglobinA1c,erythrocytesedimentation rate(ESR),Creactiveprotein,infectiousstudies(Epstein–Barrvirus[EBV],varicella-zostervirus,syphilis, Lyme),andrheumatologicstudies(anti-nuclearantibody[ANA],anti-neutrophiliccytoplasmic antibody [ANCA], angiotensin converting enzyme [ACE], serum protein electrophoresis [SPEP], AntiRo/La) because thesetests help rule out thecommon causes ofneuropathy. A lumbarpuncturecanalsobeusedtolookforoccultinfectionormalignancy.

COMMONETIOLOGIESOFLUMBOSACRAL PLEXOPATHY

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SystemicEtiologies

Diabetes

Diabetic LSP (or diabetic amyotrophy) typically occurs in long-term type 2 diabetics. Persistentlyhighbloodsugar producesanischemicmicrovasculopathy.Althoughonly1%of diabeticsdevelopanLSP,thosewhodohavesignificantmorbidity.Patientspresentwithacute onsetofunilateral neuropathicpain(stabbing,burning,aching) andallodynia inthethighor leg,usuallylastingweeks.Asthepainsubsides,patientsexperienceproximalmorethandistal weakness out of proportion to the pain. Over months, the symptoms become bilateral and diffuse. Autonomic involvement is common. NCS reveal multifocal primary axonal

degeneration.41Unfortunately,manypatientshavelong-termdisabilityrequiringwheelchairsor walkers.Becauseproximalsegmentsoftheplexusreinnervateearlier,footdropis themost notablechronicsymptom.

IdiopathicPlexitis

Formostidiopathicplexitis,theunderlyingpathologyremainsunclear;inflammationisthought tobe the primary culprit. Presentation is acute-onset severe pain intheproximal pelvis or upperlegthatsubsidesoverseveralweeks,followedbyweaknessthatsubsidesovermonths. Sometimes, patients reporta preceding illnessor vaccination.In cases of progressive LSP, ESR may be elevated, indicating a systemic inflammatory response, and steroids or immunosuppressivetherapycanbeused.

Infectious,Inflammatory,andInfiltrative

Infectious, inflammatory, and infiltrative causes of LSP are very rare. They should be considered in patients with HIV; who have concomitant infections with echovirus, EBV, cytomegalovirus, Lyme;or whoare undergoing HIV seroconversion.Although patientsmost often experience radicular symptoms, LSP can also occur. Other considerations include

compressionfromanabscess,sarcoidosis,andamyloidosis.

42,43

CompressiveEtiologies

Postpartum

Postpartum LSP occurs in about 1/2,600 births, and tends to affect the lumbosacral trunk (L4/L5).Riskfactorsincludelargeinfantsize,prolongedorarrestedlabor,andmaternalshort stature.Themechanismiscompressionoftheplexusbythefetalheadasitpassesthroughthe pelvic brim, where the plexus is no longer cushioned by the psoas muscle. Because the peroneal fibers of thesciatic nerve are located posteriorly, nearest tobone, they are most vulnerabletocompression.Forthisreason,“footdrop”isthemostcommonpresentingfeature, and women are often misdiagnosed as having a compressive peroneal neuropathy (from positioningduringlabor).Subtleweaknessofkneeflexion,hipflexion,abduction,andinternal rotation may help localize the lesion to the lumbosacral plexus, rather than a peripheral

nerve.44NCSmayshowsignsofdemyelination.However,ifthereisprolongedcompression,

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leadingtosevereischemicdamage,axonallossmayoccur.Prognosisisusuallyexcellent,and recoveryisexpectedwithin2to3months;iflonger,axonallossshouldbesuspected.

Neoplastic

Neoplasms typically injure the lumbosacral plexus via direct invasion, or infiltration. ColorectalcarcinomaisthemostcommontumorleadingtoanLSP,butothercommonculprits

includepelvic tumorsandperipheral nervesheathtumors.

45,46

DistanttumorscancauseLSP

viabonemetastasesormeningealcarcinomatosis,whichisseenmorecommonlyinleukemia, lymphoma,melanoma,andlungandbreastcancer.

In neoplasm-induced LSP, theprimary symptom is severe pain(91%), characterized as achingorlancinating,whichisworsewithmovementorstanding.Weakness(typicallyinthe distributionofthesacralplexus),sensoryloss,andareflexiafollowthepain.Fiftypercentof patients have radicular signs with positive straight leg raise. Urinary incontinence is most commonlyassociatedwithepiduralextensionoftumor,butonly12%ofpatientshavelossof

sphinctertone.

Gadolinium-enhancedMRIofthepelviscanshow compressionor directinvasionofthe pelvis.If leptomeningeal spreadoftumoris considered, MRI ofthelumbarspineshouldbe ordered, and if this is negative, a lumbar puncture can help with the diagnosis. Therapy response and prognosis depend on the tumor type. Earlier diagnosis, with less neurologic involvement,predictsabettertreatmentresponse.Unfortunately,patientsareoftenresistantto

traditionalpainmanagementmethods.Radiationcangivepainreliefinupto50%ofpatients.

Dorsal rhizotomycan beconsidered for refractory pain,because itcan significantly reduce painratinganddailynarcoticuse,butadditionalresearchisneededinthisarea.

