Neurological improvement following revision of vascular graft remnants in the upper extremity.

Remnant vascular grafts may result in significant neurological deficits owing to compression of adjacent neural structures. We report this finding in two cases after extracorporeal membrane oxygenation decannulation and removal of an arteriovenous fistula in the upper extremity. In both cases, removal of the graft, patch arteriotomy, and external neurolysis resulted in significant recovery of neurological function. We review the preoperative workup, diagnostic studies, and technical approach to treatment in an effort to increase recognition among vascular and cardiovascular surgeons and to demonstrate a safe and effective management option through a multidisciplinary approach.

Anterior Congenital Radial Head Dislocation in an Adult with Associated Posterior Interosseous Nerve Palsy.

Introduction: Anterior congenital radial head dislocation (CRHD) is a rare abnormality that is less commonly seen in the adult population. Most of the time, adult-onset symptoms are due to the prolonged dislocation of the radiocapitellar joint that has been present since birth. One of the possible complications of having a prolonged radial head dislocation is the presence of neuropathies such as posterior interosseous nerve (PIN) palsy. There has been, however, no literature published regarding the relationship of CRHD with PIN palsy. Case Report: We here report a 66-year-old male incidentally diagnosed with anterior CRHD with concomitant PIN palsy after acquiring a fracture of the lateral humeral condyle. Open reduction internal fixation of the lateral condyle was done along with decompression of the said nerve. PIN palsy was completely recovered 2 months after surgery. Conclusion: Surgeons must be aware that PIN palsies can occur in the presence of a chronic radial head dislocation, even if asymptomatic. Prompt nerve decompression as well as removal of the mechanical block is pertinent to avoid the perilous effects of an irreversible PIN palsy.

EUS-guided radiofrequency ablation of solid pancreatic lesions: An updated review.

Recent years have brought to light newly developed therapeutic modalities for the treatment of premalignant and malignant pancreatic lesions. The role of EUS-guided radiofrequency ablation (EUS-RFA) as a treatment modality for malignant pancreatic lesions is still under evaluation. Several animal studies and human studies have demonstrated the safety and efficacy of EUS-RFA in the management of premalignant and malignant pancreatic lesions. EUS-RFA therapy can potentially ablate these lesions safely and with minimally invasive techniques. In this article, we provide an updated review of the application of EUS-RFA of pancreatic lesions. We also review the clinical efficacy and safety of this technique and future directions.

Clinical efficacy of EUS-guided celiac plexus neurolysis versus EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain relief in advanced pancreatic cancer: A long-term retrospective study.

Background and Objective: To compare the efficacy of EUS-guided celiac plexus neurolysis (CPN) and celiac plexus irradiation with iodine-125 (125I) seeds with absolute ethanol for relieving pain in patients with advanced pancreatic cancer. Methods: We retrospectively analyzed data of 81 patients with advanced pancreatic cancer who underwent EUS-CPN or EUS-125I implantation between January 2017 and December 2020. Postoperative pain was assessed using visual analog scale (VAS) scores; self-assessments of quality of life and the median survival time were compared between the 2 groups. Results: EUS-CPN and 125I implantation were performed in 43 and 38 patients, respectively. Postoperative VAS scores were significantly lower than the preoperative levels in both groups. One week after the operation, 26 patients (60.5%) in the EUS-CPN group achieved partial pain relief, whereas no patients in the EUS-125I seed group experienced pain relief. However, after 4 weeks postoperatively, VAS scores had decreased, and the rate of partial pain relief was higher for EUS-125I seeds than for EUS-CPN. Self-assessments of quality of life were similar in both groups during the first 1 month after the procedure. Conclusions: Both EUS-CPN and EUS-125I seeds can safely and effectively relieve pain in patients with advanced pancreatic cancer. Although EUS-125I seeds take additional time to show effects, the extent and duration of pain relief are better compared with CPN, and interestingly, the median survival time was different.

Hourglass-like constrictions of the radial nerve in the neuralgic amyotrophy: A case report.

