Neurosurgical treatment of leprosy neuropathy in a low-incidence, European country.

INTRODUCTION: Leprosy is nowaday increasingly encountered in non-endemic countries. Nerve involvement is common. Swelling of the nerves may lead to entrapment neuropathy causing pain and neurological deficits. Delay in diagnosis and treatment may lead to loss of chance of improvement. Surgical decompression in conjunction with medical therapy allows relief of symptoms. METHODS: We present a retrospective series of 21 patients surgically treated in our center for leprosy entrapment neuropathy. We report presentation, treatment, and outcome at follow-up including a brief literature review. RESULTS: Twenty-one patients were treated for nerve entrapments in four different anatomical districts. We reported good clinical outcomes mainly in motor deficits but also in improvement of sensitive deficits and pain symptoms. We did not experience surgical complications. DISCUSSION: Although there is a lack of high-quality prospective studies comparing medical and surgical treatment of leprosy neuropathy, benefits of surgery are widely reported in series and case reports from endemic countries. There is scant literature from low-incidence countries even if leprosy incidence is nowaday increasing in these countries and will likelihood further increase in the future. Our results are in line with the literature presenting good outcomes after surgery. CONCLUSION: We believe that a precise knowledge of the pathology and its management is crucial also for physicians who work in low-incidence countries to maximize healing chances with timely diagnosis and treatment.

Lessons From Leprosy: Peripheral Neuropathies and Deformities in Chronic Demyelinating Diseases.

In light of the World Health Organization's push to accelerate progress toward a leprosy-free world by 2020, it is fitting to look back on the evolution of progress in treating lepromatous neuropathy and limb deformities. To date, no surgeon has had as great an impact on the understanding and treatment of this disease as Dr Paul Brand. Before Dr Brand's accomplishments, few surgeons participated in the management of the deformed leprous patient. By challenging conventional beliefs, Dr Brand revealed that many of the deformities associated with leprosy were in fact caused by nerve damage and subsequent limb anesthesia. His pioneering work centered on tendon transfers to provide hand and foot mobility to leprous patients, revolutionizing the surgical management of this patient population and restoring functionality to the lives of otherwise stigmatized and functionally handicapped individuals. In the process, he provided us with the surgical principles and techniques that we still apply today. Because of its predilection for the peripheral nervous system, leprosy also provides an excellent opportunity to investigate mechanisms of demyelination and chronic nerve degeneration in nonacute peripheral neuropathies. Processes underlying demyelination of infectious, traumatic, and genetic etiologies overlap and precede the onset of acute neuronal derangement. Glial pathology has been shown to be a common pathological element in leprosy, Charcot-Marie-Tooth type I, multiple sclerosis, and chronic nerve compression injury. The aim of this article is to provide an overview of lepromatous neuropathy with its subsequent deformities as it relates to the pathophysiology, surgical management, and potential therapeutic targets of other modern peripheral neuropathies.

Análise dos resultados de neurolises em pacientes com hanseniase / Analysys of the results of neurólises in patients with leprosy

O objetivo deste estudo é avaliar a eficácia da neurólise cirúrgica no tratamento da neurite periférica em pacientes com hanseníase. Trata-se de um estudo retrospectivo de vinte e cinco pacientes hansenianos submetidos à neurólise com média de idade de 39,4 anos. A perda sensitiva foi quantificada pelo método dos monofilamentos de Siemmens-Weistein e a dor foi informada pelo paciente através de escala numérica analógica. As variáveis foram analisadas pré e pós operatoriamente. O Teste da Binomial, utilizado para a análise comparativa entre as avaliações sensitiva, mostrou variação não significativa estatisticamente (p > 0,05) nas medições pré e pós-operatórias, indicando ausência de progressão da parestesia. Houve melhora significativa da dor em todos os pacientes. Conclusão: a neurólise cirúrgica foi eficaz no alívio da dor e interrompeu a progressão da perda sensitiva na neuropatia periférica de hansenianos.

Prevalence of leprous neuropathy determined by neurosensory testing in an endemic zone in Ecuador: Development of an algorithm to identify patients benefiting from early neurolysis.

The success of a microneurosurgical intervention in leprous neuropathy (LN) depends on the diagnosis of chronic compression before irreversible paralysis and digital loss occurs. In order to determine the effectiveness of a different approach for early identification of LN, neurosensory testing with the Pressure-Specified Sensory Device™ (PSSD), a validated and sensitive test, was performed in an endemic zone for leprosy. A cross-sectional study was conducted to analyze a patient sample meeting the World Health Organization (WHO) criteria for Hansen's disease. The prevalence of LN was based on the presence of ≥1 abnormal PSSD pressure threshold for a two-point static touch. A total of 312 upper and lower extremity nerves were evaluated in 39 patients. The PSSD found a 97.4% prevalence of LN. Tinel's sign was identified in 60% of these patients. An algorithm for early identification of patients with LN was proposed using PSSD testing based on the unilateral screening of the ulnar and deep peroneal nerves.

Peripheral neuropathy of the upper extremity: medical comorbidity that confounds common orthopedic pathology.

