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.

Neurosurgical prevention of ulceration and amputation by decompression of lower extremity peripheral nerves in diabetic neuropathy: update 2006.

BACKGROUND: A triad of metabolic abnormalities are known that render the peripheral nerve in diabetes mellitus susceptible to chronic compression: conversion of glucose to sorbitol increases the intraneural water content, slowing of axoplasmic transport of proteins hinders structural repair, glycosylation of endoneurial collagen reduces perineurial gliding. In the early 1990s, Dellon et al demonstrated that removal of a site of anatomic narrowing of the tibial nerve in the rat model prevented neuropathic walking. METHOD: Scientific literature related to this concept was reviewed. Through the end of 2006, there have been 15 peer-reviewed studies that used the inclusion criteria of (1) presence of symptomatic neuropathy, (2) positive Tinel sign over the tarsal tunnel demonstrating a site of compression, (3) no previous history of ulcer or amputation and (4) used the Dellon Triple Decompression technique (neurolysis of the peroneal nerve at the knee and the dorsum of the foot, and neurolysis of the tibial nerve in the four medial ankle tunnels). FINDINGS: These studies demonstrated relief of pain in 88% and restoration of sensation in 79% of patients. One study demonstrated that the natural history of diabetic neuropathy can be changed by observing no ulcers/amputations in the operated leg of 50 diabetics followed for a mean of 4.5 years, while 12 ulcers and 3 amputations occurred in the non-operated contralateral limb (p < 0.001). Results of a multi-centered prospective study are available at NeuropathyRegistry.com, demonstrating a reduction in the prevalence of ulceration in 665 diabetics at 2.5 years from 15 to 0.6% in those diabetics without a previous history of ulceration and from 50 to 2.2% in 44 patients with a previous history of ulceration. CONCLUSIONS: Decompression of superimposed nerve compressions in the patient with symptomatic neuropathy reliably relieves pain, restores sensation, and thereby prevents ulceration and amputation.

Prolonged survival in bronchogenic carcinoma associated with HL-A antigens W-19 and HL-A5: a preliminary report.

The HL-A antigens were determined retrospectively in a group of 14 surgically cured bronchogenic carcinoma patients and prospectively in another group of 100 untreated patients. In the retrospective group, the frequencies of antigens W-19 and HL-A5 were significantly increased when compared with the noncancer control and the prospective lung cancer populations. In the latter group, 60% of the patients with W-19 and 58% with HL-A5 survived without evidence of tumor for at least 1 year after treatment compared with 15% of patients with neither of these antigens, P less than 0.01 and 0.005, respectively. These comparisons were for adenocarcinoma and squamous carcinoma. The patient groups for oat cell and undifferentiated carcinoma were too small for valid statistical comparisons. This preliminary study suggests that the presence of HL-A antigens W-19 and HL-A5 confers resistance to dissemination of bronchogenic carcinoma.

The innervation of the medial humeral epicondyle: implications for medial epicondylar pain.

The purpose of this study was identification of the innervation of the medial humeral epicondyle which has not been described before. In 20 patients, the medial intermuscular septum was evaluated histopathologically: the nerve was identified in 15 specimens without S-100 staining, and in the remaining 5 with S-100 staining. In six fresh cadavers, bilateral dissections identified the source of this nerve as the radial nerve in the axilla, coursing adjacent to the ulnar nerve in the upper arm, then moving laterally to be superficial to, or within, the medial intermuscular septum, until the nerve terminated in the periosteum of the medial humeral epicondyle, at the origin of the flexor-pronator muscle mass. In one specimen, a branch from the ulnar nerve in the axilla contributed to this nerve to the medial humeral epicondyle.

Radial sensory nerve entrapment.

Fifty-one patients with entrapment of the radial sensory nerve were examined. The entrapment was usually due to a crush or twisting injury to the wrist or forearm or to repetitive pronation/supination movements at work. Presenting symptoms were usually pain or burning over the dorsoradial aspect of the wrist, aggravated by pinching or gripping activities. Results of physical examination demonstrated a positive Tinel's sign over the radial sensory nerve as it exits the deep fascia, a false-positive Finkelstein test, and a positive hyperpronation provocative test. The results of nonoperative and surgical management are presented.