Neuralgic amyotrophy (NA) is a peripheral nerve disorder that has a classical presentation as motor deficit after severe pain, but it is still overlooked or misdiagnosed. Formerly, the diagnosis was based on the clinical picture and electrophysiology; however, sophisticated imaging and surgical modalities showed structural abnormalities such as hourglass-like constrictions of the nerves. In this article, we present a case presenting with drop hand mimicking radial nerve entrapment. The patient was diagnosed with NA and surgery revealed hourglass-like constrictions. The clinical findings were improved after neurorrhaphy and physical therapy. In conclusion, hourglass-like constrictions can be prognostic factors of NA and should be searched carefully.

Anatomical-based classification of dorsolateral parametrectomy for deep endometriosis. Correlation with surgical complications and functional outcomes: A single- center prospective study.

OBJECTIVE: To evaluate complication rate and functional outcomes of nerve-sparing parametrectomy for deep endometriosis in relation to the extension of the surgical procedure, based on recognizable anatomical landmarks. METHODS: This was a prospective single-center study including all patients undergoing parametrectomy for deep endometriosis from September 2020 to June 2023 at our tertiary center. Dorsolateral parametrectomies were divided into parametrectomies medial to the presacral fascia and cranial to the medial rectal artery (superficial parametrectomy), and parametrectomies in which one of the two landmarks was overcome during the surgical procedure, leading to the excision of tissue lateral to the presacral fascia (deep parametrectomy type 1, or DP1) or caudal to the medial rectal artery (DP2). Finally, we used the hypogastric fascia as landmark to define type 3 deep parametrectomy (DP3), when the procedure was deeply lateral to the fascia. RESULTS: Bladder voiding deficit occurred in 9.7% of cases, with higher rates in DP2 (20.8%) and DP3 (30%) groups. Regarding postoperative gastrointestinal function, our data showed a significant improvement over time in all groups, with the exception of DP2; instead an improvement in postoperative bladder function was only shown in DP3. Parametrectomy was not associated with a simultaneous improvement in sexual function expressed with the female sexual function index, in any of the four groups. CONCLUSION: Our classification constitutes a concrete approach for comparing, in a standardized way, the complications and functional outcomes of parametrectomy, which, even if carried out by expert surgeons, demonstrates a non-negligible rate of bladder voiding deficit.

Chemical neurolysis for the conservative treatment of hip fractures.

Aim: Hip fracture management is challenging when surgical risks outweigh benefits. Inadequate analgesia from conservative treatments prompted new procedures targeting hip capsule denervation. This study evaluates the efficacy and safety of single injection chemical hip neurolysis in the pericapsular nerve group plane. Materials & methods: In eligible patients, an ultrasound-guided diagnostic block was performed using 5 ml of 2% lidocaine in the pericapsular nerve group plane. If positive, 6 ml of 99.9% alcohol was administered. Results: From May 2022 to May 2023, five patients underwent hip neurolysis. None reported pain at day 5 or during follow-up. There were no adverse effects. Conclusion: Chemical neurolysis seems to provide effective and safe conservative treatment for hip fractures, offering reliable analgesia for nonsurgical candidates.

Managing hip fractures is difficult, especially when surgery is too risky. Traditional pain relief methods often do not work well enough, so doctors are exploring new ways to reduce pain by targeting the nerves around the hip.In this study, we looked at a new technique called chemical neurolysis to see if it can safely and effectively relieve pain for people with hip fractures who can not have surgery.For this procedure, doctors first used a special technique to find the right spot near the hip using ultrasound. Then, they injected a small amount of a numbing medicine called lidocaine to see if it helped with the pain. If it did, they followed up by injecting alcohol to block the pain nerves more permanently.Between May 2022 and May 2023, five patients received this treatment. All of them reported no pain 5 days after the procedure and there were no negative side effects. We continued to check on them regularly to monitor their progress.In conclusion, chemical neurolysis appears to be a safe and effective way to manage hip fracture pain for patients who cannot undergo surgery, providing reliable pain relief without major risks.

