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Lin Y, Sahr M, Lan R, Nguyen J, Tan ET, Sneag DB. MRI findings correlate with difficult dissection during proximal hamstring repair and with postoperative sciatica. Skeletal Radiol 2024:10.1007/s00256-024-04668-6. [PMID: 38581584 DOI: 10.1007/s00256-024-04668-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/22/2024] [Accepted: 03/24/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE This study examines the correlation between MRI findings and difficult dissection during proximal primary hamstring repair and postoperative sciatica. MATERIALS AND METHODS A total of 32 cases of surgically repaired hamstring tendon tears that underwent preoperative and postoperative MRI were divided into sciatica (n = 12) and control (n = 20) groups based on the presence or absence of postoperative sciatica. Cases were scored by two blinded musculoskeletal radiologists for imaging features associated with difficult surgical dissection and the development of subsequent sciatica. Intra- and interrater agreements, as well as correlation of MRI findings with symptoms (odds ratio, OR), were calculated. RESULTS On preoperative MRI, diffuse hamstring muscle edema pattern suggestive of active denervation (OR 9.4-13.6), and greater sciatic perineural scar circumference (OR 1.9-2) and length (OR 1.2-1.3) were significantly correlated with both difficult dissection and postoperative sciatica. Preoperatively, a greater number of tendons torn (OR 3.3), greater tear cross-sectional area (CSA, OR 1.03), and increased nerve T2-weighted signal (OR 3.2) and greater perineural scar thickness (OR 1.7) were also associated with difficult dissection, but not postoperative sciatica. On postoperative MRI, hamstring denervation, sciatic nerve tethering to the hamstring tendon, and development of perineural scar and greater perineural scar extent were all significantly correlated with postoperative sciatica. CONCLUSION Preoperative hamstring MRI demonstrates findings predictive of difficult sciatic nerve dissection; careful MRI evaluation of the nerve and for the presence and extent of perineural scar is important for preoperative planning. Preoperative and postoperative MRI both depict findings that correlate with postoperative sciatica.
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Affiliation(s)
- Yenpo Lin
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, 10021, USA
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Meghan Sahr
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, 10021, USA.
| | - Ranqing Lan
- Biostatistics Core Facility, Hospital for Special Surgery, New York, NY, USA
| | - Joe Nguyen
- Biostatistics Core Facility, Hospital for Special Surgery, New York, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, 10021, USA
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El-Latif NA, El Zehary RR, Ibrahim FM, Denewar M. Bone marrow stem cells with or without superparamagnetic iron oxide nanoparticles as a magnetic targeting tool: Which is better in regeneration of neurolysed facial nerve? An experimental study. Heliyon 2024; 10:e26675. [PMID: 38434051 PMCID: PMC10906296 DOI: 10.1016/j.heliyon.2024.e26675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 01/29/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024] Open
Abstract
Aim This study was performed to evaluate neural regenerative capacities of bone marrow stem cells (BMSCs) with or without superparamagnetic iron oxide nanoparticles (SPIONs) as a magnetic targeting tool after neurolysis of the facial nerve (FN) in albino rats. Methods Thirty-eight male albino rats were selected. Two of them were euthanized for normal FN histology assessment. Thirty-six rats were injected with ethanol in the FN nerve for neurolysis induction and assessed one week post-operatively by eye blinking test. Animals were divided into three groups, each containing twelve rats: Group I (positive control) was injected with Dulbecco Modified Eagle's medium (DMEM-F12), group II was injected with BMSCs in DMEM-F12, and group III was injected with BMSCs in DMEM-F12 with poly l-lysine coated SPIONs (0.5 mmol/mL). Monitoring of SPIONs in the rat's body was carried out by MRI. A circular neodymium magnet N52 (0.57 T, 2 × 5 mm) was placed on each rat in group III just below the right ear at the site of surgery to attract SPIONs labeled BMSCs, left in place for 24 h, and then removed. From each group, six rats were euthanized at the end of the 4th and 8th week of treatment, respectively. The right FN trunks were extracted for routine histological examination using H&E stain. Immunohistochemical examination by anti-S100B was performed to characterize the thickness of the myelin sheath formed by the Schwann cells. Ultra-structural examination was performed to study changes in axons, myelin sheaths, and Schwann cells. Results Regeneration of nerve fibers, Schwan cells, and myelin sheaths was better in group II than in groups I and III histologically, immunohistochemically, and ultra-structurally. Conclusion BMSCs alone could ameliorate FN regeneration better than magnetic targeting treatment using BMSCs labeled with SPIONs.
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Affiliation(s)
| | | | | | - Mona Denewar
- Oral Biology, Faculty of Dentistry, Mansoura University, Egypt
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Chang DL, Mirman B, Mehta N, Pak D. Applications of Cryo neurolysis in Chronic Pain Management: a Review of the Current Literature. Curr Pain Headache Rep 2024:10.1007/s11916-024-01222-w. [PMID: 38372950 DOI: 10.1007/s11916-024-01222-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to evaluate and summarize the literature investigating cryoneurolysis in the treatment of various chronic pain pathologies. RECENT FINDINGS There is an increasing amount of interest in the use of cryoneurolysis in chronic pain, and various studies have investigated its use in lumbar facet joint pain, SI joint pain, post-thoracotomy syndrome, temporomandibular joint pain, chronic knee pain, phantom limb pain, neuropathic pain, and abdominal pain. Numerous retrospective studies and a more limited number of prospective, sham-controlled prospective studies suggest the efficacy of cryoneurolysis in managing these chronic pain pathologies with a low complication rate. However, more blinded, controlled, prospective studies comparing cryoneurolysis to other techniques are needed to clarify its relative risks and advantages.
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Affiliation(s)
- David L Chang
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY, 10029, USA.
| | - Benjamin Mirman
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Neel Mehta
- Weill Cornell Medical College, Department of Anesthesiology, New York Presbyterian Hospital, New York, NY, USA
| | - Daniel Pak
- Weill Cornell Medical College, Department of Anesthesiology, New York Presbyterian Hospital, New York, NY, USA
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Pang Z, Zhu S, Shen YD, Qiu YQ, Liu YQ, Xu WD, Yin HW. Functional outcomes of different surgical treatments for common peroneal nerve injuries: a retrospective comparative study. BMC Surg 2024; 24:64. [PMID: 38368360 PMCID: PMC10874551 DOI: 10.1186/s12893-024-02354-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 02/09/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND This study aims to assess the recovery patterns and factors influencing outcomes in patients with common peroneal nerve (CPN) injury. METHODS This retrospective study included 45 patients with CPN injuries treated between 2009 and 2019 in Jing'an District Central Hospital. The surgical interventions were categorized into three groups: neurolysis (group A; n = 34 patients), nerve repair (group B; n = 5 patients) and tendon transfer (group C; n = 6 patients). Preoperative and postoperative sensorimotor functions were evaluated using the British Medical Research Council grading system. The outcome of measures included the numeric rating scale, walking ability, numbness and satisfaction. Receiver operating characteristic (ROC) curve analysis was utilized to determine the optimal time interval between injury and surgery for predicting postoperative foot dorsiflexion function, toe dorsiflexion function, and sensory function. RESULTS Surgical interventions led to improvements in foot dorsiflexion strength in all patient groups, enabling most to regain independent walking ability. Group A (underwent neurolysis) had significant sensory function restoration (P < 0.001), and three patients in Group B (underwent nerve repair) had sensory improvements. ROC analysis revealed that the optimal time interval for achieving M3 foot dorsiflexion recovery was 9.5 months, with an area under the curve (AUC) of 0.871 (95% CI = 0.661-1.000, P = 0.040). For M4 foot dorsiflexion recovery, the optimal cut-off was 5.5 months, with an AUC of 0.785 (95% CI = 0.575-0.995, P = 0.020). When using M3 toe dorsiflexion recovery or S4 sensory function recovery as the gold standard, the optimal cut-off remained at 5.5 months, with AUCs of 0.768 (95% CI = 0.582-0.953, P = 0.025) and 0.853 (95% CI = 0.693-1.000, P = 0.001), respectively. CONCLUSIONS Our study highlights the importance of early surgical intervention in CPN injury recovery, with optimal outcomes achieved when surgery is performed within 5.5 to 9.5 months post-injury. These findings provide guidance for clinicians in tailoring treatment plans to the specific characteristics and requirements of CPN injury patients.
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Affiliation(s)
- Zhen Pang
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Shuai Zhu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yun-Dong Shen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China
- Department of Orthopedics and Hand Surgery, the First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Yan-Qun Qiu
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China
| | - Yu-Qi Liu
- Institute of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
| | - Wen-Dong Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China
- Department of Orthopedics and Hand Surgery, the First Affiliated Hospital of Fujian Medical University, Fujian, China
- Institute of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, China
- Priority Among Priorities of Shanghai Municipal Clinical Medicine Center, Shanghai, China
- The National Clinical Research Center for Aging and Medicine, Fudan University, Shanghai, China
| | - Hua-Wei Yin
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.
- Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China.
- Department of Orthopedics and Hand Surgery, the First Affiliated Hospital of Fujian Medical University, Fujian, China.
- Institute of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China.
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, China.
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Fabry A, Nedunchelian M, Stacoffe N, Guinebert S, Zipfel J, Krainik A, Maindet C, Kastler B, Grand S, Kastler A. Review of craniofacial pain syndromes involving the greater occipital nerve: relevant anatomy, clinical findings, and interventional management. Neuroradiology 2024; 66:161-178. [PMID: 38159141 DOI: 10.1007/s00234-023-03273-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
Craniofacial pain syndromes exhibit a high prevalence in the general population, with a subset of patients developing chronic pain that significantly impacts their quality of life and results in substantial disabilities. Anatomical and functional assessments of the greater occipital nerve (GON) have unveiled its implication in numerous craniofacial pain syndromes, notably through the trigeminal-cervical convergence complex. The pathophysiological involvement of the greater occipital nerve in craniofacial pain syndromes, coupled with its accessibility, designates it as the primary target for various interventional procedures in managing craniofacial pain syndromes. This educational review aims to describe multiple craniofacial pain syndromes, elucidate the role of GON in their pathophysiology, detail the relevant anatomy of the greater occipital nerve (including specific intervention sites), highlight the role of imaging in diagnosing craniofacial pain syndromes, and discuss various interventional procedures such as nerve infiltration, ablation, neuromodulation techniques, and surgeries. Imaging is essential in managing these patients, whether for diagnostic or therapeutic purposes. The utilization of image guidance has demonstrated an enhancement in reproducibility, as well as technical and clinical outcomes of interventional procedures. Studies have shown that interventional management of craniofacial pain is effective in treating occipital neuralgia, cervicogenic headaches, cluster headaches, trigeminal neuralgia, and chronic migraines, with a reported efficacy of 60-90% over a duration of 1-9 months. Repeated infiltrations, neuromodulation, or ablation may prove effective in selected cases. Therefore, reassessment of treatment response and efficacy during follow-up is imperative to guide further management and explore alternative treatment options. Optimal utilization of imaging, interventional techniques, and a multidisciplinary team, including radiologists, will ensure maximum benefit for these patients.
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Affiliation(s)
- Alienor Fabry
- Neuroradiology Unit, University Hospital, Grenoble, France
| | | | | | | | | | | | | | - Bruno Kastler
- Radiology Unit, Necker University Hospital, Paris, France
| | - Sylvie Grand
- Neuroradiology Unit, University Hospital, Grenoble, France
| | - Adrian Kastler
- Neuroradiology Unit, University Hospital, Grenoble, France.
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Boushabi A, Aitbenali H, Shimi M. Compression of the posterior interosseous nerve secondary to a synovial cyst: Case report and review of the literature. Int J Surg Case Rep 2024; 114:109115. [PMID: 38061087 PMCID: PMC10755040 DOI: 10.1016/j.ijscr.2023.109115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/21/2023] [Accepted: 12/01/2023] [Indexed: 01/01/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Posterior interosseous nerve syndrome secondary to compression by a synovial cyst at the elbow is a rare and often unrecognized pathology. Early management relies on complete neurolysis to achieve satisfactory functional recovery. Increasing awareness among the orthopedics will help in the early diagnosis of the disease and in the initiation of early and proper treatment. CASE PRESENTATION In this article, we report the case of a 32-year-old patient with posterior interosseous nerve syndrome secondary to compression by a synovial cyst of the elbow. Surgical management combined with post-operative rehabilitation resulted in indolence with good functional recovery. CLINICAL DISCUSSION Posterior interosseous nerve syndrome secondary to compression by a synovial cyst at the elbow is a rare entity. Anatomically, the deep branch of the radial nerve or posterior interosseous nerve passes through the Fröhse's arch or arch of the supinator muscle at the elbow, then travels between the two heads of this muscle. Several anatomical structures may compress the NIOP. Clinically, it presents as paralysis or paresis of the extensor muscles of the fingers and the abductor muscle of the thumb. Limitation of the ulnar extensor carpi may be responsible for radial deviation of the carpus in some cases. MRI is the radiological examination of choice. Electromyography plays a contributory role in diagnosis prior to surgical exploration. Surgical excision is the treatment of choice. It may be combined with radial neurolysis for better recovery. Progression after surgical treatment is generally favourable. CONCLUSION Ignorance of posterior interosseous nerve palsy syndrome frequently leads to misdiagnosis. Early management relies on complete neurolysis to achieve satisfactory functional recovery.
