Influence of nerve identification and the resection of nerves ‘at risk’ on postoperative pain in open inguinal hernia repair

Background  

Surgical strategy regarding nerve identification and resection in relation to chronic postoperative pain remains controversial. A central question is whether nerves in the operation field, when identified, should be preserved or resected. In the present study, the hypotheses that the identification and consequent resection of nerves ‘at risk’ have no influence on postoperative pain has been tested.     

Existe-t-il un retentissement sur la jonction neuromusculaire de rat lors de lésions du système nerveux central ?: Étude morphologique en microscopie confocale et technique de Koelle

State of the artIn humans, it is currently believed that peripheral nerves remain intact after central nervous system (CNS) injuries. This should lead us to observe a lack of amyotrophy in the peripheral projection areas of CNS damage. Nevertheless, the appearance of amyotrophy, described as underuse amyotrophy, is common in victims of CNS injury. Its pathophysiology remains poorly understood and is currently being debated. Amyotrophy could result directly from the structural deterioration of a nervous fiber in the muscular area corresponding to the CNS injury caused by neuromuscular junction (NMJ) changes.Aims of this studyThe aims of this study were to assess the repercussions of a CNS injury on the NMJ and peripheral nerve complex and to evaluate the involvement of peripheral nerves and NMJs in plasticity.MethodologyPeripheral nerve and muscle biopsies were collected from a group of 35 female Wistar rats that had previously undergone a thoracic spinal cord hemisection (15 rats at the T2 level (group 1), 15 rats at the T6 level (group 2), and 5 matched rats used as controls). We studied the localization and expression of the NMJ molecular components in muscle specimens by immunohistochemistry using confocal microscopy. We also searched for signs of nerve and muscle degeneration using light and electron microscopy.ResultsWe observed nonpathologic NMJs coexisting with completely denervated and partially reinnervated NMJs. We also found characteristics of embryonic behavior in rat axons secondary to axonal caliber distortions. Some authors associate this decrease in axonal activity with physiological denervation.ConclusionThis project was designed to improve the understanding of the mechanisms involved in the interactions between the first and second motoneurons after different types of CNS injuries, with variable functional repercussions. Our results strongly suggest that CNS injuries lead to both morphological and functional repercussions at the NMJ and the peripheral nerve.     

Decompression of peripheral nerves for diabetic neuropathy in the lower extremity

Consideration of the presence of a compressive neuropathy overlying an existing diabetic neuropathy in symptomatic patients and surgical decompression of these compressed nerves in selected patients is presented. The short-term results of 33 lower extremities treated with external neurolysis of the common peroneal, deep peroneal, and tarsal tunnel nerves are presented with a mean follow-up time of 3 months (range, 1 to 6 months). The surgery was performed in an attempt to relieve pain and to restore normal sensation in the foot. All procedures were performed under spinal or general anesthesia. Candidates for the procedure were type 1 or type 2 diabetics with symptomatic somatosensory neuropathy (pain, burning, tingling, and/or numbness) and preoperative computer-assisted neurosensory testing that confirmed the presence of elevated nerve threshold levels and axonal degeneration in the foot and leg. External neurolysis of the involved nerves provided good to excellent results in 90.0% of those patients with preoperative neuropathic pain, and restored sensation at good to excellent levels in 66.7% of those patients with preoperative neuropathic numbness. The mean visual analog score for pain assessment was 9.0 preoperatively and 3.2 postoperatively for those patients with pain as a symptomatic complaint (n = 30). There were 4 complications (12%) and all were early cases consisting of a noninfected wound dehiscence of the tarsal tunnel incision, which went on to heal without consequence. These initial short-term results suggest that external neurolysis of the common peroneal, deep peroneal, and tarsal tunnel nerves in selected patients with symptomatic diabetic neuropathy and an overlying compression neuropathy as determined by using computer-assisted neurosensory testing appears to be an effective treatment for providing pain relief and restoration of sensation in the foot.     

Diabetic lumbosacral polyradiculoneuropathies

Opinion statement  

The role of peripheral nerve stimulation in the era of ultrasound-guided regional anaesthesia

With the widespread use of ultrasound for localising nerves during peripheral nerve blockade, the value of electrical nerve stimulation of evoked motor responses has been questioned. Studies continue to show that, compared with nerve stimulation, ultrasound guidance alone leads to: significantly improved block success; decreased need for rescue analgesia; decreased procedural pain; and lower rates of vascular puncture. Nerve stimulation combined with ultrasound does also not appear to improve block success rates, apart from those blocks where the nerves are challenging to view, such as the obturator nerve. The role of nerve stimulation has changed in the last 15 years from a technique to locate nerves to that of an adjunct to ultrasound. Nerve stimulation can serve as a monitor against needle-nerve contact and may be useful in avoiding nerves that are in the needle trajectory during specific ultrasound guided techniques. Nerve stimulation is also a useful adjunct in teaching novices ultrasound-guided regional anaesthesia, especially when the position and or appearance of nerves may be variable. In this review, the changing role of nerve stimulation in contemporary regional anaesthetic practice is presented and discussed.     

