Wide Awake Tendon Transfers in Leprosy Patients in India.

Dr Akbar Khan began using the wide awake local anesthesia no tourniquet (WALANT) technique for leprosy tendon transfers in the summer of 2015 at the Damien Foundation Hospital in Nellore, India. This article summarizes his first 18 months of experience and describes 5 of his operations. He found that WALANT provides effective anesthesia with good visibility for leprosy tendon transfers. WALANT permits economically disadvantaged leprosy patients to afford the surgery. All of the leprosy patients who have undergone WALANT tendon transfers in this series would like the same technique for their next tendon transfers.

Laparoscopic-Assisted Percutaneous Endoscopic Cecostomy (LAPEC) in Children and Young Adults.

OBJECTIVE: We evaluated the safety and efficacy of the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC) procedure both in children and young adults, along with review of their pre-operative motility profiles, antegrade continence enema (ACE) regimen, and postoperative complications. METHODS: This retrospective review investigated 38 patients (32 children and 6 young adults) that underwent the LAPEC procedure. Primary outcomes evaluated were success versus failure of the procedure and post-operative complications. Success was defined as daily stool evacuation with minimal to no fecal incontinence per week. RESULTS: Mean follow up time was 25.8 ± 22.4 months. Indications for LAPEC included slow transit constipation or colonic neuropathy (n = 22), other types of constipation (n = 5), and a variety of congenital disorders (n = 11). The overall success rate was 95% (36/38 patients) with the two failures in children, both attributed to inability to use the tube due to underlying behavioral disorders or severe anxiety. Five patients above age 18 had leakage compared to 6 in the under age 18 group (83% vs. 19, P = 0.003). There were no other significant complications. CONCLUSION: LAPEC is a safe and effective means of addressing refractory constipation and fecal incontinence in children and young adults who have failed medical management with minimal post-operative complications.

Filum terminale arteriovenous fistulas: the role of endovascular treatment.

OBJECT: The authors describe the clinical presentation, imaging features, and management of patients presenting with filum terminale arteriovenous fistulas (FTAVFs) and the role of transarterial treatment in their management. METHODS: The authors retrospectively reviewed data obtained in 10 patients with FTAVFs diagnosed between January 1990 and December 2011. RESULTS: Most patients (70%) were male, and the age of the population ranged from 31 to 72 years (mean 58.2 years). Clinical presentation was progressive paraparesis and sensory loss in the lower extremities in 9 cases, back pain in 7, radicular pain in 3, bowel/bladder disturbance in 5, and impotence in 1. The duration of symptoms varied between 2 and 24 months. Initial MRI studies showed intramedullary increased T2 signal, swollen cord, and dilated perimedullary veins in all patients. One patient had syringomyelia, presumably caused by venous hypertension transmitted by the perimedullary venous system. Embolization was attempted in 7 patients and was curative in 6 patients. Surgery was performed in the other 4 patients in whom embolization was unsuccessful or deemed not feasible. There was no treatment-related complication in either group. Symptoms, venous congestion in the cord, and syringomyelia improved on follow-up in all patients. CONCLUSIONS: Embolization should be considered the treatment of choice for FTAVFs and can effectively treat the majority of patients presenting with an FTAVF. In a smaller group of patients in whom the angioarchitecture is unfavorable, open surgery is recommended.

Intracranial neurostimulation for pain control: a review.