Tibial nerve branching in the tarsal tunnel.

To provide an anatomical basis for diagnosis and treatment of the tarsal tunnel syndrome, the relationship of the tibial nerve to the tarsal tunnel was investigated in 31 feet of 20 cadavers. The bifurcation into medial and lateral plantar nerves occurred within 1 cm of the malleolar-calcaneal axis in 90% of the feet. Seven of 11 bilateral specimens were bilaterally symmetrical in the bifurcation location; three varied within 1 cm between sides; and in the fourth cadaver, one side bifurcated at 3 cm and the other at 5 cm proximal to the axis. The calcaneal nerve showed great variability; in seven cadavers, it arose within, in eight cadavers proximal to, and in five cadavers there were multiple branches arising both proximal to and within the tarsal tunnel.

Nonoperative management of cubital tunnel syndrome: an 8-year prospective study.

This study reports the results of a prospective trial of nonoperative management of the cubital tunnel syndrome in 128 patients. Forty-three of the patients had bilateral ulnar nerve compression. At study's end, information was available on 94% of patients and 164 managed extremities, at a mean of 58.6 months of follow-up. We scored the degree of severity of cubital tunnel syndrome numerically, based on concepts of the pathophysiology of chronic nerve compression. For statistical purposes, a successful outcome of the nonoperative regimen was not having an operation. Life-table analysis demonstrated that 89% of patients with symptoms only, 67% of patients with abnormal sensorimotor thresholds, and 38% of patients with abnormal sensorimotor innervated density did not have surgery. These differences were significant (p < 0.001) by both parametric and nonparametric analysis. A history of elbow injury significantly worsened outcome (p < 0.02), but the results of the pretreatment electrodiagnosis did not. We conclude that a strict nonoperative regimen be supervised in the initial management of the cubital tunnel syndrome.

Reinnervation of distal sensory nerve environments by regenerating sensory axons.

This study investigated the specificity of sensory nerve regeneration in a primate model. In adult cynomolgus monkeys, the femoral nerve was explored in the groin and two sensory branches identified. A sensory branch was sectioned and introduced into the proximal channel of a Y-shaped silicone chamber. This proximal sensory nerve stump was given distal choices of distal sensory nerve graft or distal sensory nerve which was intact to the distal sensory cutaneous receptors. After eight months, histological analysis confirmed axonal growth directed towards both the distal nerve graft and the distal nerve intact to the distal cutaneous receptors. However, the number of nerve fibres directed towards the distal nerve was significantly greater than the number of nerve fibres directed towards the nerve graft (P less than 0.004). These results suggest that while both distal nerve graft and distal intact nerve act as specific targets to regenerating proximal primate nerve, the presence of an intact distal end-organ positively enhances sensory regeneration.

Comparison of the Semmes-Weinstein monofilaments with the Pressure-Specifying Sensory Device.

Measuring human sensibility remains a challenge, with the primary limitation being the instrumentation traditionally available. The Pressure-Specifying Sensory Device (PSD) permits quantitation of the human pressure perception threshold by means of transducers that couple two rounded prongs to a personal computer. If just one prong is perceived in constant contact with the skin, the cutaneous pressure threshold is directly obtained, scaling along a continuum from .05 to 100 g/mm2 (readout on computer monitor). This measurement is analogous to that obtained with the series of Semmes-Weinstein monofilaments (SWM) (readout in logarithmic marking on nylon rod). The present study evaluated twenty normal volunteers and ten nerve-impaired patients with both the PSD and the SWM. There was a poor correlation between the measurement offeree (r = 0.21) and pressure (r = 0.29) obtained with the PSD and the SWM. This study reaffirms the value of measuring pressure perception threshold during the sensibility evaluation, while calling attention to selection of instrumentation for obtaining this measurement.

Multiple primary malignant neoplasms. A search for an immunogenetic basis.

