A 1-stage surgical treatment for postherniorrhaphy neuropathic pain: triple neurectomy and proximal end implantation without mobilization of the cord.

BACKGROUND: The recommended surgical treatment for chronic neuropathic pain after herniorrhaphy has been a 2-stage operation including: (1) ilioinguinal and iliohypogastric neurectomies through an inguinal approach and (2) genital nerve neurectomy through a flank approach. HYPOTHESIS: A 1-stage surgical procedure resecting all 3 nerves from an anterior approach avoids a second operation through the flank and successfully treats chronic neuralgia. SETTING: A private practice dedicated to abdominal wall hernia surgery in general community hospitals. PATIENTS: Between 1995 and 2001, 49 patients underwent triple neurectomies with proximal end implantation to treat chronic postherniorrhaphy neuralgia. INTERVENTION: Triple neurectomy of the ilioinguinal, iliohypogastric, and genital nerves performed under local anesthesia with implantation of their proximal ends and without mobilization of the spermatic cord. RESULTS: Two patients (4%) reported no improvement. Eighty percent of patients recovered completely, and 16% had transient insignificant pain with no functional impairment. These results are comparable to the results of the 2-stage operation. CONCLUSIONS: Simultaneous neurectomy of the ilioinguinal, iliohypogastric, and genital nerves without mobilization of the spermatic cord is an effective 1-stage procedure to treat postherniorrhaphy neuralgia. It is performed under local anesthesia and avoids testicular complications. Proximal end implantation of the nerves prevents adherence of the cut ends to the aponeurotic structure of the groin, which can result in recurrence of the pain.

End-to-side neurorrhaphy as a salvage procedure for irreparable nerve injuries. Technical note.

After a few reports on end-to-side nerve repair at the beginning of the last century, the technique was put aside until its recent reintroduction. The authors present their results in three patients with median nerve defects that were between 15 and 22 cm long and treated using end-to-side median-to-ulnar neurorrhaphy through an epineurial window. The follow-up times were between 32 and 38 months. Sensory evaluation involved superficial touch, pinprick, and two-point discrimination tests. Motor evaluation was completed by assessing the presence of opposition and by palpating the abductor pollicis brevis muscle. Sensory recovery was observed in all patients in the median nerve dermatome, and motor recovery was absent, except in Case 1. End-to-side nerve repair can be a viable alternative to nerve grafting in patients with long gaps between the ends of the injured nerve.

Epineurial versus perineurial repair of peripheral nerves.

A survey of clinical and experimental work concerning the efficacy of epineurial versus perineurial suture techniques for the treatment of peripheral nerve disruption has been presented. It seems that little differences result from the utilization of either of these methods. Therefore, suture of the outer epineurium is the technique of choice for most acute nerve lacerations, since it is easier, faster, and requires less manipulation of the delicate internal neural structure. Clinical indications for outer epineurial or inner epineurial (group funicular) repair have also been discussed. The reasons why these techniques lead to similar results remain unclear. However, it would seem to be impossible to align individual axons if their vast numbers and the dynamic disruptive phenomena that occur after nerve transection are taken into account. It is now recognized that peripheral nerve regeneration studies must address events occurring at the level of the injury and additionally in the periphery and the cell body itself. The answer to the clinical problem of nerve transection will lie in our ability to manipulate axonal regeneration from the central nervous system to correct peripheral end organs. This question will not be solved by the position in which suture material is placed.

Treatment of the painful neuroma by neuroma resection and muscle implantation.

The successful treatment of the painful neuroma remains an elusive surgical goal. This report evaluates one approach to the management of this problem which entails neuroma excision and placement of the proximal end of the nerve away from denervated skin, away from tension, and into a well-vascularized environment: muscle. Seventy-eight neuromas in 60 patients with a mean follow-up of 31 months (range 18 to 43 months) were evaluated. Sixty-seven percent of these patients involved Workmen's Compensation and 57 percent had had at least one previous operation to treat their pain. The results demonstrated good to excellent results in 82 percent of the treated nerves in the entire group. Factors that were predictive of a poorer outcome were (1) digital neuroma (p less than 0.0005), (2) Workmen's Compensation (p less than 0.01), and (3) three or more previous operations for pain (p less than 0.01). Transposition of nerves into small superficial muscles or muscles with significant excursion resulted in treatment failures. The etiology and histopathology of treatment failures are reviewed. Treatment of radial sensory neuromas by transposition of the radial sensory nerve into the brachioradialis muscle when any associated injury to the lateral antebrachial cutaneous nerve was also treated, gave good to excellent relief of pain, and improved hand function in 88 percent of the patients.

Technical aspects of peripheral nerve repair.

This essay describes the internal topographical anatomy of peripheral nerves and outlines the use of this information in the specific steps of nerve suture. Repair is detailed in the context of overall wound management and those factors are emphasized which can be controlled by the surgeon and which have a definite effect on the functional outcome.

Treatment of end-neuromas, neuromas-in-continuity and scarred nerves of the digits by proximal relocation.

This paper reports the results of treatment by proximal relocation of 104 painful nerves in 57 digits in 48 patients. These included 86 digital nerves and 18 terminal branches of the superficial radial nerve and the dorsal branch of the ulnar nerve. Eighty-three were end-neuromas and 14 were neuromas-in-continuity, of which nine followed nerve repair and five occurred following a closed crush injury. Seven were painful as a result of tethering in scarred tissue. Eighty nerves (77%) required a single relocation and 24 (23%) required more than one operation. Ninety-eight per cent of nerve relocations achieved complete pain relief at the primary site. One patient had mild pain on pressure at the primary site after relocation of two nerves from this site. Over 90% of the nerves had no spontaneous pain, pain on movement or hypersensitivity of the overlying skin at the final site of relocation. However, the incidence of mild or no pain on direct pressure at the site of nerve relocation was lower at 83% as relocated nerves, although traumatized less often at the sites chosen for relocation, can still be painful on direct pressure.

