[Clinical thinking and decision-making in practice. A nurse with low back pain radiating to both legs]

A 50-year-old nurse with chronic back pain developed painful paraesthesia in the legs and saddle region during walking. Because pain in the legs could not be provoked by standing erect, the orthotic-lordotic cauda syndrome or neurogenic intermittent claudication (spinal canal stenosis) became unlikely and vascular intermittent claudication likely. The femoral pulses were absent. Angiography showed severe stenosis of the distal aorta which was successfully treated by percutaneous transluminal angioplasty.

[Painful paresthesia after removal of the sural nerve for autologous nerve transplantation]

The sural nerve is the most common nerve serving as a donor in an autologeous nerve grafting procedure. However, there is a certain risk for the development of painful paraesthesias at the donor site. Patients in whom a short segment of the sural nerve was resected are suspected to have a greater risk. In a retrospective study we investigated the incidence of painful paraesthesias following removal of a segment of the sural nerve for a grafting procedure. The study includes 41 patients, who were followed at least for one year after surgery (mean 30 months). 9 patients (22%) complained of persisting painful paraesthesias at the donor site suggesting a neuroma at the proximal stump of the sural nerve. The comparison of the length of the nerve segment harvested for grafting shows a tendency for patients with shorter segments having a greater risk to develop painful paraesthesias. However, the difference between the two groups was statistically not significant.

Sympathetically mediated pain after reduction mammoplasty: an unusual complication

We present a case report of a patient who developed an unusual bilateral breast pain syndrome after a reduction mammoplasty. Her symptoms and physical examination findings resolved after four stellate ganglion blocks, of which two on each side were performed over a period of 2 weeks. The case serves to alert clinicians to the possibility of a patient developing a sympathetically mediated pain syndrome after reduction mammoplasty.

Catamenial mononeuropathy and radiculopathy: a treatable neuropathic disorder

OBJECT

The aim of this study was to investigate the indications and treatment options in patients with lower-extremity neuropathies and radiculopathies caused by endometriosis.

METHODS

The authors identified five patients whose symptoms included catamenial pain, weakness, and sensory loss involving the sciatic and femoral nerves and multiple lumbosacral nerve roots. Radiographic studies supported the diagnosis of catamenial neuropathy or radiculopathy, but definitive diagnosis depended on surgical and pathological examination. Treatment of symptoms, including physical therapy and a course of antiinflammatory or analgesic medication, was not helpful. Patients responded favorably to hormonal therapy. Laparoscopy or open exploration for extrapelvic lesions was performed for diagnosis or for treatment when hormone therapy failed. Pain and sensory symptoms responded well to therapy. Weakness improved, but never recovered completely.

CONCLUSIONS

Catamenial neuropathy or radiculopathy should be considered when evaluating reproductive-age women with recurring focal neuropathic leg pain, weakness, and sensory loss.

Radial artery use in bypass grafting does not change digital blood flow or hand function

BACKGROUND

Patient selection criteria have not been clearly established for use of the radial artery as a bypass conduit. To help establish such criteria, we measured changes in digital blood flow and hand function after radial artery removal.

METHODS

Ninety-eight patients of the first 122 consecutive patients considered for radial artery harvest met predetermined criteria by vascular noninvasive studies to undergo removal of the radial artery. In 42 of these 98 patients, the radial artery was actually used as a bypass conduit; 28 of these 42 patients returned for noninvasive vascular studies, a critical review of hand function, and a hand symptom questionnaire.

RESULTS

There were no significant differences between the operated and nonoperated hands for digital-brachial indices, cold response, grip or pinch strength, digital two-point discrimination, or nine-hole peg tests. The patients had an increased incidence of a small amount of forearm numbness and tingling, but no increase of pain or cold intolerance.

CONCLUSIONS

For properly selected patients, there are minimal changes in hand function after radial artery removal.

Endoscopic treatment of carpal tunnel syndrome: a critical review

OBJECT

The goal of this paper is to present a critical review of the endoscopic procedures currently in use for the treatment of carpal tunnel syndrome. Endoscopic techniques and outcomes are discussed.

METHODS

An extensive review of published articles on the subject of endoscopic carpal tunnel release surgery is presented, encompassing six endoscopic techniques used to treat carpal tunnel syndrome. Since the first report in 1987, 7091 patients have undergone 8068 operations. The overall success rate has been 96.52%, with a complication rate of 2.67% and a failure rate of 2.61%. The mean time to return to work in patients not receiving Workers' Compensation was 17.8 days, ranging between 10.8 and 22.3 days. The most common complications were transient paresthesias of the ulnar and median nerves. Other complications included superficial palmar arch injuries, reflex sympathetic dystrophy, flexor tendon lacerations, and incomplete transverse carpal ligament division. In many studies in which open and endoscopic techniques were compared, it was reported that patients in the the latter group experienced significantly less pain and returned to work and activities of daily living earlier.