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Affiliation(s)
- Ayoub Boushabi
- CHU Mohammed VI Tangier, Department of Orthopedic Traumatology, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University.
| | - Hicham Aitbenali
- CHU Mohammed VI Tangier, Department of Orthopedic Traumatology, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University
| | - Mohammed Shimi
- CHU Mohammed VI Tangier, Department of Orthopedic Traumatology, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University
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Chalk C, Namiranian D. Meralgia paresthetica. Handb Clin Neurol 2024; 201:195-201. [PMID: 38697741 DOI: 10.1016/b978-0-323-90108-6.00013-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Meralgia paresthetica is a common but probably underrecognized syndrome caused by dysfunction of the lateral femoral cutaneous nerve. The diagnosis is based on the patient's description of sensory disturbance, often painful, on the anterolateral aspect of the thigh, with normal strength and reflexes. Sensory nerve conduction studies and somatosensory evoked potentials may be used to support the diagnosis, but both have technical limitations, with low specificity and sensitivity. Risk factors for meralgia paresthetica include obesity, tight clothing, and diabetes mellitus. Some cases are complications of hip or lumbar spine surgery. Most cases are self-limited, but a small proportion of patients remain with refractory and disabling symptoms. Treatment options include medications for neuropathic pain, neurolysis, neurectomy, and radioablation, but controlled trials to compare efficacy are lacking.
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Affiliation(s)
- Colin Chalk
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada.
| | - Dina Namiranian
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
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Oosterbos C, Rummens S, Bogaerts K, Van Hoylandt A, Hoornaert S, Weyns F, Dubuisson A, Ceuppens J, Schuind S, Groen JL, Lemmens R, Theys T. A randomized controlled trial comparing conservative versus surgical treatment in patients with foot drop due to peroneal nerve entrapment: results of an internal feasibility pilot study. Pilot Feasibility Stud 2023; 9:181. [PMID: 37908016 PMCID: PMC10617035 DOI: 10.1186/s40814-023-01407-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Based on the lack of literature to support any treatment strategy in patients with foot drop due to peroneal nerve entrapment, a prospective study randomizing patients between surgery and conservative treatment is warranted. Since studies comparing surgery to no surgery are often challenging, we first examined the feasibility of such a randomized controlled trial. METHODS/DESIGN An internal feasibility pilot study was conducted to assess several aspects of process, resource, management, and scientific feasibility. The main objective was the assessment of the recruitment rate. The criterion to embark on a full study was the recruitment of at least 14 patients in 6 participating centers within 6 months. Cross-over rate, blinding measures, training strategies, and trial assessments were evaluated. The trial was entirely funded by the KCE Trials public funding program of the Belgian Health Care Knowledge Centre (ID KCE19-1232). RESULTS The initial duration was prolonged due to the COVID-19 pandemic. Between April 2021 and October 2022, we included 19 patients of which 15 were randomized. Fourteen patients were treated as randomized. One drop-out occurred after randomization, prior to surgery. We did not document any cross-over or accidental unblinding. Training strategies were successful. Patients perceived the quality of life questionnaire as the least relevant assessment. Assessment of ankle dorsiflexion range of motion was prone to interobserver variability. All other trial assessments were adequate. DISCUSSION Recruitment of the anticipated 14 patients was feasible although slower than expected. The Short-Form Health Survey (SF-36) and assessment of ankle dorsiflexion range of motion will no longer be included in the full-scale FOOTDROP trial. CONCLUSION The FOOTDROP study is feasible. TRIAL REGISTRATION ClinicalTrials.gov, identifier NCT04695834 . Registered 4 January 2021.
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Affiliation(s)
- Christophe Oosterbos
- Research Group experimental Neurosurgery and Neuroanatomy KULeuven and the Leuven Brain Institute, Leuven, Belgium.
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium.
| | - Sofie Rummens
- Department of Physical Medicine and Rehabilitation, University Hospitals Leuven, Leuven, Belgium
| | - Kris Bogaerts
- Department of Public Health and Critical Care, I-BioStat, KU Leuven, Belgium and I-BioStat, UHasselt, Belgium
| | - Anaïs Van Hoylandt
- Research Group experimental Neurosurgery and Neuroanatomy KULeuven and the Leuven Brain Institute, Leuven, Belgium
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Sophie Hoornaert
- Research Group experimental Neurosurgery and Neuroanatomy KULeuven and the Leuven Brain Institute, Leuven, Belgium
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Frank Weyns
- Department of Neurosurgery, Ziekenhuis-Oost Limburg, Genk, Belgium
- Neurosciences, Faculty of Medicine and Life Sciences, UHasselt, Hasselt, Belgium
| | - Annie Dubuisson
- Department of Neurosurgery, University Hospitals Liège, Liège, Belgium
| | - Jeroen Ceuppens
- Department of Neurosurgery, Algemeen Ziekenhuis Groeninge, Kortrijk, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Erasme Hospital, Brussels, Belgium
| | - Justus L Groen
- Leiden Nerve Center, Department of Neurosurgery, University of Leiden, Leiden, the Netherlands
| | - Robin Lemmens
- KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology, Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Tom Theys
- Research Group experimental Neurosurgery and Neuroanatomy KULeuven and the Leuven Brain Institute, Leuven, Belgium
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
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Prudhon J, Caillet T, Bellier A, Cavalié G. Variations of the obturator nerve and implications in obturator nerve entrapment treatment: an anatomical study. Surg Radiol Anat 2023; 45:1227-1232. [PMID: 37429990 DOI: 10.1007/s00276-023-03202-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 07/01/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Obturator nerve entrapment or idiopathic obturator neuralgia is an unfamiliar pathology for many physicians which can lead to diagnostic errancy. This study aims to identify the potential compression areas of the obturator nerve to improve therapeutic management. MATERIAL AND METHODS 18 anatomical dissections of lower limbs from 9 anatomical cadavers were performed. Endopelvic and exopelvic surgical approaches were utilized to study the anatomical variations of the nerve and to identify areas of entrapment. RESULTS On 7 limbs, the posterior branch of the obturator nerve passed through the external obturator muscle. A fascia between the adductor brevis and longus muscles was present in 9 of the 18 limbs. The anterior branch of the obturator nerve was highly adherent to the fascia in 6 cases. In 3 limbs, the medial femoral circumflex artery was in close connection with the posterior branch of the nerve. CONCLUSION Idiopathic obturator neuropathy remains a difficult diagnosis. Our cadaveric study did not allow us to formally identify one or more potential anatomical entrapment zones. However, it allowed the identification of zones at risk. A clinical study with staged analgesic blocks would be necessary to identify an anatomical area of compression and would allow targeted surgical neurolysis.
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Affiliation(s)
- J Prudhon
- Laboratoire d'Anatomie Des Alpes Françaises (LADAF), UFR de Médecine de Grenoble, Domaine de la Merci, 38706, La Tronche Cedex, France.
| | - T Caillet
- Laboratoire d'Anatomie Des Alpes Françaises (LADAF), UFR de Médecine de Grenoble, Domaine de la Merci, 38706, La Tronche Cedex, France
| | - A Bellier
- Laboratoire d'Anatomie Des Alpes Françaises (LADAF), UFR de Médecine de Grenoble, Domaine de la Merci, 38706, La Tronche Cedex, France
| | - G Cavalié
- Laboratoire d'Anatomie Des Alpes Françaises (LADAF), UFR de Médecine de Grenoble, Domaine de la Merci, 38706, La Tronche Cedex, France
- Service de Chirurgie Orthopédique et Traumatologie, CHU Grenoble-Alpes, BP217, 38043, Grenoble Cedex 09, France
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Cottias P, Gaujac N, Bouché PA, Anract P. Unusual entrapment symptomatology treated in 115 cases by neurolysis of the common fibular nerve at the fibular head combined with neurolysis of the posterior tibial nerve at the tarsal tunnel. Orthop Traumatol Surg Res 2023; 109:103485. [PMID: 36435376 DOI: 10.1016/j.otsr.2022.103485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/12/2022] [Accepted: 02/22/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Entrapment of the common fibular nerve (CFN) at the head of the fibula and entrapment of the posterior tibial nerve (PTN) at the tarsal tunnel are the most common nerve entrapment syndromes in the lower limb. Our aim was to study the results of combined neurolysis of the CFN and PTN for chronic lower limb pain. We hypothesized that combined neurolysis allowed a reduction of this chronic pain. MATERIAL AND METHOD This bi-centric retrospective study took place from January 2015 to November 2018, with a single senior surgeon. The inclusion criteria were all patients operated on for an idiopathic entrapment syndrome with neurolysis of the PTN at the tarsal tunnel, combined with neurolysis of the CFN at the head of the fibula. The primary endpoint was the pain evolution assessed on a numerical analogue scale (NAS) preoperatively and postoperatively on D+21, and at the last follow-up. The secondary endpoint was to determine the prognostic factors on the clinical outcome of neurolysis. RESULTS One hundred and fifteen neurolysis were included, comprising 64 women and 38 men with a mean age of 57±17.6 years. The preoperative pain (NAS0) was evaluated at 6±2.4 points. At D+21 postoperatively, there was a significant reduction in pain (NASD+21: 3±2.6 points, p<0.01). Similarly, at the last follow-up (with a mean follow-up of 37±8.4 months), there was a significant reduction in pain (NASLFU: 2±2.5, p<0.01). A history of systemic inflammatory disease was the only factor associated with a less significant decrease in pain at D+21, according to a multivariate analysis (p<0.01). There were 14 complications (12%) not requiring revision surgery. CONCLUSION This study is the first to demonstrate the efficacy of combined neurolysis of the CFN at the head of the fibula and the PTN at the tarsal tunnel, in the treatment of idiopathic nerve entrapment syndrome of the lower limb. LEVEL OF EVIDENCE IV; Retrospective comparative study.
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Affiliation(s)
- Pascal Cottias
- Service de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire Cochin, 27, rue du Faubourg Saint Jacques, 75014 Paris, France; Centre chirurgical de Rémusat, 21, rue Rémusat, 75016 Paris, France
| | - Nicolas Gaujac
- Service de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire Cochin, 27, rue du Faubourg Saint Jacques, 75014 Paris, France
| | - Pierre-Alban Bouché
- Service de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire Cochin, 27, rue du Faubourg Saint Jacques, 75014 Paris, France
| | - Philippe Anract
- Service de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire Cochin, 27, rue du Faubourg Saint Jacques, 75014 Paris, France
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Pai GM, Bhat AK, Acharya AM, Datta A. Bilateral Post-traumatic Brachial Plexus Injury in an Adult: A Note on the Probable Mechanism of Injury. Indian J Orthop 2023; 57:1545-1550. [PMID: 37609014 PMCID: PMC10441834 DOI: 10.1007/s43465-023-00948-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 06/27/2023] [Indexed: 08/24/2023]
Abstract
Bilateral brachial plexus injury is rare following a motor vehicle accident in an adult. We report a 35-year-old man with a bilateral brachial plexus injury. Explaining the mechanism of such an injury is essential to prognosticate the outcome. Fall from the bike, and the position determines the mechanism. The head-shoulder hitting the surface has an avulsion injury (ipsilateral), and the recoiling effect causes traction injury to the contralateral side. Our case had a C5,6 avulsion injury on the right side (ipsilateral) and a C5,6 traction injury (contralateral) to his left side. Surgical exploration and distal nerve transfers were done on the right side. The patient improved his shoulder and elbow function of grade 3, neurolysis of the brachial plexus was done on the left side, and the recovery was complete at 12 months of follow-up.
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Affiliation(s)
- G. Mithun Pai
- Department of Hand Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Anil K. Bhat
- Department of Hand Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Ashwath M. Acharya
- Department of Hand Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Aakriti Datta
- Department of Hand Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
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12
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Schönberg B, Pigorsch M, Huscher D, Baruchi S, Reinsch J, Zdunczyk A, Scholz C, Uerschels AK, Dengler NF. Diagnosis and treatment of meralgia paresthetica between 2005 and 2018: a national cohort study. Neurosurg Rev 2023; 46:54. [PMID: 36781569 PMCID: PMC9925535 DOI: 10.1007/s10143-023-01962-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/22/2023] [Accepted: 02/01/2023] [Indexed: 02/15/2023]
Abstract
The prevalence of meralgia paresthetica (MP), which is caused by compression of the lateral femoral cutaneous nerve (LFCN), has been increasing over recent decades. Since guidelines and large-scale studies are lacking, there are substantial regional differences in diagnostics and management in MP care. Our study aims to report on current diagnostic and therapeutic strategies as well as time trends in clinical MP management in Germany. Patients hospitalized in Germany between January 1, 2005, and December 31, 2018, with MP as their primary diagnosis were identified using the International Classification of Disease (ICD-10) code G57.1 and standardized operations and procedures codes (OPS). A total of 5828 patients with MP were included. The rate of imaging studies increased from 44% in 2005 to 79% in 2018 (p < 0.001) and that of non-imaging diagnostic studies from 70 to 93% (p < 0.001). Among non-imaging diagnostics, the rates of evoked potentials and neurography increased from 20%/16% in 2005 to 36%/23% in 2018 (p < 0.001, respectively). Rates of surgical procedures for MP decreased from 53 to 37% (p < 0.001), while rates of non-surgical procedures increased from 23 to 30% (p < 0.001). The most frequent surgical interventions were decompressive procedures at a mean annual rate of 29% (± 5) throughout the study period, compared to a mean annual rate of 5% (± 2) for nerve transection procedures. Between 2005 and 2018, in-hospital MP care in Germany underwent significant changes. The rates of imaging, evoked potentials, neurography, and non-surgical management increased. The decompression of the LFCN was substantially more frequent than that of the LFCN transection, yet both types of intervention showed a substantial decrease in in-hospital prevalence over time.
