John M. Felder

Postoperative Headache Following Acoustic Neuroma Resection: Occipital Nerve Injuries Are Associated With a Treatable Occipital Neuralgia

Objective.— To demonstrate that occipital nerve injury is associated with chronic postoperative headache in patients who have undergone acoustic neuroma excision and to determine whether occipital nerve excision is an effective treatment for these headaches.

The role of peripheral nerve surgery in diabetic limb salvage.

Background: Peripheral neuropathy is highly prevalent among patients with diabetes mellitus and demonstrates well-established consequences of limb loss following lower extremity ulceration, infection, and amputation and upper extremity loss of function. Symptomatic neuropathy is recognized by neuropathic pain, paresthesias, and the development of trophic limb changes. The objective of this review is to define the role of peripheral nerve surgery in the treatment of diabetic patients with upper or lower extremity symptomatic peripheral neuropathy and/or chronic postoperative pain. Methods: At locations of decreased anatomical cross-sectional area, compression points impinge on peripheral nerve fascicles, and because of a synergistic effect of the metabolic derangements of diabetes, these points of compression are implicated in nerve abnormality and dysfunction. The surgical outcomes literature following decompression is reviewed, and specific recommendations are made for appropriate surgical candidate selection. In addition, the operative techniques used in peripheral nerve surgery are outlined. Results: Peripheral nerve surgery for diabetic peripheral neuropathy is indicated when symptoms of pain, allodynia, or trophic changes persist despite optimization of medical management. Surgical treatment is considered an adjunct therapy to medical optimization and should be used when there is clinical and/or electrodiagnostic evidence of compression neuropathy or a postsurgical neuroma-related chronic pain syndrome that is refractory to conservative management. Conclusion: Review of available reports in the surgical literature demonstrates that the results of peripheral nerve surgery are promising for the prevention of limb loss in chronic diabetes mellitus, for diminishment of pain, and for restoration of sensory/motor function.

Plexiform Schwannoma of the Foot: A Review of the Literature and Case Report

Plexiform schwannoma is a rare variety of benign nerve sheath tumor that is usually confined to the head and neck or trunk. In this article, we describe the case of a plexiform schwannoma of the foot in an adult male. In addition to a review of the literature, we discuss diagnostic characteristics and differentiators for this tumor, an approach to surgical treatment, including reconstruction of the plantar foot defect after tumor extirpation, and why it is important for practicing foot and ankle surgeons to differentiate plexiform schwannoma from other similar tumors.

Increasing the Options for Management of Large and Complex Chronic Wounds With a Scalable, Closed-System Dressing for Maggot Therapy

As reconstructive specialists, burn surgeons are often involved in managing large wounds of various etiologies. Such wounds can pose a management challenge, especially if they are chronic or occur in the setting of critical illness or multiple medical comorbidities. Medical maggots are an effective, selective, and low-risk method for wound debridement. However, their use in large and geometrically complex wounds is limited by the lack of scalability in currently available dressings, which are appropriate for smaller wounds but become cumbersome and ineffective in larger ones. This report describes a novel dressing designed for application of maggot debridement therapy in large and complex wounds. The authors then discuss how use of this dressing may create new management strategies for such wounds by allowing maggots to mechanically debride big, infected wounds. They describe the construction of a maggot containment dressing based on modified components from a negative pressure wound therapy system and provide a case report highlighting its successful clinical use in a large contaminated chronic wound resulting from Fournier’s gangrene. In the case described, the novel dressing provided scalability, containment of maggots, control of secretions, and ease of use. The dressing created an environment suitable for maggot survival and allowed effective debridement of a heavily contaminated groin wound. The novel dressing described is shown to function appropriately, allowing controlled use of maggots for effective debridement of large, irregular wounds. Facilitating the use of maggots in such wounds may broaden the algorithm for their management.

A systematic review of peripheral nerve interventional treatments for chronic headaches.

