Retropharyngeal Blastomycosis Abscess Causing Osteomyelitis, Discitis, Cervical Deformity, and Cervical Epidural Abscess: A Case Report.

Blastomycosis infection is caused by the inhalation of the spores of the dimorphic Blastomyces sp.fungus. While more commonly a self-limited infection of the lungs, extrapulmonary manifestations arise from hematogenous or contiguous spread. Disseminated infection most often includes skin lesions and osteomyelitis; however, central nervous system (CNS) involvement is infrequently reported in the literature. Herein, we present a case of a retropharyngeal blastomycosis abscess leading to cervical spine osteonecrosis with retropulsion, deformity, and a spinal epidural abscess, and we discuss the relevant literature. The patient was successfully treated with cervical traction, followed by a combined anterior-posterior cervical approach, including abscess drainage, corpectomies, and instrumented fixation. Postoperatively, the patient completed 12 months of voriconazole and had near resolution of preoperative symptoms. Expediting neurosurgical intervention, such as the utilization of decompression, the clearance of infectious burden, and the correction of alignment, is critical for preventing downstream complications. Retropharyngeal blastomycosis abscesses are rare, and we report one of the rare instances of dissemination to and the degeneration of the cervical spine.

Accessory Nerve Disruption Following Core-Needle Biopsy: A Review of Iatrogenic Accessory Nerve Injuries and an Illustrative Case.

Iatrogenic spinal accessory neve (SAN) injury is a rare complication. It most commonly occurs after open lymph node biopsies. Needle biopsy is thought to present lower risk to the SAN. However, we describe a case of a 66-year-old man who underwent core needle biopsy for lymphadenopathy and subsequently experienced ipsilateral shoulder weakness and pain. Physical examination revealed shoulder depression, lateral scapular winging, and decreased range of motion. Subsequent studies and magnetic resonance imaging demonstrated complete paralysis and denervation of SAN muscles. The nonfunctional SAN was repaired by sural nerve grafting 3 months after the injury. The patient demonstrated improved shoulder strength, range of motion, and decreased pain at 6-month follow-up. SAN injuries can be challenging to diagnose and require prompt surgical intervention. This case represents an unusual case of complete SAN disruption and palsy after core needle biopsy treated with sural nerve grafting. We review the literature on iatrogenic SAN injuries, diagnostic strategies, options for SAN surgical repair, and outcomes. SAN injuries can be challenging to diagnose but are amenable to prompt surgical options based on the mechanism and type of SAN injury.

Contiguous Meningioma and B-Cell Lymphoma: A Scoping Review and Case Illustration.

BACKGROUND: The diagnosis of a contiguous, synchronous meningioma and central nervous system B-cell lymphoma is rare and associated with paradoxical treatment paradigms. We performed a scoping review of contiguous meningioma and B-cell lymphoma and included an additional illustrative case. METHODS: The OVID Medline and PubMed databases were systematically searched using the Preferred Reporting Items of Systematic Reviews and Meta-Analysis guidelines. Only human clinical reports of contiguous, synchronous meningioma and B-cell lymphoma were included. We concurrently detailed a representative case from our institution. RESULTS: Nine case reports met our criteria, including the present case. The average age at diagnosis was 67.4 years. Patients showed a female-to-male predominance of 7:2. The diagnosis of synchronous intracranial tumors was not suspected or discovered until after surgical resection in 100% of cases. All meningiomas were grade I on histopathologic diagnosis, while lymphomas were distributed between diffuse large B-cell lymphoma (56%), metastatic lymphoma (22%), Burkitt lymphoma (11%), and follicular lymphoma (11%). All patients underwent surgical resection. Patients (n = 5) treated with adjuvant chemotherapy had evidence of longer progression-free survival (median 12 months; range, 3-18 months) than patients without adjuvant chemotherapy (n = 2; median 2 months; range, 1-3 months). CONCLUSIONS: Contiguous, synchronous meningioma/B-cell lymphoma is a rare diagnosis that may appear as an inconspicuous solitary intracranial neoplasm on imaging. Based on the limited cases and current treatment of lymphoma, progression-free survival may be contingent on the prompt initiation of chemotherapy targeting the lymphoma rather than surgical resection of the meningeal mass. Providers should prioritize prompt medical management.