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Affiliation(s)
- Benn Schönberg
- Vertebral Spine Center Berlin, Breite Straße 46/47, 13187, Berlin, Germany
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Mareen Pigorsch
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Doerte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Shlomo Baruchi
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Jennifer Reinsch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Anna Zdunczyk
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Ann-Kathrin Uerschels
- Department of Neurosurgery, Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Nora F Dengler
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
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13
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Gomez YDLC, Remotti E, Momah DU, Zhang E, Swanson DD, Kim R, Urits I, Kaye AD, Robinson CL. Meralgia Paresthetica Review: Update on Presentation, Pathophysiology, and Treatment. Health Psychol Res 2023; 11:71454. [PMID: 36937080 PMCID: PMC10019995 DOI: 10.52965/001c.71454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Purpose of Review Meralgia paresthetica (MP) is a condition characterized by paresthesias, neuropathic pain, and alterations in sensorium of the anterolateral thigh secondary to impingement of the lateral femoral cutaneous nerve (LFCN). MP is generally diagnosed by clinical history and is often a diagnosis of exclusion. When diagnosis remains a challenge, diagnostic modalities such as ultrasound, MRI, electromyography, and nerve conduction studies have been utilized as an adjunct. This review summarizes the most recent medical literature regarding MP, its pathophysiology, presentation, and current treatment options. Recent Findings Treatment options for patients with MP range from lifestyle modifications and conservative management to surgical procedures. Initial management is often conservative with symptoms managed with medications. When conservative management fails, the next step is regional blocks followed by surgical management. The conflicting data for treatment options for MP highlight how the evidence available does not point to a single approach that's universally effective for treating all patients with MP. Summary Despite the apparent success at treating MP with regional blocks and surgical interventions, much remains to be known about the dosing, frequency, and optimal interventions due to the inconclusive results of current studies. Further research including randomized controlled trials are needed to better understand the most optimal treatment options for MP including studies with a larger number of participants.
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Affiliation(s)
| | - Edgar Remotti
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Deandra Uju Momah
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Emily Zhang
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Daniel D Swanson
- Georgetown University Hospital, Department of General Surgery, Medstar, Washington, DC
| | - Rosa Kim
- Georgetown University Hospital, Department of General Surgery, Medstar, Washington, DC
| | | | - Alan D Kaye
- Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA
| | - Christopher L Robinson
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
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14
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Oosterbos C, Rummens S, Bogaerts K, Hoornaert S, Weyns F, Dubuisson A, Lemmens R, Theys T. Conservative versus surgical treatment of foot drop in peroneal nerve entrapment: rationale and design of a prospective, multi-centre, randomized parallel-group controlled trial. Trials 2022; 23:1065. [PMID: 36581937 PMCID: PMC9801603 DOI: 10.1186/s13063-022-07009-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/12/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND High-quality evidence is lacking to support one treatment strategy over another in patients with foot drop due to peroneal nerve entrapment. This leads to strong variation in daily practice. METHODS/DESIGN The FOOTDROP (Follow-up and Outcome of Operative Treatment with Decompressive Release Of The Peroneal nerve) trial is a randomized, multi-centre study in which patients with peroneal nerve entrapment and persistent foot drop, despite initial conservative treatment, will be randomized 10 (± 4) weeks after onset between non-invasive treatment and surgical decompression. The primary endpoint is the difference in distance covered during the 6-min walk test between randomization and 9 months later. Time to recovery is the key secondary endpoint. Other secondary outcome measures encompass ankle dorsiflexion strength (MRC score and isometric dynamometry), gait assessment (10-m walk test, functional ambulation categories, Stanmore questionnaire), patient-reported outcome measures (EQ5D-5L), surgical complications, neurological deficits (sensory changes, motor scores for ankle eversion and hallux extension), health economic assessment (WPAI) and electrodiagnostic assessment. DISCUSSION The results of this randomized trial may elucidate the role of surgical decompression of the peroneal nerve and aid in clinical decision-making. TRIAL REGISTRATION ClinicalTrials.gov NCT04695834. Registered on 4 January 2021.
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Affiliation(s)
- Christophe Oosterbos
- grid.5596.f0000 0001 0668 7884Research Group experimental Neurosurgery and Neuroanatomy and the Leuven Brain Institute, KU Leuven, Leuven, Belgium ,grid.410569.f0000 0004 0626 3338Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Sofie Rummens
- grid.410569.f0000 0004 0626 3338Department of Physical Medicine and Rehabilitation, University Hospitals Leuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Locomotor and Neurological disorders, KU Leuven, Leuven, Belgium
| | - Kris Bogaerts
- grid.12155.320000 0001 0604 5662Department of public health and critical care, I-BioStat, KU Leuven, Belgium and I-BioStat, UHasselt, Hasselt, Belgium
| | - Sophie Hoornaert
- grid.5596.f0000 0001 0668 7884Research Group experimental Neurosurgery and Neuroanatomy and the Leuven Brain Institute, KU Leuven, Leuven, Belgium ,grid.410569.f0000 0004 0626 3338Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Frank Weyns
- grid.470040.70000 0004 0612 7379Department of Neurosurgery, Ziekenhuis Oost-Limburg, Genk, Belgium ,grid.12155.320000 0001 0604 5662Neurosciences, Faculty of Medicine and Life Sciences, UHasselt, Hasselt, Belgium
| | - Annie Dubuisson
- Department of Neurosurgery, University Hospitals Liège, Liège, Belgium
| | - Robin Lemmens
- grid.5596.f0000 0001 0668 7884Department of Neurosciences, Experimental Neurology, KU Leuven – University of Leuven, Leuven, Belgium ,grid.11486.3a0000000104788040VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium ,grid.410569.f0000 0004 0626 3338Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Tom Theys
- grid.5596.f0000 0001 0668 7884Research Group experimental Neurosurgery and Neuroanatomy and the Leuven Brain Institute, KU Leuven, Leuven, Belgium ,grid.410569.f0000 0004 0626 3338Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
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15
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Wyse JM, Sahai AV. EUS-guided celiac plexus neurolysis for pancreas cancer - Finally established or still under review? Best Pract Res Clin Gastroenterol 2022; 60-61:101809. [PMID: 36577532 DOI: 10.1016/j.bpg.2022.101809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022]
Abstract
Patients with pancreas cancer must deal frequently with intractable and refractory pain. Endoscopic ultrasound guided-celiac plexus neurolysis (EUS-CPN) has been the most studied and used therapeutic technique aimed to destroy the pain fibres that allow the pancreas to communicate with the central nervous system. A neurolytic agent, most commonly ethanol, is optimally spread around the celiac axis in order to reduce pain and mitigate narcotic requirements. This can be performed early to prevent the spiral of pain and medication use, or more historically as salvage therapy. Different techniques to best administer the ethanol for effective EUS-CPN are still being debated. New EUS-guided injection techniques with radiofrequency, radioactive, and/or chemotherapeutic agents need more study.
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Affiliation(s)
- Jonathan M Wyse
- Division of Gastroenterology, Jewish General Hospital, McGill University, Montreal, Canada.
| | - Anand V Sahai
- Division of Gastroenterology, Center Hospitalier de l'Université de Montréal, Montreal, Canada
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16
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Pecoraro AR, Hunter CE, Colgate CL, Landman MP. Neurolysis for analgesia following pectus repair in a national cohort. J Pediatr Surg 2022; 57:315-8. [PMID: 35339278 DOI: 10.1016/j.jpedsurg.2022.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Pectus excavatum and pectus carinatum are the most common chest wall deformities of childhood. Surgical repair can be complicated by post-operative analgesic challenges. Thoracic epidural analgesia, patient-controlled analgesia, and multimodal pain control are among the most common strategies. We sought to define the current utilization of intraoperative thoracic neurolysis, hypothesizing that this would minimize length of stay (LOS) and post-operative narcotic use with relatively higher proportion of non-narcotic post-operative analgesia. METHODS We performed a retrospective review of the Pediatric Health Information System (PHIS) database between 2017 and 2020. We first identified patients who underwent a pectus repair via ICD-10-PCS codes. We used ICD-10-PCS codes 01580ZZ and 01584ZZ to identify those patients who underwent concomitant thoracic neurolysis. Statistical analyses were performed using R; p value less than 0.05 was considered significant. RESULTS We identified 2979 patients who underwent a pectus repair. 184 underwent a concomitant thoracic nerve destruction procedure (6.7%); 13 were performed in 2017 (2.01%), 76 in 2018 (10.7%), and 84 in 2019 (9.6%). LOS was shorter in those patients who underwent neurolysis (mean=2.55 vs 3.73 days, SD=1.33 vs 1.78 days, p<0.001). There were fewer post-operative ICU admissions in neurolysis patients (3/184 vs. 193/2795, p = 0.003). The cost of procedures that included a neurolysis were higher, though not significantly so (mean=$24,885.64 vs $22,200.59). CONCLUSION Thoracic neurolysis may be a useful analgesic strategy, expediating post-operative discharge and potentially obviating the need for intensive care. Further larger-scale prospective trials should be considered to further elucidate the role of this analgesia method. LEVEL OF EVIDENCE Level III.
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17
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Imran R, George S, Jose R, Shirley C, Power DM. Clinical outcomes following neurolysis and porcine collagen extracellular matrix wrapping of scarred nerves in revision carpal tunnel decompression. J Plast Reconstr Aesthet Surg 2022; 75:2802-8. [PMID: 35597709 DOI: 10.1016/j.bjps.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/03/2022] [Accepted: 04/12/2022] [Indexed: 12/31/2022]
Abstract
Scar tether after primary nerve decompression can impair physiological nerve glide and vascularity of the nerve. Revision decompression in the setting of neurostenalgia should address the scarred mesoneurium in order to prevent further entrapment and tether. This study reports on the clinical outcomes of 12 patients with neurostenalgia following carpal tunnel decompression (CTD), treated with revision CTD and a porcine submucosa extracellular matrix nerve wrap (PECM) (Axoguard® nerve protector, Axogen Inc., Alachua, FL). Eleven patients had one primary decompression procedure prior to revision surgery; one patient previously had two operations for CTD. There was a significant reduction in visual analogue pain scores (VAS) and improvement in patients' satisfaction rating and symptom resolution. Patient-reported outcome measures were recorded using the Impact of Hand Nerve Disorders (I-HaND) Scale (Version 2), which demonstrated a significant reduction in hand disability. There were no complications attributable to the procedure and no re-revision procedures necessary at the latest follow-up.
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18
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Kong FL, Bie ZX, Wang Z, Peng JZ, Li XG. Nerve Injury and Regeneration after Neurolysis: Ethanol Combined with Iodine-125 Radioactive Seed versus Ethanol Alone in Rabbits. J Vasc Interv Radiol 2022:S1051-0443(22)00994-0. [PMID: 35718341 DOI: 10.1016/j.jvir.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/01/2022] [Accepted: 06/09/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE This study aimed to prove the hypothesis that neurolysis based on ethanol injection in combination with iodine-125 (125I) radioactive seed implantation could prolong nerve regeneration time compared with ethanol injection alone. Moreover, we assessed the grade of nerve injury using both methods. MATERIALS AND METHODS Twenty female rabbits (mean 2.8 ± 0.2 kg) were randomly assigned to group A (neurolysis of the left brachial plexus nerve based on ethanol injection in combination with 125I radioactive seed implantation, n=10) and group B (neurolysis using ethanol injection alone, n=10). The right brachial plexus nerve was used as a blank control. Injury and regeneration of the brachial plexus nerve were analyzed using electromyography (EMG). Statistical tests were performed using the Mann-Whitney U test and repeated-measures analysis of variance. The results were verified with histopathological examinations. RESULTS The overall postprocedural amplitude was significantly lower in group A than in group B (P=0.01), particularly in the second month after the procedure (P=0.036). However, no statistical difference in latency was observed between the two groups (P=0.103). Histopathological examination of both groups revealed Sunderland's third-degree peripheral nerve injury (PNI), mainly characterized by axon disintegration. The degree of nerve regeneration was significantly lower in group A than in group B. CONCLUSION Neurolysis based on ethanol injection in combination with 125I radioactive seed implantation can prolong the time of nerve regeneration compared to ethanol injection alone, although both methods resulted in Sunderland's third-degree PNI.
