The scratch collapse test in the diagnosis of compression of the median nerve in the proximal forearm

Our purpose was to review the clinical usefulness of the scratch collapse test (SCT) in the diagnosis of proximal entrapment of the median nerve in the forearm. Eighteen consecutive cases were reviewed. The diagnosis was based on the patient's symptoms and signs. The SCT was positive in the affected forearm in all clinical assessments before surgery and it was negative in all after median nerve release. An anatomical reason for nerve compression was identified in all cases at operation. The SCT is a useful tool for the diagnosis of the proximal entrapment of the median nerve.

LEVEL OF EVIDENCE

IV.

Combined Perihamate Peripisiform and Peritrapezium Open Axial Carpal Dislocation: Description of a New Pattern of Crush Injury

BACKGROUND

Axial carpal dislocations and fracture-dislocations remain difficult to understand and to treat. The outcome is directly related to the injury pattern and long-term results are not good in most cases.

METHODS

39-year-old male admitted to our emergency department after his left hand was caught between 2 rollers for 10 minutes. He was diagnosed of an open axial carpal dislocation type B (perihamate peripisiform) and type E (peritrapezium) of Garcia-Elias. An extensive debridement, reduction of the carpometacarpal dislocations and stabilization with Kirschner wires was performed requiring a full thickness skin graft 14 days after the trauma.

RESULTS

At 4-year follow-up, he had 70° of wrist extension, and 78° of wrist flexion, grip strength of 65% compared to the healthy side and x-ray showed mild signs of osteoarthritis. He was satisfied and returned to the same job.

CONCLUSIONS

Axial carpal dislocations continue to be difficult injuries to address but also to classify. Since the prognosis depends on the injury pattern and other associated lesions, we believe that adding a type G which include the association of different patterns to the classification of Garcia-Elias could be useful not in changing the treatment but probably indicating a worse prognosis.

The Zitelli Bilobed Flap on Skin Coverage After Mucous Cyst Excision: A Retrospective Cohort of 33 Cases

PURPOSE

To study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cysts using the Zitelli modified bilobed flap.

METHODS

We surgically treated 33 patients from January 2006 to June 2015. We assessed demographic data, comorbidities, location and size of the cyst, time to wound healing, and complications.

RESULTS

The most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. The mucous cyst recurred in 1 of 33 cases. There were no major complications.

CONCLUSIONS

The Zitelli bilobed flap can provide good-quality skin coverage over the distal interphalangeal joint in a short period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Biceps to Triceps Transfer in Tetraplegic Patients: Our Experience and Review of the Literature

Background: Management and indications for surgery in the tetraplegic patient are highly complex because of the substantial functional deficits that they present and their effect on their daily activity. Our purpose was to evaluate the functional outcome in tetraplegic patients who underwent biceps-to-triceps transfer surgery according to Zancolli's modified technique. Methods: This is a retrospective study of 6 biceps-to-triceps transfers using Zancolli's modified technique in 4 patients. Mean follow-up was 45 months. We evaluated each patient's DASH (Disabilities of the Arm, Shoulder and Hand) score before surgery and 12 months later. Results: In the 6 arms that underwent surgery, full and active elbow extension against gravity at 12 months after surgery was achieved. The mean DASH score was 73.2 preoperatively and 20.8 twelve months postoperatively. One complication occurred. One patient reported loss of elbow flexion preventing thigh lift for transfers. This was resolved with a program of rehabilitation and specific muscle strengthening Conclusions: Zancolli's modified technique is simple and effective, with few complications, whereby we can provide more autonomy for the tetraplegic patient.

