Vestibulodynia: Clinical characteristics, first-line treatments, and factors associated with escalation of treatment with EMG-guided injections of botulinum toxin in a retrospective french cohort study.

BACKGROUND: Vestibulodynia is a highly prevalent chronic pain disorder affecting the vulva having a major impact on women's physical, psychological, and sexual well-being. It remains an underrecognized disease that responds insufficiently to therapies such as physiotherapy and medication. AIM: To assess the global efficacy of first-line therapies and factors associated with treatment escalation in women with vestibulodynia. PATIENTS AND METHODS: This retrospective cohort study was conducted at the dermatology outpatient clinic of the University Hospital in Besancon (France) between 2013 and 2017 and follow-up until 2021. RESULTS: Among 132 patients, the mean [standard deviation] age at diagnosis was 27.2 [±9.45] years, with an average duration of symptoms of 42.3 [±37.92] months. Most cases comprised provoked (75.0%) or secondary (72.7%) vestibulodynia. At least one comorbid pain or psychologic condition was identified respectively in 63 (47.7%) and 23 patients (54.5%). Vulvar hyperesthesia associated with pelvic floor muscle dysfunction was present in 121 patients (91.6%) and vulvar erethism was noted in 94 patients (71.2%). First-line treatments consisted of pelvic floor physiotherapy with biofeedback in 85% of patients, associated with amitriptyline in 36% of cases, and of additional lidocaine cream in 17%. Fifty-two patients (39%) presented at least a good response to first-line treatment, with only 21 (15%) being in complete remission, irrespective of therapeutic strategy (p = 0.25). Botulinum toxin injections were performed in 54 patients. Patients with either primary vestibulodynia (p = 0.04) or spontaneous vestibulodynia (p = 0.03) were more likely to receive this treatment. CONCLUSION: Our study highlights the current lack of efficacy of first-line treatments in vestibulodynia. Considering the high prevalence of muscular dysfunction, botulinum toxin injections are of particular interest despite a lack of randomized controlled trials in this indication.

Two-dimensional and shear wave elastography ultrasound: A reliable method to analyse spastic muscles?

INTRODUCTION: Few data exist on the feasibility and reliability of measuring muscular atrophy in 2 dimensions (2D) by ultrasonography (US) and elasticity with shear wave elastography (SWE) in spastic muscles. METHODS: Fourteen patients with chronic stroke took part in 2 intersession reliability experiments performed with 1-week intervals between sessions. Pennation angle (PA), muscle thickness (MT), and shear elastic modulus (µ) were measured in spastic gastrocnemius medialis (GM) muscles at rest and at maximal passive stretching in paretic and nonparetic legs. RESULTS: On the paretic side, the coefficient of variation (CV) in GM was 6.30% for MT and 6.40% for PA at rest and was 7.53% and 8.26% for MT and PA, respectively, at maximal passive stretching. The reliability of the µ measurement was good only for GM at rest on the paretic side (CV = 9.86%). DISCUSSION: 2D US associated with SWE shows promise for assessing structural changes in muscles. With some methodological adaptations, this approach could help guide spasticity treatment. Muscle Nerve 57: 222-228, 2018.

Successive motor nerve blocks to identify the muscles causing a spasticity pattern: example of the arm flexion pattern.