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19
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Choi JY, Hong WH, Kim MJ, Chae SW, Suh JS. Operative treatment options for Morton's neuroma other than neurectomy - a systematic review. Foot Ankle Surg 2022; 28:450-459. [PMID: 34736848 DOI: 10.1016/j.fas.2021.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/24/2021] [Accepted: 10/13/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The effectiveness of operative treatments other than neurectomy for Morton's neuroma remains debatable despite several reported studies. This review aimed to evaluate the effects of operative treatments for Morton's neuroma other than neurectomy using an algorithmic approach and a structured critical framework to assess the methodological quality of reported studies. METHODS Several electronic databases were searched for articles published until August 2021 that evaluated the outcomes of operative treatments other than neurectomy in patients diagnosed with Morton's neuroma. Data searches, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the clinical outcomes were evaluated using objective, subjective, and negative outcomes; complications; and reoperation rate and type. RESULTS After reviewing 11,213 studies, 22 studies were finally included. Although a number of studies with high level of evidence are limited, we divided them according to four categories: (1) neurolysis with or without nerve transposition, (2) minimally invasive nerve decompression, (3) metatarsal osteotomy, and (4) additional procedures after nerve transection or neurectomy. All categories showed reliable outcomes except minimally invasive nerve decompression. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy. CONCLUSION Whether the alternative procedures were superior to neurectomy remains unclear as the number of good quality studies was limited. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy. Furthermore, performing simultaneous dorsal transposition of the nerve along with neurolysis is more recommended than neurolysis alone. Surgeons should be more careful with minimally invasive deep transverse intermetatarsal ligament release and metatarsal shortening osteotomy as their effectiveness remains inconclusive. Finally, we strongly recommend performing intramuscular embedding or intermuscular transposition of the nerve cutting end if neurectomy or nerve transection is inevitable. LEVEL OF EVIDENCE Level III, systematic review.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
| | - Woi Hyun Hong
- College of Medicine, Medical Research Information Center, Chungbuk National University, 1 Chungdae-ro, Seowon-gu, Cheongju-si, Chungcheongbuk-do, South Korea.
| | - Min Jin Kim
- Health Care Center, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Bucheon-si, Gyeonggi-do, South Korea.
| | - Su Whi Chae
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
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20
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Abstract
Foot drop is a common clinical condition which may substantially impact physical function and health-related quality of life. The etiologies of foot drop are diverse and a detailed history and physical examination are essential in understanding the underlying pathophysiology and capacity for spontaneous recovery. Patients presenting with acute foot drop or those without significant spontaneous recovery of motor deficits may be candidates for surgical intervention. The timing, mechanism, and severity of neural injury resulting in foot drop influence the selection of the most appropriate peripheral nerve surgery, which may include direct nerve repair, neurolysis, nerve grafting, or nerve transfer.
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Affiliation(s)
- Nishant Dwivedi
- Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, Saint Louis, Missouri 63110, USA.
| | - Ambika E Paulson
- Georgetown University School of Medicine, Washington, DC 20007, USA
| | - Jeffrey E Johnson
- Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, Saint Louis, Missouri 63110, USA
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, Saint Louis, Missouri 63110, USA
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21
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Cai Z, Zhou X, Wang M, Kang J, Zhang M, Zhou H. Splanchnic nerve neurolysis via the transdiscal approach under fluoroscopic guidance: a retrospective study. Korean J Pain 2022; 35:202-208. [PMID: 35354683 PMCID: PMC8977204 DOI: 10.3344/kjp.2022.35.2.202] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/18/2021] [Accepted: 12/20/2021] [Indexed: 11/21/2022] Open
Abstract
Background Neurolytic celiac plexus block (NCPB) is a typical treatment for severe epigastric cancer pain, but the therapeutic effect is often affected by the variation of local anatomical structures induced by the tumor. Greater and lesser splanchnic nerve neurolysis (SNN) had similar effects to the NCPB, and was recently performed with a paravertebral approach under the image guidance, or with the transdiscal approach under the guidance of computed tomography. This study observed the feasibility and safety of SNN via a transdiscal approach under fluoroscopic guidance. Methods The follow-up records of 34 patients with epigastric cancer pain who underwent the splanchnic nerve block via the T11-12 transdiscal approach under fluoroscopic guidance were investigated retrospectively. The numerical rating scale (NRS), the patient satisfaction scale (PSS) and quality of life (QOL) of the patient, the dose of morphine consumed, and the occurrence and severity of adverse events were recorded preoperatively and 1 day, 1 week, 1 month, and 2 months after surgery. Results Compared with the preoperative scores, the NRS scores and daily morphine consumption decreased and the QOL and PSS scores increased at each postoperative time point (P < 0.001). No patients experienced serious complications. Conclusions SNN via the transdiscal approach under flouroscopic guidance was an effective, safe, and easy operation for epigastric cancer pain, with fewer complications.
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Affiliation(s)
- Zhenhua Cai
- Department of Pain Management, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Pain Management, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiaolin Zhou
- Department of Pain Management, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Mengli Wang
- Department of Anesthesiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiyu Kang
- Department of Pain Management, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Mingshuo Zhang
- Department of Pain Management, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Huacheng Zhou
- Department of Pain Management, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
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22
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Abdelbaser I, Shams T, El-Giedy AA, Elsedieq M, Ghanem MA. Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study. Rev Esp Anestesiol Reanim (Engl Ed) 2022; 69:71-78. [PMID: 35183469 DOI: 10.1016/j.redare.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/21/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Celiac plexus neurolysis (CPN) has been used to control pancreatic cancer (PC) pain, up to our knowledge, there is no study compared intraoperative CPN and computed tomography (CT)-guided techniques. OBJECTIVES To compare the effects of intraoperative and CT-guided CPN in unresectable PC on pain intensity and analgesic requirements. METHODS A total of 90 patients were enrolled in this prospective, randomized, open label, controlled, non-inferiority study, 20 patients were excluded or lost to follow up. The patients were randomly allocated to either intraoperative or CT-guided CPN group. A mixture of 20 mL ethanol 90%, 100 mg lignocaine and 5 mg dexamethasone was infused on each side of the aorta in both groups. Visual analogue score (VAS) and oral daily tramadol consumption were recorded at day 7, 14, 30, 60, 120 and 180 days after intervention. Occurrence of any intervention related complications were reported. RESULTS Median VAS was similar in both intraoperative and CT-guided CPN groups from day 7 up to 180 days after intervention. The median daily analgesic consumption of oral tramadol (mg) was comparable in both intraoperative and CT-guided CPN groups after intervention at day 7 (50 versus 50), day14 (50 versus 50), day 30 (50 versus 50), day 60 (50 versus 50), day 120 (100 versus 75) and day 180 (100 versus 100). The incidence of diarrhea, vomiting, hypotension and back pain was similar in both groups. CONCLUSION Intraoperative CPN is non-inferior to CT-guided CPN as both techniques were similarly associated with reduced pain severity and analgesics requirements.
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Affiliation(s)
- I Abdelbaser
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt.
| | - T Shams
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt
| | - A A El-Giedy
- Department of Gastrointestinal Surgery, Faculty of Medicine, Mansoura University, Egypt
| | - M Elsedieq
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt
| | - M A Ghanem
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt
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Abstract
Symptomatic celiac artery compression syndrome (CACS) or median arcuate ligament syndrome (MALS) is a controversial diagnosis that should be considered in patients with chronic abdominal pain of unknown etiology despite an extensive medical evaluation. Once suspected, patients should undergo mesenteric duplex ultrasound. Diagnosis is confirmed with elevated celiac artery velocities which normalize with deep inspiration followed by CT angiogram showing the typical "J-hook" conformation of the celiac artery. Patients should then undergo evaluation by a multi-disciplinary team to appropriately select and prepare patients for potential surgical treatment. Surgical options include release of the median arcuate ligament, with or without neurolysis of the celiac nerve plexus, and with or without concomitant revascularization procedures. Approaches can be open, laparoscopic, or robotic. Surgical treatment has an overall success rate of 70-80% with patients reporting improved abdominal pain and quality of life. Post-operatively, patients can have persistent or recurrent abdominal pain and should undergo re-evaluation for possible need for a revascularization procedure for stenosis of the celiac artery or celiac plexus block if the celiac artery flow is normalized. Additionally, some patients will have persistent pain consistent with functional gastrointestinal disorder (FGID) that will then require medical management. Psychiatric comorbidities have been identified as a predisposing factor that may predict poorer outcomes, and there are preliminary findings suggesting that patients with dysautonomia diagnoses may have worse outcomes as well.
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Zheng W, Dong X, Wang D, Hu Q, Du Q. Long Time Efficacy and Safety of Microvascular Decompression Combined with Internal Neurolysis for Recurrent Trigeminal Neuralgia. J Korean Neurosurg Soc 2021; 64:966-974. [PMID: 34689474 PMCID: PMC8590912 DOI: 10.3340/jkns.2020.0315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/26/2021] [Indexed: 11/27/2022] Open
Abstract
Objective To explore the clinical efficacy and safety of microvascular decompression (MVD) combined with internal neurolysis (IN) in the treatment of recurrent trigeminal neuralgia (TN) after MVD.
Methods Sixty-four patients with recurrent TN admitted to the hospital from January 2014 to December 2017 were divided into two groups according to the surgical method. Twenty-nine patients, admitted from January 2014 to December 2015, were treated with MVD alone, whereas 35 admitted from January 2016 to December 2017 were treated with MVD+IN. The postoperative efficacy, complications, and pain recurrence rate of the two groups were analyzed. Results The efficacy of the MVD+IN and MVD groups were 88.6% and 86.2%, and the cure rates were 77.1% and 65.5% respectively. There was no statistically significant difference between the two groups (p>0.05). The cure rate (83.3%) of patients in the MVD+IN group, who were only found thickened arachnoid adhesions during the operation that could not be fully released, was significantly higher than that of the MVD group (30.0%) (p<0.05), while the efficacy (91.7% vs. 70%) of the two groups was not statistically different (p>0.05). For patients whose arachnoid adhesions were completely released, there had no significant difference (p>0.05) in the efficacy (87% vs. 94.7%) and recurrence rate (5.0% vs. 11.1%). The incidence of postoperative facial numbness (88.6%) in the MVD+IN group was higher than that in the MVD group (10.3%) (p<0.01). The long-term incidence of facial numbness was not statistically significant (p>0.05). In the 18–36 months follow-up, the recurrence rate of patients in the MVD+IN group (9.7%) and in the MVD group (16%) were not statistically different (p>0.05).
Conclusion A retrospective comparison of patients with recurrent TN showed that both MVD and MVD combined with IN can effectively treat recurrent TN. Compared with MVD alone, MVD combined with IN can effectively improve the pain cure rate of patients with recurrent TN who have only severe arachnoid adhesions. The combination does not increase the incidence of long-term facial numbness and other complications.
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Affiliation(s)
- Wenhao Zheng
- The Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaoqiao Dong
- Department of Neurosurgery, The First People's Hospital of Hangzhou, Zhejiang University School of Medicine, Hangzhou, China
| | - Din Wang
- Department of Neurosurgery, The First People's Hospital of Hangzhou, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiang Hu
- Department of Neurosurgery, The First People's Hospital of Hangzhou, Zhejiang University School of Medicine, Hangzhou, China
| | - Quan Du
- Department of Neurosurgery, The First People's Hospital of Hangzhou, Zhejiang University School of Medicine, Hangzhou, China
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Son BC, Lee CI, Choi JG. External Neurolysis in Microvascular Decompression for Magnetic Resonance Imaging-Negative Idiopathic Trigeminal Neuralgia. World Neurosurg 2021:S1878-8750(21)01617-X. [PMID: 34688934 DOI: 10.1016/j.wneu.2021.10.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Internal neurolysis has been proposed as an alternative to microvascular decompression in patients with idiopathic trigeminal neuralgia (TN) in whom neurovascular compression is not confirmed by magnetic resonance imaging (MRI). External neurolysis, which straightens and realigns the trigeminal nerve root axis by dissecting the arachnoid membranes around the nerve, was reported 20 years ago in the context of so-called negative exploration when MRI did not confirm the absence of the offending vessel, but is not currently used. METHODS External neurolysis was performed in 4 patients with idiopathic TN with typical evoked neuralgic pain despite the absence of suspected offending vessels on MRI. The surgical findings that caused TN were summarized and the outcomes were evaluated using the Barrow Neurological Institute Pain Intensity Scale (BNI-PS). RESULTS Tethering and distortion of the nerve root by surrounding arachnoid membranes were commonly found. All 4 patients showed complete pain relief immediately after surgery. During the follow-up period of 26.5 ± 16.92 months (±standard deviation), 3 of 4 patients had no pain (score I, BNI-PS). One patient received a score of IIIa on the BNI-PS assessment. There was no instance of recurrence or side effects associated with the surgery. CONCLUSIONS Idiopathic TN can be induced by individual variation of the surrounding inner arachnoid membranes supporting the trigeminal nerve root, and the condition cannot be identified by MRI. Intradural external neurolysis may be considered an effective treatment for MRI-negative idiopathic TN.
