Rahul K. Nath

Spinal cord stimulation is effective in the management of reflex sympathetic dystrophy.

OBJECTIVE: The purpose of this study was to determine the efficacy of spinal cord stimulation (SCS) in patients with symptoms of reflex sympathetic dystrophy (RSD), a disabling clinical condition with significant consequences of morbidity and loss of productivity. METHODS: We have used epidural SCS for pain control during the past 15 years. An analysis of our records revealed 12 consecutive patients diagnosed as having RSD before undergoing SCS. Eight of the 12 patients had undergone previous ablative sympathectomy. The mean age of the nine men and three women was 38.2 years. All suffered extremity injuries from a variety of causes. RESULTS: All 12 patients experienced relief of pain after trial stimulation and had their systems permanently implanted. At an average of 41 months follow-up, all patients were using their stimulators regularly and only two were receiving adjunctive minor pain medication. The level of pain present pre- and postoperatively was determined by administering a modified McGill Pain Questionnaire and a visual analog scale to each patient. Eight patients reported excellent pain relief, and four patients described good results. Five minor complications occurred. CONCLUSION: SCS is an effective treatment for the pain of RSD, including recurrent pain after ablative sympathectomy. The low morbidity of this procedure and its efficacy in patients with refractory pain related to RSD suggest that SCS is superior to ablative sympathectomy in the management of RSD.

The expression of transforming growth factor type beta in fetal and adult rabbit skin wounds

Transforming growth factor, subtype beta (TGF-beta) exists in several isoforms and is known to have important roles in adult wound healing by promoting collagen and extracellular matrix component deposition. It is also believed that TGF-beta influences normal developmental processes during embryo-genesis. Immunolocalization of two isoforms, TGF-beta 1 and TGF-beta 2, in healing fetal and adult rabbit skin wounds shows distinctly different forms of expression of these molecules. TGF-beta 1 and TGF-beta 2 are both expressed within the developing fetal dermis, but no differential upregulation in the area of the healing wound is noted. In contrast, the expression of TGF-beta 1 and TGF-beta 2 is increased in adult wounds by day 7 after wounding, within macrophages that are abundant by this time. High levels of TGF-beta 1 and TGF-beta 2 within adult wounds might indicate that the relative paucity and differential distribution of these factors in fetal wounds are important in the production of scar in adults and the absence of scar in the fetus. Further, these patterns of expression suggest fundamental differences between fetal and adult tissues in accomplishing wound repair.

Ulnar nerve transection as a complication of two-portal endoscopic carpal tunnel release: A case report

Endoscopic release of the transverse carpal ligament for relief of median nerve compression neuropathy has recently been promoted as superior to traditional open surgical methods. A decreased incidence of scar tenderness, postoperative hand weakness, and pillar pain and an earlier return to work have been suggested. As a consequence of the limited surgical exposure inherent to endoscopic procedures, there has been concern regarding potential risks to neurovascular structures in the hand. We report a case involving complete transection of the ulnar nerve during two-portal endoscopic carpal tunnel release requiring sural nerve grafting for reconstruction.

Antibody to transforming growth factor beta reduces collagen production in injured peripheral nerve

&NA; Epineurial scarring in peripheral nerve after injury inhibits normal axonal regeneration primarily due to fibroblast deposition of type I collagen. The transforming growth factor beta (TGF‐&bgr;) family is an important class of signaling molecules that has been shown to stimulate fibroblasts to produce collagen. The aim of this study was to design a prototypic therapeutic system in which the neutralization of TGF‐&bgr; in crushed rat sciatic nerve would decrease collagen formation. A total of 45 experimental Lewis rats were used. Group 1 animals (20 rats) sustained a unilateral crush injury to the sciatic nerve with injection of phosphate buffer solution. Group 2 animals (20 rats) sustained a unilateral crush injury to the sciatic nerve with injection of phosphate‐buffered saline and goat, anti‐rat, panspecific TGF‐&bgr; antibody. Group 3 control animals (five rats) underwent only exposure of sciatic nerve with injection of antibody. All animals were killed at 14 days and sciatic nerve specimens were harvested at that time. Slides of experimental tissue were processed using a 35S‐labeled oligomer for procollagen alpha‐1 mRNA, then dipped in photographic emulsion and examined by darkfield autoradiography. Morphometric analysis of pixel counts was then performed. A significant reduction in total pixel count per high‐power field and in total number of fibroblasts per high‐power field was found in crushed rat sciatic nerve treated with anti‐TGF‐&bgr; antibody when compared with those treated only with phosphate‐buffered saline. These findings are consistent with successful reduction in procollagen induction after a crush injury by topical administration of blocking antibody against transforming growth factor beta. The concept of growth factor blockade for therapeutic collagen reduction is attractive in the context of nerve injury, and the current article provides a model for future clinical application. (Plast. Reconstr. Surg. 102: 1100, 1998.)

