Colgajo glúteo mayor en reconstrucción de úlcera isquiática bilateral / Gluteal maximus flap for reconstruction of bilateral ischial ulcer

Propósito y objetivo. Demostrar una de las opciones más empleadas para la cobertura de úlceras isquiáticas en paciente parapléjico. El colgajo glúteo mayor sería de primera elección en el caso presentado de una paciente con diagnóstico de escaras isquiáticas bilateral Grado IV. Introducción. El colgajo glúteo mayor, colgajo musculocutáneo, es un procedimiento muy utilizado y de primera línea para el tratamiento de úlceras isquiáticas. Debemos tener en cuenta que para el éxito y buena evolución de la cirugía es necesario la conformación de un equipo multidisciplinario, para su seguimiento y control. Las opciones de cobertura dependen de la topografía de la lesión. Algunas de las opciones de cobertura son: colgajo glúteo inferior de rotación, colgajo glúteo inferior de avance en V-Y, colgajo de isquiotibiales en V-Y, colgajo de cara posterior de muslo y colgajo extendido de fascia lata, entre otros. Material y método. Se presenta el caso clínico de una paciente femenina con diagnóstico patológico de cavernoma intramedular D9, que padece paraplejía de un año de evolución, presentando escara isquiática bilateral grado IV acompañadas de osteomielitis. Se trató quirúrgicamente con colgajo glúteo mayor bilateral Resultados. En esta paciente se alcanzó una adecuada cobertura del defecto, que permitió su pronta rehabilitación, y un minucioso control posoperatorio que no mostró complicaciones ni recidiva, hasta la fecha. Discusión. Las úlceras isquiáticas profundas ubicadas cerca del tracto genitourinario presentan mayor dificultad para su reconstrucción. El colgajo musculocutáneo de glúteo mayor a pedículo inferior permite el cierre de cualquier úlcera isquiática y el cierre primario del sitio donador asegurando un cierre sin tensión; otras opciones quirúrgicas, como los colgajos basados en la pelvis o el tronco, son menos susceptibles a la tensión que aquellos ubicados en la porción móvil de la extremidad inferior, por lo que los colgajos de glúteo mayor, inferior y de cara posterior al muslo tienen mayor porcentaje de éxito que los colgajos de tensor de fascia lata e isquiotibiales. Conclusión. El colgajo glúteo mayor es un tratamiento de primera elección para la cobertura de úlceras isquiáticas de alta morbilidad en pacientes parapléjicos, tratado por un equipo multidisciplinario, cuya técnica quirúrgica presentó buena cobertura con un control estricto del posoperatorio con excelente evolución y sin ninguna complicación esperada

Rat exposure in mice with neuropathic pain induces fear and antinociception that is not reversed by 5-HT2C receptor activation in the dorsal periaqueductal gray.

Previous studies have demonstrated that serotonin 5-HT2C receptors in the dorsal periaqueductal gray (dPAG) mediate both anxiety and antinociception in mice submitted to the elevated plus maze. The present study examined the effects of intra-dPAG infusion of the serotonin 5-HT2C receptor agonist (MK-212) in the defensive reactions and antinociception in mice with neurophatic pain confronted by a predator. Neuropathic pain was induced by chronic constriction injury (CCI) of the sciatic nerve, and predator confrontation was performed using the rat exposure test (RET). Our results demonstrated that both sham-operated and CCI mice exhibited intense defensive reactions when confronted by rats. However, rat-exposed CCI mice showed reduced pain reactivity in comparison to CCI mice exposed to a toy rat. Intra-dPAG infusion of MK-212 prior to predator exposure did not significantly alter defensive or antinociceptive responses. To our knowledge, our results represent the first evidence of RET-induced antinociception in mice. Moreover, the results of the present study suggest that 5-HT2C receptor activation in the dPAG is not critically involved in the control of predator-evoked fearful or antinociceptive responses.

Long-term antidepressant treatment inhibits neuropathic pain-induced CREB and PLCγ-1 phosphorylation in the mouse spinal cord dorsal horn.

UNLABELLED: The effect of long-term administration of imipramine, a tricyclic antidepressant, on the phosphorylation status of cyclic adenosine monophosphate-responsive element-binding protein (CREB), mitogen-activated protein kinase family members, and phospholipase γ-1 (PLCγ-1) was investigated in the dorsal horn of the spinal cord following peripheral nerve lesion. Nerve injury induced an ipsilateral long-lasting increased phosphorylation of CREB and PLCγ-1 but not extracellular signal-regulated kinase (ERK1,2), p38, and c-Jun N-terminal kinase. Daily administration of imipramine (5, 10, or 30 mg/kg) for 21 days progressively reduced both tactile-induced neuropathic pain hypersensitivity and thermal hyperalgesia. After withdrawal of treatment, the antinociceptive effect of imipramine was gradually abolished but still remained for at least 3 weeks. Conversely, no analgesic effect was observed with short-term imipramine treatment. Moreover, imipramine therapy reversed nerve injury-induced CREB and PLCγ-1 phosphorylation but had no effect on ERK1,2, p38, and c-Jun N-terminal kinase activity. These results indicate that long-term administration of imipramine may prevent some of the harmful changes in the spinal cord dorsal horn following nerve injury. However, imipramine analgesic effect takes time to develop and mature, which might explain in part why the clinical analgesic effect of tricyclic antidepressants develops with a delay after the beginning of treatment. Our data also provide evidence that prolonged imipramine treatment may induce antinociception in neuropathic pain conditions because of its action on the PLCγ-1/CREB-signaling pathway. PERSPECTIVE: This article demonstrates that long-term treatment with imipramine reverses some of the marked effects induced by peripheral nerve injury in the spinal dorsal horn that contribute to long-term maintenance of sensory disorder, providing a new view to the mechanisms of action of these drugs.