Intracranial neurostimulation for pain relief is most frequently delivered by stimulating the motor cortex, the sensory thalamus, or the periaqueductal and periventricular gray matter. The stimulation of these sites through MCS (motor cortex stimulation) and DBS (deep brain stimulation) has proven effective for treating a number of neuropathic and nociceptive pain states that are not responsive or amenable to other therapies or types of neurostimulation. Prospective randomized clinical trials to confirm the efficacy of these intracranial therapies have not been published. Intracranial neurostimulation is somewhat different than other forms of neurostimulation in that its current primary application is for the treatment of medically intractable movement disorders. However, the increasing use of intracranial neurostimulation for the treatment of chronic pain, especially for pain not responsive to other neuromodulation techniques, reflects the efficacy and relative safety of these intracranial procedures. First employed in 1954, intracranial neurostimulation represents one of the earliest uses of neurostimulation to treat chronic pain that is refractory to medical therapy. Currently, 2 kinds of intracranial neurostimulation are commonly used to control pain: motor cortex stimulation and deep brain stimulation. MCS has shown particular promise in the treatment of trigeminal neuropathic pain and central pain syndromes such as thalamic pain syndrome. DBS may be employed for a number of nociceptive and neuropathic pain states, including cluster headaches, chronic low back pain, failed back surgery syndrome, peripheral neuropathic pain, facial deafferentation pain, and pain that is secondary to brachial plexus avulsion. The unique lack of stimulation-induced perceptual experience with MCS makes MCS uniquely suited for blinded studies of its effectiveness. This article will review the scientific rationale, indications, surgical techniques, and outcomes of intracranial neuromodulation procedures for the treatment of chronic pain.

A tribute to Dr. David Kline: a new approach to an old peripheral nerve problem--splicing instead of regenerating disrupted axons.

OBJECTIVE: Our goal is to develop a novel method to repair damaged axons. This method relies on acutely restoring axonal continuity rather than the traditional approach of promoting axonal regeneration. METHODS: Micro- and nanoechnological methods, in combination with focal application of electrical fields, are applied to individual and groups of axons both in vitro and in vivo. RESULTS: Application of these techniques has permitted micromanipulation of axons at the cellular level and fusion of axonal membranes. CONCLUSION: Although a great deal more work is necessary, our findings suggest that it may one day be possible to repair acutely disrupted axons by splicing their membranes back together.

Peripheral nerve stimulation: lead position monitoring by reconstruction CT angiography--a technical report.

BACKGROUND: The authors investigated the possibility of improving positioning of stimulation leads in patients with chronic neuropathic peripheral nerve pain and good pain relief from implantation of a peripheral nerve stimulator (PNS). METHODS: This pilot study includes four patients suffering from Chronic Regional Pain Syndrome type II (CRPS II) or neuropathic mononeuropathy treated with PNS therapy. The affected extremities and corresponding implantation sites were examined using computer tomographic scans (CT), additional CT angiography (CTA), reconstruction techniques and postprocessing procedures. RESULTS: It was possible to prove a close relation between the implanted device and the neurovascular bundle in each of these cases. Thus, indirect lead position control was obtained. CONCLUSIONS: Computer tomographic techniques represent a reliable method for the position control of implanted peripheral nerve electrodes. Hence, this procedure should surpass general radiographies in detecting lead displacements.

Physical therapy following peripheral nerve surgeries.

Post-operative care of the surgical patient significantly contributes to the success of the surgical procedure. Post-operative physical therapy is directed at reducing pain and inflammation, preventing or minimizing scar tissue, and returning the patient to full function. An individualized and well-planned therapeutic exercise program is an integral part of the post-operative care. Manual therapy techniques are utilized to break up scar tissue and reduce joint stiffness. Pain and inflammation can be addressed by modalities such as ultrasound, laser, and electrical stimulation in addition to cryotherapy.

Long-term peripheral nerve stimulation for painful nerve injuries.