CONCLUSIONS

Success and complication rates of endoscopic carpal tunnel release surgery are similar to those for standard open procedures.

The management of thermomechanically compacted gutta percha extrusion in the inferior dental canal

Endodontic material inadvertently forced into the inferior dental canal during root-canal therapy can cause damage to the underlying nerve. The effect of toxic filling materials on nervous tissues has been well publicised, however, the thermal and pressure changes produced by chemically bland materials has not been adequately highlighted. In the case reported, thermoplasticised gutta percha was inadvertently introduced into the canal during endodontic treatment of a lower molar. Factors affecting the outcome are discussed and guidelines are presented for the management of such a case with reference to surgery against observation.

Transforaminal nerve root sleeve injection with corticosteroids, hyaluronidase, and local anesthetic in the failed back surgery syndrome

Millions of patients with chronic sciatica are still treated with epidural corticosteroids. The efficacy of epidural corticosteroids remains questionable, especially in the chronic failed back surgery syndrome (CFBSS). The affected nerve root sleeve(s) are localized with the help of fluoroscopy and contrast dye. Local anesthetic diluted in 1,500 U hyaluronidase and 40 mg methylprednisolone is injected. Twenty patients with CFBSS, a small retrospective pilot study group, were treated. The success rate is evaluated using a verbal pain rating scale, 1 month and 3 months after the last injection. Initially, 12 patients obtained very good pain relief, sustained for >3 months in 11 patients. In one patient, pain returned after >1 month. No complications were observed. This technique is worthwhile for patients with CFBSS and where epidural fibrosis is suspected to be the pain origin.

Dysaesthetic neck pain with syncope

Neurogenic dysaesthetic pain in the neck following surgery for tumours in the neck is rare. Rarer still is the combination of pain following surgery with syncope. We looked at four patients who had tumours within the neck excised and then went on to develop neurogenic dysaesthetic neck pain associated with syncope. Distinction is made between neurogenic dysaesthetic pain following neck surgery and glossopharyngeal neuralgia which has been previously reported in association with neck surgery and also glossopharyngeal neuralgia with syncope. Spinal cord stimulation was used successfully to treat the dysaesthetic pain and syncope in three of the patients while the fourth patient died from the effects of his tumour. Medical practitioners may wish to consider spinal cord stimulation in relation to treating neurogenic dysaesthetic neck pain with syncope.

Is short-term neurosensory testing after removal of mandibular third molars efficacious?

OBJECTIVE

The purpose of this study was the validation of two-point discrimination, Semmes-Weinstein, and pinprick tests of possible sensory disturbance of the inferior alveolar nerve after the surgical removal of lower wisdom teeth.

STUDY DESIGN

Forty-two patients who had undergone elective unilateral lower wisdom tooth removal and 30 control subjects were given two-point discrimination, Semmes-Weinstein, and pinprick tests bilaterally in the dermatome of the mental nerve. Test results were compared to the patients subjective experiences of sensory disturbance. Statistical analysis was done with multivariate analysis of variance.

RESULTS

Untreated sides in patients and test sides in control subjects agreed well for all tests. Five of the 42 patients mentioned sensory disturbance, which was confirmed objectively in 3 (by pinprick and two-point discrimination tests). Testing revealed that 16 of the 42 patients had abnormal pinprick and two-point discrimination tests without subjective sensory disturbance. No abnormal values were found for Semmes-Weinstein tests in any of the patients. Multivariate analysis of variance identified a univariately significant effect of the two-point discrimination test (p = 0.027); all other interactions were multivariately insignificant.

CONCLUSION

The value of neurosensory testing after third molar removal is limited because of inconsistency between objective test results and subjective findings.

A human clinical and histologic report of an osseointegrated titanium alloy root form implant

Endosteal implants fail for a variety of reasons. These include failure to osseointegrate, long-term loss of osseointegration, and invasion of a vital structure or anatomic placement that prohibits its use. This case report describes the removal of an implant because of patient discomfort secondary to invasion of the mandibular canal. These histologic findings offered a unique opportunity to examine an osseointegrated human dental implant section.

Resection of the radial head after Mason type-III fractures of the elbow: follow-up at 16 to 30 years

We reviewed 21 patients with Mason type-III fractures of the radial head treated by resection, evaluating the results at 16 to 30 years by a standard questionnaire and clinical and radiological examination of the elbow and wrist. Seventeen patients had an excellent result, three were good and one fair. Resection of the radial head is a satisfactory method of treatment of such fractures. Prosthetic replacement seems to be indicated only when there is valgus instability of the elbow.