Sacral nerve infiltrative endometriosis presenting as perimenstrual right-sided sciatica and bladder atonia: case report and description of surgical technique.

Endometriosis infiltrating the sacral nerve roots is a rarely reported manifestation of the disease. The objectives of this article are to report such a case and to describe the surgical technique for laparoscopic decompression of sacral nerve roots and treatment of endometriosis at this site. The patient as a 38-year-old woman who had undergone 2 previous laparoscopic procedures for electrocoagulation of peritoneal endometriosis and self-reported perimenstrual right-sided sciatica and urinary retention. Clinical examination revealed allodynia (pain from a stimulus that does not normally cause pain) on the S2 to S4 dermatomes and hypoesthesia on part of the S3 dermatome. Magnetic resonance imaging showed an endometriotic nodule infiltrating the anterior rectal wall. Laparoscopic exploration of the sacral nerve roots demonstrated vascular compression of the lumbosacral trunk and endometriosis entrapping the S2 to S4 sacral nerve roots, with an endometrioma inside S3. The endometriosis was removed from the sacral nerve roots and detached from the sacral bone, and a nodulectomy of the anterior rectal wall was performed. Normal urinary function was restored on postoperative day 2, and pain resolved after a period of post-decompression. Intrapelvic causes of entrapment of sacral nerve roots are rarely described in the current literature, either because of misdiagnosis or actual rareness of the condition. Recognition of the clinical markers for these lesions may lead to an increase in diagnosis and specific treatment.

Anti-allodynic and anti-oedematogenic properties of the extract and lignans from Phyllanthus amarus in models of persistent inflammatory and neuropathic pain.

This study investigated the anti-allodynic and anti-oedematogenic effects of the hexanic extract, lignan-rich fraction and purified lignans from a plant used in the traditional medicine, Phyllanthus amarus, in the inflammatory and neuropathic models of nociception. The hexanic extract inhibited the allodynia and the oedema induced by the intraplantar injection of complete Freund's adjuvant (CFA). The inhibition observed was 76 +/- 7% (ipsilateral paw), 64 +/- 7% (contralateral paw), and 41 +/- 2% (oedema). Otherwise, the lignan-rich fraction or the pure lignans did not affect CFA-induced allodynia. Administered chronically, the lignan fraction reduced CFA-induced paw oedema (39 +/- 9%). When evaluated in the model of neuropathic pain caused by partial ligation of sciatic nerve, the hexanic extract inhibited the mechanical allodynia (77 +/- 7%), with a similar efficacy to the gabapentin (71 +/- 10%). The anti-allodynic effects of hexanic extract of P. amarus seem not to be associated with the impairment of motor co-ordination or with the development of tolerance. Finally, the treatment with hexanic extract inhibited the increase of myeloperoxidase activity, either following intraplantar injection of CFA or after sciatic nerve injury. It is concluded that, apart from its anti-inflammatory actions, which are probably linked to the presence of lignans, another as yet unidentified active principle(s) present in the hexanic extract of P. amarus produces pronounced anti-allodynia in two models of inflammatory and neuropathic pain. Considering that few drugs are currently available for the treatment of chronic pain, especially of the neuropathic type, the present results may have clinical relevance and open new possibilities for the development of new anti-allodynic drugs.

Clinical and morphological study of calf enlargement following S-1 radiculopathy

A hipertrofia da panturrilha no curso de ciática é raramente observada. É relatado o caso de uma paciente com 28 anos de idade que apresentou episódios repetidos de dor lombar irradiada para nádega e pé esquerdos. Um ano após o início dos sintomas, notou aumento da panturrilha esquerda. Estudos radiográficos revelaram degeneraçäo do disco de L5-S. O exame eletromiográfico mostrou desnervaçäo muscular com velocidade de conduçäo motora normal. Foram realizadas biópsias dos músculos gastrocnêmios. No esquerdo notou-se hipertrofia das fibras tipo 2, em comparaçäo ao gastrocnêmio direito. A microscopia eletrônica revelou aumento do número de mitocôndrias nas fibras hipertrofiadas. Explicaçäo satisfatória para a hipertrofia muscular na vigência de desnervaçäo ainda näo foi definida

Clinical and morphological study of calf enlargement following S-1 radiculopathy.

Calf enlargement following sciatica is a rare condition. It is reported the case of a 28-year-old woman who complained of repeated episodes of lower back pain radiating into the left buttock and foot. One year after the beginning of her symptoms, she noticed enlargement of her left calf. X-ray studies disclosed L5-S1 disk degeneration. EMG showed muscle denervation with normal motor conduction velocity. Open biopsies of the gastrocnemius muscles were performed. The left gastrocnemius muscle showed hypertrophic type 2 fibers in comparison with the right gastrocnemius. Electron microscopy showed mildly increased number of mitochondria in these fibers. A satisfactory explanation for denervation hypertrophy has yet to be provided.