In the orthopedic patient, the diagnosis of a compression neuropathy may be straightforward. However, various medical comorbidities can obscure this diagnosis. It is paramount for the practicing orthopedic surgeon to have an appreciation for the medical pathology of common axonal neuropathies to properly diagnose, treat, and refer a patient with altered sensation in the upper extremity. The prevalence of diabetes in the United States is 10%, and roughly 20% of diabetic patients have peripheral neuropathy. In addition to diabetes, 32% of heavy alcohol users present with polyneuropathy. With advancements in the treatment of human immunodeficiency virus/acquired immunodeficiency syndrome clinicians may see the long-term effects of the virus manifested as axonal neuropathies and extreme allodynia. In some regions of the world, Hansen's disease usurps diabetes as the most common cause of polyneuropathy. Based on patient demographics and social habits, Lyme disease, multiple sclerosis, and syphilis can all manifest as polyneuropathies. Understanding the common medical causes of neuropathy will aid the orthopedic surgeon in differentiating simple compression neuropathies from diseases mimicking or confounding them.

Decompressive surgery for treating nerve damage in leprosy. A Cochrane review.

OBJECTIVE: Decompressive surgery is used for treating nerve damage in leprosy. We assessed the effectiveness of decompressive surgery for patients with nerve damage due to leprosy. METHODS: A broad search strategy was performed to find eligible studies, selecting randomised controlled trials (RCTs) comparing decompressive surgery alone or plus corticosteroids with corticosteroids alone, placebo or no treatment. Two authors independently assessed quality and extracted data. Where it was not possible to perform a meta-analysis, the data for each trial was summarised. RESULTS: We included two randomised controlled trials involving 88 people. The trials examined the added benefit of surgery over prednisolone for treatment of nerve damage of less than 6 months duration. After 2 years follow-up there was no significant difference in nerve function improvement between people treated with surgery plus prednisolone or with prednisolone alone. Adverse effects of decompression surgery were not adequately described. CONCLUSIONS: Evidence from randomised controlled trials does not show a significant added benefit of surgery over steroid treatment alone. Well-designed randomised controlled trials are needed to establish the effectiveness of the combination of surgery and medical treatment compared to medical treatment alone.

Decompressive surgery for treating nerve damage in leprosy.

BACKGROUND: Leprosy causes nerve damage which may result in nerve function impairment and disability. Decompressive surgery is used for treating nerve damage, although the effect is uncertain. OBJECTIVES: To assess the effects of decompressive surgery on nerve damage in leprosy. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (November 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2007), MEDLINE (from January 1950 to November 2007), EMBASE (from January 1980 to November 2007), AMED (from January 1985 to November 2007), CINAHL (from January 1982 to November 2007) and LILACS (from January 1982 to November 2007) in November 2007. We checked reference lists of the studies identified, the Current Controlled Trials Register (www.controlled-trials.com), conference proceedings and contacted trial authors. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of decompressive surgery for nerve damage in leprosy. DATA COLLECTION AND ANALYSIS: The primary outcome was improvement in sensory and motor nerve function after one year. Secondary outcomes were improvement in nerve function after two years, change in nerve pain and tenderness, and adverse events. Two authors independently extracted data and assessed trial quality. We contacted trial authors for additional information. We collected adverse effects information from the trials and non-randomised studies. MAIN RESULTS: We included two randomised controlled trials involving 88 people. The trials examined the added benefit of surgery over prednisolone for treatment of nerve damage of less than six months duration. After two years follow-up there was no significant difference in nerve function improvement between people treated with surgery plus prednisolone or with prednisolone alone. Adverse effects of decompressive surgery were not adequately described. AUTHORS' CONCLUSIONS: Decompressive surgery is used for treating nerve damage in leprosy but evidence from randomised controlled trials does not show a significant added benefit of surgery over steroid treatment alone. Well-designed randomised controlled trials are needed to establish the effectiveness of the combination of surgery and medical treatment compared to medical treatment alone.

Flexor carpi ulnaris transfer successfully used to gain strengthening of flexor digitorum superficialis tendons.

Transfer of the flexor carpi ulnaris (FCU) to replace the power of the paralysed extensor digitorum communis and extensor pollicies longus has been described in the literature. However the use of FCU for strengthening flexor digitorum superficialis (FDS) is relatively not widely known. In this report the use of the technique is dicussed to successfully restore the strength of the fingers of a leprosy patient with considerable partial high median palsy to this patient's urgent need and at his request. This surgical procedure and results of a single case are shown as a preliminary report.

Detection of neuropathy due to Mycobacterium leprae using noninvasive neurosensory testing of susceptible peripheral nerves.