[Simple tibiotalar luxation. Apropos of 16 cases]

Tibiotalar dislocations without fracture are extremely rare lesions. This series included 16 patients, 12 of whom have been examined clinically and radiographically. The purpose of this study was to specify the injury mechanism of the various anatomical types and to assess the long term outcome. The group included eight posteromedial dislocations (50%), four posterior dislocations (25%), one anterior dislocation, one high variety, one of the Huguier type, and one complex dislocation. The sex ratio was 14 males/2 females with an average age of 37 years. In half of the cases, dislocations were open. The average follow-up period was 11 years (range, 1 to 26 years). The eight closed dislocations and the open case type I according to the Cauchoix classification received non-operative treatment by reduction in the emergency room and immobilization in a plaster cast for 6 weeks. The seven patients who presented open dislocations Cauchoix type 2 and type 3 were treated by surgical debridement and ligament repair, followed in all cases by a plaster cast boot, and in two cases by temporary transplantar pinning. Twelve patients were reexamined clinically according to the Gay and Evrard modified score, and were radiographically evaluated with lateral and anteroposterior views focused on the tibiotalar joint, on both sides, static and dynamic. Anatomical factors resulting in predisposition such as medial malleolus shortness or lack of coverage of the talus have been evaluated. No patient presented tibiotalar joint instability. A 5 degrees to 10 degrees loss in the range of dorsiflexion was frequently observed. Two patients presented joint stiffness. In four cases, patients complained about paresthesias in the areas of the anterior tibial nerve or intermediary dorsal cutaneous nerve. Four cases of degenerative arthritis were radiographically observed, two of which presented an overall narrowing of the joint over 50%. Degenerative arthritis had occurred within the first four years in these 4 cases. The talus coverage index was similar to the standard population. Shortness of the medial malleolus was present in only two cases. The long-term prognosis after tibiotalar dislocation without fracture proves to be good. One should favor orthopedic treatment. The absence of tibiotalar instability argues against carrying out emergency ligamentous repair. Evolution towards degenerative arthritis is to be anticipated in 25% of cases, especially following open dislocations, or if transplantar pinning was required due to instability of the initial reduction.

[Sensorimotor polyneuropathy and systemic amyloidosis as paraneoplastic symptoms of a carcinoid-like well differentiated carcinoma of the breast]

HISTORY AND ADMISSION FINDINGS

A 75-year-old woman was admitted because of weakness and paraesthesias in both legs. 15 years earlier a chest radiogram had shown numerous round foci of uncertain cause. Physical examination confirmed muscular weakness in all limbs, especially the legs, as well as abnormal superficial and deep sensory perception.

INVESTIGATIONS

Electromyography registered a patchy pattern of intentional muscular activity and marked denervation activity but largely normal nerve conduction. There was no evidence of inflammatory disease in the laboratory tests, including the CNS. DIAGNOSIS, COURSE AND TREATMENT: The neurological findings indicated progressive axonal sensorimotor polyneuropathy. A paraneoplastic cause was suspected, but search for a primary tumour was unsuccessful. The patient developed a urinary infection from which she died in septic shock. A carcinoid-like well-differentiated carcinoma of the breast with hematogenous metastases to liver, spleen and lung was discovered at autopsy. It also revealed severe systemic AA-type amyloidosis, involving liver, spleen heart and kidneys. In addition there was a severe progressive axonal neuropathy and marked neurogenic atrophy of the peripheral skeletal musculature. No amyloid deposition was seen.

CONCLUSION

In case of amyloidosis and polyneuropathy of uncertain cause a paraneoplastic pathogenesis should be considered in the differential diagnosis, even in the absence of proven malignancy.

Schwannomatosis: a clinical entity distinct from neurofibromatosis type 2

BACKGROUND

Schwannomatosis includes multiple cutaneous schwannomas, central nervous system tumors and various neurologic deficits.

OBJECTIVE

To specify the clinical presentation of schwannomatosis, excluding neurofibromatosis type 2 (NF2).

METHODS

Patients with at least 2 cutaneous schwannomas were evaluated for NF2 criteria.

RESULTS

5 men and 2 women (mean age 54 +/- 18 years) we included. Two cases were familial. Cutaneous schwannomas were tender nodules with onset above the age of 30 years. Four patients had paresthesias. Four patients had hypacusis, but auditory brainstem responses showed no retrocochlear involvement. No vestibular schwannoma or central nervous system tumor was found with magnetic resonance imaging in 6 patients. Spinal imaging performed in 6 patients was normal in 5 and showed a spinal schwannoma in the 6th patient.

CONCLUSION

We strictly eliminated the diagnosis of NF2 in our patients. Exclusion of NF2 in suspected schwannomatosis is essential for further molecular genetic studies.