Ultrasound as a Useful Tool for a Peripheral Nerve Surgeon: Examples in Clinical Practice.

BACKGROUND: Peripheral nerve surgeons often require additional imaging for examination, diagnostic testing, and preoperative planning. Point-of-care ultrasound (US) is a cost-effective, accessible, and well-established technique that can assist the surgeon in diagnosing and treating select peripheral nerve pathologies. With this knowledge, the properly trained surgeon may perform US-guided nerve blocks to help accurately diagnose and treat causes of neuropathic pain. We offer this paper, not as an exhaustive review, but as a selection of various peripheral nerve pathologies, which the senior author treats, and their associated US examination findings. Our goal is to encourage other peripheral nerve surgeons to incorporate US into their practices. METHODS: We provide various cases from our outpatient peripheral nerve clinic demonstrating relevant US anatomy. We also review techniques for US guided nerve blocks with relevant anatomic landmarks. RESULTS: US imaging successfully assisted in identification and injection techniques for various peripheral nerve pathologies in a surgeon's practice. Examples were presented from the neck, trunk, upper extremity, and lower extremity. CONCLUSION: Our review highlights the use of US by a peripheral nerve surgeon in an outpatient private practice clinic to diagnose and treat select peripheral nerve pathologies. We encourage reconstructive surgeons to add US to their arsenal of diagnostic tools.

Complex regional pain syndrome patient treated with a below knee amputation, implanting nerves directly into muscle: A case report.

Persistent, disabling lower extremity pain, outside the distribution of a single nerve, is termed chronic regional pain syndrome (CRPS), but, in reality, this chronic pain is often due to multiple peripheral nerve injuries. It is the purpose of this report to describe the first application of the "traditional," nerve implantation into muscle, usually used in the treatment of a painful neuroma, as a pre-emptive surgical technique in doing a below knee amputation (BKA). In 2011, a 51-year-old woman developed severe, disabling CRPS, after a series of operations to treat an enchondroma of the left fifth metatarsal. When appropriate peripheral nerve surgeries failed to relieve distal pain, a BKA was elected. The approach to the BKA included implantation of each transected peripheral nerve directly into an adjacent muscle. At 5.0 years after the patient's BKA, the woman reported full use of this extremity, using the prosthesis, and was free of phantom limb and residual limb pain. This anecdotal experience gives insight that long-term relief of lower extremity CRPS can be achieved by a traditional BKA utilizing the approach of implanting each transected nerve into an adjacent muscle.

Two-Team Surgical Approach to Improve Retroperitoneal Nerve Identification in the Treatment of Groin Pain.

BACKGROUND: An estimated 700,000 groin hernia repairs are performed in the United States each year. Studies have shown that up to 50% of patients who undergo groin hernia repair are affected by persistent pain beyond the first few days after surgery. At 2 to 5 years after either open or laparoscopic, mesh or without mesh, 10% to 12% of these patients will have persistent and disabling pain. If the ilioinguinal, iliohypogastric, or genitofemoral nerves are injured below the transversalis muscle layer, the traditional external, open approach to nerve resection will not help these patients. The traditional internal, laparoscopic, approach to the retroperitoneum can be used for nerve resection, but identification of the correct nerve is difficult. Therefore, we have developed a 2-team, dual approach, combining open and endoscopic approaches to solve this problem. METHODS: A retrospective review of the electronic medical records was performed to identify all patients who underwent a dual approach for groin denervation after persistent postherniorraphy pain. This dual approach included an external incision paired with a laparoscopic, retroperitoneal approach to identify and/or transect the ilioinguinal, iliohypogastic, lateral femoral cutaneous, and genital branch of the genitofemoral nerve. Inclusion criteria are persistent groin pain with alleviation after preoperative nerve block and either a failed attempt at an external approach groin denervation or pain after a primary laparotomy/laparoscopy procedure. RESULTS: Thirteen patients met the inclusion criteria. All patients underwent a dual approach, and nerves were identified and confirmed in both the external groin and laparoscopic approaches. When placed on a scale from excellent/good to fair/poor relief of pain, 10 patients (77%) described excellent/good relief and 3 (23%) continued to have persistent pain. CONCLUSIONS: A combined open surgical procedure, to identify the lateral femoral cutaneous nerve, and a laparoscopic procedure in the retroperitoneum have demonstrated the feasibility of this approach to identify correctly the nerve to be resected to relieve disabling groin pain.

