Cold intolerance and neuropathic pain after peripheral nerve injury in upper extremity.

Cold intolerance and pain can be a substantial problem in patients with peripheral nerve injury. We aimed at investigating the relationships among sensory recovery, cold intolerance, and neuropathic pain in patients affected by upper limb peripheral nerve injury (Sunderland type V) treated with microsurgical repair, followed by early sensory re-education. In a cross-sectional clinical study, 100 patients (male/female 81/19; age 40.5 ± 14.8 years and follow-up 17 ± 5 months, mean ± SD), with microsurgical nerve repair and reconstruction in the upper extremity and subsequent early sensory re-education, were evaluated, using Cold Intolerance Symptoms Severity questionnaire-Italian version (CISS-it, cut-off pathology >30/100 points), CISS questionnaire-12 item version (CISS-12, 0-46 points-grouping: healthy that means no cold intolerance [0-14], mild [15-24], moderate [25-34], severe [35-42], very severe [43-46] cold intolerance), probability of neuropathic pain (DouleurNeuropathique-4; [DN4] 4/10), deep and superficial sensibility, tactile threshold (monofilaments), and two-point discrimination (cutoff S2; Medical Research Council scale for sensory function; [MRC-scale]). A high CISS score is associated with possible neuropathic pain (DN4 ≥ 4). Both a low CISS-it score (ie, < 30) and DN4 < 4 is associated with good sensory recovery (MRC ≥ 2). In conclusion patients affected by upper limb peripheral nerve injuries with higher CISS scores more often suffer from cold intolerance and neuropathic pain, and the better their sensory recovery is, the less likely they are to suffer from cold intolerance and neuropathic pain.

Quantitative validation of sensory mapping in persistent postherniorrhaphy inguinal pain patients undergoing triple neurectomy.

PURPOSE: Neurectomy of the inguinal nerves may be considered for selected refractory cases of chronic postherniorrhaphy inguinal pain (CPIP). There is to date a paucity of easily applicable clinical tools to identify neuropathic pain and examine the neurosensory effects of remedial surgery. The present quantitative sensory testing (QST) pilot study evaluates a sensory mapping technique. METHODS: Longitudinal (preoperative, immediate postoperative, and late postoperative) dermatomal sensory mapping and a comprehensive QST protocol were conducted in CPIP patients with unilateral, predominantly neuropathic inguinodynia presenting for triple neurectomy (n = 13). QST was conducted in four areas on the affected, painful side and in one contralateral comparison site. QST variables were compared according to sensory mapping outcomes: (o)/normal sensation, (+)/pain, and (-)/numbness. Diagnostic ability of the sensory mapping outcomes to detect QST-assessed allodynia or hypoesthesia was estimated through calculation of specificity and sensitivity values. RESULTS: Preoperatively, patients exhibited mechanical hypoesthesia and allodynia and pressure allodynia and hyperalgesia in painful areas mapped (+) (p < .05); sensory mapping outcome (+) demonstrated high ability to detect mechanical allodynia [sensitivity 0.74 (95% CI 0.61-0.86), specificity 0.94 (0.84-1.00)] and pressure allodynia [sensitivity 0.96 (0.89-1.00), specificity 1.00 (1.00-1.00)], but not thermal allodynia. Postoperatively, mapped areas of numbness (-) were associated with mechanical and thermal hypoesthesia (p < .05); (-) showed high sensitivity and specificity to detect mechanical and cold hypoesthesia. CONCLUSIONS: Sensory mapping provides an accurate clinical neuropathic assessment with strong correlation to QST findings of preoperative mechanical and pressure allodynia, and postoperative mechanical and thermal hypoesthesia in CPIP patients undergoing neurectomy.

High Median Nerve Injury: Motor and Sensory Nerve Transfers to Restore Function.

This article describes the clinically significant motor and sensory deficits that follow high median nerve injuries and addresses the indications, limitations, and outcomes of nerve transfers, when striving to overcome the deficits these patients' experiences. Preferred surgical reconstructive strategy using motor and sensory nerve transfers, and surgical techniques used to perform these transfers, are described.