Infragluteal Exposure for Resection of Subgluteal Tumors: A Surgical Technique for Accessing the Sciatic Nerve and Notch.

Sciatic nerve impingement via a tumor of or trauma to the proximal subgluteal region creates a considerable surgical challenge that is debated in the literature. The neurosurgery literature favors the infragluteal approach, while in orthopaedics, the transgluteal approach is preferred. The goal of our study was to present an operative technique for the infragluteal approach to the subgluteal region with a step-by-step procedural guide to increase awareness among orthopaedic surgeons of alternative surgical approaches to the sciatic notch. We retrospectively reviewed the case of a 62-year-old female found to have a subgluteal myxoma who underwent the infragluteal approach for tumor excision. We then highlighted the anatomic considerations via cadaveric dissection photographs, artistic renditions, and intra-operative images. Our patient underwent tumor resection and sciatic nerve exploration via the infragluteal approach with a successful outcome. In comparison to other approaches in the literature, the infragluteal approach provides a safer dissection with more options for an extension of the exposure and potentially fewer functional deficits. We conclude that orthopaedic surgeons should strongly consider utilizing this approach to the sciatic notch rather than a transgluteal approach.

Spontaneous Hip Dislocation Complicating the Management of Malignant Peripheral Nerve Sheath Tumor Arising Within a Plexiform Neurofibroma.

Neurofibromatosis type 1 (NF1) is one of the most common inherited neurological disorders. It can cause plexiform neurofibromas, leading to diffuse enlargement of a nerve or nerves within the body. There are benign in general, however, can cause significant symptoms due to their size, including bony erosion, pain, and joint instability. Unfortunately, they also have the capacity to become malignant by internal transformation into a malignant peripheral nerve sheath tumor (MPNST). The case presented here is a 27-year-old male with NF1 that was followed for years with a pelvic girdle plexiform neurofibroma whose course was complicated by transformation to MPNST and a spontaneous hip dislocation. He underwent excision, Girdlestone procedure, chemotherapy, and radiation. Unfortunately, he subsequently developed lung metastases and is part of a clinical trial with an MDM2 inhibitor and pembrolizumab.

Phrenic Nerve Stimulator Placement via the Cervical Approach: Technique and Anatomic Considerations.

BACKGROUND: Diaphragmatic pacing via phrenic nerve stimulation can help improve breathing and facilitate mechanical ventilation weaning in patients with respiratory failure secondary to brainstem injury, high cervical spinal cord injury, or congenital central hypoventilation. Devices can be placed utilizing several techniques; however, nuances regarding placement are not well published. OBJECTIVE: To describe our experience with phrenic nerve stimulator placement via the cervical approach with a focus on surgical anatomy, variations, and technique. METHODS: Placement of phrenic nerve stimulator via a cervical approach is described in detail. RESULTS: Successful placement of phrenic nerve stimulator without complication. CONCLUSION: The cervical approach for the placement of a phrenic nerve stimulator is a safe and effective option for patients. Detailed knowledge of anatomy and anatomic variations is required. Potential advantages and disadvantages are discussed.

Internal Neurolysis of the Common Peroneal Nerve With Lower Extremity Flexion Increases Likelihood for Direct End-End Nerve Repairs.

