The role of imaging in focal neuropathies

Electrodiagnostic testing (EDX) has been the diagnostic tool of choice in peripheral nerve disease for many years, but in recent years, peripheral nerve imaging has been used ever more frequently in daily clinical practice. Nerve ultrasound and magnetic resonance (MR) neurography are able to visualize nerve structures reliably. These techniques can aid in localizing nerve pathology and can reveal significant anatomical abnormalities underlying nerve pathology that may have been otherwise undetected by EDX. As such, nerve ultrasound and MR neurography can significantly improve diagnostic accuracy and can have a significant effect on treatment strategy. In this chapter, the basic principles and recent developments of these techniques will be discussed, as well as their potential application in several types of peripheral nerve disease, such as carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow (UNE), radial neuropathy, brachial and lumbosacral plexopathy, neuralgic amyotrophy (NA), fibular, tibial, sciatic, femoral neuropathy, meralgia paresthetica, peripheral nerve trauma, tumors, and inflammatory neuropathies.

State of the Art and Advances in Peripheral Nerve Surgery

This review is intended to describe and actualize the basic knowledge of the three basic entities that affect the peripheral nerve system and can be treated by surgery: nerve trauma, chronic nerve compressions, and tumors.Regarding trauma, emphasis is given on the timing of surgery, given the fact that the moment in which the surgery is performed and the employed microsurgical reconstruction technique are the most important factors in the final result. Open lesions with associated nerve injury should be managed with an early exploration carried out before 7 days. Closed injuries are usually deferred, with few exceptions, from 3 to 6 months after the trauma.In turn, chronic compressions require an appropriate clinical, neurophysiological, and imaging diagnosis. Isolated sensory symptoms can be treated actively though without surgery: motor signs like atrophy should be regarded as a sign for immediate surgery, as a deferred treatment might cause an irreversible nerve and muscular damage. Endoscopic approaches are a valuable tool for treatment in selected neuropathies.Finally, nerve tumors demand a thorough preoperative evaluation, as benign tumors are treated in a very different way when compared to malignant lesions. Benign tumors can usually be safely and completely resected without sacrificing the nerve of origin. When malignancy is confirmed, extensive resection to optimize patient survival is the main objective, potentially at the expense of neurological function. This may then be followed by adjuvant radiation and/or chemotherapy, depending on the nature of the tumor and the completeness of resection attained. The role of nerve biopsy remains controversial, and several modern diagnostic techniques might be helpful.

The effect of ozone injection within a common peroneal nerve schwannoma: A mistreatment due to a misdiagnosis

Background:

Peripheral schwannomas can be misdiagnosed or mistreated as they can mimic other subcutaneous lesions, leading to wrong diagnosis and, therefore, to improper treatment.

Case Description:

A 23-years-old male presented a painful growing nodule at the left popliteal fossa, with distally irradiated pain. A first magnetic resonance imaging depicted a heterogeneous lesion between common peroneal and sural nerves but, surprisingly, the patient was submitted to perilesional injection of ozone-oxygen mixture, causing the onset of intense neuropathic pain. A second MRI showed a morphological change of tumor characteristics. He finally underwent surgery but, intraoperatively, inter-fascicular fibrous adherences were noticed, making the tumor removal more difficult and riskier. The histopathological diagnosis was of schwannoma with areas of foreign body reaction.

Conclusion:

The injection of ozone or other substances within a subcutaneous swelling should be avoided, before a complete imaging assessment; because of such swelling could be a peripheral nerve schwannoma. The correct assessment of a lesion of the limbs determining radiating pain should be carefully demanded to a thorough history, clinical examination, and appropriate imaging technique. To avoid incorrect management, the treatment of such tumors should be performed in the first place by dedicated equips with proven expertise in this field.

Intraneural angioleiomyoma of the median nerve presenting as a forearm mass: A case report

Angioleiomyoma is a solitary form of leiomyoma which is typically encountered in the subcutis. They are mostly seen in lower extremities, and the upper extremity is the second most common location for these lesions. There are only a few reports about the presence of an angioleiomyoma within a peripheral nerve in the upper extremity. Here we report a 56-year-old male patient who was referred to our clinic after an attempt was made for removal of a forearm mass at another institution. The lesion was encased within the median nerve and there was an unusual hypervascularity around the tumor with numerous vessels entering the lesion. Removal of the tumor without apparent damage to nerve fascicles was possible. Histopathological examination of the excision material revealed an intraneural angioleiomyoma. Following surgery, the patient was free of any functional deficits and no evidence of recurrence was observed at one year follow-up. There is no data regarding recurrence in intraneural lesions due to the lack of a large series. It would not be wrong to recommend spare grossly uninvolved fascicles if the nerve in question is not expendable.