Botulinum Toxin A has been the main treatment for spasticity since the beginning of the 1990s. Surprisingly, there is still no consensus regarding injection parameters or, importantly, how to determine which muscles to target to improve specific functions. The aim of this study was to develop a systematic approach to determine this, using the example of the arm flexion pattern. We first determined anatomical landmarks for selective motor block of the brachialis nerve, using 20 forearms from 10 fresh cadavers in Ecole Européenne de Chirurgie and a university-based dissection centre, Paris, France. We then carried out selective blocks of the motor nerves to the brachialis, brachioradialis and biceps brachii in patients with stroke with an arm flexion pattern, in a University Rehabilitation Hospital, Garches, France. We measured: the resting angle of the elbow angle in standing (manual goniometer), active and passive range of extension, and spasticity using the Held and Tardieu and the Modified Ashworth scales. Range of passive elbow extension was also measured with the shoulder in 90° of flexion. The resting angle of the elbow in standing decreased by 35.0° (from 87.6 ± 23.7 to 52.6 ± 24.2°) with inhibition of brachialis, by a further 3.9° (from 52.6 ± 24.2 to 48.7 ± 23.7°) with inhibition of brachioradialis and a further 14.5° (from 48.7 ± 23.7to 34.2 ± 20.7°) with inhibition of biceps brachii. These results were consistent with the clinical evaluation of passive elbow range of motion with the shoulder at 90°. Sequential blocking of the nerves to the three main elbow flexors revealed that the muscle that limited elbow extension the most, was brachialis. This muscle should be the main target to improve the arm flexion pattern. These results show that it is important not simply to inject the most superficial or powerful muscles to treat a spastic deformity. A comprehensive assessment is required. The strategy proposed in this paper should increase the effectiveness of botulinum toxin injections by ensuring that the relevant muscles are targeted.

Anatomical and computed tomography study of the eighth costochondral junction: topography for costochondral graft harvesting.

INTRODUCTION: Costochondral grafts have long been used in maxillofacial reconstruction, but have been little used in trauma and orthopedic cases. This surgical technique requires that a graft be harvested from the thorax in the area of the eighth rib. Pleuropulmonary complications are very rare. Although the harvesting technique is simple, it needs to be demystified. GOAL OF STUDY: This study was performed to define anatomical relationships in the eighth costochondral junction and identify topographical and anatomical landmarks that will make it easier to harvest this structure. METHOD: This was a two-part study. First, an anatomical study was carried out on human cadaver thoraxes to define topographical landmarks and study the anatomical surroundings of the eighth costochondral junction. Second, an imaging study was performed using a database of existing patient computed tomography (CT) scans of the chest and abdomen to confirm the topographical landmarks defined in the first part of the study. The spine was used as a reference for both studies. The location of the eighth costochondral junction was defined relative to the spinal processes along with its location on the lower rib cage hemiperimeter in the transverse plane starting at the corresponding spinous process. RESULTS: The eighth costochondral junction was in line with the spinal process of the twelfth thoracic vertebra in the vast majority of cases and located at two-thirds of the lower rib cage hemiperimeter from the posterior median sulcus, regardless of the patient's chest shape, age and gender. This junction was always located under a single muscle (external oblique) and protected by a thick perichondrium layer, which separates it from the intercostal pedicles, endothoracic fascia and parietal pleura. DISCUSSION: This two-part study has identified reliable landmarks for harvesting of an osteochondral graft at the eighth costochondral junction and, by describing its anatomical surroundings, helps take the mystery out of its harvesting. These landmarks were identified in supine cadavers and in free-breathing patients lying in supine for the CT portion. This position must be used when identifying these landmarks in a patient undergoing costochondral autograft harvesting for cartilage reconstruction.

Long-term assessment of effectiveness and quality of life of OnabotulinumtoxinA injections in provoked vestibulodynia.

BACKGROUND: Provoked vestibulodynia is a relatively common condition that affects sexual activity. Multidisciplinary care is indicated and OnabotulinumtoxinA injections are safe and effective treatment in this indication. AIMS: To assess the long-term efficacy of OnabotulinumtoxinA in provoked vestibulodynia. MATERIALS AND METHODS: Twenty-one patients treated with OnabotulinumtoxinA injections (50U in each bulbospongiosus muscle) 24 months prior to the study were included. Data on pain [assessed using a visual analogue scale (VAS)], quality of life [measured by the Dermatology Life Quality Index (DLQI)] and quality of sex life [assessed using the Female Sexual Function Index (FSFI)] were collected before treatment, and 3 and 24 months after injection. RESULTS: Nineteen patients participated in the study and 37% had no pain after 24 months. Significant improvements were noted in the VAS, DLQI and FSFI scores between baseline and 24 months post treatment (P < 0.0001). After 24 months, 18 patients (95%) were able to have sexual intercourse. This study was open and non-controlled. DISCUSSION AND CONCLUSION: 100U OnabotulinumtoxinA injections constitute an effective treatment in provoked vestibulodynia with results maintained after 2 years. They significantly improve pain, and have a positive impact on patient quality of life and sex life. Beneficial effects continue in the long-term, allowing patients to resume sexual activity.