Diagnostic Accuracy of Selective 3-T MR Neurography-guided Retroperitoneal Genitofemoral Nerve Blocks for the Diagnosis of Genitofemoral Neuralgia.

Purpose To determine if 3-T magnetic resonance (MR) neurography-guided retroperitoneal genitofemoral nerve (GFN) blocks are safe and effective for the diagnosis of genitofemoral neuralgia. Materials and Methods Following institutional review board approval and informed consent, 26 subjects (16 men, 10 women; mean age, 42 years [range, 24-78 years]; mean body mass index, 28 kg/m2 [range, 20-35 kg/m2]) with intractable groin pain were included. By using a 3-T MR imaging system, intermediate-weighted turbo spin-echo pulse sequences, and MR-conditional needles, diagnostic MR neurography-guided GFN blocks were performed in the retroperitoneum. Outcome variables included technical success, procedure time, complications, and rates of positive and negative GFN blocks in association with therapeutic outcomes. For the assessment of a learning curve, Mann-Whitney test was used. P values ≤ .05 were considered to indicate a statistically significant difference. Results In 26 subjects, 30 retroperitoneal GFN blocks were performed. Twelve (40%) were performed with an anterior needle path, 12 (40%) with a lateral needle path, and six (20%) with a posterior needle path. GFN blocks were technically successful in 24 of 26 (92%) subjects, achieving appropriate scrotal anesthesia. No complications occurred. The time required for a GFN block was 40 minutes (range, 18-67 minutes). The rate of a successful GFN intervention after a positive GFN block was 88% (14 of 16). The rate of a successful intervention of an alternative target after a negative GFN block was 71% (five of seven). Conclusion Selective retroperitoneally directed MR neurography-guided GFN blocks are safe and effective with high technical success and positive effect on surgical decision making in patients with presumed genitofemoral neuralgia. © RSNA, 2017 Online supplemental material is available for this article.

Pain after breast surgery: Etiology, diagnosis, and definitive management.

BACKGROUND: Breast procedures are among the most common surgeries performed by Plastic Surgeons. The prevalence of persistent pain remains unknown. Our experience has been that persistent breast pain is often related to intercostal nerve trauma. The purpose of this article was to increase awareness of this problem while describing the diagnostic and management strategies for patients with post-operative breast pain. METHODS: A retrospective review of 10 patients with breast pain was stratified according to the index surgical procedures: implant-based reconstruction (7), breast reduction (1), breast augmentation (1), and mastopexy (1). Outcomes were assessed with a numerical analog score. Physical examination demonstrated painful trigger points along the pathway of one or more intercostal nerves. Prior to surgery, each patient improved ≥5 points after a diagnostic Xylocaine/Marcaine local anesthesia block of the suspected intercostal nerves. At surgery, one or more intercostal nerves were resected and implanted into adjacent muscles. RESULTS: At a mean of 16.5 months, there were six excellent, one good, and three poor self-reported results. Intercostal nerves resected included the intercostal-brachial (5 patients), 3rd (7 patients), 4th (8 patients), 5th (9 patients), 6th (7 patients), and 7th (1 patient). Multiple intercostal nerves were resected as follows: 3 nerves (4 patients), 4 nerves (1 patient), 5 nerves (3 patients), 6 nerves (1 patient), and 8 nerves (1 patient). CONCLUSIONS: Intercostal neuromas can be the source of breast pain following breast surgery. The same clinical and diagnostic approach used for upper and lower extremity neuroma pain can be used in patients with breast pain. © 2016 Wiley Periodicals, Inc. Microsurgery 36:535-538, 2016.

Rectal pain of neural origin: resection of sensory rectal branches of pudendal nerve.