Internal Neurolysis for Trigeminal Neuralgia: A Preliminary Single-institution Experience in Japan.

Internal neurolysis (IN) is a surgical procedure in which the trigeminal fibers are separated between the pons and porus trigeminus to relieve trigeminal neuralgia (TN). Recent investigations revealed that the number of nerve bundles made by IN varies, and immediate postoperative hypesthesia exceeded 90% and pain control rate at 1 year was 77%-93.5%. We present the preliminary experience of 18 patients who underwent IN for TN between June 2020 and June 2022. The Barrow Neurological Institute pain scale (BNI-PS) was recorded preoperatively and in June 2023, and the Barrow Neurological Institute hypesthesia scale (BNI-HS) was recorded preoperatively, immediate postoperatively and in June 2023. Intraoperatively, the number of bundles made by IN was reviewed. Preoperative BNI-PS ranged between VI and V. Two patients experienced BNI-HS II due to percutaneous procedure prior to IN. Intraoperatively, 3 bundles were made by IN in 7 patients, 4 bundles in 5, and 5 bundles in 6. Immediate postoperative BNI-HS I was recorded in 6 patients and II in 12 (66.7%). The last follow-up revealed that BNI-PS I and II were recorded in 13 patients (72.2%) and BNI-HS I and II in 6 patients, respectively. Our results demonstrated that the rates of immediate postoperative hypesthesia (66.7%) and pain control (72.2%) at 1 year or later were below those of previous reports. Therefore, we are currently combing to make at least 6 bundles. Detailed surgical technique and cardiac reflex alerts during the procedure are described.

Patient Questions Surrounding Posterior Nasal Nerve Ablation for Chronic Rhinitis.

Objective: In-office ablation of the posterior nasal nerve (PNN) has emerged as an effective treatment option for chronic rhinitis patients. This study explored questions patients commonly search online regarding this therapy and the quality of content available. Study Design: A retrospective analysis of online search criteria and sources was performed with subsequent analysis of results. Setting: Search and data acquisition was in September of 2023. Methods: Most common search terms related to cryotherapy and radiofrequency neurolysis of the PNN were identified with associated People Also Ask (PAA) questions. Questions were categorized and organized into subtopics and sources evaluated using readability and quality metrics. Results: A total of 255 unique PAA questions and 175 unique websites were identified. The most common subtopics were related to facts about chronic rhinitis (26.7%) and rhinitis treatment options (25.1%). Nearly a quarter (24.3%) of websites were from commercial sources. Quality metrics indicate difficult-to-read and low-quality materials. Conclusion: Existing online resources need improvement to provide patients material that is easier to read. Physicians counseling patients should be aware of these areas for adequate shared decision making.

Surgical approaches for pudendal nerve entrapment: insights from a systematic review and meta-analysis.

BACKGROUND: Pudendal nerve entrapment (PNE) is an underdiagnosed condition affecting a spectrum of pelvic functions, primarily pain, as outlined by Nantes diagnostic criteria. Although numerous surgical decompression techniques are available for its management, consensus on efficacy and safety is lacking. This study conducts a systematic review and meta-analysis to assess the efficacy and complication rates of the main surgical decompression techniques. METHODS: A comprehensive literature search was conducted in PubMed®, Embase®, Web of Science®, and ClinicalTrails.gov® on 19th of April 2023. Initial screening involved title and abstract evaluation, with subsequent retrieval and assessment of abstracts and full-text articles. Studies assessing pain outcomes before and after surgical release of the pudendal nerve were included. Studies without full-text, focusing on diagnostic methods or with outcomes relating solely to LUTS, digestive symptoms, or sexual dysfunction, were excluded. Risk of bias assessement was conducted using the National Institute of Health (NIH) Study Quality Assessment tool. Studies were categorized based on three surgical techniques: perineal, transgluteal, and laparoscopic transperitoneal. Random-effects meta-analysis with subgroup analysis were used. Meta-regression analyses were conducted to investigate the influence of covariates on the observed outcomes. RESULTS: Nineteen studies, comprising 810 patients, were included. The overall significant pain relief rate across all techniques was estimated at 0.67 (95% CI 0.54 to 0.78) with considerable heterogeneity (I2 = 80.4%). Subgroup analysis revealed success rate for different techniques: laparoscopic (0.91, 95% CI 0.64 to 0.98), perineal (0.69, 95% CI 0.52 to 0.82), and transgluteal (0.50, 95% CI 0.37 to 0.63). The laparoscopic technique exhibited a complication rate of 16.0%. Meta-regression indicated that patient age and median follow-up significantly influenced outcomes. CONCLUSION: While comparing surgical techniques is challenging, this meta-analysis highlights important outcome differences. The laparoscopic technique appears most promising for pain improvement. However, the study also emphasizes the need for further robust, long-term research due to significant heterogeneity across studies and prevelent risk of bias. PROSPERO database: CRD42023496564.