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Abdelbaser I, Shams T, El-Giedy AA, Elsedieq M, Ghanem MA. Direct intraoperative versus percutaneous computed tomographyguided celiac plexus neurolysis in non-resectable pancreatic cancer: A randomized, controlled, non-inferiority study. Rev Esp Anestesiol Reanim (Engl Ed) 2021; 69:S0034-9356(21)00141-9. [PMID: 34565567 DOI: 10.1016/j.redar.2020.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Celiac plexus neurolysis (CPN) has been used to control pancreatic cancer (PC) pain, up to our knowledge, there is no study compared intraoperative CPN and computed tomography (CT)-guided techniques. OBJECTIVES To compare the effects of intraoperative and CT-guided CPN in unresectable PC on pain intensity and analgesic requirements. METHODS A total of 90 patients were enrolled in this prospective, randomized, open label, controlled, non-inferiority study, 20 patients were excluded or lost to follow up. The patients were randomly allocated to either intraoperative or CT-guided CPN group. A mixture of 20ml ethanol 90%, 100mg lignocaine and 5mg dexamethasone was infused on each side of the aorta in both groups. Visual analogue score (VAS) and oral daily tramadol consumption were recorded at day 7, 14, 30, 60, 120 and 180 days after intervention. Occurrence of any intervention related complications were reported. RESULTS Median VAS was similar in both intraoperative and CT-guided CPN groups from day 7 up to 180 days after intervention. The median daily analgesic consumption of oral tramadol (mg) was comparable in both intraoperative and CT-guided CPN groups after intervention at day 7 (50 versus 50), day14 (50 versus 50), day 30 (50 versus 50), day 60 (50 versus 50), day 120 (100 versus 75) and day 180 (100 versus 100). The incidence of diarrhea, vomiting, hypotension and back pain was similar in both groups. CONCLUSION Intraoperative CPN is non-inferior to CT-guided CPN as both techniques were similarly associated with reduced pain severity and analgesics requirements.
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Affiliation(s)
- I Abdelbaser
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egipto.
| | - T Shams
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egipto
| | - A A El-Giedy
- Department of Gastrointestinal Surgery, Faculty of Medicine, Mansoura University, Egipto
| | - M Elsedieq
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egipto
| | - M A Ghanem
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egipto
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de Ruiter GCW, Clahsen PC, Oosterhuis JWA. Suprainguinal Re-Resection of the Lateral Femoral Cutaneous Nerve in Persistence or Recurrence of Meralgia Paresthetica After Previous Transection: Results of a Case Series. World Neurosurg 2021; 155:e830-e835. [PMID: 34520865 DOI: 10.1016/j.wneu.2021.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Suprainguinal re-resection of the proximal nerve stump can be performed in case of persistent or recurrent symptoms of meralgia paresthetica after previous transection of the lateral femoral cutaneous nerve (LFCN). Currently, no long-term results for this procedure have been reported in the literature. METHODS In this study, 20 consecutive patients with persistent (13 cases) or recurrent (7 cases) symptoms of meralgia paresthetica were reoperated at a mean interval of 16 months after the first transection of the LFCN. The proximal nerve stump was sent for histopathologic analysis of a potential traumatic neuroma. Outcome was assessed using a 5-point Likert scale, which was obtained at a mean interval of 3.5 years after the suprainguinal re-resection. RESULTS The proximal stump of the LFCN was identified in 90% of the cases. Successful pain relief (Likert 1 or 2) was obtained in 65% of the patients. A neuroma was found in 11 cases (55%), mostly in recurrent cases after a pain-free interval. The indication for recurrence of symptoms more frequently resulted in successful pain relief (71%) compared with results for the indication for persistence of symptoms (62%). There was no correlation between the presence of a neuroma and the chance for pain relief. CONCLUSIONS Suprainguinal re-resection of the LFCN can be a successful procedure, both for persistence and recurrence of symptoms of meralgia paresthetica after previous transection, with long-lasting pain relief. Several factors, however, should be considered before performing this relatively new technique in patients that are discussed in this article.
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Affiliation(s)
- Godard C W de Ruiter
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands.
| | - Pieter C Clahsen
- Department of Pathology, Haaglanden Medical Center, The Hague, the Netherlands
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Regev GJ, Ben Shabat D, Khashan M, Ofir D, Salame K, Shapira Y, Kedem R, Lidar Z, Rochkind S. Management of chronic knee pain caused by postsurgical or posttraumatic neuroma of the infrapatellar branch of the saphenous nerve. J Orthop Surg Res 2021; 16:464. [PMID: 34289862 PMCID: PMC8293565 DOI: 10.1186/s13018-021-02613-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/12/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Injury to the infrapatellar branch of the saphenous nerve (IBSN) is a relatively common complication after knee surgery, which can interfere with patient satisfaction and functional outcome. In some cases, injury to the IBSN can lead to formation of a painful neuroma. The purpose of this study was to report the results of surgical treatment in a series of patients with IBSN painful neuroma. METHODS We retrospectively identified 37 patients who underwent resection of IBSN painful neuroma at our institution, after failure of non-operative treatment for a minimum of 6 months. Injury to the IBSN resulted from prior orthopedic surgery, vascular surgery, tumor resection, trauma, or infection. Leg pain and health-related quality of life were measured using the numeric rating scale (NRS) and EuroQol 5 dimensions (EQ-5D) questionnaire, respectively. Clinically meaningful improvement in leg pain was defined as reduction in NRS by at least 3 points. Predictors of favorable and unfavorable surgical outcome were investigated using multivariable logistic regression analysis. RESULTS Patient-reported leg pain, health-related quality of life, and overall satisfaction with the surgical outcome were obtained at 94 ± 52.9 months after neuroma surgery. Postoperative patient-reported outcomes were available for 25 patients (68% of the cohort), of whom 20 patients (80.0%) reported improvement in leg pain, 17 patients (68.0%) reported clinically meaningful improvement in leg pain, and 17 patients (68%) reported improvement in health-related quality of life. The average NRS pain score improved from 9.43 ± 1.34 to 5.12 ± 3.33 (p < 0.01) and the average EQ-5D functional score improved from 10.48 ± 2.33 to 7.84 ± 2.19 (p < 0.01). Overall patient reported satisfaction with the surgical outcome was good to excellent for 18 patients (72.0%). Older age, multiple prior orthopedic knee surgeries, and failed prior attempts to resect an IBSN neuroma were associated with non-favorable surgical outcome. CONCLUSION We conclude that surgical intervention is efficacious for appropriately selected patients suffering from IBSN painful neuroma.
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Affiliation(s)
- G J Regev
- The Peripheral Nerve Reconstruction Unit, Department of Neurosurgery and Orthopedic Surgery, Tel Aviv University, Tel Aviv, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - D Ben Shabat
- The Peripheral Nerve Reconstruction Unit, Department of Neurosurgery and Orthopedic Surgery, Tel Aviv University, Tel Aviv, Israel
| | - M Khashan
- The Peripheral Nerve Reconstruction Unit, Department of Neurosurgery and Orthopedic Surgery, Tel Aviv University, Tel Aviv, Israel
| | - D Ofir
- The Peripheral Nerve Reconstruction Unit, Department of Neurosurgery and Orthopedic Surgery, Tel Aviv University, Tel Aviv, Israel
| | - K Salame
- The Peripheral Nerve Reconstruction Unit, Department of Neurosurgery and Orthopedic Surgery, Tel Aviv University, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Shapira
- The Peripheral Nerve Reconstruction Unit, Department of Neurosurgery and Orthopedic Surgery, Tel Aviv University, Tel Aviv, Israel
| | - R Kedem
- Academic Branch, Medical Corps, IDF, Tel Aviv, Israel
| | - Z Lidar
- The Peripheral Nerve Reconstruction Unit, Department of Neurosurgery and Orthopedic Surgery, Tel Aviv University, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Rochkind
- The Peripheral Nerve Reconstruction Unit, Department of Neurosurgery and Orthopedic Surgery, Tel Aviv University, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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29
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Quevedo Orrego E, Robla Costales J, Rodríguez Aceves C, Diana Martín R, González Álvarez A, Socolovsky M. Neuropathic inguinal pain due to nerve injury after a laparoscopic appendectomy: first pediatric case described in the literature. Childs Nerv Syst 2021; 37:1825-1830. [PMID: 33904935 DOI: 10.1007/s00381-021-05177-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/18/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the first pediatric case in the literature of neuropathic inguinal pain secondary to iatrogenic nerve injury that occurred during a laparoscopic appendectomy, detailing clinical and morphological findings before and after surgery. The literature on adult patients is reviewed and pathophysiological, therapeutic, and prognostic factors are discussed. CLINICAL PRESENTATION A 14-year-old female patient presented with a history of a laparoscopic appendectomy 3 years previously. Three months post-operatively, she developed progressively worsening neuropathic inguinal pain refractory to neuromodulators and several nerve blocks. Given her deterioration, poor response to conservative therapy, and clearly meeting the criteria for chronic post-operative inguinal pain (CPIP), surgical management was undertaken. RESULTS Open surgery was performed through the previous incision, during which injury to a branch of the iliohypogastric nerve (IH) was confirmed. Neurolysis of the affected branch was performed, after which the patient experienced significant pain relief, resolution of allodynia, and reversal of skin hyperpigmentation. After discharge, analgesic therapy was gradually withdrawn and, ultimately, discontinued altogether. CONCLUSIONS Understanding the neuroanatomy of the inguinal region is an indispensable requirement for all surgeons operating in this region, to avoid complications including CPIP and optimize patient outcomes. Surgical management of CPIP can be effective for controlling severe pain in patients in whom conservative management has failed. Studies are needed in the pediatric population to identify specific characteristics of this entity in youth.
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Affiliation(s)
| | - Javier Robla Costales
- Neurosurgical Department, HM Hospitales Regla/San Francisco, Calle Cardenal Landázuri 2, 24003, León, Spain.
| | | | - Rubén Diana Martín
- Neurosurgical Department, Complejo Asistencial Universitario de León, León, Spain
| | | | - Mariano Socolovsky
- Neurosurgical Department, Complejo Asistencial Universitario de León, León, Spain.,Peripheral Nerve & Plexus Program, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
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30
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Hou S, Novy D, Felice F, Koyyalagunta D. Efficacy of Superior Hypogastric Plexus Neurolysis for the Treatment of Cancer-Related Pelvic Pain. Pain Med 2021; 21:1255-1262. [PMID: 31343689 DOI: 10.1093/pm/pnz151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Cancer-related abdominal and pelvic pain syndromes can be debilitating and difficult to treat. The objective of this study was to evaluate the efficacy of superior hypogastric plexus blockade or neurolysis (SHPN) for the treatment of cancer-related pelvic pain. DESIGN Retrospective study. SETTING MD Anderson Cancer Center, Houston, Texas. METHODS We enrolled 46 patients with cancer-related pelvic pain who underwent SHPN. A numeric rating scale (NRS) was used for pain intensity, and symptom burden was evaluated using the Edmonton Symptom Assessment System at baseline, visit 1 (within one month), and visit 2 (within one to six months). RESULTS Forty-six patients who received SHPN showed a significant reduction in pain score from 6.9 to 5.6 at visit 1 (P = 0.01). Thirty of the 46 patients continued to complete visit 2 follow-up, and the NRS score was consistently lower at 4.5 at visit 2 (P < 0.0001), with anxiety and appetite improved significantly. There was no significant change in the morphine equivalent dose at visits 1 and 2. The efficacy of the block was not influenced by patients' age, gender, type of cancer, cancer stage, regimen of chemotherapy and/or radiation therapy, diagnostic block, approach or laterality of procedure, or type or amount of neurolytic agent. Nonsmokers with high baseline pain scores were more likely to have improved treatment outcomes from SHPN at short-term follow-up. Adverse effects with SHPN were mild and well tolerated. CONCLUSIONS SHPN was an effective and relatively safe procedure for pain associated with pelvic malignancies. There is a need for larger prospective trials.
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Affiliation(s)
- Saiyun Hou
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, Texas
| | - Diane Novy
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, Texas
| | - Francis Felice
- Department of Anesthesiology, University of Texas Health Science Center, Houston, TX 77030
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31
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Lanzetti RM, Astone A, Pace V, D'Abbondanza L, Braghiroli L, Lupariello D, Altissimi M, Vadalà A, Spoliti M, Topa D, Perugia D, Caraffa A. Neurolysis versus anterior transposition of the ulnar nerve in cubital tunnel syndrome: a 12 years single secondary specialist centre experience. Musculoskelet Surg 2021; 105:69-74. [PMID: 32036564 DOI: 10.1007/s12306-020-00647-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 02/02/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Various conservative treatments and surgical techniques have been reported in the literature as efficient and feasible measures to treat the cubital tunnel syndrome. However, there has been no consensus on the best management of the syndrome, and uniform standardised guidelines have not yet been accepted or introduced. With our study, we present our experience on the clinical efficacies and outcomes of the surgical techniques of neurolysis alone and neurolysis associated with ulnar nerve anterior transposition at the elbow joint in patients with neuropathic symptoms due to cubital tunnel syndrome. MATERIALS AND METHODS A total of 107 patients with cubital tunnel syndrome were retrospectively enrolled, surgically treated and followed up in our study. The cohort was divided into two groups: 41 patients treated only with neurolysis of the ulnar nerve (Group 1), and 66 patients treated with neurolysis and anterior transposition (Group 2). Of the participants, 35 were women and 72 were men. The average age was 54 years. Significant comorbidities were preoperatively diagnosed in 26 patients. Conservative measures had been considered, followed by surgical management if appropriate. A pre-op electromyography was performed for all patients. All surgical procedures were performed by the same surgical team. A post-operative follow-up was carried out, and the findings were recorded. The "McGowan" and "Wilson and Krout" classifications and the DASH score were used. A satisfaction questionnaire was administered to all patients post-operatively at 2 weeks). RESULTS Ulnar nerve neurolysis and anterior transposition surgery were all successfully performed. Overall complications were post-operative haematoma (8%) and wound problems (5%). In 6% there was recurrence of symptoms. In 11% there was no improvement of symptoms. Pre-op McGowan classifications for groups 1 and 2 were 0% and 0% (grade 0), 21% and 24% (grade 1), 46% and 44% (grade 2), and 33% and 34% (grade 3), respectively. The post-op McGowan classifications were 34% and 37% (grade 0), 39% and 40% (grade 1), 23% and 20% (grade 2), and 4% and 3% (grade 3), respectively. The post-op Wilson and Krout classifications were 45% and 46% (excellent), 26% and 28% (good), 19% and 15% (fair), and 10% and 11% (poor), respectively. The DASH score means for groups 1 and 2 were 14.8 and 15.2, respectively. A negative Froment's sign was present in 73.2% and 71.2%, respectively. In Group 1, the post-op satisfaction questionnaire scores were 0 for one patient, 1 for four patients, 2 for seven patients, 3 for ten patients, 4 for twelve patients and 5 for seven patients. In Group 2, the post-op satisfaction questionnaire scores were 0 for three patients, 1 for nine patients, 2 for twelve patients, 3 for fifteen patients, 4 for eighteen patients and 5 for nine patients. CONCLUSIONS In our experience, the surgical technique to treat the cubital tunnel syndrome most efficiently and feasibly has not yet been established in terms of indications and outcomes. This is supported by the data present in the international literature. Good and similar results were obtained with neurolysis alone and neurolysis associated with anterior transposition of the ulnar nerve (in line with the international data). In conclusion, more high-quality studies of greater statistical power are needed to provide a consensus on the surgical indications and techniques to treat the cubital tunnel syndrome and to establish internationally standardised guidelines.