BACKGROUND: Although peripheral nerve stimulation (PNS) has been used in the treatment of pain since 1965, only a few follow-up studies have been published. The aim of the present retrospective study was to carefully assess the long-term efficacy and safety of PNS in the treatment of painful nerve injuries. METHODS: Patients suffering from intractable pain due to peripheral nerve injuries underwent PNS after careful selection. Long-term results were evaluated based upon patients' reports of pain intensity on a visual analog scale (VAS) and their consumption of analgesics. Two categories of results were chosen: good, referring to 50% or more relief of pain with abstinence from analgesic medications; and poor, with less than 50% improvement. RESULTS: Of 154 referred patients, 46 (26 women and 20 men) were found suitable for PNS. Four etiologic factors were identified, the most common being nerve lesion following an operation in the region of the hip or knee. Other etiologies included entrapment neuropathy, pain following nerve graft, and painful neuropathy following a traumatic injection. The follow-up period was 3-16 years. Of the 46 patients who underwent surgery, the results were classified as good in 36 (78%) patients and as poor in 10 (22%) patients. Overall, pain intensity dropped from a VAS of 69 +/- 12 before surgery to 24 +/- 28 postoperatively (P < 0.001). CONCLUSIONS: PNS can produce good pain relief in the majority of carefully selected patients suffering from isolated painful neuropathies.

Interventional neurophysiology of the sacral nervous system.

Clinical neurophysiological tests have been introduced for the sacral neuromuscular system to aid with diagnosis of neurogenic conditions involving the lower urinary tract, anorectal and sexual dysfunction. The tests have, however, the potential to be of value in different interventions outside of the neurophysiological laboratory. EMG monitoring can be used for exact application of botulinum toxin by the relatively non-invasive transcutaneous approach in treatment of male detrusor sphincter dyssynergia. Checking for compound muscle action potentials of the external anal sphincter is proposed as the best method for exact placement of wire electrodes close to the 3rd sacral roots in treating lower urinary tract dysfunction by 'neuromodulation'. Presently the most established use of clinical neurophysiological techniques--outside the laboratory--as related to the sacral neuromuscular system is in the operating theatre. These tests have been introduced to identify relevant structures, for instance pudendal afferents within dorsal sacral roots, which should be spared during rhizotomy procedures for treatment of spasticity. Modified techniques are used intraoperatively to monitor the integrity of the lower sacral reflex arc (the bulbocavernosus reflex) or the lower sacral afferents throughout the spinal cord (pudendal SEP). Clinical neurophysiological tests are expected to become established in several interventions involving the sacral neuromuscular system.

Estimulaçäo elétrica da medula espinal para o tratamento da dor crônica: resultados / Eletrical stimulation of spinal cord for the treatment of chronic pain

Os resultados do tratamento de 50 doentes através do método da neuroestimulaçao da medula espinal sao apresentados. A dor foi decorrente de lesao traumática do cone medular e das raízes da cauda eqüina em 8 doentes, lesao da medula espinal em 14, neuropatia pós-herpética em 6, distrofia simpático-reflexa em 8, fibrose peridural em 6, doença oncológica em 1, avulsao das raizes do plexo braquial em 4 e decorrente da amputaçao de membros em 3 (dor em membro fantasma em 2 e no coto de amputaçao em 1). Os resultados foram considerados bons e excelentes, durante o período de seguimento, em 26 doentes (52 por cento). Vinte e quatro (48 por cento) nao se beneficiaram com a estimulaçao elétrica da medula espinal. Em 2 doentes o sistema implantado teve que ser removido devido a infecçao. Um dos doentes apresentou complicaçoes transitórias decorrentes de síndrome cordonal posterior. A estimulaçao elétríca da medula espinal nao contribuiu para o alívio da dor em 7 doentes com lesao traumática da medula espinal e raízes da cauda eqüina. Um doente teve excelente resultado após o implante; entretanto, observou-se recorrência da dor durante o acompanhamento clínico.Em 7 doentes com mielopatia, o resultado satisfatório obtido com o implante permaneceu durante o período de seguimento (mediana de 8,9 meses). Em doentes com nevralgia pós-herpética foram observados resultados bons e excelentes após o ato operatório; no entanto, foram observadas recorrência parcial da dor em l e recorrência total em outro. Dentre os 7 doentes com distrofia simpático-reflexa, a estimulaçao da medula espinal resultou no alívio imediato e persistente da sintomatologia em 6. Um doente apresentou recorrência da dor. A estimulaçao elétrica da medula espinal propiciou alívio imediato da dor em 2 doentes com avulsao das raizes do plexo braquial. Entretanto, a dor recorreu em 1.Um doente com dor no coto de amputaçao e 2 com dor no membro fantasma nao apresentaram alívio com estimulaçao elétrica da medula espinal. O doente com dor oncológica visceral apresentou resultado satisfatório durante os 2 últimos meses de vida.Baseado na análise deste trabalho, é possível concluir que a estimulaçao elétríca da medula espinal é especialmente recomendada para o tratamento das síndromes neuropáticas com lesao mínima ou parcial das estruturas nervosas, como as que ocorrem em casos de distrofia simpático-reflexa, radiculopatias ou lesao parcial da medula espinal.