Lingual and inferior alveolar nerve injuries after third molar removal.

Trigeminal nerve injury is a rare, but serious complication of a common procedure, which results in a clinically relevant problem that deserves attention. The emergence of microsurgical repair of trigeminal injury has provided clinicians with treatment options for patients who experience persistent neurosensory deficits. The area of microsurgical repair of trigeminal nerves is now in its adolescence. While great strides have been made in the field since its conception, it is certain that a new generation of oral and maxillofacial surgeons wil bring further progress to the field. In the future, better quantitative sensory testing methods, more accurate imaging modalities, and advances in surgical technique will certainly improve the management of patients with impacted third molars. As clinicians, every day we are confronted with the management of impacted third molars. It is important to evaluate each patient individually with an appropriate clinical and radiographic exam. Every patient should be informed of the relative risks and benefits of third molar removal and a joint decision should be reached between the clinician and patient regarding ideal treatment. However, even with ideal management, complications will occur. If a patient does present with signs of a nerve injury the clinician should carefully document the neurosensory deficit and monitor the patient over time. If the patient exhibits a significant sensory deficit for more than one month a referral for evaluation to a tertiary care center capable of surgical repair of the injury is recommended. The occurrence of a "trigger" or Tinel's like sign is improtant as an indication for surgery but may not occur for a month after injury.

Abdominal auras in patients with mesial temporal sclerosis.

To better clarify abdominal auras and their clinical correlates, we enrolled 331 temporal lobe epilepsy patients who received surgical treatment. Detailed descriptions of their auras were obtained before surgery and reconfirmed during postoperative outpatient follow-ups. Pathology revealed mesial temporal sclerosis (MTS) in 256 patients (77.3%) and 75 non-MTS. Of 214 MTS patients with auras, 78 (36.4%) reported abdominal auras (vs. 30.4% in non-MTS, p=0.439): 42 with left-sided seizure onset, and 36 with right-sided seizure onset. Moreover, 49 of the 78 MTS patients had abdominal auras accompanied by rising sensations (vs. 2 of 14 in non-MTS group, p=0.004). The "rising air" was initially described to locate to the epigastric (47.8%) or periumbilical area (45.7%) and mostly reached the chest (40.4%) or remained in the abdominal region (27.1%). An epigastric location of "rising air" favored a left-sided seizure onset, and non-epigastric areas favored right-sided seizure onset (p=0.018). Finally, we found that abdominal auras with or without rising sensations did not predict postoperative seizure outcomes.

What factors are associated with functional sensory recovery following lingual nerve repair?

PURPOSE: To identify factors associated with functional sensory recovery (FSR) after lingual nerve repair. MATERIALS AND METHODS: This retrospective cohort study was composed of subjects who underwent lingual nerve repair from 2004 through 2010. The predictor variables were demographic, anatomic, and operative measurements. The primary outcome measurement was FSR (ie, FSR achieved, yes or no). The secondary outcome measurements were time to FSR and an improvement of at least 2 levels on the British Medical Research Council scale of neurosensory function. Descriptive, bivariate, and multiple logistic regression statistics were computed to identify associations between the predictor variables and FSR. A Cox proportional hazards model was used to identify associations between the predictors and time to FSR. P ≤ .05 was considered statistically significant. RESULTS: The sample was composed of 55 subjects with a mean age of 30.7 ± 11.2 years. The mean duration from injury to repair was 151.6 days (range, 41 to 384 days). Most patients (74.5%) achieved FSR postoperatively, with a mean time to FSR of 262.8 days (median, 208 days). Eighty-six percent of subjects showed an improvement of at least 2 levels on the British Medical Research Council scale. In multiple regression models, younger subjects were more likely to achieve FSR (odds ratio, 1.10; 95% confidence interval, 1.01 to 1.18; P = .02); subjects with better preoperative neurosensory function achieved FSR faster (hazard ratio, 1.9; 95% confidence interval, 1.2 to 3.1; P = .01). CONCLUSION: Most patients undergoing lingual nerve repair achieved FSR. Younger subjects were more likely to achieve FSR. Subjects with better preoperative neurosensory function achieved FSR faster.