Radiofrequency facet rhizotomy in the treatment of chronic neck and low back pain.

The value of radiofrequency facet rhizotomy in the treatment of patients with chronic neck and low back pain problems is assessed on the basis of experience with 117 consecutive patients. Only patients with positive responses to facet blocking with local anesthetic were selected. Overall results in 50 neck procedures were: excellent, 16%; good, 34%; fair, 18%; poor, 28%; and lost to follow-up, 4%. In the 71 lumbar rhizotomies results were: excellent, 15%; good, 20%; fair, 27%; poor, 31%; and lost to follow-up, 7%. Average follow-up time was 13.7 months. We conclude that radiofrequency rhizotomy is a valuable tool in the treatment of chronic neck and low back pain.

Mid-term results of stapled hemorrhoidopexy for third- and fourth-degree hemorrhoids--correlation with the histological features of the resected tissue.

BACKGROUND: Stapled hemorrhoidopexy is used to remove a circumferential strip of mucosa and submucosa about 4 cm above the dentate line, in order to restore the correct anatomical relationships of the anal canal structures. We evaluated the histological features of the resected tissue obtained after stapled hemorrhoidopexy with correlation to the short-term and mid-term results. METHODS: This retrospective study evaluated 234 cases of stapled hemorrhoidopexy. Data concerning postoperative bleeding, anal pain, incontinence, stenosis, and recurrence of hemorrhoids were collected from hospital and outpatient clinic records. Histologic slides were examined for the type of epithelium, presence of muscle fibers, nerve endings, and degree of vascular ectasia. RESULTS: Some 52% of the biopsies revealed on the surface a combination of glandular with squamous epithelium, meaning a stapling line at the level of the transitional zone/dentate line. Smooth muscle fibers were more frequent as the stapling line approached the level of the dentate line/transitional zone (p = 0.0028). Internal sphincter fibers were present in 36% of the cases, yet there were no cases of anal incontinence. Inclusion of merely squamous epithelium in the resected tissue correlated with severe postoperative pain persisting one week after surgery (p < 0.0001), whereas the concurrent presence of squamous and glandular epithelium correlated only with severe pain on the first postoperative day (p = 0.018). Nerve endings were more frequent in patients with anal pain one week after surgery (p = 0.02). The rate of recurrence of symptoms was 3%, which did not correlate with any of the histological parameters tested. CONCLUSIONS: Though stapled hemorrhoidopexy is performed according to well-established technical guidelines, it is too difficult to be standardized.

Neuroma transposition and intramuscular implantation using the Mitek "soft-tissue anchor": a new technique.

The authors describe a new technique for intramuscular implantation of a nerve ending after peripheral neuroma excision. Sixteen peripheral neuromas in 10 patients were excised and then implanted into muscle tissue using the Mitek anchor. The positions of the anchors were documented by immediate anteroposterior and lateral radiographs. These views were repeated at 2 months to assess any migration. All patients had resolution of the symptoms related to their neuromas. No substantial migration was noted in any of the patients. The Mitek anchor can be used as a "soft-tissue" anchor to position a nerve ending reliably at a precise depth and tension in muscle tissue with minimal trauma.

Long-term effects of gustatory neurectomy on fungiform papillae in the young rat.

Recent evidence from mature hamster fungiform papillae indicates that following denervation taste buds are present from 21 to 330 days in the absence of discernible intragemmal nerve fibers. In contrast, most prior taste bud degeneration studies focused on shorter survival times. The present inquiry in young rats examined the issue of postneurectomy buds, in which regeneration of the resected chorda tympani or facial nerves was prevented and anterior tongue tissue examined over a range of relatively long survival times (30-90 days). Conditions for observing potential taste buds used three histologic stains and a definition of the taste bud not necessarily requiring pore identification. In each case, serial section examination of the anterior-most 2-3 mm of lingual epithelium revealed 29-56 bud-containing fungiform papillae on the unoperated side. In contrast, ipsilateral to the neurectomy, only zero-7 medially-placed, mature-looking buds were observed per case, as well as zero-3 more laterally situated fungiform papillae containing small clusters of cells in basal epithelium that lacked the vertical organization and cytoplasmic staining intensity of mature taste buds. These cell aggregates were distributed evenly across survival time and stain used. Therefore, in young rats following gustatory neurectomy, longer survival times, per se, would not appear to be a prerequisite for sustaining fungiform taste buds. The appearance of "midline" buds postsurgery may be attributed to either normal contralateral or a net bilateral innervation, and/or ipsilateral denervation and bud loss inducing neural sprouting from the contralateral side.

Refinements in nerve to muscle neurotization.

A modified surgical technique is introduced, enabling restoration of muscle function with direct muscular neurotization. Reliable clinical outcomes result from this technique. We report on a series of 10 patients in whom the supplying motor nerve had been lost at the level of the neuromuscular junction as the result of trauma or tumor resection. Our modification of the operative technique ensures a wide distribution of nerve fibers throughout the remaining muscle tissue and produces a mean motor recovery of M4 after a period of 1 to 2 years.

[Treatment of painful neuromas of the hand by intra-osseous implantation]. / Traitement des névromes douloureux à la main par enfouissement intra-osseux.

A number of techniques have been developed to prevent or treat painful neuromas in the hand. Intra-osseous implantation of the ends of the nerves, as described by Boldrey in 1943, has only been extensively applied over recent years. Between 1977 and 1983, we used this technique to treat twenty eight cases of painful neuromas in a group of twenty patients. All but two of the patients were permanently improved and the best results were obtained in neuromas of the anterior branch of the radial nerve.