VascularEtiologies

VascularcausesofLSPincludeRPhematoma,aneurysmsorpseudoaneurysms,andischemia. Becauseofitsrichvascularsupply,ischemiaisarareetiology,butwhenitdoesoccur,itis thoughttobeatthemicrovascularlevel.Arterialpseudoaneurysmscanoccurpostoperatively

inthesettingofinfectionordefectivevascularanastomoses.

50–52

Commonlocationsinclude theabdominalaorta;internal,external,andcommoniliacarteries;superiorandinferiorgluteal arteries;andhypogastricarteries.Becausetherootsofthesacralplexuslieincloseproximity totheinternaliliacvessels,theyaremorepronetovascularcompression.

LSPfrom RPhematoma occurs mostcommonlyinthesetting of anticoagulation,butcan also occur in patients with clotting disorders, after femoral artery catheterization, or after lumbarplexusnerveblock.RPhematomasmostoftenoccurinthepsoasmuscle,andthuscause compressionofthelumbarplexus.SmallerRPhematomasoftenaffectthefemoralnervealone, whereaslargeronesinvolvemoreofthelumbarplexus.

Commonsymptomsincludetendernessorfullnessintheinguinalorsuprainguinalregion, severebackpain,lowerquadrantpain,andweaknessofhipflexionandkneeextension,with reduced or absent patellar reflex. Neurologic recovery is generally complete, or near

complete.53 For anticoagulated patients, coagulopathy should be immediately reversed, and

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physiciansshould be vigilant-intreating hypovolemic shock. Instable patients,conservative managementwithbloodtransfusionsandbedrestisappropriate.

IatrogenicEtiologies

RadiationPlexopathy

Radiation-induced LSP rarely occurs with conventional radiation methods and dosing. It occursmorefrequentlywithhigher dosing usedinintracavitaryradiation,and some reports show increased risk with radiationdoses exceeding60Gy. Doses above 10 Gy have been showntocausechangesinSchwanncells,endoneuralfibroblasts,perineuralcells,andcellsof

smallvesselwalls.

Symptomsofradiationplexopathyinjurytypicallyoccur1yearaftertreatment,withapeak onset at 5 years. Unlike malignant LSP, radiation-induced LSP is typically painless, and presentswithbilaterallegweakness,sometimes accompaniedbysensoryloss. EMGcanbe very useful in diagnostically challenging patients, as about half of patients with radiation plexopathydemonstratemyokymia.

Therearenoeffectivetherapiesforradiationplexopathy.Althoughsomephysiciansassert benefit from hyperbaric oxygen, at least one randomized, double-blinded trial has shown

otherwise.55 Dysesthesias can be treated with neuropathic pain medications such as amitriptyline, venlafaxine, or gabapentin. Physical therapy is sometimes helpful in patients withweakness.

TraumaticEtiologies

IndirectTrauma

Sincethelumbosacralplexusisprotectedbyboneandmultiplemusclelayers,directtraumais uncommon. However, sacral, pelvic, or acetabular fractures, or sacroiliac dislocation, can causeindirecttraumatothelumbosacralplexus.Thesacralplexusismorecommonlydamaged thanthelumbarplexus,anditismorepronetoinjurywithsacralfracturesorsacroiliacjoint

dislocation,whencomparedwithpelvicoracetabularfractures.56Inmostcases,diagnosisis explainedbythemechanismofinjury,andasuggestiveexam.However,EMGcanbeusedto helpconfirmthediagnosis.

Postoperative

The lumbosacral plexus can be damaged mechanically during operationsoftheneighboring kidneys and internal genital organs. Ischemia to theLSP has been showntooccur in renal transplant patients if the internal iliac artery is used for allograft revascularization. Postoperative abscess or hematoma formation in the psoas muscle, or elsewhere in the retroperitoneum, can cause LSP through mass effect. Some investigators propose that postoperativeLSPmayberelatedtoinflammatorymechanisms,basedonnervebiopsyfindings that indicate ischemic injury and microvasculitis. When this is the case, treatment with

immunomodulatorytherapymayhelpimproveoutcomes.

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Соседние файлы в папке Библиотека им академика М.И. Перельмана

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02.09.202620 Мб0Книга_2812_Библиотеки_им_академика_М_И_Перельмана.epub
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02.09.202619 Мб0Книга_2815_Библиотеки_им_академика_М_И_Перельмана.pdf
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02.09.202619 Мб0Книга_2816_Библиотеки_им_академика_М_И_Перельмана.pdf
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02.09.202619 Мб0Книга_2817_Библиотеки_им_академика_М_И_Перельмана.pdf
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02.09.202619 Мб0Книга_2818_Библиотеки_им_академика_М_И_Перельмана.pdf
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05.09.202619 Мб1Книга_2821_Библиотеки_им_академика_М_И_Перельмана.pdf
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05.09.202618 Мб0Книга_2822_Библиотеки_им_академика_М_И_Перельмана.pdf
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05.09.202618 Мб0Книга_2823_Библиотеки_им_академика_М_И_Перельмана.pdf
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05.09.202618 Мб0Книга_2824_Библиотеки_им_академика_М_И_Перельмана.pdf
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31.08.202626 Мб0Книга_29_библиотеки_им_акад_М_И_Перельмана.pdf
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31.08.202625 Мб0Книга_30_библиотеки_им_акад_М_И_Перельмана.pdf