Introduction An understanding of common peroneal neuropathy is essential to improving current surgical techniques and overcoming limitations of permanent common peroneal nerve (CPN) damage, which negatively impacts quality of life. This study focuses on quantifying additional nerve length after CPN internal neurolysis with varying degrees of lower extremity flexion, in order to improve end-end nerve repairs in the setting of injury with a significant gap. Materials and methods Full and partial neurolysis dissections were performed on salt- and formaldehyde-perfused cadavers. For accurate measurement of additional length obtained, all dissections were palpated at the fibular head and CPNs transected proximally at the distal fascial border. We chose this site to measure the nerve length obtained because it is the common site for CPN injury and the most clinically applicable. The amount of nerve length gained from neurolysis alone was measured at the location of the common peroneal nerve passing deep to peroneus longus before and after being transected. Nerve length after neurolysis was measured in cm at 10° increments, using a protractor starting at 90° and ending at 0°. Results Both formaldehyde- and salt-perfused cadavers have a significant difference in nerve length obtained after neurolysis at each angle of measurement. This is seen for both dissection groups with p-values <0.05. Conclusions In this study, we found a direct statistically significant relationship between extent of neurolysis and increased angle of measurement, to amount of addition nerve length obtained in both neurolysis groups despite fixation type.

A Unique Case of a High-Grade Neuroepithelial Tumor With EML4-ALK Fusion in a Five-Month-Old.

We present a unique and challenging case of a high-grade neuroepithelial tumor with echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) fusion in a five-month-old child. This tumor was difficult to classify, with glial and ependymal features, reinforcing the impact of a molecular-based diagnosis in correct classification and management. The patient had two tumor resections and underwent chemotherapy following the Head Start trial treatment regimen. The patient remains well, with no residual disease on MRI 15 months after initial resection. Further studies are needed to determine the frequency of EML4-ALK fusions in these types of tumors and to optimize therapeutic protocols for children and adults, alike, suffering from this disease.

A Randomized Trial of Complications of Peripherally and Centrally Inserted Central Lines in the Neuro-Intensive Care Unit: Results of the NSPVC Trial.

OBJECTIVE: The objective of this study was to compare the relative number of complications from peripherally inserted central venous catheters (PICC) and centrally inserted central venous catheters (CVC) in the neuroscience intensive care unit (NSICU). METHODS: This study was carried out in a 32-bed NSICU in a large academic hospital in the USA from July 2015 until January 2017. Patients admitted requiring central venous access were randomly assigned to have a PICC or CVC inserted. Complications were recorded and compared. The primary outcome was all complications as well as combined numbers of large vein thrombosis, central-line-associated blood stream infections, and insertional trauma. Outcomes were compared using the Fisher's exact test, logistic regression, or unpaired T tests, as appropriate. RESULTS: One hundred and fifty-two patients were enrolled; 72 were randomized to the PICC arm and 80 to the CVC arm. There were no crossovers, withdrawals, nor losses to follow-up. The study was stopped at the second pre-planned interim analysis for futility. The combined number of large vein thrombosis, central-line-associated blood stream infection, and insertional trauma was 4/72 in the PICC arm and 1/80 in the CVC group (OR 4.6 (95% CI 0.5-42.6) p = 0.14). The number of all complications in the PICC arm was 14/72 compared to 10/80 in the CVC arm (OR 1.7 (95% CI 0.7-4.1) p = 0.24). CONCLUSIONS: PICCs and CVCs have similar numbers of complications when placed in patients admitted to the NSICU.

The Relative Location of the Major Femoral Nerve Motor Branches in the Thigh.

In peripheral nerve surgery, repair of the femoral nerve (FN) requires identification of normal nerve elements both proximal and distal to the level of the injury. We identified FN branches to the sartorius (SRT) and quadriceps muscles in 16 embalmed specimens and calculated the length of each branch to its point of entry into its respective muscle. The SRT and rectus femoris (RF) muscles were mobilized but not transected to mimic the surgical approach. Ratios of the length of each motor branch as a unit of the total length of the thigh, defined as the FN at the inguinal ligament to the superior margin of the patella were also calculated. The proximal branch to RF spanned a ratio of .19 ± .11 (mean ± standard deviation) from the FN at the inguinal ligament to its endpoint. The ratio of the distal branch to the RF was .29 ± .08. The ratio of the proximal SRT branch was .20 ± .05. The distal branch to SRT was located at a ratio of .43 ± .11. The proximal branch to vastus lateralis (VL) was .26 ± .08. The distal branch to VL was .39 ± .07. The ratio of the motor branch to vastus intermedius (VI) was .30 ± .05. Lastly, the branch to vastus medialis (VM) was .55 ± .06. The motor branch to SRT frequently emerged as a bifurcation of itself and saphenous nerve within the adductor canal. Knowledge of the relative location of the motor branches of the FN in the thigh can be helpful to surgeons during the nerve exploration and repair.