Role of Endoscopic Ultrasound in Pancreatic Cancer Diagnosis and Management.

The emergence of endoscopic ultrasound (EUS) has significantly impacted the diagnosis and management of pancreatic cancer and its associated sequelae. While the definitive role of EUS for pancreatic cancer remains incompletely characterized by currently available guidelines, EUS undoubtedly offers high diagnostic accuracy, the precise staging of pancreatic neoplasms, and the ability to perform therapeutic and palliative interventions. However, current challenges to EUS include limited specialized expertise and variability in operator proficiency. As the technology and techniques continue to evolve and become more refined, EUS is poised to play an increasingly integral role in shaping pancreatic cancer care.

The Safety and Effectiveness of Interval Stellate Ganglion Neurolysis in a Patient with Bilateral Digital Ischemia of Hands Due to Buerger's Disease: A Case Report.

Introduction: Thromboangiitis obliterans (TAO) or Buerger's disease (BD) is a small and medium-sized arteriovenous segmental occlusive inflammatory disease frequently occurring in men as compared to women. Although a common etiological agent is smoking or tobacco consumption, it has also been reported infrequently in non-smokers. Except for smoking other etiological agents, HLA, autoimmune diseases like systemic lupus erythematosus, and periodontitis have also been suggested. Minimally invasive pain and spine intervention (MIPSI) like stellate ganglion neurolysis with 8% phenol, 10 days apart in patients suffering from bilateral digital ischemia of both hands is a safe and effective treatment. Case Report: Fifty-five-year-old female with chief complaints of burning pain, swelling, and blackening of all five fingers of the right and four fingers of the left hands excluding the thumb for the past 3 months. On examination, pulse was almost absent at the wrist in both hands. There was no history of smoking. Under aseptic precautions, fluoroscopy and radiocontrast guidance stellate ganglion neurolysis with a 22G spinal needle, 2 ml of 8% phenol, 2 ml of 0.25% bupivacaine and 4 mg of dexamethasone were given at C7 vertebral level 10 days apart on both sides. After 3-4 months of stellate ganglion phenol chemical neurolysis, involved fingers were saved except the gangrenous part which was autoamputated itself in due course of time. Conclusion: Bilateral interval (10 days apart) chemical neurolysis of stellate ganglion in Buerger's disease involving both hands is a safe and effective technique in terms of control of disease progression, pain, cardiac complications, and recurrent laryngeal nerve-related complications.

Meralgia paresthetica.

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.

Buerger's Disease of Hand; my Experience with Phenol Chemical Neurolysis of Stellate Ganglion: Case Series of Six Patients.

