Selective Peripheral Denervation and Selective Nerve Injury for the Treatment of Cervical Dystonia Through a Periauricular Incision.

Traditional selective peripheral denervation methods for treating cervical dystonia (CD) involve complete transection of the nerves to muscles through a posterior incision proximally after they exit the spinal cord. This report presents a case where anterior muscles involved in CD cannot be easily addressed through the traditional posterior approach. Furthermore, complete denervation of certain muscles, such as the trapezius, can lead to functional limitations. The objective of this report is to describe an anterior surgical treatment approach for focal CD. Specifically, we describe the use of a periauricular incision to perform selective peripheral denervation of anterior and posterior neck muscles at a more peripheral location near their target muscle entry point. Complete denervation was performed for expendable muscles while Sunderland third-degree nerve injury was performed to weaken nonexpendable muscles. This approach facilitates clearer identification of nerves as they enter the pathologic target muscle. Additionally, the therapeutic use of Sunderland third-degree nerve injury in the treatment of CD is a useful adjunct to muscles that are nonexpendable as it allows for only partial denervation as opposed to complete denervation with traditional methods.

Functional organization of adult motor cortex is dependent upon continued protein synthesis.

The functional organization of adult cerebral cortex is characterized by the presence of highly ordered sensory and motor maps. Despite their archetypical organization, the maps maintain the capacity to rapidly reorganize, suggesting that the neural circuitry underlying cortical representations is inherently plastic. Here we show that the circuitry supporting motor maps is dependent upon continued protein synthesis. Injections of two different protein synthesis inhibitors into adult rat forelimb motor cortex caused an immediate and enduring loss of movement representations. The disappearance of the motor map was accompanied by a significant reduction in synapse number, synapse size, and cortical field potentials and caused skilled forelimb movement impairments. Further, motor skill training led to a reappearance of movement representations. We propose that the circuitry of adult motor cortex is perpetually labile and requires continued protein synthesis in order to maintain its functional organization.

Bupivacaine digital blocks: how long is the pain relief and temperature elevation?

BACKGROUND: The goals of this study are threefold: (1) to determine what effect epinephrine has on the duration of bupivacaine finger block anesthesia; (2) to see whether the duration of action of bupivacaine on digital pain relief is the same duration as numbness to touch/pressure; and (3) to assess the fingertip temperature changes that result from bupivacaine digital blocks. METHODS: The ring fingers of both hands of 44 volunteers were randomized to injection of bupivacaine with or without 1:200,000 epinephrine. The durations of time for digits to return to normal pain, touch, pressure sensation, and fingertip temperature were measured and recorded. RESULTS: There were three main findings: (1) the pain block of bupivacaine lasts only half as long (15 hours) as the return to normal sensation (30 hours); (2) the effect of adding epinephrine to bupivacaine prolongs the duration of pain relief in a finger block for only an additional 1.5 hours; (3) in addition to pain relief, bupivacaine finger blocks cause fingertip hyperemia with consistent significant fingertip temperature elevation that lasts 15 hours. CONCLUSIONS: The duration of bupivacaine pain relief is the clinically important factor that needs to be reported in bupivacaine trials. Patients should be informed that the return of pain will occur much sooner than the return of normal sensation. Adding epinephrine to bupivacaine does not add a clinically significant length of time to pain relief. Bupivacaine finger blocks provide prolonged hyperemia and pain block to fingertips, which may be useful in the treatment of acute frostbite. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Review of thumb carpometacarpal arthritis classification, treatment and outcomes.

Thumb carpometacarpal osteoarthritis (CMC OA) is a common disease, affecting up to 11% and 33% of men and women in their 50s and 60s, respectively, which leads to pain, laxity and weakness of the CMC joint. Based on the staging of the CMC OA, different forms of treatment can be used, including both conservative and surgical measures. Surgical options include osteotomy, trapezial excision, ligament reconstruction with or without tendon interposition, and various prosthetic interpositional implants with or without trapezial excision. The present article reviews the staging of CMC OA, the evaluation of hand function using patient-reported questionnaires, and outcomes of both conservative and surgical treatments. The present review also introduces a commercially available interpositional spacer surgical technique for CMC OA and the early evidence that the literature has shown for improving hand function, strength and stability of the thumb CMC joint postoperatively.

Superior pedicle breast reduction techniques increase the risk of postoperative drainage.

BACKGROUND: The most frequent complication after bilateral reduction mammoplasty (BRM) is the formation of seromas and hematomas. If a group of patients who are at increased risk of seroma and hematoma are identified, the use of drains in this group would be beneficial. We hypothesized that superior pedicle reductions would have increased postoperative drainage. METHODS: A prospective observational study was conducted to identify independent risk factors for increased drainage after BRM. Blinded research nurses were employed to record the amount of drainage during the postoperative period. Univariate and multivariate regression analyses were used to identify risk factors for increased postoperative drainage. RESULTS: The study included a total of 111 patients. Univariate analysis identified the amount of preoperative infiltration (P < 0.001), the amount of liposuction (P < 0.001), the amount of surgically resected tissue (P = 0.001), the type of reduction (P < 0.001), the patient's chest circumference (P = 0.035), and the patient's body mass index (BMI) (P = 0.015) as significant predictors of postoperative drainage. Multivariate regression analysis identified the amount of tissue resected and the type of reduction as the only 2 independent predictors of postoperative drainage. The use of superior pedicle technique predicted 43% of the variability in postoperative wound drainage. CONCLUSIONS: The use of the superior pedicle technique for BRM is associated with a significant increase in postoperative drainage. Surgeons using this technique should consider the routine use of drains to avoid possible complications of seroma, infection, and poor wound healing.