The occurrence of multiple primary malignant neoplasms in single individuals is well documented. Although many hypotheses have been advanced to explain this occurrence, there has been no study to determine if a presumed "increased susceptibility to cancer" has an immunogenetic basis. We evaluated the cellular immunity and histocompatibility antigens of 42 patients who had had from two to four multiple primary malignant neoplasms. We failed to demonstrate a preexisting impairment of immunocompetence or abnormal HL-A antigen frequencies in these patients. The occurrence of multiple primary malignant neoplasms in related tissues, eg, lung/larynx/oral cavity, and the occurrence of successive primary malignant neoplasms at a time interval consistent with the patient's being cured of preceding malignant neoplasms suggest that multiple primary malignant neoplasms result from repetitive induction by the same or similar etiologic factors in patients who are cured after treatment of the first malignant neoplasm.

Histocompatibility antigens and solid malignant neoplasms.

To evaluate the relation between histocompatibility antigen phenotypes and solid malignant neoplasms, HL-A type was determined in 633 cancer patients and compared with those of 489 normal controls. HL-A8 was elevated in patients with squamous cancer, melanoma, and adenocarcinoma. The highest incidence occurred in patients with salivary gland adenocarcinoma (67% vs only 17% in normal controls). A threefold increase in HL-A5 was detected in patients with connective tissue sarcomas (28% incidence vs 9% in normal controls). Antigen frequencies did not vary when analyzed by time of diagnosis or interval after treatment. The finding that certain malignant neoplasms have associations with increased frequency of individual HL-A antigens may give clues to cause and genesis for these tumors.

Improved imaging of rat hindfoot prints for walking track analysis.

Walking track analysis is an investigative technique that allows a researcher to assess objectively the functional capacity of the limb in the rat sciatic nerve model. This study has shown that paint and paper is a better method for imaging the rat foot plantar surface than other methods described in the literature. The block printing paint has the distinct advantage of keeping radial diffusion error to a minimum. Paint more correctly images the important anatomical landmarks of the rat plantar surface. There is better traction (less slippage) rendering the prints easier to interpret. The authors conclude that the paint and paper is a superior method to the other methods currently available.

Neural activity originating from a neuroma in the baboon.

Single nerve fiber recordings were obtained from traumatically induced neuromas of the superficial radial nerve in baboons 1-7 months after injury. Eight to 18% of the fibers had spontaneous activity, and 67% of these were unmyelinated. Myelinated as well as unmyelinated fibers responded to mechanical stimulation of the neuroma whereas no fibers responded to similar stimulation of the normal nerve. Apparent crosstalk of action potential activity between fibers at the neuroma was observed which could be due to electrical coupling, though retrograde sprouting is another possible explanation. These abnormalities in neural activity originating from a neuroma in the primate are qualitatively similar to those noted in other species and may provide an explanation for certain abnormal sensory phenomena associated with peripheral nerve injury.

Outcome of the operative management of nerve injuries in the ilioinguinal region.

BACKGROUND: Injuries to the ilioinguinal, iliohypogastric, and genitofemoral nerves can result in pain in the inguinal region. STUDY DESIGN: A retrospective analysis of 13 patients with such injuries is reported, with emphasis on the cause of the injury, diagnosis, and the outcome of operative management. RESULTS: The causes of the injuries included appendectomy, inguinal herniorrhaphy, inguinal lymph node dissection, orchiectomy, total abdominal hysterectomy, abdominoplasty, iliac crest bone graft, and femoral catheter placement. Diagnosis of the injury was based on patient history and physical examination. CONCLUSIONS: The outcome of operative management was graded as excellent (n = 10) and good (n = 3). Patient satisfaction was high postoperatively; all were able to return to their normal activity level.

Surgical management of groin pain of neural origin.