Exosomes impact survival to radiation exposure in cell line models of nervous system cancer.

Radiation is utilized in the therapy of more than 50% of cancer patients. Unfortunately, many malignancies become resistant to radiation over time. We investigated the hypothesis that one method of a cancer cell's ability to survive radiation occurs through cellular communication via exosomes. Exosomes are cell-derived vesicles containing DNA, RNA, and protein. Three properties were analyzed: 1) exosome function, 2) exosome profile and 3) exosome uptake/blockade. To analyze exosome function, we show radiation-derived exosomes increased proliferation and enabled recipient cancer cells to survive radiation in vitro. Furthermore, radiation-derived exosomes increased tumor burden and decreased survival in an in vivo model. To address the mechanism underlying the alterations by exosomes in recipient cells, we obtained a profile of radiation-derived exosomes that showed expression changes favoring a resistant/proliferative profile. Radiation-derived exosomes contain elevated oncogenic miR-889, oncogenic mRNAs, and proteins of the proteasome pathway, Notch, Jak-STAT, and cell cycle pathways. Radiation-derived exosomes contain decreased levels of tumor-suppressive miR-516, miR-365, and multiple tumor-suppressive mRNAs. Ingenuity pathway analysis revealed the most represented networks included cell cycle, growth/survival. Upregulation of DNM2 correlated with increased exosome uptake. To analyze the property of exosome blockade, heparin and simvastatin were used to inhibit uptake of exosomes in recipient cells resulting in inhibited induction of proliferation and cellular survival. Because these agents have shown some success as cancer therapies, our data suggest their mechanism of action could be limiting exosome communication between cells. The results of our study identify a novel exosome-based mechanism that may underlie a cancer cell's ability to survive radiation.

Targeting IL-13Rα2 for effective treatment of malignant peripheral nerve sheath tumors in mouse models.

OBJECTIVEMalignant peripheral nerve sheath tumors (MPNSTs) are aggressive soft tissue sarcomas that harbor a high potential for metastasis and have a devastating prognosis. Combination chemoradiation aids in tumor control and decreases tumor recurrence but causes deleterious side effects and does not extend long-term survival. An effective treatment with limited toxicity and enhanced efficacy is critical for patients suffering from MPNSTs.METHODSThe authors recently identified that interleukin-13 receptor alpha 2 (IL-13Rα2) is overexpressed on MPNSTs and could serve as a precision-based target for delivery of chemotherapeutic agents. In the work reported here, a recombinant fusion molecule consisting of a mutant human IL-13 targeting moiety and a point mutant variant of Pseudomonas exotoxin A (IL-13.E13 K-PE4E) was utilized to treat MPNST in vitro in cell culture and in an in vivo murine model.RESULTSIL-13.E13 K-PE4E had a potent cytotoxic effect on MPNST cells in vitro. Furthermore, intratumoral administration of IL-13.E13 K-PE4E to orthotopically implanted MPNSTs decreased tumor burden 6-fold and 11-fold in late-stage and early-stage MPNST models, respectively. IL-13.E13 K-PE4E treatment also increased survival by 23 days in the early-stage MPNST model.CONCLUSIONSThe current MPNST treatment paradigm consists of 3 prongs: surgery, chemotherapy, and radiation, none of which, either singly or in combination, are curative or extend survival to a clinically meaningful degree. The results presented here provide the possibility of intratumoral therapy with a potent and highly tumor-specific cytotoxin as a fourth treatment prong with the potential to yield improved outcomes in patients with MPNSTs.