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Affiliation(s)
- R M Lanzetti
- Orthopaedics and Traumatology Unit, Department Emergency and Acceptance, San Camillo- Forlanini Hospital Rome, Rome, Italy.
- , Rome, Italy.
| | - A Astone
- Orthopaedics and Traumatology Unit, Università di Perugia, Perugia, Italy
| | - V Pace
- Orthopaedics and Traumatology Unit, Università di Perugia, Perugia, Italy
| | - L D'Abbondanza
- Orthopaedics and Traumatology Unit, Università di Perugia, Perugia, Italy
| | - L Braghiroli
- Orthopaedics and Traumatology Unit, Università di Perugia, Perugia, Italy
| | - D Lupariello
- Department of Surgical and Medical Sciences and Translational Medicine, "Sapienza" University of Rome, Rome, Italy
- Orthopaedic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - M Altissimi
- Orthopaedics and Traumatology Unit, Università di Perugia, Perugia, Italy
| | - A Vadalà
- Department of Surgical and Medical Sciences and Translational Medicine, "Sapienza" University of Rome, Rome, Italy
- Orthopaedic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - M Spoliti
- Orthopaedics and Traumatology Unit, Department Emergency and Acceptance, San Camillo- Forlanini Hospital Rome, Rome, Italy
| | - D Topa
- Orthopaedics and Traumatology Unit, Department Emergency and Acceptance, San Camillo- Forlanini Hospital Rome, Rome, Italy
| | - D Perugia
- Department of Surgical and Medical Sciences and Translational Medicine, "Sapienza" University of Rome, Rome, Italy
- Orthopaedic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - A Caraffa
- Orthopaedics and Traumatology Unit, Università di Perugia, Perugia, Italy
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32
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de Ruiter GCW, Wesstein M, Vlak MHM. Preoperative Ultrasound in Patients with Meralgia Paresthetica to Detect Anatomical Variations in the Course of the Lateral Femoral Cutaneous Nerve. World Neurosurg 2021; 149:e29-e35. [PMID: 33647484 DOI: 10.1016/j.wneu.2021.02.100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/20/2021] [Accepted: 02/21/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Sometimes during surgery for meralgia paresthetica, it can be difficult to find the lateral femoral cutaneous nerve (LFCN). The aims of this study were to study the prevalence of different anatomical variations in patients, compare preoperative ultrasound (US) data with intraoperative findings, and investigate the effect of type of anatomical variation on duration of surgery and success rate of localizing the LFCN. METHODS Fifty-four consecutive patients with idiopathic meralgia paresthetica who underwent either a neurolysis or neurectomy procedure were included. All patients preoperatively underwent US of the LFCN. Anatomical variations were categorized into type A, B, C, D, and E using the classification of Aszmann and Dellon. The cross-sectional area of the LFCN at the inguinal ligament and the distance of the LFCN to the anterior superior iliac spine were noted. Correlations with intraoperative findings were investigated, as well as the effect on duration of surgery and success rate of finding the LFCN. Clinical outcome was assessed using the Likert scale. RESULTS The most frequent anatomical variant was type B (79%), followed by type C (9%), D (5%), and E (7%). No type A was encountered. Correlation between preoperative US and intraoperative findings was 100%. During surgery, the LFCN could be identified in all cases. Duration of surgery did not significantly vary for the different anatomical variants. CONCLUSIONS Preoperative US is reliable in detecting anatomical variations of LFCN. This information can be very helpful in identifying the LFCN more frequently and easily during surgery, especially in more medial variants.
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Affiliation(s)
- Godard C W de Ruiter
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands.
| | - Michel Wesstein
- Department of Clinical Neurophysiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Monique H M Vlak
- Department of Clinical Neurophysiology, Haaglanden Medical Center, The Hague, The Netherlands
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Urits I, Schwartz R, Herman J, Berger AA, Lee D, Lee C, Zamarripa AM, Slovek A, Habib K, Manchikanti L, Kaye AD, Viswanath O. A Comprehensive Update of the Superior Hypogastric Block for the Management of Chronic Pelvic Pain. Curr Pain Headache Rep 2021; 25:13. [PMID: 33630172 DOI: 10.1007/s11916-020-00933-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW This is a comprehensive review of the superior hypogastric block for the management of chronic pelvic pain. It reviews the background, including etiology, epidemiology, and current treatment available for chronic pelvic pain. It then presents the superior hypogastric block and reviews the seminal and most recent evidence about its use in chronic pelvic pain. RECENT FINDINGS Several definitions exist for chronic pelvic pain (CPP), making the diagnosis more challenging for the clinician; however, they commonly describe continuous pain lasting 6 months in the pelvis, with an overwhelming majority of patients being reproductive-aged women. This pain is often one of mechanical, inflammatory, or neuropathic. It is generally underdiagnosed and affects anywhere between 5 and 26% of women. The diagnosis of chronic pelvic pain is clinical, consisting of mainly of a thorough history and physical and ruling out other causes. The pathophysiology is often endometriosis (70%) and also includes PID, adhesions, adenomyosis, uterine fibroids, chronic processes of the GI and urinary tracts, as well as pelvic-intrinsic musculoskeletal causes. Treatment includes physical therapy, cognitive behavioral therapy, and oral and parenteral opioids. Interventional techniques provide an added tier of treatment and may help to reduce the requirement for chronic opioid use. Superior hypogastric plexus block is one of the available interventional techniques; first described in 1990, it has been shown to provide long-lasting relief in 50-70% of patients who underwent the procedure. Two approaches described so far, both under fluoroscopy, have seen similar results. More recently, ultrasound and CT-guided procedures have also been described with similar success. The injectate includes local anesthetic, steroids, and neurolytic agents such as phenol or ethanol. CPP is a common debilitating condition. It is diagnosed clinically and is underdiagnosed globally. Current treatments can be helpful at times but may fall short of satisfactory pain relief. Interventional techniques provide an added layer of treatment as well as reduce the requirement for opioids. Superior hypogastric plexus block provides long-lasting relief in many patients, regardless of approach. Evidence level is limited, and further RCTs could help provide better tools for evaluation and patient selection.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA, USA
| | - Ruben Schwartz
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, FL, USA.
| | - Jared Herman
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Amnon A Berger
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - David Lee
- Department of Anesthesiology, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Christopher Lee
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Alec M Zamarripa
- Department of Anesthesiology, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Annabel Slovek
- Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA
| | - Kelly Habib
- Department of Anesthesiology, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA, USA.,Department of Anesthesiology, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.,Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
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Lu VM, Puffer RC, Everson MC, Gilder HE, Burks SS, Spinner RJ. Treating Morton's neuroma by injection, neurolysis, or neurectomy: a systematic review and meta-analysis of pain and satisfaction outcomes. Acta Neurochir (Wien) 2021; 163:531-43. [PMID: 32056015 DOI: 10.1007/s00701-020-04241-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Individual evidence suggests that multiple modalities can be used to treat entrapment pathology by Morton's neuroma, including injection, neurolysis, and neurectomy. However, their impacts on patient pain and satisfaction have yet to be fully defined or elucidated. Correspondingly, our aim was to pool systematically identified metadata and substantiate the impact of these different modalities in treating Morton's neuroma with respect to these outcomes. METHODS Searches of 7 electronic databases from inception to October 2019 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. The incidences of outcomes were extracted and pooled by random-effects meta-analysis of proportions. RESULTS A total of 35 articles satisfied all criteria, reporting a total of 2998 patients with Morton's neuroma managed by one of the three modalities. Incidence of complete pain relief after injection (43%; 95% CI, 23-64%) was significantly lower than neurolysis (68%; 95% CI, 51-84%) and neurectomy (74%; 95% CI, 66-82%) (P = 0.02). Incidence of complete satisfaction after injection (35%; 95% CI, 21-50%) was significantly lower than neurolysis (63%; 95% CI, 50-74%) and neurectomy (57%; 95% CI, 47-67%) (P < 0.01). The need to proceed to further surgery was significantly greater following injection (15%; 95% CI, 9-23%) versus neurolysis (2%; 95% CI, 0-4%) or neurectomy (5%; 95% CI, 3-7%) (P < 0.01). Incidence of procedural complications did not differ between modalities (P = 0.30). CONCLUSIONS Although all interventions demonstrated favorable procedural complication incidences, surgical interventions by either neurolysis or neurectomy appear to trend towards greater incidences of complete pain relief and complete patient satisfaction outcomes compared to injection treatment. The optimal decision-making algorithm for treatment for Morton's neuroma should incorporate these findings to better form and meet the expectations of patients.
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Boumediane M, Meyer N, Facca S, Pizza C, Liverneaux P. Revision surgery for carpal tunnel syndrome: a retrospective study comparing the combination of Canaletto® and Dynavisc® gel versus Dynavisc® gel alone. Hand Surg Rehabil 2021; 40:57-63. [PMID: 33144250 DOI: 10.1016/j.hansur.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 11/24/2022]
Abstract
The aim of this study was to assess the value of using a Canaletto® implant in combination with a gel composed of carboxymethylcellulose and polyethylene oxide in the surgical treatment of recurrent carpal tunnel syndrome (CTS). The case series included 31 patients with 32 hands operated for the second time for recurrent (22 cases) or recalcitrant (9 cases) CTS by neurolysis. The average patient age was 62 years. Dynavisc® gel alone was applied around the median nerve in the first 16 cases (Group I). The Canaletto® implant combined with Dynavisc® gel was used in the last 16 cases (group II). With an average follow up of 8 months (for group I) and 11 months (for group II), the pre/postoperative variation in pain assessed with a visual analog scale was 1.38/10 (group I) and 2.04/10 (group II), the QuickDASH score was 20.1/100 (Group I) and 20.48/100 (Group II), grip strength was 8% (Group I) and 20% (Group II), sensory nerve conduction speed was 23.20 m/s (group I) and 15.51 m/s (group II) and distal motor latency was 1.55 m/s (group I) and 1.21 m/s (group II). Ten patients recovered from hypoesthesia in both groups, 6 patients in group I and 2 patients in group II regained good trophicity of their superficial thenar muscles. Two patients from group II had not improved clinically although their electromyography had become normal. One patient from group II suffered a postoperative infection that required removal of the Canaletto® implant. He subsequently improved slightly. Our study found that for recurrent or recalcitrant CTS, the combination of Dynavisc® anti-adhesion gel around the median nerve and a Canaletto implant® after neurolysis results in outcomes that are as good as Dynavisc® alone, with a significant improvement of the QuickDASH score without the Canaletto®. In conclusion, the use of Dynavisc® gel alone around the median nerve after neurolysis seems to be as effective as other techniques described in literature but less invasive or time-consuming, and not associated with donor site morbidity such as the flexor tendon sheath.