Grafting the C5 root to the musculocutaneous nerve partially restores hand sensation in complete palsies of the brachial plexus.

BACKGROUND: In complete brachial plexus palsy, we have hypothesized that grafting to the musculocutaneous nerve should restore some hand sensation because the musculocutaneous nerve can drive hand sensation directly or via communication with the radial and median nerves. OBJECTIVE: To investigate sensory recovery in the hand and forearm after C5 root grafting to the musculocutaneous nerve in patients with a total brachial plexus injury. METHODS: Eleven patients who had recovered elbow flexion after musculocutaneous nerve grafting from a preserved C5 root and who had been followed for a minimum of 3 years were screened for sensory recovery in the hand and forearm. Six matched patients who had not undergone surgery served as controls. Methods of assessment included testing for pain sensation using Adson forceps, cutaneous pressure threshold measurements using Semmes-Weinstein monofilaments, and the static 2-point discrimination test. Deep sensation was evaluated by squeezing the first web space, and thermal sensation was assessed using warm and cold water. RESULTS: All grafted patients recovered sensation in a variable territory extending from just over the thenar eminence to the entire lateral forearm and hand. Seven patients were capable of perceiving 2-0 monofilament pressure on the thenar eminence, palm, and dorsoradial aspect of the hand. All could differentiate warm and cold water. None recovered 2-point discrimination. None of the patients in the control group recovered any kind of sensation in the affected limb. CONCLUSION: Grafting the musculocutaneous nerve can restore nociceptive sensation on the radial side of the hand.

Treatment modalities of neurosensory deficit after lower third molar surgery: a systematic review.

PURPOSE: To conduct a systematic review to answer the clinical question, "What are the available treatment modalities and their outcomes of neurosensory deficit after lower third molar surgery?" MATERIALS AND METHODS: A systematic search, including a computer search of several databases with specific keywords, a reference search, and a manual search of 3 key maxillofacial journals were performed. Relevant articles were then evaluated and those that fulfilled the 6 predetermined criteria were chosen to enter the final review. The various treatment modalities and their outcomes of neurosensory deficit after lower third molar surgery, in the selected studies in the final review, were analyzed. RESULTS: Ten articles entered the final review. Six treatment modalities of lingual nerve or inferior alveolar nerve deficit after lower third molar surgery were identified. External neurolysis, direct suturing, autogenous vein graft, and a Gore-Tex tube as a conduit were the 4 surgical treatments. Significant improvement after surgical treatment ranged from 25% to 66.7%. Acupuncture and low-level laser therapy were 2 available nonsurgical treatment modalities that were found to have produced significant improvement in sensation after treatment in more than 50% of subjects. There was insufficient information to determine the best timing of treatment of nerve injury after third molar surgery. CONCLUSIONS: Four surgical treatments and 2 nonsurgical treatments were identified in the management of neurosensory disturbance after lower third molar surgery. Most treatments showed an improvement in sensation but the outcomes were variable. Complete recovery was uncommon in all kinds of available treatments.

Very distal sensory nerve transfers in high median nerve lesions.

PURPOSE: We report on the results of reconstruction of fingertip sensation by very distal nerve transfer in 8 patients with high median nerve lesions. METHODS: Before surgery, patients underwent sensory testing of the hand using Semmes-Weinstein monofilaments. All patients had surgery within 1 year of trauma. For sensory reconstruction, branches of the radial nerve on the proximal phalanx of the index and thumb were sutured to the ulnar proper digital nerve of the thumb and radial proper digital nerve of the index finger. Patients were followed up for 12 months. RESULTS: After median nerve lesions, zones of lost protective sensation were confined to the middle and index finger and the thumb. Sensation on the palm of the hand and proximal phalanx was preserved. Radial nerve transfer to palmar nerves restored protective or better sensation to the fingertips in all patients. Better results were observed for the thumb. Locognosia was acquired in all thumbs, and in 4 of 8 index fingers. Good results were detected even in patients who had undergone surgery later than 6 months after injury. CONCLUSIONS: Fingertip sensation can be restored by very distal nerve transfer of radial nerve branches to palmar nerves at the level of the proximal phalanx. This method of reconstruction appears useful in high median nerve lesions. In chronic lesions of the median nerve at the wrist and lesions in older patients, very distal nerve transfers might be adjunct to nerve grafting.