BACKGROUND: An approach to surgical management of the patient with groin pain is described based on our experience with 54 patients, six of whom had bilateral symptoms. History and physical examination are sufficient to relate the pain to one or more of the lateral femoral cutaneous (LFC), ilioinguinal (II), iliohypogastric (IH), or genitofemoral (GF) nerves. STUDY DESIGN: Retrospective analysis of patients with groin pain is reported, with emphasis on cause, involved nerves, and outcomes of operative management. The LFC was decompressed. The II, IH, and GF nerves were resected. Outcomes were graded as excellent, good, and poor in terms of pain relief and functional restoration. RESULTS: For the entire series of patients with painful groins, excellent relief of pain was achieved in 68% and restoration of function achieved in 72%. Ten percent had a poor result. The best results were for II and IH, which were 78% and 83% excellent for both pain relief and restoration of function, with 11% and 17% having a poor result, respectively. The worst results were for the small group of patients with a GF problem, 50% of whom had an excellent and 25% a poor result. Patients who were likely to get an LFC entrapment were those with a nerve located above or within the inguinal ligament. Complications included bruising and cautery injury to the LFC. CONCLUSIONS: Groin pain of neural origin can be relieved with a high degree of patient satisfaction by considering whether one or more of four different nerves are the source of that pain, by realizing that symptoms can be referred to regions other than the groin, such as the pelvic viscera (IH), the knee (LFC), and the testicle (GF), and by treating the appropriate nerve(s) by either neurolysis (LFC) or resection.

Hypopharyngeal and laryngeal involvement with Darier disease.

The presence of mucosal Darier disease (keratosis follicularis) was evaluated clinically and histologically in four consecutive patients with moderate to extensive cutaneous manifestations of this disease. Fiberoptic endoscopy demonstrated hypopharyngeal or laryngeal involvement or both in each patient. A dearth of corps ronds and grains in these anatomical regions was observed histologically. The routine evaluation of mucosal involvement in Darier disease should result in a higher incidence of hypopharyngeal and laryngeal lesions than is currently known. Furthermore, the recognition of hypopharyngeal and laryngeal involvement with Darier disease must be emphasized because of the clinical similarity to leukoplakia and squamous cell carcinoma.

Spontaneous resolution of endogenous Candida endophthalmitis complicating intravenous hyperalimentation.

Untreated patients with endogenous Candida endophthalmitis who have not died of disseminated disease have required enucleation. A 57-year-old woman had endogenous Candida endophthalmitis developing subsequent to catheter sepsis during hyperalimentation, in which no antimycotic therapy was employed. The endophthalmitis resolved, and good visual acuity was preserved.

Stretch palsy of the spinal accessory nerve. Case report.

Although sharp and blunt injury to the spinal accessory nerve has been well-documented, stretch or traction-type injury has not been reported previously. Such a case, treated successfully with nerve grafting, is described.

Peripheral nerve injury by chymopapain injection.

Chymopapain injected into the intervertebral disc space (chemonucleolysis) has been used clinically in patients with disc disease with success. Neurosurgical complications secondary to the procedure have, however, been reported. In this study, the authors have investigated the possible neurotoxic effect of chymopapain on the peripheral nerve in rat and primate models. While the extrafascicular injection caused no nerve fiber damage, the intrafascicular injection caused dose-related nerve fiber damage in both species.

The operative treatment of peroneal nerve palsy.

We retrospectively reviewed the results of operative decompression for peroneal nerve palsy in thirty-one patients who had been managed between 1980 and 1990. All patients had been managed non-operatively for at least two months after they had initially been seen. Intraoperatively, we found epineurial fibrosis and bands of fibrous tissue constricting the peroneal nerve at the level of the fibular head and at the proximal origin of the peroneus longus muscle. At a mean of thirty-six months (range, twelve to seventy-two months) postoperatively, thirty (97 per cent) of the thirty-one patients reported subjective and functional improvement and were able to discontinue the use of the ankle-foot orthosis. In contrast, only three of nine patients who had been managed non-operatively reported subjective and functional improvement (p < 0.01). Peroneal nerve palsy does not always resolve spontaneously; if it is left untreated, the loss of dorsiflexion of the ankle and persistent paresthesias can result in severe functional disability. Therefore, if non-operative measures do not lead to improvement within two months, we believe that operative decompression should be considered.