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Le Hanneur M, Colas M, Serane-Fresnel J, Lafosse L, Grandjean A, Silvera J, Lafosse T. Endoscopic brachial plexus neurolysis in the management of infraclavicular nerve injuries due to glenohumeral dislocation. Injury 2020; 51:2592-600. [PMID: 32778326 DOI: 10.1016/j.injury.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Infraclavicular brachial plexus (BP) injury secondary to glenohumeral joint (GHJ) dislocation is a rather common complication, which may be accountable for long-lasting deficits. The purpose of this study was to assess the potential benefits of BP neurolysis in such presentation, using an endoscopic approach. MATERIALS AND METHODS All patients who underwent endoscopic BP neurolysis in the setting of infraclavicular BP palsy due to GHJ dislocation were included. Preoperative physical examination was conducted to classify the observed motor and sensitive deficits into nerves and/or cord lesions. Six weeks after the trauma, examination was repeated and endoscopic BP neurolysis was elected if no significant improvements were observed. If nerve ruptures and/or severe damages were identified during surgery, nerve reconstructions were conducted within a month; in other cases, follow-up examinations were conducted at 6 weeks, 3 and 6 months to assess the course of postoperative recovery. RESULTS Eleven patients were included, including 6 men and 5 women, with a mean age of 43 ± 23 years (16;73). Six patients had at least one cord involved, four patients had isolated axillary nerve palsy, and one patient had a complete BP palsy. In 7 patients with cord lesions and/or isolated axillary nerve palsy, at least grade-3 strength, according to the British Medical Research Council grading system, was noted in all affected muscles within 6 weeks following the neurolysis; after 3 months of follow-up, grade-4 strength was observed in all muscles, and all but patients but one had fully recovered within 6 months. In 3 patients with isolated axillary nerve palsy, complete nerve ruptures (n=2) and severe damages (n=1) were identified under scopic magnification; secondary nerve transfers were conducted to reanimate the axillary nerve, and all patients fully recovered within a year. In one patient with complete BP palsy, improvements started after 6 months of follow-up, and full recovery was yielded after 2 years. No intra- and/or postoperative complications were noted. CONCLUSIONS At the cost of minimal additional morbidity, endoscopic BP neurolysis appears to be a safe and reliable procedure to shorten recovery delays in most patients presenting with BP palsy due to GHJ dislocation.
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Sun H, He M, Pang J, Guo X, Huo Y, Ma J. Continuous Lumbar Sympathetic Blockade Enhances the Effect of Lumbar Sympatholysis on Refractory Diabetic Neuropathy: A Randomized Controlled Trial. Diabetes Ther 2020; 11:2647-2655. [PMID: 32915421 PMCID: PMC7547930 DOI: 10.1007/s13300-020-00918-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION There are a number of options for the symptomatic treatment of peripheral neuropathy, but the overall treatment outcomes remain unsatisfactory. METHODS A total of 60 patients with refractory diabetic neuropathy were randomly assigned to two groups. Patients in Group A were treated with computed tomography (CT)-guided sympathetic neurolysis with alcohol, and patients in Group B were treated with a combined therapy of CT-guided catheterization to achieve continuous lumbar block for 4 weeks followed by neurolysis with alcohol administered via the catheter. The outcomes of these two treatment strategies were then analyzed in terms of pain relief, blood flow in the lower limb microcirculation, plasma levels of inflammatory mediators, and complications. RESULTS The visual analog scale (VAS) pain scores of all patients after treatment decreased significantly at the different evaluation time points compared with pre-treatment values, with the intergroup analysis revealing that the VAS scores were lower in Group B patients than in Group A patients at all post-treatment time points. Skin temperature, capillary filling time, and blood oxygen saturation level were significantly improved in all patients at the 1- and 7-day post-treatment assessment compared to pre-treatment values, but patients in Group B showed a greater improvement. The plasma levels of inflammatory mediators were lower in all patients at the 7-day post-treatment assessment compared to pre-treatment values, with those of patients in Group B being statistically significantly lower than those of patients in Group A. CONCLUSION Combined treatment with continuous lumbar sympathetic block followed by neurolysis with alcohol provided more benefit in all assessed outcomes than sympathetic alcohol neurolysis alone. The results show that the procedures were associated with satisfactory safety outcomes and sustained analgesic effects, thereby providing clinical evidence supporting the use of this novel treatment for patients with painful diabetic neuropathy.
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Affiliation(s)
- Haiyan Sun
- Center of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Mingwei He
- Center of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Jinlei Pang
- Center of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Xiangfei Guo
- Center of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Yansong Huo
- Center of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Jun Ma
- Center of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
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Suzuki H, Matsui Y, Iwai T, Nishida M, Iwasaki N. Usefulness of ultrasonography for diagnosing iatrogenic spinal accessory nerve palsy after lymph node needle biopsy: a case report. BMC Musculoskelet Disord 2020; 21:712. [PMID: 33129299 PMCID: PMC7603778 DOI: 10.1186/s12891-020-03737-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background Spinal accessory nerve (SAN) palsy is rare in clinical settings. Iatrogenicity is the most common cause, with cervical lymph node biopsy accounting for > 50% of cases. However, SAN palsy after lymph node needle biopsy is extremely rare, and the injury site is difficult to identify because of the tiny needle mark. Case presentation A 26-year-old woman was referred to our hospital with left neck pain and difficulty abducting and shrugging her left shoulder after left cervical lymph node needle biopsy. Five weeks earlier, a needle biopsy had been performed at the surgery clinic because of suspected histiocytic necrotizing lymphadenitis. No trace of the needle biopsy site was found on the neck, but ultrasonography (US) showed SAN swelling within the posterior cervical triangle. At 3 months after the injury, her activities of daily living had not improved. Therefore, we decided to perform a surgical intervention after receiving informed consent. We performed neurolysis because the SAN was swollen in the area consistent with the US findings, and nerve continuity was preserved. Shoulder shrugging movement improved at 1 week postoperatively, and the trapezius muscle manual muscle testing score recovered to 5 at 1 year postoperatively. The swelling diameter on US gradually decreased from 1.8 mm preoperatively to 0.9 mm at 6 months. Conclusion We experienced a rare case in which US was useful for iatrogenic SAN palsy. Our results suggest that preoperative US is useful for localization of SAN palsy and that postoperative US for morphological evaluation of the SAN can help assess recovery.
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Affiliation(s)
- Hisataka Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Yuichiro Matsui
- Department of Orthopaedic Surgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan.
| | - Takahito Iwai
- Division of Laboratory and Transfusion Medicine/Diagnostic Center for Sonography, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Mutsumi Nishida
- Division of Laboratory and Transfusion Medicine/Diagnostic Center for Sonography, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
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Khan Y, Prakash S, Kalra P, Arora S, Dhal A. Functional Outcome of Early, Selective Surgical Nerve Decompression in Leprous Neuropathy. J Hand Surg Asian Pac Vol 2020; 25:407-416. [PMID: 33115348 DOI: 10.1142/s2424835520500435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Leprous neuropathy is a significant, yet preventable, cause of disability worldwide. Decompressive surgery and oral steroids have been used along with Multi Drug Therapy (MDT) for treating leprous neuropathy with varied success as reported in literature. Methods: We prospectively studied 16 peripheral nerves in 10 patients with leprous neuropathy of less than a year duration and not responding to steroid therapy in 3 weeks. The patients were divided into 2 groups: Group-A (decompressive nerve surgery was done within 12 weeks of onset of neurological deficit), and Group-B (nerve decompression was performed after 12 weeks from onset of neurological deficit). Post-operatively patients were assessed for regression of deformity, sensory, motor, vasomotor recovery and neuropathic pain. Results: Median age of patients was 32 years (range; 18 years to 46 years). Mean motor score and mean grip strength was significantly better for group A patients at 2 years follow-up (p < 0.05). Mean sensory score improved significantly in both the groups (p < 0.05). Similarly, mean VAS score for neuropathic pain improved significantly in both the groups (p < 0.05). Recovery of autonomic function was observed in 3 nerves in group A and 1 in group B. Conclusions: The cases who underwent nerve decompression surgery within 12 weeks had better functional outcomes, especially in terms of motor recovery, than those who were operated after that. Studies involving larger number of patients are required to draw firm conclusions.
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Affiliation(s)
- Yasim Khan
- Department of Orthopaedic Surgery, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi, India
| | - Saket Prakash
- Department of Orthopaedic Surgery, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi, India
| | - Pulkit Kalra
- Department of Orthopaedic Surgery, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi, India
| | - Sumit Arora
- Department of Orthopaedic Surgery, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi, India
| | - Anil Dhal
- Department of Orthopaedic Surgery, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi, India
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Yu X, Jiang Z, Pang L, Liu P. Surgical efficacy analysis of tarsal tunnel syndrome: a retrospective study of 107 patients. Cell Tissue Bank 2020; 22:115-122. [PMID: 33106965 DOI: 10.1007/s10561-020-09871-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its terminal branches compressed by its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. The current study was a retrospective study of 107 cases of patients with TTS, in which the onset characteristics were summarized, the factors that might affect the surgical treatment effects of TTS were discussed and analyzed. The syndrome diagnoses and treatment experiences of TTS were extracted and analyzed. In our cohort, TTS was more often found in middle-aged and older women. And the medial plantar nerve bundle was the most frequently affected nerve structure. The efficacy of surgical treatment were correlated to the causes of the disease, involved nerve bundles, methods of operation, and whether neurolysis of the epineurium was performed. Neurolysis of the epineurium is was recommended for patients with an enlarged tibial nerve due to impingement. The Singh method was recommended to release the tibial nerve and its branches. Patients with negative preoperative EMG results should carefully be cautious when considering their decision to undergo surgical treatment.
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Affiliation(s)
- Xin Yu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Ziping Jiang
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Lei Pang
- Department of Anesthesiology, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Pengcheng Liu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China.
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Hachinota A, Tada K, Yamamoto D, Nakajima T, Nakada M, Tsuchiya H. Preventive Effect of Alginate Gel Formulation on Perineural Adhesion. J Hand Surg Asian Pac Vol 2020; 25:164-171. [PMID: 32312202 DOI: 10.1142/s2424835520500186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Perineural adhesion is a potential complication of manipulating peripheral nerves. Using a model of median nerve manipulation in the carpal tunnel, perineural adhesion preventive effects of an alginate gel formulation were examined. Methods: After exposing carpal tunnels of Japanese white rabbits and dissecting the median nerve, the gliding floor was excised as much as possible and the transverse carpal ligament was repaired to induce a perineural tissue reaction. Prior to wound closure, 0.5 ml of alginate gel formulation was administered into the right carpal tunnel (formulation group) and 0.5 ml of physiological saline was administered into the left carpal tunnel (control group). At 1, 2, 3, and 6 weeks after treatment, electrophysiological evaluation of thenar distal latency, macroscopic evaluation with adhesion score, and pathological evaluation of carpal tunnel cross sections were performed (N = 4-5 at each time point). Results: Although distal latency tended to be low in the formulation group, there was no significant difference between the groups according to electrophysiological evaluation. Macroscopic evaluation revealed that the adhesion score was always lower in the formulation group than in the control group; over the course of treatment, it remained unchanged in the formulation group, but peaked at 3 weeks after treatment in the control group. In pathological evaluation, neural perfusion peaked at 2-3 weeks after treatment in both groups; neural perfusion tended to be lower in the formulation group than in the control group. Conclusions: Results suggested that the peak tissue response associated with nerve dissection occurred 2-3 weeks after treatment and that the repair process started subsequently. The alginate gel formulation modified the surrounding environment of the nerve and promoted repair by acting as a physical barrier against perineural fibrosis. The preventive effect of alginate gel on perineural adhesion may improve treatment outcomes of constrictive neuropathy.
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Affiliation(s)
- Ai Hachinota
- Department of Orthpaedic Surgery, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
| | - Kaoru Tada
- Department of Orthpaedic Surgery, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
| | - Daiki Yamamoto
- Department of Orthpaedic Surgery, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
| | - Tadahiro Nakajima
- Department of Orthpaedic Surgery, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
| | - Mika Nakada
- Department of Orthpaedic Surgery, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthpaedic Surgery, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
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Spielman AF, Sankaranarayanan S, Skowronski P, Lessard AS, Panthaki Z. Recurrent and persistent carpal tunnel syndrome: "Triple-therapy approach". J Orthop 2020; 22:431-435. [PMID: 33041567 DOI: 10.1016/j.jor.2020.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 07/24/2020] [Accepted: 09/06/2020] [Indexed: 12/31/2022] Open
Abstract
Background Various procedures have been described for patients undergoing a revision carpal tunnel release. These can include repeat open decompression with external or internal neurolysis, tenosynovectomy, endoscopic release, various flap techniques, saphenous vein wrapping and use of prosthetic implants. This study reports a case series of 30 consecutive patients who underwent revision carpal tunnel release at single institution from 2012 to 2018. Our surgical plan in all the patients involved a combination of these three techniques (triple therapy approach): neurolysis (external or internal) and tenosynovectomy, collagen matrix conduit wrap (NeuraWrap; Integra LifeSciences or Axoguard Nerve Protector, AxoGen Inc), and hypothenar fat flap. Materials and methods A total of 30 patient records were identified. The index surgery was performed by a variety of surgeons at varied private institutions as well as the VA hospital. However, all of the revision interventions in this series were performed by the senior author (Z.J.P.). Demographic data (age, sex, hand dominance, comorbidities, alcohol, and smoking history) were collected. Preoperative and postoperative symptoms were recorded for all patients, including: subjective outcomes, need for additional surgery and complications. Mean VAS preoperatively and postoperatively were compared using a paired t-test. All statistical analyses were performed with SPSS 20 (IBM, Chicago, IL). Results Patient reported measures of resolution of symptoms and VAS scores documented at 3 months. Of the 30 patients who underwent surgery for persistent or recurrent carpal tunnel syndrome, symptoms resolved completely in 25 patients. 2 patients were lost to follow up. 3 patients showed no improvement. The mean preoperative VAS score was 4.37 and declined to 1.23 after surgery (P < .0001). Conclusion Our study demonstrates that a combination of neurolysis and tenosynovectomy along with a nerve wrap and hypothenar fat flap should be considered in patients presenting with recurrent or persistent carpal tunnel syndrome.