Fracture related ulnar and sciatic nerve transections: a report of two cases and literature review.

INTRODUCTION: Case reports, case series, and case control studies have looked at the incidence of complete nerve transection in the setting of fracture and the need for surgical exploration dating back to the 1920s. We present two cases of nerve laceration accompanying traumatic fracture with a thorough review of the literature. METHODS: We used the following search terms: "ulnar nerve" OR "sciatic nerve" AND "laceration" OR "transection" AND "fracture." Results were reviewed and included for discussion if they specifically reported ulnar or sciatic nerve laceration accompanying traumatic fracture. RESULTS: Our search yielded 15 papers reporting a total of 10 ulnar nerve lacerations and nine sciatic nerve lacerations. We present two additional cases. The first is a patient with a humerus fracture and complete ulnar nerve transection. The second case is a patient who suffered a femur fracture and complete transection of the sciatic nerve. CONCLUSION: Nerve laceration accompanying traumatic fracture is rare. We review the reported cases of nerve laceration and present two cases treated at our institution. Though uncommon, nerve laceration should be considered in the setting of traumatic fracture with neurological injury, particularly open fractures.

The Leg Wound of King Philip II of Macedonia.

Objective King Philip II, the father of Alexander the Great, suffered a penetrating wound to the leg from a spear that left him severely handicapped. His skeletal remains represent the first and only case of an injury from ancient Greece that can be directly compared to its historical record. The objective of the study was to confirm the identity of the male occupant of Royal Tomb I in Vergina, Greece as Philip II of Macedonia by providing new evidence based on anatomical dissection and correlation with the historical description of the wounds. Methods Radiographs and photographs of the leg in Royal Tomb I in Vergina were examined. Anatomical dissection of a cadaver with a reconstructed wound similar to Philip's was also completed to identify associated soft-tissue injuries. Results The left leg was penetrated by an object at the knee which resulted in joint diastasis, external rotation of the tibia, knee ankylosis, and formation of a granuloma around the related object. This caused massive trauma to the joint but spared the popliteal artery. This resulted in ligamentous injury as well as injury to the peroneal nerve and probably the tibial nerve, resulting in a complete palsy of those nerves. Conclusion This evidence exactly matches the historical sources and shows conclusively that the leg and Tomb I belong to Philip II. The anatomic and archaeologic evidence also serve as independent verification of some of the historical record of that period, better enabling scholars to judge the reliability of various texts. Furthermore, it gives invaluable information about surgical practices in ancient Greece according to Hippocratic methods and their outcomes. Finally, this sheds new light on the occupants of Royal Tomb II including the fact that the armor recovered there may have belonged to Alexander the Great.

Impact of an External Ventricular Drain Placement and Handling Protocol on Infection Rates: A Meta-Analysis and Single Institution Experience.

BACKGROUND: Numerous studies have examined the impact of initiating an external ventricular drain (EVD) placement and handling protocol on the infection rate dating back to the early 2000s. METHODS: We report a quantitative systematic review of the published literature, described our own protocol (including a mandatory checklist), and present our single institution experience. Search terms "external ventricular drain protocol" or "external ventricular drain placement protocol" or "preventing infections in external ventricular drains" or "external ventricular drain infections" were entered into standard search engines in a systematic fashion. Articles were reviewed and graded independently for class of evidence. There were 10 relevant class IV articles and no discrepancies among article ratings (i.e., κ = 1). The published evidence was reviewed and evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. RESULTS: Our meta-analysis revealed a statistically significant drop in rates of EVD infection after initiation of the protocol, although the overall quality of the body of evidence according to the GRADE criteria was "very poor". Preimplementation and postimplementation infection rates were collected and analyzed in combination with the results from our literature review. The EVD infection rate in our institution was 12% in the 8 months before protocol initiation (January 2015 to August 2015), and dropped to 0% in the 7 months after initiation. CONCLUSIONS: Although the quality of the literature supporting EVD placement protocols is poor, all published studies show a consistent and substantial benefit, and this effect was recapitulated in our own meta-analysis-based prospective EVD protocol experience.