Effect of corticosteroid injection for trochanter pain syndrome: design of a randomised clinical trial in general practice

Background  

Regional pain in the hip in adults is a common cause of a general practitioner visit. A considerable part of patients suffer from (greater) trochanteric pain syndrome or trochanteric bursitis. Local corticosteroid injections is one of the treatment options. Although clear evidence is lacking, small observational studies suggest that this treatment is effective in the short-term follow-up. So far, there are no randomised controlled trials available evaluating the efficacy of injection therapy.     

Neuralgic amyotrophy (Parsonage-Turner syndrome)

Neuralgic amyotrophy (Parsonage-Turner syndrome or brachial plexus neuritis) is an uncommon syndrome whose cause is unknown. The suprascapular and axillary nerves and corresponding muscles are affected most frequently. The disorder exhibits a broad range of clinical manifestations, and patients frequently present to physicians of different subspecialties. Accurate diagnosis can be challenging and requires a thorough history and physical examination. Nerve conduction velocity and imaging studies assist in the evaluation. Treatment consists of symptomatic management. Symptoms can persist for more than than a year, but most patients note resolution of symptoms over time.     

Ultrasound-guided genicular nerves block vs. local infiltration analgesia for total knee arthroplasty: a randomised controlled non-inferiority trial

Genicular nerves block is a promising technique to treat acute postoperative pain in total knee arthroplasty. Similar to surgeon-administered local infiltration analgesia, it targets sensory branches from the knee capsule, but through a selective ultrasound-guided injection that reduces local anaesthetic dose (150 ml ropivacaine 0.2% with local infiltration analgesia vs. 20 ml with genicular nerves block). This randomised non-inferiority trial compared the analgesic efficacy of genicular nerves block vs. local infiltration analgesia in the first 24 h following total knee arthroplasty. Sixty patients were randomly allocated to receive either ultrasound-guided block of five genicular nerves or local infiltration analgesia. The primary outcome was rest pain numeric rating scale (0–10) at 24 h. Secondary outcomes included pain numeric rating scale (rest and movement) and cumulative opioid consumption during the first 24 h. We analysed 29 patients in the genicular nerves block group and 30 in the local infiltration analgesia group. We found that the median difference (95%CI) in postoperative rest pain at 24 h (non-inferiority criteria, Δ = 1) was −1.0 (−2.0 to 1.0, p < 0.001). Median difference in cumulative opioid consumption was 0.0 mg (−3.0–5.0, p < 0.001) meeting the non-inferiority criteria, Δ = 23 mg. We conclude that genicular nerves block of five nerves provides non-inferior analgesia in the first 24 h following surgery compared with local infiltration analgesia, but with a considerable reduction in the local anaesthetic dose.     

Hernia repair: why do we continue to perform mesh repair in the face of the human toll of inguinodynia?

Fifteen to 20 years ago, transversalis and Shouldice Hospital repairs were standard, with a 4% to 6% rate of recurrence. With a focus on recurrence, various mesh repairs were proposed to reduce the incidence of recurrence. With these repairs, an increased incidence of inguinodynia due to the entrapment of the nerves proximate (adjacent) to the mesh has been observed. Many surgeons doubted its existence; however, there is sufficient evidence that with mesh repair in which the affected nerves are resected, the incidence of severe pain is lessened considerably. Triple neurectomy has been proposed as a therapy, but only 80% of patients are relieved of pain. Recurrence is insufficient to make patients' lives miserable, with mesh repair reporting up to a 21% incidence of inguinodynia. Although few surgeons today perform this procedure and most residents have never seen it, the author proposes that mesh repairs be abandoned and the transversalis or Shouldice Hospital repair be adopted.     