Hypothenar hammer syndrome. A case report

Hypothenar hammer syndrome is an uncommon injury of the ulnar artery in its passage through Guyon's canal, and has been associated with repetitive trauma. Its diagnosis requires of a high level of suspicion and a careful clinical interview. The appropriate treatment is not well defined in the literature, ranging widely from medical treatment to reconstructive surgery. A clinical case is presented of a 52 year-old healthy male, who presented with numbness of his fourth and fifth fingers after a trauma at the hypothenar eminence. The Allen test highlighted an absence of vascularisation from the ulnar artery, thus suspecting an ulnar artery thrombosis, which was later confirmed by angio-MRI. The thrombosed segment was resected and a by-pass with a forearm vein was performed to reconstruct the distal arterial flow, presenting with a good functional outcome at 6months follow-up.

[Bristow-Latarjet Technique for anterior glenohumeral instability]

BACKGROUND

In treatment of anterior shoulder instability, many surgical techniques have been described, all of them with advantages and disadvantages. Our goal is to study the half term results on patients that underwent open Bristow-Latarjet surgery considering the preoperative ISIS value.

MATERIAL AND METHODS

This is a retrospective study of 33 patients which underwent open Bristow-Latarjet surgery in our center between 2005 and 2012. Average age of 33.2 years and follow up of 75 months. Results were taken by Rowe and Constant scores, DASH questionnaire and we also recorded a subjective assessment of the result by each patient.

RESULTS

No recurrence was reported. No reoperations. Mean Rowe score was 74.6 points and mean Constant score was 70 points. In the disability questionnaire (DASH), the mean value was 22.9 points. The outcome assessment by the patients was positive in 78.8%. The migration of a screw occurred in one patient but he still asymptomatic. No other complication was identified.

CONCLUSIONS

The Bristow-Latarjet technique is a reliable technique, with few complications and with an excellent rate of recurrence in treatment of chronic shoulder instability as reported in literature; it should be used as primary surgery in some cases and the preoperative ISIS score is an excellent and simple guide to select correctly the surgical technique for each patient.

[Anaesthetic management of excision of a cervical intraspinal tumor with intraoperative neurophysiologic monitoring in a pregnant woman at 29 weeks]

The intraoperative neurophysiological monitoring is a technique used to test and monitor nervous function. This technique has become essential in some neurosurgery interventions, since it avoids neurological injuries during surgery and reduces morbidity. The experience of intraoperative neurophysiological monitoring is limited in some clinical cases due to the low incidence of pregnant women undergoing a surgical procedure. A case is presented of a 29-weeks pregnant woman suffering from a cervical intraspinal tumour with intense pain, which required surgery. The collaboration of a multidisciplinary team composed of anaesthesiologists, neurosurgeons, neurophysiologists and obstetricians, the continuous monitoring of the foetus, the intraoperative neurophysiological monitoring, and maintaining the neurophysiological and utero-placental variables were crucial for the proper development of the surgery. According to our experience and the limited publications in the literature, no damaging effects of this technique were detected at maternal-foetal level. On the contrary, it brings important benefits during the surgery and for the final result.

[Four surgical tips in the treatment of epicondylitis]

INTRODUCTION AND OBJECTIVES

Lateral epicondylitis is a common injury in the population. Most patients improve with conservative treatment, but in a small percentage surgery is necessary. The aim of this study is to analyse the clinical results obtained by a «4 surgical tips» technique.

MATERIALS AND METHOD

This is a retrospective study of 35 operated elbows, with a mean follow-up of 5.3 years. In all cases epicondylar denervation, removal of the angiofibroblastic degeneration core, epicondylectomy, and release of posterior interosseous nerve, was performed. Each patient was evaluated using the Broberg and Morrey Rating System (BMRS), Mayo Elbow Performance Score (MEPS), Visual Analogue Scale (VAS), DASH questionnaire, and a survey of subjective assessment.

RESULTS

BMRS mean score was 97.2 points, with 95.71 points with the MEPS. The mean decrease in VAS was 8.12 points, and the mean score on the DASH was 1.68 points. The results were rated as excellent or very good by 94.3% of patients. There was one recurrence, which resolved with further surgery. Two neuropraxia of the posterior interosseous nerve occurred, which completely recovered in 10 weeks.