The critical chemical and mechanical regulation of folic acid on neural engineering.

The mandate of folic acid supplementation in grained products has reduced the occurrence of neural tube defects by one third in the U.S since its introduction by the Food and Drug Administration in 1998. However, the advantages and possible mechanisms of action of using folic acid for peripheral nerve engineering and neurological diseases still remain largely elusive. Herein, folic acid is described as an inexpensive and multifunctional niche component that modulates behaviors in different cells in the nervous system. The multiple benefits of modulation include: 1) generating chemotactic responses on glial cells, 2) inducing neurotrophin release, and 3) stimulating neuronal differentiation of a PC-12 cell system. For the first time, folic acid is also shown to enhance cellular force generation and global methylation in the PC-12 cells, thereby enabling both biomechanical and biochemical pathways to regulate neuron differentiation. These findings are evaluated in vivo for clinical translation. Our results suggest that folic acid-nerve guidance conduits may offer significant benefits as a low-cost, off-the-shelf product for reaching the functional recovery seen with autografts in large sciatic nerve defects. Consequently, folic acid holds great potential as a critical and convenient therapeutic intervention for neural engineering, regenerative medicine, medical prosthetics, and drug delivery.

MLN8237 treatment in an orthoxenograft murine model for malignant peripheral nerve sheath tumors.

OBJECTIVEMalignant peripheral nerve sheath tumors (MPNSTs) are soft-tissue sarcomas arising from peripheral nerves. MPNSTs have increased expression of the oncogene aurora kinase A, leading to enhanced cellular proliferation. This makes them extremely aggressive with high potential for metastasis and a devastating prognosis; 5-year survival estimates range from a dismal 15% to 60%. MPNSTs are currently treated with resection (sometimes requiring limb amputation) in combination with chemoradiation, both of which demonstrate limited effectiveness. The authors present the results of immunohistochemical, in vitro, and in vivo analyses of MLN8237 for the treatment of MPNSTs in an orthoxenograft murine model.METHODSImmunohistochemistry was performed on tumor sections to confirm the increased expression of aurora kinase A. Cytotoxicity analysis was then performed on an MPNST cell line (STS26T) to assess the efficacy of MLN8237 in vitro. A murine orthoxenograft MPNST model transfected to express luciferase was then developed to assess the efficacy of aurora kinase A inhibition in the treatment of MPNSTs in vivo. Mice with confirmed tumor on in vivo imaging were divided into 3 groups: 1) controls, 2) mice treated with MLN8237, and 3) mice treated with doxorubicin/ifosfamide. Treatment was carried out for 32 days, with imaging performed at weekly intervals until postinjection day 42. Average bioluminescence among groups was compared at weekly intervals using 1-way ANOVA. A survival analysis was performed using Kaplan-Meier curves.RESULTSImmunohistochemical analysis showed robust expression of aurora kinase A in tumor cells. Cytotoxicity analysis revealed STS26T susceptibility to MLN8237 in vitro. The group receiving treatment with MLN8237 showed a statistically significant difference in tumor size compared with the control group starting at postinjection day 21 and persisting until the end of the study. The MLN8237 group also showed decreased tumor size compared with the doxorubicin/ifosfamide group at the conclusion of the study (p = 0.036). Survival analysis revealed a significantly increased median survival in the MLN8237 group (83 days) compared with both the control (64 days) and doxorubicin/ifosfamide (67 days) groups. A hazard ratio comparing the 2 treatment groups showed a decreased hazard rate in the MLN8237 group compared with the doxorubicin/ifosfamide group (HR 2.945; p = 0.0134).CONCLUSIONSThe results of this study demonstrate that MLN8237 is superior to combination treatment with doxorubicin/ifosfamide in a preclinical orthoxenograft murine model. These data have major implications for the future of MPNST research by providing a robust murine model as well as providing evidence that MLN8237 may be an effective treatment for MPNSTs.