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Affiliation(s)
| | | | - Piotr Skowronski
- Burn and Reconstructive Centers of America, Doctors Hospital, Augusta, GA, USA
| | - Anne-Sophie Lessard
- Division of Plastic and Reconstructive Surgery, DeWitt Daughtry Department of Surgery, Miami, FL, USA
| | - Zubin Panthaki
- Division of Plastic and Reconstructive Surgery, DeWitt Daughtry Department of Surgery, Miami, FL, USA
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Ayache A, Unglaub F, Tsolakidis S, Schmidhammer R, Löw S, Langer MF, Spies CK. [Revision surgery for carpal and cubital tunnel syndrome]. Orthopade 2020; 49:751-761. [PMID: 32857166 DOI: 10.1007/s00132-020-03969-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Carpal tunnel syndrome, a compressive neuropathy of the median nerve at the wrist and cubital tunnel syndrome, a compressive neuropathy of the ulnar nerve at the elbow, are the two most common peripheral nerve compression syndromes. Chronic compressive neuropathy of peripheral nerves causes pain, paraesthesia and paresis. Treatment strategies include conservative options, but only surgical decompression can resolve the mechanical entrapment of the nerve with proven good clinical results. However, revision rates for persistent or recurrent carpal tunnel syndrome is estimated at around 5% and for refractory cubital tunnel syndrome at around 19%. Common causes for failure include incomplete release of the entrapment and postoperative perineural scarring. THERAPY Precise diagnostic work-up is obligatory before revision surgery. The strategy of revision surgery is first complete decompression of the affected nerve and then providing a healthy, vascularized perineural environment to allow nerve gliding and nerve healing and to avoid recurrent scarring. Various surgical options may be considered in revision surgery, including neurolysis, nerve wrapping and nerve repair. In addition, flaps may provide a well vascularized nerve coverage in the case of recurrent carpal tunnel syndrome. In the case of recurrent cubital tunnel syndrome, anterior transposition of the ulnar nerve is mostly performed for this purpose. RESULTS In general, revision surgery leads to improvement of symptoms, although the outcome of revision surgery is less favourable than after primary surgery and complete resolution of symptoms is unlikely.
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Affiliation(s)
- A Ayache
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland
| | - F Unglaub
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland.,Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - S Tsolakidis
- Millesi Center, Nervenchirurgie und Rekonstruktive Chirurgie, Wien, Österreich
| | - R Schmidhammer
- Millesi Center, Nervenchirurgie und Rekonstruktive Chirurgie, Wien, Österreich
| | - S Löw
- Praxis für Handchirurgie und Unfallchirurgie, Bad Mergentheim, Deutschland
| | - M F Langer
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - C K Spies
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland.
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Van Royen K, Berghs B. Entrapment of the Median Nerve after Elastic Intramedullary Nailing of a Pediatric Forearm Fracture. J Hand Surg Asian Pac Vol 2020; 25:232-235. [PMID: 32312210 DOI: 10.1142/s2424835520720066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Closed reduction and fixation with elastic intramedullary nails is a popular technique to treat displaced pediatric forearm fractures and has yielded good functional results. Postoperative neurological symptoms can be due to neuropraxia and expectative treatment has been advised for 3 months until further investigation is necessary. We present a case of an 11-year-old boy that presented with median nerve palsy 2 months after a displaced forearm fracture treated with elastic intramedullary nails. Ultrasound and nerve conduction study confirmed the presence of a median nerve entrapped in the callus of the radial fracture. Surgical exploration demonstrated that the nerve was twisted around the intramedullary device. After neurolysis and surgical repair the patient finally recovered 2 years after the operation. This case highlights the possibility of median nerve entrapment after reduction with elastic intramedullary nails. Symptoms should be recognized early, and urgent surgical exploration is needed to prevent irreversible damage.
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Affiliation(s)
- Kjell Van Royen
- Department of Orthopaedics and Traumatology, Upper Limb Unit, Orthoclinic, AZ Sint-Jan AV Brugge, Bruges, Belgium
| | - Bart Berghs
- Department of Orthopaedics and Traumatology, Upper Limb Unit, Orthoclinic, AZ Sint-Jan AV Brugge, Bruges, Belgium
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Atthakomol P, Oflazoglu K, Eberlin KR, Winograd J, Chen NC, Lee SG. Obesity status is a risk factor for secondary surgery after neurolysis, direct nerve repair or nerve grafting in traumatic brachial plexus injury: a retrospective cohort study. BMC Surg 2020; 20:73. [PMID: 32295588 PMCID: PMC7160993 DOI: 10.1186/s12893-020-00737-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 04/06/2020] [Indexed: 11/30/2022] Open
Abstract
Background The objective of the study was to investigate the association between obesity and the presence of secondary surgery following neurolysis, direct nerve repair, or nerve grafting in patients with traumatic brachial plexus injury. Methods In this retrospective chart review spanning two Level I medical centers in a single metropolitan area, 57 patients who underwent neurolysis, direct nerve repair, or nerve grafting for brachial plexus injuries between 2002 and 2015 were identified. Risk regression analysis was used to evaluate the association between obesity status and secondary surgery. Results After controlling for the confounding variables of age, high energy injury, associated shoulder dislocation and associated clavicle fracture using multivariate regression (risk regression), the risk ratio of secondary surgery in obese patients compared to non-obese patients was 6.99 (P = 0.028). The most common secondary surgery was tendon or local muscle transfer. Conclusions There is an increased risk of secondary surgery in obese patients compared to non-obese patients of the same age and with the same severity of injury. The increased risk may be due to challenges related to powering a heavier upper extremity. A weight reduction program might be considered as part of the preoperative strategy.
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Affiliation(s)
- Pichitchai Atthakomol
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA. .,Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. .,Musculoskeletal Science and Translational Research Center, Chiang Mai University, Chiang Mai, Thailand.
| | - Kamilcan Oflazoglu
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kyle R Eberlin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Winograd
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Neal C Chen
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sang-Gil Lee
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Lu VM, Spinner RJ. Morton's neuroma as a surgical example of entrapment syndrome. J Plast Reconstr Aesthet Surg 2020; 73:1105-1106. [PMID: 32178989 DOI: 10.1016/j.bjps.2020.02.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/25/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Victor M Lu
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, US
| | - Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, US.
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Häckel S, Albers CE, Bastian JD, Hoppe S, Benneker LM, Keel MJB. Direct anterior decompression of L4 and L5 nerve root in sacral fractures using the pararectus approach: a technical note. Arch Orthop Trauma Surg 2020; 140:343-51. [PMID: 31520112 DOI: 10.1007/s00402-019-03276-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To describe a new surgical technique for neurolysis and decompression of L4 and L5 nerve root entrapment after vertical sacral fractures via the pararectus approach for acetabular fractures, and to present four case examples. PATIENTS AND METHODS We retrospectively evaluated four patients suffering radiculopathy from entrapment of the L4 or L5 nerve root in vertical sacral fractures between January and December 2016. The mean follow-up period after surgery was 18 (range 7-27) months. All patients underwent direct decompression and neurolysis of the L4 and L5 nerve roots via the single-incision, intrapelvic, extraperitoneal pararectus approach. RESULTS In all patients, the L4 and L5 nerve root was successfully visualized and decompressed, proving feasibility of the pararectus approach for this indication. No patient presented with a neural tear. Complete neurologic recovery was present in one patient at last follow-up; two patients had incomplete recovery of their radiculopathy; and one patient had no improvement after nerve root decompression. CONCLUSIONS The pararectus approach allows for sufficient visualisation and direct decompression and neurolysis of the L4 and L5 nerve root entrapped in vertical sacral fractures. Although neurologic recovery was not achieved in all patients in this small case series, the approach may be a suitable alternative to posterior approaches and other anterior approaches such as the lateral window of the ilioinguinal approach.
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Song JH, Kang C, Hwang DS, Kang DH, Kim YH. Dorsal suspension for Morton's neuroma: A comparison with neurectomy. Foot Ankle Surg 2019; 25:748-754. [PMID: 30342917 DOI: 10.1016/j.fas.2018.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 08/07/2018] [Accepted: 09/26/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to investigate and compare the clinical outcomes of dorsal suspension with those of neurectomy for the treatment of Morton's neuroma. METHODS We conducted a retrospective study of dorsal suspension and neurectomy group. The dorsal suspension was performed by dorsal transposition of neuroma over the dorsal transverse ligament after neurolysis. The visual analog scale (VAS), the Foot and Ankle Ability Measure (FAAM), postoperative satisfaction, and complications were evaluated. RESULTS Both groups reported significant pain relief, and there were no significant differences between the groups with respect to postoperative pain. The postoperative FAAM outcomes showed no significant between-group differences. Satisfaction analysis showed 'excellent' and 'good' results in the dorsal suspension and neurectomy groups (95% and 77.7%, respectively). Complications of numbness and paresthesia reported in the dorsal suspension group (5% and 5%, respectively) were significantly fewer than those of neurectomy group (61.1% and 33.3%, respectively) (both, p<.05). CONCLUSIONS With its favorable results, dorsal suspension can be another operative option for the treatment of Morton's neuroma. LEVEL OF EVIDENCE Level III, retrospective comparative case series.
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Affiliation(s)
- Jae Hwang Song
- Department of Orthopedic Surgery, Konyang University Hospital, Konyang University School of Medicine, Daejeon, South Korea
| | - Chan Kang
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea.
| | - Deuk Soo Hwang
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Dong Hun Kang
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Yong Hwan Kim
- Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
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Uemura T, Takamatsu K, Okada M, Yokoi T, Onode E, Miyashima Y, Konishi S, Nakamura H. A case series of seven patients with recurrent median nerve neuropathy treated by the revision surgery of median nerve neurolysis and wrapping with radial artery perforator adipose flap. J Plast Reconstr Aesthet Surg 2019; 73:453-459. [PMID: 31757685 DOI: 10.1016/j.bjps.2019.09.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/09/2019] [Accepted: 09/28/2019] [Indexed: 11/19/2022]
Abstract
Adhesion neuropathy of the median nerve with persistent pain can be a challenging problem. Currently, coverage of the median nerve with a well-vascularized soft tissue is deemed necessary after secondary neurolysis. Herein, we reviewed the outcomes of seven patients with a persistent median nerve neuropathy after a primary open carpal tunnel release or a median nerve repair, treated with neurolysis and median nerve wrapping with radial artery perforator adipose flaps. During the revision surgery, after a careful and complete neurolysis of the scarred median nerve, the distally based radial artery perforator adipose flap without its fascia was raised and rotated to wrap the median nerve. The mean size of the perforator flap was 1146 mm2, which was enough to wrap the median nerve in all patients. At 26 months postsurgery, both the visual analog scale score for pain with tingling, and the patient-reported outcome measures improved. There was no recurrence of the median nerve adhesion neuropathy and no major complications were noted. Tinel's sign at the palmar wrist completely disappeared in four patients and was relieved in three patients. The median distal motor latency becomes recordable, and closer to a normal compound motor action potential postoperatively in all patients. Secondary neurolysis and median nerve wrapping with a radial artery perforator adipose flap, which was modified to be softer and thinner than the radial artery perforator adipofascial flap, was a successful treatment for the recurrent median nerve neuropathy in terms of both pain relief and restoration of the hand function.
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Affiliation(s)
- Takuya Uemura
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, 1-2-22 Matsuzakicho, Abeno-ku, Osaka 545-0053, Japan; Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan.
| | - Kiyohito Takamatsu
- Department of Orthopaedic Surgery, Yodogawa Christian Hospital, 1-7-50 Kunijima, Higashiyodogawa-ku, Osaka 533-0024, Japan
| | - Mitsuhiro Okada
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Takuya Yokoi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Ema Onode
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Yusuke Miyashima
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, 1-2-22 Matsuzakicho, Abeno-ku, Osaka 545-0053, Japan
| | - Sadahiko Konishi
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, 1-2-22 Matsuzakicho, Abeno-ku, Osaka 545-0053, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
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Abstract
PURPOSE OF REVIEW Chronic pain of the lower extremity remains challenging to manage. Radiofrequency ablation procedure applies heat to nerve fibers with the goal of mitigating chronic pain conditions of the knee. However, the clinical efficacy has not yet been adequately established. The goal of this review paper is to report the use of radiofrequency ablations in the treatment of osteoarthritis of the knee. RECENT FINDINGS PubMed and the Cochrane Controlled Trials Register were searched (final search 28 February 2018) using the MeSH terms "radiofrequency ablation," "neurolysis," "radiofrequency therapy," "pain syndrome," "analgesia," and "pain" in the English literature. Bibliographies of the published papers were screened for relevance to lower extremity radiofrequency ablation therapies. The quality of selected publications was assessed using the Cochrane risk of bias instrument. Of the 923 papers screened, 317 were further investigated for relevance. Our final search methodology yielded 19 studies that investigated the use of radiofrequency ablation at the knee. Of these 19 studies, there were four randomized control trials, two non-randomized control trials, three prospective studies, two retrospective studies, one case-control study, one technical report, and seven case reports. In summary, the data available suggests radiofrequency ablation as a promising and efficacious with all 19 studies revealing significant short- and long-term pain reductions in patients with knee pain.
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