The prevalence of disability in patients with Hansen disease is related to peripheral nerve dysfunction. This dysfunction, which is due to chronic nerve compression, is the result of invasion of the peripheral nerve by Mycobacteria leprae. This suggests that early identification of M. leprae would be aided by detection of early stages of peripheral nerve compression. Traditional evaluation of peripheral nerve function with monofilaments, electrodiagnostic testing, or by observing motor palsy or digital ulcers unfortunately identifies only late sequelae of peripheral nerve dysfunction. The cutaneous pressure threshold required to identify 1 from 2 static-touch stimuli was obtained with the Pressure-Specified Sensory Device in upper and lower extremities of 51 patients who completed multidrug therapy for Hansen disease. Abnormal peripheral nerve function was identified in each patient and in each of the 120 bilateral nerves that were evaluated. The degree of nerve dysfunction included the range from early to late stages of nerve compression, suggesting that this method of neurosensory testing offers the possibility for early detection of peripheral nerve problems in Hansen disease.

Shall we continue with nerve trunk decompression in leprosy?

There is a tendency to compare the results of surgery with that of oral corticosteroid therapy in leprous neuritis as if the two are competing methods. Surgery helps by removing the external compressive force and improves circulation so that steroids can reach and effectively act at the site of inflammation, minimizing the ischaemic and compression damage to nerve fibres. Often nerve decompression in leprosy is requested rather late so that the desired results are not always achieved. With emphasis on "elimination of leprosy", the disease is being managed in endemic states by field programmes where individual patient is not the priority unlike in the general hospitals and among practitioners where the welfare of the patient is the priority. It is therefore important to create awareness about compression neuropathy in leprosy and the need for combination therapy so as to bring down the morbidity and disability.

Ulnar and median nerves in paucibacillary leprosy--a follow-up study of electrophysiological functions in patients before and after nerve trunk decompression.

Electrophysiological functions of ulnar and median nerves in paucibacillary leprosy patients were studied. Patients who showed deterioration of sensory motor functions in spite of steroid therapy were offered nerve decompression together with oral steroids. On periodic follow-up of those who opted for surgery, it was observed, in general, that NCV and amplitude remained reduced even though clinical recovery occurred. Only 80% recovery of electrophysiological functions was seen (as compared to control levels), even in cases that showed good results. Motor function recovered better than sensory function. Complete electrophysiological recovery, if it occurs at all, takes much longer than clinical recovery.

[Transposition of the tendon of M. tibialis posterior an effective treatment of drop foot; retrospective study with follow-up in 12 patients]. / Transpositie van de pees van de M. tibialis posterior effectief bij een klapvoet; retrospectief onderzoek met follow-up bij 12 patiënten.

OBJECTIVE: To evaluate the results of transposition of the tendon of the M. tibialis posterior in patients with a drop foot. DESIGN: Descriptive, retrospective and follow-up investigation. METHODS: Surgical treatment was carried out in 12 patients with a drop foot (9 women and 3 men, with an average age of 37 years) in the period 1986-1998. The aetiology of the drop foot was a traumatic or iatrogenic lesion of the peroneal nerve or sciatic nerve in 9 patients and in 3 patients spina bifida occulta, leprosy and a herniation of a lumbar disc respectively. None of the patients had important comorbidity. Treatment consisted of lengthening the Achilles tendon according to Huckstep, transposition of the tibial posterior tendon in two tails to the dorsomedial and dorsolateral side of the foot, and six weeks of immobilisation in plaster of Paris. RESULTS: The postoperative period was without complications. The treatment improved the heel-toe steppage gait in all patients. None of the 10 patients who had used an orthosis preoperatively still used it at the time of the follow up. Fifty per cent of the patients acquired a dorsiflexion of the foot of more than 0 degree. The results were in accordance with those in the literature. CONCLUSION: Transposition of the tibial posterior tendon is a worthwhile alternative for those patients with a drop foot (and without important comorbidity) who cannot walk satisfactorily with an ankle-foot orthosis.

Single tendon--two insertion versus two tendon transfers for reablement of ulnar-median palsied thumb in leprosy.

Twenty-three opponensplasties for ulnar median paralysis in 20 leprosy patients were performed by two different procedures i.e. extensor indicis proprius and flexor digitorum superficialis transfers using standard techniques. The results were evaluated using various objective and subjective, anatomical and functional parameters. Two tendon transfers appeared to be superior to single tendon two insertion transfers. It was concluded that if situation permits, two tendon transfers should be performed for combined ulnar median paralysis.

[Results of 466 nerve decompressions in 123 leprosy patients during polychemotherapy with a minimum follow-up of one year. Value of preventive surgery in a leprosy control program]. / Résultats de 466 décompressions nerveuses chez 123 lépreux en cours de polychimiothérapie avec un recul minimum de un an. Intérêt de la chirurgie préventive dans un programme de lutte contre la lèpre.

The clinical expression of leprosy is primarily cutaneous but its serious neurologic manifestations are maiming. Mutilations mainly of limb ends are due to peripheric nerves compression and may appear before or during the clinical treatment of the illness. Their appearance which is not automatically related to multiple Hansen's bacilli, may be prevented surgically by nervous decompression. The authors report their experiences of 466 nervous decompressions of 123 patients (89 men and 34 women), among them, 14 were pauci-bacillary and 109 multi-bacillary. They conclude that very good results (complete recovery or improvement of sensitivity, disappearing of pain) have been obtained through simple and easy-to-learn surgeries.