Muscle structure and stiffness assessment after botulinum toxin type A injection. A systematic review.

BACKGROUND: Botulinum toxin type A manages spasticity disorders in neurological central diseases. Some studies have reported that it might induce muscle changes. METHODS: We present a literature review abiding by the PRISMA statement guidelines. The purpose was to explore the structural and passive biomechanical muscle properties after botulinum toxin type A injections in healthy and spastic limb muscles, on animals and humans, as well as methods for evaluating these properties. We searched the PubMed and Cochrane Library databases using the following keywords: "Botulinum toxin" AND ("muscle structure" OR "muscle atrophy") and, "Botulinum toxin" AND "muscle elasticity". RESULTS: From the 228 initially identified articles, 21 articles were included. Histological analyses were performed, especially on animals. A neurogenic atrophy systematically occurred. In humans, one year after a single injection, the histological recovery remained incomplete. Furthermore, 2D ultrasound analyses showed a reduction of the gastrocnemius thickness and pennation angle. MRI volumetric analysis evidenced muscular atrophy six months or one year after a single injection. Passive muscle stiffness depends on these structural changes. On the short term, the biomechanical analysis showed an elastic modulus increase in animals whereas no change was recorded in humans. On the short term, ultrasound elastography imaging showed a decreased elastic modulus. DISCUSSION: To date, few data are available, but all show a structural and mechanical muscle impact post injections, specifically muscle atrophy which can linger over time. Further studies are necessary to validate this element, and the possibility of change must be taken into account particularly with repeated injections. Thus, in clinical practice, 2D ultrasound and ultrasound elastography are two non-invasive techniques that will help physicians to develop an efficient long term monitoring.

Cadaver study of the topography of the musculotendinous junction of the finger extensor muscles: applicability to tendon rupture following closed wrist trauma.

Rupture of the extensor pollicis longus (EPL) tendon in the wrist is a delayed complication that can occur after wrist injury. Several etiology-related hypotheses have been made to explain these ruptures. The one most commonly accepted is necrosis at the musculotendinous junction of the EPL, which is compressed between the extensor retinaculum and dorsal aspect of the radius. To confirm this hypothesis, we performed an anatomical study to show the close relationship between the extensor retinaculum and the musculotendinous junction of the EPL muscle. We calculated the distance between the musculotendinous junction of the various finger extensor muscles and the proximal edge of the extensor retinaculum. We were able to show that this junction is located under the extensor retinaculum for the extensor indicis (EI) and EPL muscles, but the latter is in the third extensor compartment, which is a tight, confined space. Any pressure increase in this space following trauma, for example, can bring about compartment syndrome at this musculotendinous junction, which some authors have found to be poorly vascularized.

Dimensions of the trapezium bone: a cadaver and CT study.

PURPOSE: The primary purpose of this study was to define the size of the trapezium bone through measurements on cadaver specimens and CT scans of living subjects. The secondary purpose of this study was to determine if any correlation existed between the size of the trapezium and local anatomical parameters. METHODS: The radio-ulnar length (L), dorsopalmar width (ℓ) and height (h) of the distal surface of the trapezium were measured by two independent observers on 20 cadaver specimens. The same measurements were carried out by two other observers on anonymized CT scans from 18 patients. The inter- and intra-observer agreement was determined using the intraclass correlation coefficient. RESULTS: In the cadavers, the mean length, width and height of the trapezium were 22.8, 15.5 and 15.2 mm, respectively. On the CT scans, these same dimensions were 19.2, 11.4 and 11.6 mm. Inter-observer agreement was statistically significant in both parts of the study. DISCUSSION: The dimensions of the trapezium bone were about 3.33 mm larger in cadavers than on CT scans. These differences can be explained partially by a systematic under-sizing error on the CT scans and the fact that the cartilage layer cannot be directly visualized. CONCLUSION: This study was able to define the dimensions of the trapezium bone. It may be possible to predict the trapezium height from the length of the forearm or the width of the radial epiphysis. Our data can be used to adjust the size of trapezium implants to the dimensions of the patient's bone.