CONCLUSIONS

Using the «4 surgical tips» technique, clinical resolution of symptoms in 97.1% was achieved at the first operation. Therefore, it appears to be an effective, reproducible technique with few complications, in the surgical treatment of lateral epicondylitis resistant to conservative treatment.

[Perioperative considerations for performing a brain biopsy on a patient with subtype VV2 sporadic Creutzfeldt-Jakob disease]

Creutzfeldt-Jakob disease (CJD) is the most common transmissible spongiform encephalopathy. It is an infectious, progressive, degenerative neurological disorder, with a presumably long incubation period, but a rapid fatal course. CJD is transmitted by a proteinaceous infectious agent, or «prion». Because the prions are difficult to eradicate and are resistant to the currently used sterilization methods, special precautions must be taken with all surgical instruments. It is recommended the single-use equipment, destruction of contaminated equipment, decontamination of reusable instruments, use of protective clothing, and storing and quarantining surgical instruments. The single-use equipment and some tissues and body fluids from the patient with CJD are highly infectious and must be incinerated. We report a case of a patient who had undergone brain biopsy for suspected of CJD, being confirmed to have sporadic CJD. Specific preventive measures were taken to reduce the risk of transmission to healthcare workers.

Differential presynaptic control of the synaptic effectiveness of cutaneous afferents evidenced by effects produced by acute nerve section

In the anaesthetized cat, the acute section of the saphenous (Saph) and/or the superficial peroneal (SP) nerves was found to produce a long-lasting increase of the field potentials generated in the dorsal horn by stimulation of the medial branch of the sural (mSU) nerve. This facilitation was associated with changes in the level of the tonic primary afferent depolarization (PAD) of the mSU intraspinal terminals. The mSU afferent fibres projecting into Rexed's laminae III-IV were subjected to a tonic PAD that was reduced by the acute section of the SP and/or the Saph nerves. The mSU afferents projecting deeper into the dorsal horn (Rexed's laminae V-VI) were instead subjected to a tonic PAD that was increased after Saph and SP acute nerve section. A differential control of the synaptic effectiveness of the low-threshold cutaneous afferents according to their sites of termination within the dorsal horn is envisaged as a mechanism that allows selective processing of sensory information in response to tactile and nociceptive stimulation or during the execution of different motor tasks.

Hyperhidrosis related to nevirapine therapy

A 70-year-old white man presented to the internal medicine outpatient clinic with symptoms of significant hyperhidrosis. He had been started on antiretroviral therapy (ART) with tenofovir, lamivudine and nevirapine. The patient complained of excessive sweating following severe asthenia after taking nevirapine. Based on these findings, we suspected that the causative agent was nevirapine and a diagnosis of hyperhidrosis due to nevirapine was made. Nevirapine treatment was stopped and was substituted with efavirenz: the patient continued on therapy with tenofovir and lamivudine. The hyperhidrosis symptoms resolved in 2-3 days. No relapse was observed with the new ART regimen. Drugs that induce hyperhidrosis can cause patient discomfort and embarrassment. In our patient, this adverse drug reaction also caused severe asthenia that decreased the patient's physical and emotional quality of life. There was a temporal relationship between the developments of symptoms and starting nevirapine therapy. Once nevirapine was suspended and switched to efavirenz, excessive sweating resolved. An objective causality assessment revealed that the adverse effect was probable. Until further data are available, clinicians should consider discontinuation of nevirapine therapy in patients who develop severe hyperhidrosis.