BACKGROUND: A neural origin should be considered in the differential diagnosis of rectal pain if the onset of the pain is in relationship to previous surgery on the anus or rectum. STUDY DESIGN: A retrospective cohort was identified by computer search of office files from May 2010 to December 2012. Seven patients, two males, and five females, were identified who have been treated surgically for complaints of isolated rectal pain arising from coloproctectomy in three patients (inflammatory bowel disease) and after hemorrhoidectomy in three patients and one patient with mesh placed for urinary incontinence. Patient's mean age was 52.5 years. Mean duration of pain was 29.9 months (range, 9-120 months). Diagnosis was demonstrated by an anesthetic block of the pudendal nerve. Surgical approach was excision of rectal sensory branches of the pudendal nerve in the ischiorectal fossa and implantation of these nerves into the gluteus maximus muscle. RESULTS: Outcome data are available, with a mean follow-up of 17.7 months (range, 13-30 months). Of the three coloproctectomy patients, two are considered excellent results and one a poor result. All three of the hemorrhoidectomy patients are excellent results. The one patient who had the mesh placement for urinary incontinence required two attempts to remove all sensory rectal branches and then achieved excellent pain relief. CONCLUSION: Chronic rectal pain should be considered to have a pudendal neural origin after previous anal/rectal surgery. Resection of all rectal sensory branches can give excellent and lasting relief of pain.

High-resolution 3-T MR neurography of the lumbosacral plexus.

The lumbosacral plexus comprises a network of nerves that provide motor and sensory innervation to most structures of the pelvis and lower extremities. It is susceptible to various traumatic, inflammatory, metabolic, and neoplastic processes that may lead to lumbrosacral plexopathy, a serious and often disabling condition whose course and prognosis largely depend on the identification and cure of the causative condition. Whereas diagnosis of lumbrosacral plexopathy has traditionally relied on patients' medical history, clinical examination, and electrodiagnostic tests, magnetic resonance (MR) neurography plays an increasingly prominent role in noninvasive characterization of the type, location, and extent of lumbrosacral plexus involvement and is developing into a useful diagnostic tool that substantially affects disease management. With use of 3-T MR imagers, improved coils, and advanced imaging sequences, which provide exquisite spatial resolution and soft-tissue contrast, MR neurography provides excellent depiction of the lumbrosacral plexus and its peripheral branches and may be used to confirm a diagnosis of lumbrosacral plexopathy with high accuracy or provide superior anatomic information should surgical intervention be necessary.

High-resolution magnetic resonance-guided posterior femoral cutaneous nerve blocks.

OBJECTIVE: To assess the feasibility, technical success, and effectiveness of high-resolution magnetic resonance (MR)-guided posterior femoral cutaneous nerve (PFCN) blocks. MATERIALS AND METHODS: A retrospective analysis of 12 posterior femoral cutaneous nerve blocks in 8 patients [6 (75%) female, 2 (25%) male; mean age, 47 years; range, 42-84 years] with chronic perineal pain suggesting PFCN neuropathy was performed. Procedures were performed with a clinical wide-bore 1.5-T MR imaging system. High-resolution MR imaging was utilized for visualization and targeting of the PFCN. Commercially available, MR-compatible 20-G needles were used for drug delivery. Variables assessed were technical success (defined as injectant surrounding the targeted PFCN on post-intervention MR images) effectiveness, (defined as post-interventional regional anesthesia of the target area innervation downstream from the posterior femoral cutaneous nerve block), rate of complications, and length of procedure time. RESULTS: MR-guided PFCN injections were technically successful in 12/12 cases (100%) with uniform perineural distribution of the injectant. All blocks were effective and resulted in post-interventional regional anesthesia of the expected areas (12/12, 100%). No complications occurred during the procedure or during follow-up. The average total procedure time was 45 min (30-70) min. CONCLUSIONS: Our initial results demonstrate that this technique of selective MR-guided PFCN blocks is feasible and suggest high technical success and effectiveness. Larger studies are needed to confirm our initial results.

Meralgia paresthetica: 3-Tesla magnetic resonance neurography.