An unusual case of Y-shaped right renal vein.

Vascular renal anomalies are frequent, multiple and well described and result from errors in vessel embryogenesis between the 6th and 10th week of gestation. Historically, variations are described in anatomic dissection and currently mostly in image interpretation. We report an anatomic variation concerning the right renal vein which, to our knowledge, has never been described in the literature either by dissection or by radiological examination. This variation was discovered during the routine dissection of an embalmed male body. It consists of a Y-shaped right renal vein and is associated with multiple retroperitoneal variations: a bilateral accessory renal artery, a trident ending of the right renal artery and a left testicular vein variation. Venous and arterial renal anatomy and its variations are fundamentally important in renal surgery, especially concerning living donor renal grafts. These variations may be diagnosed thanks to injected tomodensitometry which has a good sensitivity and specificity for anomalies. Preoperative diagnosis of an anatomic vascular renal variation may reduce morbidity during surgery, which is why precise examination of injected tomography should be mandatory.

An MRI evaluation of changes in piriformis muscle morphology induced by botulinum toxin injections in the treatment of piriformis syndrome.

PURPOSE: Botulinum toxin (BT) injection is a new treatment for piriformis syndrome (PS). The main purpose of our study was to use MRI to evaluate changes in piriformis muscle morphology after treatment with BT injections. PATIENTS AND METHODS: Twenty patients presenting with PS who had undergone an MRI were included retrospectively: 12 patients treated with BT injections and eight untreated patients. The following parameters were assessed and compared to a normal contralateral muscle: maximum thickness, volume, and Goutallier's classification grade of fatty infiltration of the piriformis and internal obturator muscles. Pain was assessed through a visual analogue scale (VAS). RESULTS: The untreated patients had no significant difference in the volume (P=1.0) or thickness of the piriformis muscle (P=0.61). The treated patients showed a significant reduction in the thickness (-4.2mm; P<0.001) and volume (-74.4mm(3); P<0.001) and an increase in the fatty infiltration (P<0.001) of the piriformis muscle treated by BT injection. Muscular atrophy was correlated with the number of BT injections and with the time until an MRI was performed. There was also significant pain relief after BT treatment. CONCLUSION: BT leads to atrophy and fatty degeneration of the piriformis muscle that can be quantified by MRI and these factors explain why BT injections are effective in the treatment of PS.

[Clinical and paraclinical evaluations of bladder sensitivity. Review of the literature]. / Évaluation clinique et paraclinique de la sensibilité vésicale. Revue de la littérature.

INTRODUCTION: The aim of this work was to carry out a review of the literature on the clinical and paraclinical evaluation of bladder sensory (BS) to better understand BS disorders in nonneurological patients. METHODS: Thirty-three articles were selected from the Medline(®) Database between 1992 and 2012 using the following key words: "sensory/sensitivity bladder evaluation", "sensory/sensitivity bladder scale", "sensory/sensitivity bladder questionnaire", "urodynamic bladder sensory", "urgency questionnaire" and "Overactive Bladder (OAB) questionnaire". RESULTS: Evaluation of BS by asking questions during cystometry is validated (LE 2). The sensation of the desire to void progresses linearly with bladder filling (LE 2). Many symptoms and quality of life questionnaires related to BS anomalies have been proposed. Bladder diaries, frequency/volume curves (LE 2) and clinical algorithms (LE 3) could be an alternative to evaluate BS. CONCLUSION: Current evaluation only provides a partial view of BS. A multidimensional approach should lead to better understanding of BS disorders.