Changes in correlation between spontaneous activity of dorsal horn neurones lead to differential recruitment of inhibitory pathways in the cat spinal cord

Simultaneous recordings of cord dorsum potentials along the lumbo-sacral spinal cord of the anaesthetized cat revealed the occurrence of spontaneous synchronous negative (n) and negative-positive (np) cord dorsum potentials (CDPs). The npCDPs, unlike the nCDPs, appeared preferentially associated with spontaneous negative dorsal root potentials (DRPs) resulting from primary afferent depolarization. Spontaneous npCDPs recorded in preparations with intact neuroaxis or after spinalization often showed a higher correlation than the nCDPs recorded from the same pair of segments. The acute section of the sural and superficial peroneal nerves further increased the correlation between paired sets of npCDPs and reduced the correlation between the nCDPs recorded from the same pair of segments. It is concluded that the spontaneous nCDPs and npCDPs are produced by the activation of interconnected sets of dorsal horn neurones located in Rexed's laminae III–IV and bilaterally distributed along the lumbo-sacral spinal cord. Under conditions of low synchronization in the activity of this network of neurones there would be a preferential activation of the intermediate nucleus interneurones mediating Ib non-reciprocal postsynaptic inhibition. Increased synchronization in the spontaneous activity of this ensemble of dorsal horn neurones would recruit the interneurones mediating primary afferent depolarization and presynaptic inhibition and, at the same time, reduce the activation of pathways mediating Ib postsynaptic inhibition. Central control of the synchronization in the spontaneous activity of dorsal horn neurones and its modulation by cutaneous inputs is envisaged as an effective mechanism for the selection of alternative inhibitory pathways during the execution of specific motor or sensory tasks.

[Puerperal pathology]

The puerperium is the period from the end of labour to the appearance of the first menstruation. The possible pathologies that can occur in this period of time are the most frequent cause of maternal mortality even in our setting. The pathology of lactation includes failure of breastfeeding, cracks in the nipple, mammary ingurgitation and puerperal mastitis. Puerperal infection is a frequent obstetric complication although clinical guidelines for prophylaxis have considerably reduced its incidence. The vascular pathology of the puerperium includes clinical features of great seriousness, representing one of the main causes of maternal mortality. These include deep vein thrombosis, of which pulmonary thromboembolism is the most serious complication. It does not appear that a psychiatric pathology is more frequent in the puerperium than in other periods of life, but the clinical features related to this period are described, such as "blues", puerperal depression and puerperal psychosis. Finally, other clinical features which although infrequent can constitute a medical emergency in the puerperium are: Sheehan's syndrome, peripartum cardiomyopathy and postpartum thyroids.

High serum levels of leptin are associated with post-stroke depression

BACKGROUND

Depression is a frequent mood disorder that affects around 33% of stroke patients and has been associated with both poorer outcome and increased mortality. Our aim was to test the possible association between inflammatory and neurotrophic molecular markers and the development of post-stroke depression.

METHOD

We studied 134 patients with a first episode of ischemic stroke without previous history of depression or speech disorders. We screened for the existence of major depression symptoms in accordance with DSM-IV criteria and a Yesavage Geriatric Depression Scale (GDS) score >11 at discharge and 1 month after stroke. At these times, serum levels of molecular markers of inflammation [interleukin (IL)-1beta, IL-6, intracellular adhesion molecule 1 (ICAM-1), tumor necrosis factor (TNF)-alpha, leptin and high-sensitivity C-reactive protein (hs-CRP)] and neurotrophic factors [brain-derived neurotrophic factor (BDNF)] were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Twenty-five patients (18.7%) were diagnosed as having major depression at discharge. Out of 104 patients who completed the follow-up period, 23 were depressed at 1 month (22.1%). Patients with major depression showed higher serum leptin levels at discharge [43.4 (23.4-60.2) v. 6.4 (3.7-16.8) ng/ml, p<0.001] and at 1 month after stroke [46.2 (34.0-117.7) v. 6.4 (3.4-12.2) ng/ml, p<0.001). Serum levels of leptin >20.7 ng/ml were independently associated with post-stroke depression [odds ratio (OR) 16.4, 95% confidence interval (CI) 5.2-51.5, p<0.0001]. Leptin levels were even higher in the eight patients who developed depression after discharge [114.6 (87.6-120.2) v. 7.2 (3.6-13.6) ng/ml, p<0.0001].

CONCLUSIONS

Serum leptin levels at discharge are found to be associated with post-stroke depression and may predict its development during the next month.