OBJECTIVE: To assess the diagnostic accuracy and observer performance of 3-Tesla magnetic resonance neurography (MRN) in the evaluation of meralgia paresthetica (MP). MATERIALS AND METHODS: Two independent readers were blinded to the clinical diagnosis and evaluated the MRN studies of the pelvis of 11 patients with MP and 28 control participants. In each study, the lateral femoral cutaneous nerves were assessed for signal alteration and/or neuroma formation, indicating lateral femoral cutaneous neuropathy, at various levels along their course. Intra- and inter-observer reliability was evaluated. RESULTS: Both readers exhibited substantial intraobserver agreement in detecting signal alterations and neuroma formation of the lateral femoral cutaneous nerve (LFCN). The readers demonstrated moderate interobserver agreement in detecting signal alteration of the LFCN and poor interobserver agreement in diagnosing neuroma formation. Sensitivity, specificity, positive predictive value, and negative predictive value of LFCN neuropathy diagnosis were ≥ 71 % and ≥ 94 % for both readers respectively. The diagnostic test accuracy was ≥ 90 % for both readers. CONCLUSION: 3-Tesla MRN provides reliable and accurate diagnostic evaluation of meralgia paresthetica.

Magnetic resonance neurography of common peroneal (fibular) neuropathy.

OBJECTIVE: To examine diagnostic accuracy of semiquantitative and qualitative magnetic resonance neurography criteria in common peroneal nerve (CPN) neuropathy. MATERIALS AND METHODS: Institutional review board approval was obtained with a waiver of informed consent for this Health Insurance Portability and Accountability Act-compliant retrospective study. A review of 28 knees in 28 subjects (12 males and 16 females; age range, 13-84 years; mean [SD] age, 42 [20] years) who had undergone magnetic resonance neurography of the knee was performed. Thirteen patients who had a final diagnosis of CPN were classified as cases, and 15 patients who lacked a final diagnosis of CPN neuropathy were classified as controls. Morphological characteristics of the CPN, including nerve T2 signal intensity, nerve size, nerve course, fascicles morphology, regional muscle edema, and fatty infiltration, and an overall assessment of the CPN as being normal or abnormal were evaluated by 2 independent radiologists blinded to the clinical history. Overall sensitivity, specificity, and accuracy compared against our reference standards were expressed as percentages. Interobserver agreements were assessed using linear weighted κ statistics. RESULTS: Common peroneal nerve T2 signal abnormality had the highest sensitivity (77%) in identifying CPN neuropathy. Except for T2 signal abnormality, overall specificity for the nerve morphological parameters and muscle denervation change assessed was fairly high, ranging from 94% to 100%. The consensus accuracy ranged from 68% to 79% for the morphological characteristics assessed. The interobserver reproducibility was very good (k = 0.90 to 0.91) for assessment of regional muscle denervation changes and moderate (k = 0.46 to 0.59) for morphological CPN characteristics. CONCLUSION: Magnetic resonance neurography is a useful modality in supplementing the diagnosis of CPN. Using predefined classification criteria helps standardize the morphological criteria of CPN neuropathy diagnosis.

High resolution imaging of tunnels by magnetic resonance neurography.

Peripheral nerves often traverse confined fibro-osseous and fibro-muscular tunnels in the extremities, where they are particularly vulnerable to entrapment and compressive neuropathy. This gives rise to various tunnel syndromes, characterized by distinct patterns of muscular weakness and sensory deficits. This article focuses on several upper and lower extremity tunnels, in which direct visualization of the normal and abnormal nerve in question is possible with high resolution 3T MR neurography (MRN). MRN can also serve as a useful adjunct to clinical and electrophysiologic exams by discriminating adhesive lesions (perineural scar) from compressive lesions (such as tumor, ganglion, hypertrophic callous, or anomalous muscles) responsible for symptoms, thereby guiding appropriate treatment.

High-resolution 3-T MR neurography of peroneal neuropathy.