The piriformis muscle syndrome: an exploration of anatomical context, pathophysiological hypotheses and diagnostic criteria.

INTRODUCTION: The piriformis muscle syndrome (PMS) has remained an ill-defined entity. It is a form of entrapment neuropathy involving compression of the sciatic nerve by the piriformis muscle. Bearing this in mind, a medical examination is likely to be suggestive, as a classical range of symptoms corresponds to truncal sciatica with frequently fluctuating pain, initially in the muscles of the buttocks. PATHOPHYSIOLOGICAL HYPOTHESES: The piriformis muscle is biarticular, constituting a bridge in front of and below the sacroiliac joint and behind and above the coxo-femoral joint. It is essentially a lateral rotator but also a hip extensor, and assumes a secondary role as an abductor. Its action is nonetheless conditioned by the position of the homolateral coxo-femoral joint, and it can also function as a hip medial rotator, with the hip being flexed at more than 90°. The main clinical manoeuvres are derived from these types of biomechanical considerations. For instance, as it is close to the hip extensors, the piriformis muscle is tested in medial rotation stretching, in resisted contraction in lateral rotation. On the other hand, when hip flexion surpasses 90°, the piriformis muscle is stretched in lateral rotation, and we have consequently laid emphasis on the manoeuvre we have termed Heel Contra-Lateral Knee (HCLK), which must be prolonged several tens of seconds in order to successfully reproduce the buttocks-centred and frequently associated sciatic symptoms. CONCLUSION: A PMS diagnosis is exclusively clinical, and the only objective of paraclinical evaluation is to eliminate differential diagnoses. The entity under discussion is real, and we favour the FAIR, HCLK and Freiberg stretching manoeuvres and Beatty's resisted contraction manoeuvre.

Piriformis muscle syndrome: diagnostic criteria and treatment of a monocentric series of 250 patients.

OBJECTIVES: Piriformis Muscle Syndrome (PMS) is caused by sciatic nerve compression in the infrapiriformis canal. However, the pathology is poorly understood and difficult to diagnose. This study aimed to devise a clinical assessment score for PMS diagnosis and to develop a treatment strategy. MATERIAL AND METHODS: Two hundred and fifty patients versus 30 control patients with disco-radicular conflict, plus 30 healthy control subjects were enrolled. A range of tests was used to produce a diagnostic score for PMS and an optimum treatment strategy was proposed. RESULTS: A 12-point clinical scoring system was devised and a diagnosis of PMS was considered 'probable' when greater or equal to 8. Sensitivity and specificity of the score were 96.4% and 100%, respectively, while the positive predictive value was 100% and negative predictive value was 86.9%. Combined medication and rehabilitation treatments had a cure rate of 51.2%. Hundred and twenty-two patients (48.8%) were unresponsive to treatment and received OnabotulinumtoxinA. Visual Analogue Scale (VAS) results were 'Very good/Good' in 77%, 'Average' in 7.4% and 'Poor' in 15.6%. Fifteen of 19 patients unresponsive to treatment underwent surgery with 'Very good/Good' results in 12 cases. CONCLUSIONS: The proposed evaluation score may facilitate PMS diagnosis and treatment standardisation. Rehabilitation has a major role associated in half of the cases with botulinum toxin injections.

Fixation of split anterior tibialis tendon transfer by anchorage to the base of the 5th metatarsal bone.

Split anterior tibialis transfer is a procedure, frequently performed in combination with triceps surae lengthening, to treat equinovarus foot deformity in adult hemiplegia patients. The authors present their surgical technique, with tendon fixation by an anchor to the base of the fifth metatarsal. Although bone-tendon anchor fixation is widespread in orthopedic surgery, it is original in this type of indication. It is simpler, and less traumatic for the bone than a bone tunnel and less traumatic for the sole than transplantar fixation. The very distal attachment to the base of the 5th metatarsal bone solves the common problem of adjusting the tension of tendon transfer. The authors report their experience of 22 split transfers from 2005 to 2008.