A clinical pilot study to assess functional return following continuous muscle stimulation after nerve injury and repair in the upper extremity using a completely implantable electrical system.

This clinical pilot study evolved from a 10-year experience in the experimental laboratory using continuous muscle stimulation in a series of animal studies following nerve injury and microsurgical repair. A completely implantable system was developed (Medtronic) to provide electrical stimulation to the denervated muscles until nerve regeneration had occurred. Both peripheral nerve injuries in the extremities and facial nerve severances were studied, and a definite improvement in functional capacity was obtained as well as improved morphology compared with nonstimulated controls. In this study, 13 patients with peripheral nerve injuries in the upper extremity are included. All patients had muscle stimulation for extended periods until nerve regeneration was evident; a careful analysis of their functional capacity was then completed. There were five patients with median nerve injuries, four with ulnar nerve or combined median-ulnar nerve injuries, and four with severed radial nerves. All patients showed satisfactory nerve regeneration on clinical examination and electromyographic studies. Motor recovery was usually better than sensory return. Functional muscle analysis varied somewhat from patient to patient, but every patient had a satisfactory to excellent recovery. Patients with low nerve lesions had better results, but muscle recovery even in patients with mid-forearm or higher nerve injuries was most encouraging. Functional recovery in radial nerve injuries was close to normal in all cases. The results from this pilot study have clearly shown the benefits of continuous muscle stimulation using an implantable system following nerve injury and repair.

"Karate kid" finger.

The ulnar dorsal digital nerve of the little finger overlies the prominence of the ulnar hemicondyle of the middle phalanx at the proximal interphalangeal joint level and is vulnerable to contusion injury when the hand is used to perform karate chops. Localized perineural and interfascicular fibrosis may ensue. Neurolysis is curative.

The effect of low-frequency electrical stimulation on denervation atrophy in man.

The effect of low frequency electrical stimulation (LES) on denervation atrophy and recovery of the muscles was examined in a group of 73 patients with a single or a combined total lesion of the median, ulnar or peroneal nerves. The differences between the patients were evaluated by means of clinical muscle force testing, EMG, dynamometry (ulnar and median nerve lesions), computer tomography (ulnar nerve lesions) and ultrasonography (median and peroneal nerve lesions). A beneficial effect of LES could not be shown.

Dorsal root entry zone lesion versus spinal cord stimulation in the management of pain from brachial plexus avulsion.

In six patients with total or partial brachial plexus avulsion, spinal cord stimulation was tried as pain treatment. Two patients had had amputation of the arm and suffered from phantom limb and stump pain. After a mean follow-up of 14 months two patients were painfree, one had partial relief and required analgesics and in three patients there was no effect. In eleven patients, including the three patients in whom spinal cord stimulation had failed to produce a long-lasting pain relief, dorsal root entry zone (DREZ) lesions were performed. At early follow-ups all these patients reported substantial pain relief, but after a mean follow-up of 17 months the results were less favorable: Three patients were pain-free, three had a marked improvement and five had recurrence of the original pain. Neither of the two methods of treatment produced any serious side-effects or permanent sequelae.