Management of mandibular nerve injuries from dental implants.

Treatment of the patient who has sustained a nerve injury from dental implant procedures involves prompt recognition of this complication, evaluation of sensory dysfunction, the position of the nerve vis-à-vis the implant, and timely management of the injured nerve. In some patients, removal or repositioning of the implant and surgical exploration and repair of the injured nerve will maximize the implant patient's potential for a successful recovery from nerve injury.

Non ruptured MCA aneurysms presenting with insular related symptoms.

OBJECTIVE: To present a new semiological description of unruptured middle cerebral artery (MCA) aneurysms. METHODS: We present a series of three MCA aneurysms presenting with progressive or paroxystic somatosensory symptoms in combination with visceral, motor, language or autonomic symptoms. RESULTS: A surgical approach was proposed for two aneurysms, and both patients experienced complete resolution of their symptoms. The third aneurysm was successfully excluded by endovascular coiling but the symptoms persisted. CONCLUSIONS: To our knowledge this is the first description of unruptured aneurysms presenting with insular-related symptoms.

Retrospective review of microsurgical repair of 222 lingual nerve injuries.

PURPOSE: Injury to the lingual nerve (LN) is a known complication associated with several oral and maxillofacial surgical procedures. We have reviewed the demographics, timing, and outcome of microsurgical repair of the LN. MATERIALS AND METHODS: A retrospective chart review was completed of all patients who had undergone microsurgical repair of the LN by one of us (R.A.M.) from March 1986 through December 2005. A physical examination, including standardized neurosensory testing, was completed of each patient preoperatively. All patients were followed up periodically after surgery for at least 1 year, with neurosensory testing repeated at each visit. Sensory recovery was determined from the patient's final neurosensory testing results and evaluated using the guidelines established by the Medical Research Council Scale. The following data were collected and analyzed: patient age, gender, nerve injury etiology, chief sensory complaint (numbness or pain, or both), interval from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at the final evaluation. The patients were classified according to whether they achieved "useful sensory recovery" or better, according to the Medical Research Council Scale, or had unsatisfactory or no improvement in sensation. Logistic regression methods and associated odds ratios (OR) were used to quantify the association between the risk factors and improvement. Receiver operating characteristic curve analysis was used to find the age threshold and duration that maximally separated the patient outcomes. RESULTS: A total of 222 patients (51 males and 171 females; average age 31.1 years, range 15 to 61) underwent LN repair and returned for at least 1 year of follow-up. The most common cause of LN injury was mandibular third molar removal (n = 191, 86%), followed by sagittal split mandibular ramus osteotomy (n = 14, 6.3%). Most patients complained preoperatively of numbness (n = 122, 55%) or numbness with pain (n = 94, 42.3%). The average interval from injury to surgery was 8.5 months (range 1.5 to 96). The most commonly performed operation was excision of a proximal stump neuroma with neurorrhaphy (n = 154, 69%), followed by external decompression with internal neurolysis (n = 29, 13%). Nineteen patients (8.6%) underwent an autogenous nerve graft procedure (greater auricular or sural nerve) for reconstruction of a nerve gap. A collagen cuff was placed around the repair site in 8 patients (3.6%; external decompression with internal neurolysis in 2 and neurorrhaphy in 6). Recovery from neurosensory dysfunction (defined by the Medical Research Council Scale as ranging from "useful sensory function" to a "complete return of sensation") was observed in 201 patients (90.5%; 146 patients with complete recovery and 55 patients with recovery to "useful sensory function"), and 21 patients (9.5%) had no or inadequate improvement. Using the logistic regression model, a shorter interval between nerve injury and repair resulted in greater odds of improvement (OR 0.942, P = .0064); with each month that passed, the odds of improvement decreased by 5.8%. The receiver operating characteristic analysis revealed that patients who waited more than 9 months for repair were at a significantly greater risk of nonimprovement. Statistical significance was observed between patient age and outcome (OR 0.945, P = .0067) representing a 5.5% decrease in the chance of recovery for every year of age in patients 45 years old and older. The odds of a return of acceptable neurosensory function were better when the patient's presenting symptom was pain and not numbness (OR 0.04, P < .001). CONCLUSIONS: Microsurgical repair of LN injury has the best chance of successful restoration of acceptable neurosensory function if done within 9 months of the injury. The likelihood of recovery after nerve repair decreased progressively when the repair occurred more than 9 months after injury and with increasing patient age.