ObjectiveThis study aimed to systematically compare the outcomes of different types of interventional procedures offered for the treatment of headaches and targeted toward peripheral nerves based on available published literature. BackgroundMultiple procedural modalities targeted at peripheral nerves are being offered to patients for the treatment of chronic headaches. However, few resources exist to compare the effectiveness of these modalities. The objective of this study was to systematically review the literature to compare the published outcomes and effectiveness of peripheral nerve surgery, radiofrequency (RF) therapy, and peripheral nerve stimulators for chronic headaches, migraines, and occipital neuralgia. MethodsA broad literature search of the MEDLINE and CENTRAL (Cochrane) databases was undertaken. Relevant studies were selected by 2 independent reviewers and these results were narrowed further by the application of predetermined inclusion and exclusion criteria. Studies were assessed for quality, and data were extracted regarding study characteristics (study type, level of evidence, type of intervention, and number of patients) and objective outcomes (success rate, length of follow-up, and complications). Pooled analysis was performed to compare success rates and complications between modality types. ResultsOf an initial 250 search results, 26 studies met the inclusion criteria. Of these, 14 articles studied nerve decompression, 9 studied peripheral nerve stimulation, and 3 studied RF intervention. When study populations and results were pooled, a total of 1253 patients had undergone nerve decompression with an 86% success rate, 184 patients were treated by nerve stimulation with a 68% success rate, and 131 patients were treated by RF with a 55% success rate. When compared to one another, these success rates were all statistically significantly different. Neither nerve decompression nor RF reported complications requiring a return to the operating room, whereas implantable nerve stimulators had a 31.5% rate of such complications. Minor complication rates were similar among all 3 procedures. ConclusionsOf the 3 most commonly encountered interventional procedures for chronic headaches, peripheral nerve surgery via decompression of involved peripheral nerves has been the best-studied modality in terms of total number of studies, level of evidence of published studies, and length of follow-up. Reported success rates for nerve decompression or excision tend to be higher than those for peripheral nerve stimulation or for RF, although poor study quantity and quality prohibit an accurate comparative analysis. Of the 3 procedures, peripheral nerve stimulator implantation was associated with the greatest number of complications. Although peripheral nerve surgery seems to be the interventional treatment modality that is currently best supported by the literature, better controlled and normalized high-quality studies will help to better define the specific roles for each type of intervention.

Occipital artery vasculitis not identified as a mechanism of occipital neuralgia-related chronic migraine headaches.

Background: Recent evidence has shown that some cases of occipital neuralgia are attributable to musculofascial compression of the greater occipital nerve and improve with neurolysis. A mechanical interaction at the intersection of the nerve and the occipital artery may also be capable of producing neuralgia, although that mechanism remains one theoretical possibility among several. The authors evaluated the possibility of unrecognized vasculitis of the occipital artery as a potential mechanism of occipital neuralgia arising from the occipital artery/greater occipital nerve junction. Methods: Twenty-five patients with preoperatively documented bilateral occipital neuralgia–related chronic headaches underwent peripheral nerve surgery with decompression of the greater occipital nerve bilaterally, including the area of its intersection with the occipital artery. In 15 patients, a 2-cm segment of the occipital artery was excised and submitted for pathologic evaluation. All patients were evaluated intraoperatively for evidence of arterially mediated greater occipital nerve compression, and the configuration of the nerve-vessel intersection was noted. Results: None of the 15 specimens submitted for pathologic evaluation showed vasculitis. Intraoperatively, all 50 sites examined showed an intimate physical association between the occipital artery and greater occipital nerve. Conclusions: Surgical specimens from this first in vivo study provided no histologic evidence of vasculitis as a cause of greater occipital nerve irritation at the occipital artery/greater occipital nerve junction in patients with chronic headaches caused by occipital neuralgia. Based on these findings, mechanical (and not primary inflammatory) irritation of the nerve by the occipital artery remains an important theoretical cause for otherwise idiopathic cases. The authors have adopted an operative technique that includes physical separation of the nerve-artery intersection (in addition to musculofascial neurolysis) for a more thorough surgical treatment of occipital neuralgia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Tibial nerve decompression Reliable exposure using shorter incisions

Background: Patients and surgeons recognize the value of procedures that minimize scarring and tissue dissection, but technical standards do not exist with regards to incision lengths needed for tibial nerve decompression. This article introduces reproducible techniques that reliably provide exposure for release of known anatomical compression points of the tibial nerve, while minimizing the length of required skin incisions. Methods: The senior authors approach to decompression of the tibial nerve at the soleus arch and the tarsal tunnel is presented. Typical incision lengths and surgical exposure are demonstrated photographically. The safety of using this technique is examined by review of the medical records of all patients undergoing this procedure from 2003 to 2011, looking for technical complications such as unintentional damage to nerves or adjacent structures. Results: 224 consecutive patients undergoing 252 total procedures underwent release of known anatomical compression points of the tibial nerve at either the tarsal tunnel, inner ankle, or the soleus arch. Typical incision lengths used for these procedures were 5 cm for the proximal calf and 4.5 cm for the tarsal tunnel. Review of medical records revealed no incidences of unintentional injury to nerves or adjacent important structures. Functional and neurological outcomes were not assessed. Conclusions: Tibial nerve decompression by release of known anatomical compression points can be accomplished safely and effectively via minimized skin incisions using the presented techniques. With appropriate knowledge of anatomy, this can be performed without additional risk of injury to the patient, making classically‐described longer incisions unnecessarily morbid.