Diabetic amyotrophy coexisting with lumbar disk herniation and stenosis: a case report

BACKGROUND: Clinical differentiation of diabetic neuropathy from HLD or lumbar stenosis may be difficult. The issue of misdiagnosis has been discussed as a reason for poor outcome after lumbar spine surgery. The authors report a case of diabetic amyotrophy coexisting with, rather than misdiagnosis of, HLD or lumbar stenosis. CASE DESCRIPTION: This 68-year-old female diabetic patient had left sciatic pain for 3 months, and the pain was suddenly aggravated for the last 1 week. She underwent foraminotomy and diskectomy for herniated disk and stenosis at L4-5 level because of failure of conservative treatment, positive SLR test result, and radiologic evidence of disk herniation and stenosis without electrodiagnostic study or consideration of the possibility of diabetic neuropathy. Distal leg pain was resolved, but proximal thigh pain persisted after surgery. During 1 month after surgery, thigh pain got worse, and weakness of left leg developed. Electrodiagnostic study revealed diabetic amyotrophy. She was treated with a tricyclic antidepressant and an antiepileptic drug. Pain and weakness improved incompletely 8 months after medication. CONCLUSION: Electrodiagnostic and radiologic studies should be used in every diabetic patient presenting with leg pain and/or weakness to differentiate diabetic neuropathy from HLD, lumbar stenosis, or other space-occupying lesion. Thorough history taking and neurologic examination are needed to differentiate between these diseases, and the possibility of coexistence of or overlapping with these diseases should be considered. When the 2 diseases coexist as pain sources, treatment of both diseases may be needed for relief of the patient's pain.     

Cervical spondylotic amyotrophy

Cervical spondylotic amyotrophy is characterized with weakness and wasting of upper limb muscles without sensory or lower limb involvement. Two different mechanisms have been proposed in the pathophysiology of cervical spondylotic amyotrophy. One is selective damage to the ventral root or the anterior horn, and the other is vascular insufficiency to the anterior horn cell. Cervical spondylotic amyotrophy is classified according to the most predominantly affected muscle groups as either proximal-type (scapular, deltoid, and biceps) or distal-type (triceps, forearm, and hand). Although cervical spondylotic amyotrophy always follows a self-limited course, it remains a great challenge for spine surgeons. Treatment of cervical spondylotic amyotrophy includes conservative and operative management. The methods of operative management for cervical spondylotic amyotrophy are still controversial. Anterior decompression and fusion or laminoplasty with or without foraminotomy is undertaken. Surgical outcomes of distal-type patients are inferior to those of proximal-type patients.     

Surgical experience of laparoscopic retroperitoneal triple neurectomy for a patient with chronic neuropathic inguinodynia

BackgroundNeuropathic inguinodynia following inguinal hernia repair sometimes becomes a disabling disease. We report a case of successful surgical treatment of chronic refractory neuropathic pain after inguinal hernia by laparoscopic retroperitoneal triple neurectomy.Case presentationA seventy-year-old male who underwent right-side inguinal hernia repair using the Lichtenstein method revisited our hospital with inguinodynia 16 months after surgery. After a thorough assessment, the patient was diagnosed with neuropathic pain based on the following: 1) dermatomal mapping suggested ilioinguinal and iliohypogastric nerve problems, 2) pain was evoked by specific movement, 3) the site of maximum pain was slightly changed at every physical examination, and 4) no evidence of recurrence or meshoma was observed on MRI. Conservative therapies were ineffective. Surgical intervention using laparoscopic retroperitoneal triple neurectomy was performed 4 months after treatment initiation. In the lateral recumbent position, a three-port method was used. The ilioinguinal and iliohypogastric nerves and the genital branch of the genitofemoral nerves were identified and resected. Although a residual nerve emerged from L2/3 toward the inguinal region, the nerve remained in situ. Pain assessment 3 h after surgery revealed that pain was decreased but remained. Reoperation involving resection of the residual nerve was performed on the same day. Although another type of mild pain appeared 3 months after surgery, the patient resumed normal life, without any restrictions.ConclusionsLaparoscopic retroperitoneal triple neurectomy is useful for treating refractory neuropathic pain. The diagnosis of neuropathic pain via thorough preoperative assessment is vital for procedure success because the procedure would not be effective for other types of pain.     

Psychopathology predicts the outcome of medial branch blocks with corticosteroid for chronic axial low back or cervical pain: a prospective cohort study

Background  

Comorbid psychopathology is an important predictor of poor outcome for many types of treatments for back or neck pain. But it is unknown if this applies to the results of medial branch blocks (MBBs) for chronic low back or neck pain, which involves injecting the medial branch of the dorsal ramus nerves that innervate the facet joints. The objective of this study was to determine whether high levels of psychopathology are predictive of pain relief after MBB injections in the lumbar or cervical spine.     

The use & abuse of antiseptics

Diagnostic novocaine block is a safe and simple procedure. We have used it to date in 29 cases with only a single confusing result.It gives both the surgeon and the patient an exact idea of what a proposed operation on the peripheral nerves or sympathetic ganglia is capable of accomplishing.It shows just which spinal nerves or sympathetic rami are conducting pain and how many must be interrupted to desensitize the patient.In peripheral circulatory disease novocaine block of the regional vasomotor nerves shows in a quantitative fashion how much circulation can be improved by ganglionectomy.The test has proved to be of the greatest value in planning new ways of relieving pain in angina pectoris, aneurysm, tabes dorsalis, causalgia, amputation stump neuralgias, and other conditions of unknown cause.     