Argon plasma coagulation of cervical heterotopic gastric mucosa as an alternative treatment for globus sensations.

BACKGROUND & AIMS: Ablation of gastric inlet patches (GIP) in the cervical esophagus by argon plasma coagulation (APC) can alleviate chronic globus sensations in the throat. We investigated the efficacy of this therapy in a randomized, controlled multicenter trial. METHODS: Patients with chronic globus sensations and GIP were randomly assigned 1:1 to groups that were treated with APC or a sham procedure (controls). Patients and their referring physicians were blinded to therapy. All patients completed a standardized questionnaire about symptoms before and 3 months after the procedure. Thereafter, control patients were eligible for cross-over therapy. Long-term efficacy was assessed in all patients >or=6 months after APC. RESULTS: Improvement of symptoms was reported in 9 (82%) of 11 patients who received APC, compared with 0 (0%) of 10 patients in the control group (P = .002). Nine (90%) of 10 patients treated with APC had per protocol healing, compared with 0 (0%) of 9 controls (P < .001). Scores for symptom/globus assessment significantly improved in patients in the APC group, whereas patients in the control group did not perceive any symptom relief. Eight of the 10 patients who started in the control group crossed over to the APC group. Long-term efficacy (after a median follow-up of 17 months) was documented in 13 (76%) of 17 treated patients. CONCLUSIONS: Ablation of gastric inlet patches appears to be an effective therapy for alleviation of associated globus sensations. This new treatment modality might change the paradigm for treatment of these patients.

Surgical outcome of thoracic myelopathy secondary to ossification of ligamentum flavum.

OBJECTIVES: Thoracic myelopathy secondary to OLF is a rare disease described almost exclusively in Japanese patients. Few series of OLF in South Korean subjects has previously been published. This study is to describe the clinical and radiologic aspects, as well as surgical outcomes in a group of South Korean patients. METHODS: A retrospective study of 8 consecutive patients, including 4 men and 4 women (mean age, 55.6 years), was conducted from 2002 to 2005. Diagnosis in each case was established using CT. Magnetic resonance imaging was also performed in every case. All patients treated surgically and pathologic studies were performed. A comparison between the preoperative neurological status and the status at follow-up was done using Japanese Orthopaedic Association (JOA) scoring system. RESULTS: Walking difficulties were the most common presenting complaint. A picture of spastic paraparesis associated with sphincter dysfunction was the most common finding on initial examination. In each case, CT provided sufficient information to establish a diagnosis of OLF, while magnetic resonance imaging was helpful for showing spinal cord involvement. In most of the patients, OLF was located in the lower thoracic spine (T10-T11). Decompressive laminectomy with excision of the OLF resulted in significant improvement in motor weakness and gait in 5 (2 excellent, 3 good) patients who had short duration and no hyperintense intramedullary lesion of spinal cord on MRI. All patients improved in their gait and spasticity, but 2 patients had persistent sensory deficit. CONCLUSION: OLF is a rare cause of thoracic myelopathy. The frequency appears to have been rarely reported in South Korean subjects. CT with sagittal reconstructions and MRI are helpful for diagnosis and spinal cord involvement. When neurologic symptoms develop, decompressive laminectomy should be done immediately and the surgical outcome is generally good if hyperintense intramedullary signal changes of spinal cord have not yet developed.

Timing of trigeminal nerve microsurgery: a review of the literature.