Breast Capsulectomy Specimens and Their Clinical Implications

Background: Plastic surgeons routinely submit breast capsulectomy surgical specimens for pathologic evaluation. However, clinically significant findings are rarely identified. In an effort to reduce health care costs and the unnecessary use of hospital resources, this study reviews the efficacy of submitting breast capsulectomy specimens for pathologic examination. Methods: All patients from The Methodist Hospital in Houston, Texas, during the years 2000 to 2008 who underwent breast capsulectomy were selected for by Current Procedural Terminology codes 19370 and 19371 (open periprosthetic capsulotomy and periprosthetic capsulectomy of the breast, respectively). A total of 264 patients qualified for the study, and their pathology reports were reviewed. Results: The pathology reports of 434 capsulectomy specimens in 264 patients revealed benign capsules in 206 patients (78.0 percent). Additional findings, including inflammation, calcification, granuloma, and necrosis, were identified in an additional 57 patients (21.6 percent). One patient (0.4 percent) had carcinoma identified within a breast capsule. This was a patient known preoperatively to have recurrent invasive ductal carcinoma that extended into the surrounding capsule. Therefore, none of the 264 capsulectomy specimens revealed new neoplasms, occult disease, or other clinically significant findings that changed the patients postoperative treatment. Conclusions: No clinically significant findings were identified in this review of breast capsulectomy specimens in 264 patients. However, the cost for such pathologic examinations was substantial. In an effort to reduce health costs and the unnecessary use of hospital resources, breast capsulectomy specimens may not necessarily need to be routinely submitted for surgical pathologic evaluation.

Common nerve decompressions of the upper extremity: reliable exposure using shorter incisions.

BackgroundConsidering that several different specialties perform nerve decompressions in the upper extremity, universal technical standards do not exist. Many of these procedures are performed via incisions that are made unnecessarily long to achieve adequate exposure of the nerves and their known anatomical compression points. The purpose of this article is to introduce reproducible techniques that reliably allow the necessary anatomical exposure while minimizing the length of required skin incisions. MethodsThe senior author’s surgical approach to the most common nerve compression syndromes of the upper extremity is presented in detail. Typical incision lengths and surgical exposure are demonstrated photographically. The safety of using this technique is examined by review of the medical records of all patients undergoing this procedure from 2003 to 2011, looking for technical complications such as unintentional damage to nerves or adjacent structures. ResultsThree hundred twenty consecutive cases were identified in which the described techniques were used to release known anatomical compression points of the upper extremity nerves, including 161 decompressions of the ulnar nerve at the elbow, 37 decompressions of the anterior interosseous nerve and 45 of the posterior interosseous nerve in the proximal forearm, and 77 decompressions of the radial sensory nerve in the distal forearm. Typical incision lengths we used for these procedures were 5 cm for the ulnar nerve, 4.5 cm for the anterior interosseous nerve, 4 cm for the posterior interosseous nerve, and 3 cm for the radial sensory nerve. Review of medical records revealed no incidences of unintentional injury to nerves or adjacent important structures. Functional and neurological recovery outcomes were not assessed, as those would be the subject of subsequent studies. ConclusionsKnown anatomical compression points can be reliably accessed and decompressed for the treatment of all common upper extremity nerve compression syndromes using minimized skin incisions and the techniques presented in this article. With appropriate knowledge of anatomy, this can be performed without expensive equipment or any additional risk of injury to the patient, making classically described longer incisions unnecessarily morbid.

Anterior branch of the obturator nerve: a novel motor autograft for complex peripheral nerve reconstruction.

Background:Autografting is the optimal reconstruction for many nerve gaps, because the retained nerve architecture serves as a regenerative scaffold. Experimental evidence suggests that motor regeneration is favored with the use of a motor nerve graft as compared with sensory nerve autografts, but clinical descriptions are lacking in the literature. As a novel solution, we report our use of the anterior branch of the obturator nerve as a large segment motor nerve graft with minimal functional morbidity. Case:A 17-year-old boy reported progressive weakness and atrophy of the right thigh due to a multifascicular femoral nerve tumor. Motor branch defects of 7 and 4 cm were reconstructed using autografts from the motor nerve to the gracilis (MNG). The patient noted gradual clinical improvement in quadriceps strength, and repeat electromyography at 8- and 13-month follow-ups demonstrated improving motor unit action potentials and quadriceps muscle recruitment. Discussion:The MNG is readily available, with an average total donor length of 11.4 cm. The use of motor nerve grafts is supported by experimental models demonstrating superior nerve regeneration. The MNG is a compelling choice for clinical use because donor-site morbidity is minimized by redundancy of the thigh adductors and a favorable incision location. Conclusion:This is the first published description of successful use of the anterior branch of the obturator nerve as a robust donor motor nerve graft. Clinical use of this graft may maximize functional outcomes and minimizes donor-site morbidity compared with traditional sensory nerve grafts.