Cervical radiculopathy, entrapment neuropathy, and thoracic outlet syndrome: how to differentiate? Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

The common diagnoses of cervical radiculopathy and upper-extremity entrapment neuropathies can at times be difficult to differentiate. Additionally, thoracic outlet syndrome is often diagnosed when, in fact, the problem is radiculopathy or neuropathy. Another source of confusion, especially in older patients, is neuralgic amyotrophy, brachial plexitis, or the Parsonage-Turner syndrome. The differential diagnosis of unilateral arm pain, weakness, and/or sensory loss includes all of these problems. The clinical and electrodiagnostic features of each are discussed as an aid to distinguishing between these common and similar entities.     

Diabetic amyotrophy masquerading as quadriceps tendon rupture: a word of caution.

Diabetic amyotrophy is predominantly a motor condition that involves various elements of the lumbosacral plexus but particularly that related to the femoral nerve. (1,3) It can present acutely as unilateral thigh pain followed by the development of weakness and later wasting in the femoral muscles, usually first seen in the quadriceps. We report on two cases of diabetic amyotrophy from different hospitals that presented with clinical signs and symptoms of quadriceps rupture. These patients underwent surgical exploration but in both the quadriceps tendons were found to be intact. Post-operative neurological consultations established the diagnosis as diabetic amyotrophy, which was confirmed with electrodiagnostic studies. We conclude that any quadriceps rupture in diabetics should be viewed with caution. Electrodiagnostic studies and imaging with ultrasound and magnetic resonance imaging should be carried out before exploratory surgery.     

Traitement neurochirurgical de la névralgie vago-glossopharyngienne

Glossopharyngeal neuralgia, more accurately called vago-glossopharyngeal neuralgia (VGPN) because of the frequent association with pain irradiation in the sensory territory of the vagus nerve, is not always recognized because its incidence is much lower than the incidence of trigeminal neuralgia (100 times more frequent). As in trigeminal neuralgia, when pain becomes resistant to anticonvulsants - its specific medical treatment - VGPN can almost always be cured by surgery. The first option is microvascular decompression, since vascular compression is the main cause of the neuralgia. Percutaneous thermorhizotomy at the foramen jugularis (pars nervosa) is only indicated as a second option, because of unavoidable sensorimotor deficits in the ninth and tenth nerves. Tractonucleotomies at the medullary level should be reserved essentially for pain of malignant origin.     

Treatment by collagen conduit of painful post-traumatic neuromas of the sensitive digital nerve: A retrospective study of 10 cases

ObjectivesThe purpose of this retrospective study was to report the results of surgery in painful post-traumatic neuromas of the digital nerves treated by collagen conduits after excision of the neuromas, when two stumps were available.MethodsWe retrospectively reviewed all patients operated on for painful neuroma in our institution and having undergone repair with collagen conduits. Their files were retrieved by a coding file (CCAM version 10). Ten patients involving nine digital nerves and one common digital nerve were included. Primary outcome data points were static two-point discrimination, Semmes-Weinstein monofilament testing, Quick-Dash outcome survey scores, Cold Intolerance Symptom Severity (CISS) score and recurrence of pain at final follow-up. We set up a minimum follow-up period of 6 months after surgery.ResultsThe patients’ average age was 30 years. The average follow-up duration was 11.8 months. Five patients had excellent or good results (50%) at static two-point discrimination testing. Semmes-Weinstein monofilament testing results were full, diminished light touch or diminished protective sensation in nine digits (80%). The average Quick-Dash survey score was 19.3. The average CISS score was 27.8. There was no recurrence of pain.ConclusionsOur findings indicate that collagen conduit is an effective treatment for post-traumatic painful neuromas of digital nerves and common digital nerves.     

Parsonage-Turner Syndrome

Parsonage-Turner Syndrome (PTS), also referred to as idiopathic brachial plexopathy or neuralgic amyotrophy, is a rare disorder consisting of a complex constellation of symptoms with abrupt onset of shoulder pain, usually unilaterally, followed by progressive neurologic deficits of motor weakness, dysesthesias, and numbness. Although the etiology of the syndrome is unclear, it is reported in various clinical situations, including postoperatively, postinfectious, posttraumatic, and postvaccination. The identification of the syndrome in the postoperative patient remains a challenge as symptoms may easily be attributed to sequelae of surgical positioning, postoperative recovery, or postanesthetic block pain. The purpose of this review is to bring forth salient, identifiable factors which may assist the surgical clinician in identifying the condition sooner. An early and proper diagnosis affords the opportunity to treat the patient accordingly and to the satisfaction of both surgeon and patient.