Tumor targeted delivery of doxorubicin in malignant peripheral nerve sheath tumors.

Peripheral nerve sheath tumors are benign tumors that have the potential to transform into malignant peripheral nerve sheath tumors (MPNSTs). Interleukin-13 receptor alpha 2 (IL13Rα2) is a cancer associated receptor expressed in glioblastoma and other invasive cancers. We analyzed IL13Rα2 expression in several MPNST cell lines including the STS26T cell line, as well as in several peripheral nerve sheath tumors to utilize the IL13Rα2 receptor as a target for therapy. In our studies, we demonstrated the selective expression of IL13Rα2 in several peripheral nerve sheath tumors by immunohistochemistry (IHC) and immunoblots. We established a sciatic nerve MPNST mouse model in NIH III nude mice using a luciferase transfected STS26T MPNST cell line. Similarly, analysis of the mouse sciatic nerves after tumor induction revealed significant expression of IL13Rα2 by IHC when compared to a normal sciatic nerve. IL13 conjugated liposomal doxorubicin was formulated and shown to bind and internalized in the MPNST cell culture model demonstrating cytotoxic effect. Our subsequent in vivo investigation in the STS26T MPNST sciatic nerve tumor model indicated that IL13 conjugated liposomal doxorubicin (IL13LIPDXR) was more effective in inhibiting tumor progression compared to unconjugated liposomal doxorubicin (LIPDXR). This further supports that IL13 receptor targeted nanoliposomes is a potential approach for treating MPNSTs.

Correlation of Histopathology and Clinical Symptoms in Meralgia Paresthetica.

Meralgia paresthetica is a neuropathic pain disorder resulting from an entrapment neuropathy of the lateral femoral cutaneous nerve. This condition results in pain, paresthesias and numbness over the anterolateral aspect of the thigh. We present a case of meralgia paresthetica and discuss both the clinical and histopathological findings as they relate to one another. We report a case of meralgia paresthetica refractory to conservative treatment who underwent neurectomy with successful treatment of symptoms. Histopathological examination revealed moderate loss of myelinated axons with some axonal atrophy. The distinct pathologic findings were axonal regeneration clusters and thinly myelinated axons as well as moderate perineurial thickening. These findings corresponded well to the patient's preoperative symptoms of paresthesias and pain. This case serves to shed light on the pathophysiology of meralgia paresthetica and its clinical presentation. It also shows the role of surgical treatment in cases refractory to conservative management in order to alleviate painful symptoms.

Evaluating the evidence: is neurolysis or neurectomy a better treatment for meralgia paresthetica?

BACKGROUND: Meralgia paresthetica is a mononeuropathy of the lateral femoral cutaneous nerve (LCFN). Surgical treatment involves transection or decompression of the LCFN. There is no clear consensus on the superiority of one technique over the other. We performed a systematic review of the literature to answer this question. METHODS: Eligible studies included those that compared neurolysis versus neurectomy for the treatment of meralgia paresthetica after failure of conservative therapy. Our outcome of interest was resolution of symptoms. We performed a computerized search of MEDLINE (PubMed; all years) and of the Cochrane Central Register of Controlled Trials. Eligible studies had to include the words "meralgia paresthetica" and "surgery." All patients regardless of age were included, and there was no language restriction. We then reviewed the articles' titles and abstracts. All studies that compared neurolysis to neurectomy were included in the analysis. RESULTS: Of the studies identified, none were randomized controlled trials. There were two German language articles that were translated by a third researcher. Each study was evaluated by two independent researchers who assigned a level of evidence according to American Association of Neurologist algorithm and also performed data extraction (neurolysis vs. neurectomy and resolution of pain symptoms). Each study was found to be level four evidence. CONCLUSION: After reviewing the data, there was insufficient evidence to recommended one method of treatment over the other. This highlights the importance of keeping a national registry in order to compare outcomes between the two methods of treatment.