Diabetic thoracic polyradiculopathy presenting as abdominal swelling

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Surgical treatment of the 'slipping rib syndrome'

This review seeks to draw attention to the existence of the 'slipping rib syndrome' as a not uncommon clinical entity. It is characterized by trunk pain in a radicular distribution, often related to certain movements or activity, but not associated with other visceral symptoms. The diagnosis is a clinical one, with surgical excision of the affected rib and costal cartilage a successful simple treatment for relieving those patients of a severe and persistent pain syndrome.

Intercostal nerve block by jet injection

A jet injector was used to perform intercostal nerve block as a method of intra-operative and postoperative pain relief at cholecystectomy, using a concentrated solution of local analgesic. This method was shown to be as successful as the conventional needle technique. The risk of pneumothorax, and the problems of the local analgesic solution used are discussed.

Respiratory failure following intercostal nerve blockade

A case of respiratory failure following postoperative intercostal nerve blockade is described. A possible mechanism is postulated and the evidence in favour of intercostal blockade in patients with chronic airways disease is questioned. The need for caution when managing such patients with regional blockade is emphasised.

Current status of thoracic dorsal sympathectomy

This article summarizes over 20 years of experience (1962 to 1982) with cervical sympathectomy (thoracic dorsal sympathectomy) in 46 patients undergoing 68 sympathectomies. All operations were performed through an anterior supraclavicular approach. Indications for surgery were intractable Raynaud's disease (26 patients), atherosclerotic obliterative arterial disease (five), causalgia (five), posttraumatic sympathetic dystrophy (seven), collagen vascular disorders (eight), hyperhidrosis (12), occupational-related digital thrombosis (four), and thrombosis secondary to intra-arterial injection (one). The incidence of complications and side effects, both temporary and permanent, including Horner's syndrome, is reviewed in detail. Particular reference is made to the various surgical techniques of managing the stellate ganglion; four patients had two-third to three-fourth resection of the stellate ganglion down to and including the T-3 thoracic ganglion, two had preservation of the stellate ganglion and resection of the T-2 through T-4 ganglia, seven had excision of the entire stellate ganglion down to and including the T-4 ganglion, seven had resection of the lower third of the stellate ganglion down to and including the T-4 ganglion, and 48 had removal of the lower half of the stellate ganglion down to and including the T-3 ganglion. The study reviews the literature germane to anatomic considerations and suggests revisions in current texts and atlases. By retrospective analysis of the records and a follow-up questionnaire, which provided an 86% follow-up (average 8.4 years), the paper points to the distinctive clinical characteristics of the different groups within the population undergoing the operation and provides guidelines for patient selection and conclusions on the place for this operation in the management of vascular diseases involving the upper extremity.

Continuous intercostal nerve blockade for pain relief following cholecystectomy

Continuous intercostal nerve blockade was used to provide analgesia after cholecystectomy. The blockade was maintained by the insertion of a single extradural catheter into an appropriate intercostal space and by "topping-up" with local anaesthetic on demand. Of the patients studied, 92%, and 76%, required no additional analgesia in the first 24 h and first 48 h following operation, respectively. Measurements of peak flow were obtained on the 1st day after operation. A mean improvement of 37% on pre- "top-up" peak flows, was found. It is suggested that continuous intercostal analgesia is a a safe, reliable and powerful form of analgesia which may improve respiratory function after cholecystectomy.

Congenital primitive neuroectodermal tumor (neuroepithelioma) of the chest wall

Primitive neuroectodermal tumor (neuroepithelioma) is a relatively common central nervous system tumor in children. Those arising from a peripheral nerve are extremely rare in childhood. There is only one reported case in 6-year-old where the tumor arose from the sciatic nerve. A case of neuroectodermal tumor of the chest wall, arising from the intercostal nerve, in a newborn is presented. The tumor metastasized to the brain. Prominent Homer-Wright rosettes, with central eosinophilic fibrillar substance similar to that seen in neuroepithelioma of the central nervous system, were present in the primary tumor and brain metastases. Ultrastructure, as revealed by transmission electron microscopy, is also described.