The common peroneal nerve (CPN), a major terminal branch of the sciatic nerve, can be subject to a variety of pathologies, which may affect the nerve at any level from the lumbar plexus to its distal branches. Although the diagnosis of peripheral neuropathy is traditionally based on a patient's clinical findings and electrodiagnostic tests, magnetic resonance neurography (MRN) is gaining an increasing role in the definition of the type, site, and extent of peripheral nerve disorders. Current high-field MR scanners enable high-resolution and excellent soft-tissue contrast imaging of peripheral nerves. In the lower extremities, MR neurography has been employed in the demonstration of the anatomy and pathology of the CPN, as well as in the detection of associated secondary muscle denervation changes. This article reviews the normal appearance of the CPN as well as typical pathologies and abnormal findings at 3.0-T MR neurography of the lower extremity.

Prevention of ulceration, amputation, and reduction of hospitalization: outcomes of a prospective multicenter trial of tibial neurolysis in patients with diabetic neuropathy.

This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.

A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy.

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.

The application of three-dimensional diffusion-weighted PSIF technique in peripheral nerve imaging of the distal extremities.

PURPOSE: To evaluate whether the addition of the three-dimensional diffusion-weighted reversed fast imaging with steady state free precession (3D DW-PSIF) sequence improves the identification of peripheral nerves in the distal extremities. MATERIALS AND METHODS: Twelve MR neurography (MRN) studies of the distal upper extremity and 12 MRN studies of distal lower extremity were evaluated. From the 24 subjects who were enrolled, 10 had clinically suspected peripheral neuropathy, whereas 14 suffered from various orthopedic diseases and had no clinical signs of neuropathy. In each examination, the ability to identify each peripheral nerve on T2-weighted and 3D DW-PSIF sequences was evaluated using a semi-quantitative (0-2) scale. Thereafter, a total certainty score was registered for each sequence. RESULTS: Combining the results of all studies, the mean certainty score was 1.92 ± 0.28 on the 3D DW-PSIF images and 1.50 ± 0.72 on the T2-weighted images (P < 0.001). In the upper extremity studies, the corresponding certainty scores were 2.0 and 1.70 ± 0.55, respectively (P = 0.008), and in the lower extremity studies, 1.86 ± 0.35 and 1.36 ± 0.79, respectively (P < 0.001). CONCLUSION: The 3D DW-PSIF images provide improved identification of the nerves compared with the T2-weighted images, and should be incorporated in the MRN protocol, whenever accurate nerve localization and/or presurgical evaluation are required.

High-resolution MR neurography: evaluation before repeat tarsal tunnel surgery.

OBJECTIVE: The purpose of this study was to retrospectively determine the accuracy of high-resolution MR neurography (MRN) in presurgical evaluation before repeat tarsal tunnel surgery. MATERIALS AND METHODS: Ten MRN studies of nine patients (one man, eight women; mean age, 44.4 years; range, 23-67 years) who had been referred to a peripheral nerve specialist because of persistent symptoms after tarsal tunnel release were reviewed. The MRN findings studied included presence and location of focal fibrosis, presence or absence of nerve abnormality, location of nerve abnormality, and presence of neuroma formation and regional muscle denervation. The diagnostic accuracy of MRN in detection of posterior tibial nerve, medial plantar nerve, and lateral plantar nerve injury was calculated with clinical and intraoperative findings as the reference standards. RESULTS: Nine of 10 MRN studies (90%) had findings of nerve reentrapment related to focal fibrosis. Injured nerves were reliably visualized with MRN in all patients. MRN had a sensitivity of 77% for posterior tibial nerve, 100% for medial plantar nerve, and 100% for lateral plantar nerve injury, and the overall accuracy was 86%. The sensitivity of MRN was 91% for the presence of focal fibrosis affecting the three nerves and 67% for neuroma detection. Regional muscle denervation was better evaluated on MRN studies than at surgery. Smaller (1-3 mm) abnormal cutaneous nerve branches were better seen at surgery. CONCLUSION: MRN yields accurate morphologic information about the location and extent of nerve injury after failed tarsal tunnel release and facilitates preoperative diagnosis.