Introduction: Buerger's disease is common in 74.70% of cases in the lower limb but in 20.20% of cases, it is found in the upper limb or hand. The disease usually starts from pain in the finger/thumb or hand and then to more centrally.Patients presented with pain in the hand with gangrene of fingers. Pain aggravated on lifting hand above the shoulder level or above heart level in upright or lying in the bed, respectively. Case Report: In almost all patients, there was a history of smoking except one and all patients had involvement of digits of the right or left hand. Diagnosis of Buerger's disease was made based on the history of smoking, weak or absent pulse, lack of bleeding, swelling, edema, blackening, stony hard fingers or thumb on clinical examination, and color Doppler study of the limb.In all patients, Stellate ganglion chemical neurolysis with 8% phenol was done at C7-T1 under fluoroscopic and radiocontrast dye (Iohexol 300) guidance.After successful neurolysis patients got excellent pain relief, their wounds started healing, the vascularity of the diseased part increased and the disease stopped progressing. Conclusion: Stellate ganglion chemical neurolysis with phenol in Peripheral vascular disease or Buerger's disease of hand is an effective method to stop the disease procession, promoting wound healing, controlling ischemic pain, and avoiding surgical amputation.

Pudendal nerve neurolysis outcomes for urogenital and rectal disorders in patients suffering from pudendal nerve entrapment: A systematic review.

PURPOSE: Pudendal neuropathy is an uncommon condition that exhibits several symptoms depending on the site of nerve entrapment. This study aims to evaluate the efficacy of pudendal nerve neurolysis (PNN) in improving lower urinary tract symptoms, anal and/or urinary incontinence, and sexual dysfunctions. MATERIALS AND METHODS: A systematic literature search was performed on 20 May 2023 using Scopus, PubMed, and Embase. Only English and adult papers were included. Meeting abstracts and preclinical studies were excluded. RESULTS: Twenty-one papers were accepted, revealing significant findings in the field. The study identified four primary sites of pudendal nerve entrapment (PNE), with the most prevalent location likely being at the level of the Alcock canal. Voiding symptoms are commonly exhibited in patients with PNE. PNN improved both urgency and voiding symptoms, and urinary and anal incontinence but is less effective in cases of long-standing entrapment. Regarding sexual function, the recovery of the somatic afferent pathway results in an improvement in erectile function early after neurolysis. Complete relief of persistent genital arousal disorder occurs in women, although bilateral PNN is necessary to achieve the efficacy. PNN is associated with low-grade complications. CONCLUSIONS: PNN emerges as a viable option for addressing urinary symptoms, fecal incontinence, erectile dysfunction, and female sexual arousal in patients suffering from PNE with minimal postoperative morbidity.

Pudendal Nerve Neurolysis in Patients Afflicted With Pudendal Nerve Entrapment: A Systematic Review of Surgical Techniques and Their Efficacy.

To assess the effectiveness and safety of various techniques of pudendal nerve neurolysis (PNN) in patients with pudendal nerve entrapment (PNE). A comprehensive literature search was conducted on May 20th, 2023, using Scopus, PubMed, and Embase databases. Only studies in English involving adults were accepted, while meeting abstracts and preclinical studies were excluded. A total of 34 papers were included. Transperineal PNN emerged as a promising technique, demonstrating significant potential in alleviating pain, restoring erectile function in males, and improving the resolution of urinary stress incontinence in females. Furthermore, the bilateral approach consistently yielded positive outcomes in addressing urinary symptoms. The transgluteal technique appeared particularly suitable for cases of posterior PNE, situated between the sacrospinous ligament and the lesser sciatic foramen. A progressive amelioration of painful symptoms was observed during follow-up. Minimally invasive PNN is evolving and enables decompression along the entire proximal tract up to the Alcock canal, minimizing the risk of comorbidities. In addition to reducing pudendal neuralgia, robot-assisted and laparoscopic approaches determined a reduction in lower urinary tract symptoms and an improvement in erectile function, though further studies are required to corroborate these findings. PNN emerges as an effective treatment for PNE with minimal morbidity. Therefore, PNN should be tailored according to the site of PNE to enhance functional outcomes and improve patient quality of life.

MRI findings correlate with difficult dissection during proximal hamstring repair and with postoperative sciatica.

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.

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.

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.

Spasticity Treatment Beyond Botulinum Toxins.

Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity management. In this paper, we focus on innovative and revived treatment options that can be alternative or complementary to BoNT therapy, including phenol neurolysis, cryoneurolysis, and extracorporeal shock wave therapy.

Applications of Cryoneurolysis in Chronic Pain Management: a Review of the Current Literature.

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.