Injury to peripheral branches of the trigeminal nerve is a known sequelae of oral and maxillofacial surgery procedures. The most often studied and reported branches have been the inferior alveolar and lingual nerves. Many questions still remain unanswered concerning the appropriate timing of surgical repair. The literature frequently mentions specific timing guidelines, however, there is scant scientific evidence to support these guidelines. In fact, several authors of clinical series state that although many of their surgical procedures occurred fairly late due to the timing of referral and other issues such as insurance authorization, reasonable clinical results were still achieved in these patients. Various systems of nerve injury evaluation and testing methods make it difficult to draw specific timing recommendations. The consensus of literature reviewed indicates that more research is necessary in this area to better answer these questions.

Neurological bypass for sensory innervation of the penis in patients with spina bifida.

PURPOSE: Most male patients with spina bifida have normal sexual desires. During puberty they begin to realize that they can achieve erection and sexual intercourse but without any sensation in the penis. We hypothesized that restored sensation in the penis would greatly contribute to their quality of life and sexual health. In this prospective study we investigated the outcome of a new operative neurological bypass procedure in patients with spina bifida. MATERIALS AND METHODS: In 3 patients who were 17, 18 and 21 years old with a spinal lesion at L5, L4 and L3-L4, respectively, the sensory ilioinguinal nerve (L1) was cut distal in the groin and joined by microneurorrhaphy to the divided ipsilateral dorsal nerve of the penis (S2-4) at the base of the penis. All patients underwent preoperative and postoperative neurological and psychological evaluations. RESULTS: By 15 months postoperatively all patients had achieved excellent sensation on the operated side of the glans penis. They were unequivocally positive about the results and the penis had become more integrated into the body image. In 2 patients masturbation became more meaningful and 1 became more sexually active with and without his partner. CONCLUSIONS: The newly designed neurological bypass procedure in patients with spina bifida resulted in excellent sensibility in the glans penis. The new sensation appeared to contribute to the quality of the patient sexuality and sexual functioning as well as to the feeling of being a more normal and complete individual who is more conscious of the penis. This new operation might become standard treatment in patients with spina bifida in the future.

Observations on the exploration and external neurolysis of injured inferior alveolar nerves.

The inferior alveolar nerve is sometimes injured during mandibular surgery, resulting in altered sensibility. Incomplete recovery may be the result of nerve entrapment by scar tissue. Twelve patients underwent external neurolysis of the inferior alveolar nerve following prolonged sensory impairment secondary to mandibular surgery. The mean time to external neurolysis was 14 months (range 12-24 months). Five patients demonstrated improvement in sensibility, two patients returning to normal sensation. No patient had a worsening of symptoms. The results demonstrate that external neurolysis can be a useful step during surgical exploration in carefully selected patients.

Illusory persistence of touch after right parietal damage: neural correlates of tactile awareness.

We studied a patient who experienced 'palinaesthesia', an illusion of persistent touch following tactile stimulation on the left hand, subsequent to a right parietal meningioma affecting primary somatosensory regions in the postcentral gyrus (SI) and superior parietal gyrus (Brodmann area 7), but preserving the secondary somatosensory cortex (SII) in the upper lateral sulcus. This subjective sensation was accompanied by transient increases in objective measures of tactile threshold. The patient had mild deficits in superficial tactile perception, but showed severe left-sided extinction for offsets of tactile stimuli during bilateral stimulation, but not for onsets of stimuli. Functional MRI revealed increased neural activity during palinaesthesia selectively arising within the ipsilesional-right SI cortex, but no abnormality within left SI and bilateral SII. Right SI responded to the onset of new tactile stimuli on the left hand but not to their offset. By contrast, any tactile events on either hand modulated activity in contralateral SII regions, even undetected left-sided offsets. These data demonstrate that illusory persistence of touch following stimulation on the hand may result from sustained neural activity in a restricted region of the SI cortex outlasting the offset of the actual tactile stimuli. These findings also provide direct evidence for a critical role of SI in mediating conscious somatosensory experience on contralateral parts of the body.