MR neurography findings of soleal sling entrapment.

OBJECTIVE: The ever-increasing use of higher field strength (3 T) scanners and novel pulse sequences with improved spatial resolution and signal-to-noise ratio have rendered MR neurography (MRN) a valuable technique in the assessment of peripheral neuropathies. The aim of this study is to illustrate the imaging findings of high-resolution MRN in patients who suffer from tibial nerve entrapment due to a soleal fibromuscular sling and to correlate the imaging findings with intraoperative and clinical examination results. CONCLUSION: This article depicts the surgically confirmed imaging findings of high-resolution MRN in tibial nerve entrapment by the soleal sling.

Painful pelvic constriction band syndrome: a case report.

Plastic Surgeons, by training, are familiar with constriction bands of the fingers and toes. The purpose of this report is to discuss the management of a rare constriction band syndrome that was almost circumferential at the level of the T12 dermatome, and is most appropriately considered a pelvic constriction band as it was below the umbilicus. The patient had constriction bands about the toes at birth, and was also noted to have a band circumferentially below the umbilicus, which did not cause any distress and was not treated. When the patient entered high school and began to lift weights, play football, and have a growth spurt of 2 inches, he began to experience pain below each costal margin and over the iliac crest bilaterally. His physical examination demonstrated pain in the region of the subcostal nerve and the lateral cutaneous branches of L2 as they crossed the iliac crest. By CAT scan, the band appeared to include the rectus fascia. The band was excised to a depth that included the external oblique fascia and preserved the anterior rectus sheath. Small branches of the subcostal nerves and the lateral branches of L2 were killed, and, where appropriate, they were implanted into the external oblique muscle. Closure was obtained by undermining, and a Z-plasty was not included. Healing was without complications and gave an improved appearance to the trunk. At 6 months after surgery, he had resumed college-level rugby and had no further pain related to the constriction band.

Intra- and inter-examiner variability in performing Tinel's test.

PURPOSE: The Tinel sign was adopted in the early 1950s to detect sites of nerve compression. There have been few attempts to standardize how one elicits Tinel's sign. The goal of this study was to evaluate intra- and inter-examiner variability in the force generated using different techniques to elicit Tinel's sign. METHODS: Nine clinicians, consisting of 3 experienced hand and peripheral nerve surgeons, 3 junior hand and peripheral nerve surgeons, and 3 surgeons in training were included in the study. Three different Tinel-type maneuvers were evaluated: (1) striking the load cell using the dominant middle finger only ("single-finger strike"), (2) using the dominant index and middle finger together ("double-finger strike"), and (3) preloading with the nondominant thumb and then striking the thumb with the dominant middle finger ("preload"). Test subjects were instructed to use their customary range of force during the testing. Each subject performed 3 sets of 5 strikes per technique. RESULTS: There was a significant difference in nearly all subjects between the range of force generated with single- or double-finger techniques and preload technique. There was also a difference in nearly all subjects when comparing the range of forces using the single-and double-finger techniques. In addition, there were large differences in the range of forces produced by the examiners for each technique. CONCLUSIONS: There is no standardization for eliciting the Tinel sign. This study demonstrates considerable intra- and inter-examiner differences in the range of forces generated by the different Tinel's techniques that are used in clinical practice. This variability might explain clinical differences between examiners in the ability to obtain a Tinel sign in a patient and might explain the inconsistency of sensitivity and specificity reported for Tinel's sign. Further research on standardization is needed, and future study protocols using Tinel's sign should take these findings into account.

Surgical decompression for notalgia paresthetica: a case report.

Notalgia paresthetica is a rare nerve compression. From the Greek word noton, meaning "back," and algia, meaning "pain," "notalgia paresthetica" implies that symptoms of burning pain, itching, and/or numbness in the localized region between the spinous processes of T2 through T6 and the medial border of the scapula constitute a nerve compression syndrome. The compressed nerve is the dorsal branch of the spinal nerve. It is compressed by the paraspinous muscles and fascia against the transverse process of these spinal segments. This is the first report of symptomatic relief by decompression of this nerve.