Treatment of trigeminal and thoracic zoster with idoxuridine

A double-blind random selection comparison was made of the therapeutic effects in acute herpes zoster of 40% idoxuridine (IDU) dissolved in dimethyl sulphoxide (DMSO) compared with DMSO and saline flavoured with garlic. Thoracic (80 patients) and trigeminal (42 patients) zoster were investigated separately. The patients were evaluated daily until skin healing and then at 1, 3 and 6 months by registering pain, paraesthesia and sensitivity disturbances as well as by clinical and photographic evaluation of the skin lesions. Duration of pain was positively correlated to age, to delayed healing and to elevated temperature in the acute phase of zoster. The period of pain before skin eruption was considerably longer in thoracic than in trigeminal zoster, while the latter was associated with a more severe inflammatory reaction, more neurologic sequelae, but also by a faster healing of the skin lesions. IDU was highly effective in shortening the period of pain and improving skin healing in trigeminal zoster, while no effect of IDU was observed in thoracic zoster. The reason for this difference is presently not understood.

Subtotal spinal anaesthesia as a complication of intrathoracic intercostal nerve blocks

A patient developed subtotal spinal anaesthesia following intercostal nerve block performed by the surgeon during thoracotomy. Direct intraneural injection of bupivacaine appeared to be the most likely mechanism for this complication.

Alternative method of intercostal blockade. A preliminary study of the use of an injector gun for intercostal nerve blockade

An injector gun of the type developed for vaccinations was used to perform intercostal nerve blocks. Analgesia was achieved in all patients to some degree, but the effectiveness of the technique was limited by the currently available local anaesthestics.

Diabetic truncal polyneuropathy

Diabetic truncal polyneuropathy is a clinical entity characterized by sensory deficit in the distribution of the thoracic intercostal nerves. The sensory loss is relatively symmetric and involves multiple thoracic dermatomes, beginning close to the anterior midline. Diabetic truncal polyneuropathy occurs in patients with advanced distal polyneuropathy involving the limbs. This entity is important because it can be confused with myelopathies that produce sensory levels over the torso. Moreover, recognition of diabetic truncal polyneuropathy is important since this disorder is associated with autonomic neuropathy.

Diabetic thoracoabdominal neuropathy: clinical and electrodiagnostic features

Five diabetic patients developed upper back or abdominal pain associated with substantial weight loss in three. Electrophysiological evidence of associated thoracoabdominal somatic neuropathy was found in all cases. Signs of a generalized neuropathy were present in two patients, and four had asymmetrical proximal leg weakness. At least two have improved spontaneously. The syndrome is closely related to diabetic amyotrophy; it is probably more common than is recognized.

Effects of intercostal nerve blocks on pulmonary mechanics in healthy men

Bilateral block of the 5th through the 11th intercostal nerves was induced in 16 healthy men. In eight of the men, bupivacaine 0.25% was used and in the other eight, etidocaine 0.5%. Before and after induction of the block flow/volume curves, maximal airway pressures, and pulmonary compliance, were recorded, and helium spirometry and multiple and single breath nitrogen wash-outs were performed. There were no differences between the results in the two groups, and the material was therefore pooled. Total lung capacity was decreased by 4%. There was no increase in residual volume, though the maximal expiratory airway pressure decreased by 7%. There was an 8% decrease in functional residual capacity. Pulmonary recoil appeared to be unchanged, as also did the effort-independent peak expiratory flow rates. According to the pulmonary nitrogen clearance index, the overall pulmonary time constant did not alter, while the slope of the alveolar plateau in the single breath nitrogen wash-out test increased by 9%. The significance of the latter finding is unclear, but it is concluded that the nerve block had no obvious effects on pulmonary mechanics, the changes observed rather being attributable to effects on the chest wall.

[25 years of experience in the treatment of Raynaud's disease and Raynaud-like syndromes]

Reference is made to a series of 620 cases of Raynaud's phenomenon observed at the University of Milan between 1951 and 1977. The following parameters are analysed: sex, age, aetiology (where known), incidence of involvement of the four limbs, presence or otherwise of a complete sign, percentage of trophic lesions, arteriographic picture, lab examinations performed. 534 thoracic sympathectomies were performed in 464 patients with Raynaud or Raynaud-like forms. The results are described.