Successful Management of Foot Drop by Nerve Transfers to the Deep Peroneal Nerve

Traumatic damage to the common peroneal nerve due to sharp injury, gunshot wound, sciatic nerve tumor, radiculopathy, or hip replacement surgery may result in foot drop. We present an alternative strategy for reanimation of foot drop following deep peroneal nerve palsy, successfully restoring voluntary movement. Fourteen consecutive patients with deep peroneal nerve injuries resulting in foot drop underwent nerve transfer of functional fascicles of either the superficial peroneal nerve or of the tibial nerve as donor for deep peroneal-innervated muscle groups. Eleven cases had successful restoration of British motor grade 3+ to 4+/5 ankle dorsiflexion, one case had restoration of grade 3 ankle dorsiflexion, and two cases had no restoration of dorsiflexion. Nerve transfer to the deep peroneal nerve is a feasible and effective method of treating deep peroneal nerve injuries of less than 1-year duration.

Iatrogenic injury to the ilioinguinal and iliohypogastric nerves in the groin: a case report, diagnosis, and management.

A case of right-sided ilioinguinal and iliohypogastric neuralgia following laparoscopic repair in a 52-year-old man is presented. Significant pain persisted despite conservative measures and was successfully treated with resection of the ilioinguinal and iliohypogastric nerves in the retroperitoneal space. The anatomy, mechanisms of injury, and management of postherniorrhaphy neuropathy are reviewed.Choi PD, Nath R, Mackinnon SE. Iatrogenic injury to the ilioinguinal and iliohypogastric nerves in the groin: a case report, diagnosis, and management.

Rapid recovery of serratus anterior muscle function after microneurolysis of long thoracic nerve injury

Background Injury to the long thoracic nerve is a common cause of winging scapula. When the serratus anterior muscle is unable to function, patients often lose the ability to raise their arm overhead on the affected side. Methods Serratus anterior function was restored through decompression, neurolysis, and tetanic electrical stimulation of the long thoracic nerve. This included partial release of constricting middle scalene fibers and microneurolysis of epineurium and perineurium of the long thoracic nerve under magnification. Abduction angle was measured on the day before and the day following surgery. Results In this retrospective study of 13 neurolysis procedures of the long thoracic nerve, abduction is improved by 10% or greater within one day of surgery. The average improvement was 59° (p < 0.00005). Patients had been suffering from winging scapula for 2 months to 12 years. The improvement in abduction is maintained at last follow-up, and winging is also reduced. Conclusion In a notable number of cases, decompression and neurolysis of the long thoracic nerve leads to rapid improvements in winging scapula and the associated limitations on shoulder movement. The duration of the injury and the speed of improvement lead us to conclude that axonal channel defects can potentially exist that do not lead to Wallerian degeneration and yet cause a clear decrease in function.

Surgical correction of unsuccessful derotational humeral osteotomy in obstetric brachial plexus palsy: Evidence of the significance of scapular deformity in the pathophysiology of the medial rotation contracture

Background The current method of treatment for persistent internal rotation due to the medial rotation contracture in patients with obstetric brachial plexus injury is humeral derotational osteotomy. While this procedure places the arm in a more functional position, it does not attend to the abnormal glenohumeral joint. Poor positioning of the humeral head secondary to elevation and rotation of the scapula and elongated acromion impingement causes functional limitations which are not addressed by derotation of the humerus. Progressive dislocation, caused by the abnormal positioning and shape of the scapula and clavicle, needs to be treated more directly. Methods Four patients with Scapular Hypoplasia, Elevation And Rotation (SHEAR) deformity who had undergone unsuccessful humeral osteotomies to treat internal rotation underwent acromion and clavicular osteotomy, ostectomy of the superomedial border of the scapula and posterior capsulorrhaphy in order to relieve the torsion developed in the acromio-clavicular triangle by persistent asymmetric muscle action and medial rotation contracture. Results Clinical examination shows significant improvement in the functional movement possible for these four children as assessed by the modified Mallet scoring, definitely improving on what was achieved by humeral osteotomy. Conclusion These results reveal the importance of recognizing the presence of scapular hypoplasia, elevation and rotation deformity before deciding on a treatment plan. The Triangle Tilt procedure aims to relieve the forces acting on the shoulder joint and improve the situation of the humeral head in the glenoid. Improvement in glenohumeral positioning should allow for better functional movements of the shoulder, which was seen in all four patients. These dramatic improvements were only possible once the glenohumeral deformity was directly addressed surgically.

Arm rotated medially with supination – the ARMS variant: description of its surgical correction

BackgroundPatients who have suffered obstetric brachial plexus injury (OBPI) have a high incidence of musculoskeletal complications stemming from the initial nerve injury. The presence of muscle imbalances and contractures leads to typical bony changes affecting the shoulder, including the SHEAR (Scapular Hypoplasia, Elevation and Rotation) deformity. The SHEAR deformity commonly occurs in conjunction with Medial Rotation Contracture (MRC) of the arm. OBPI also causes muscle imbalances at the level of the forearm, that lead to a fixed supination deformity (SD) in a small number of patients. Both MRC and SD will cause severe functional limitations without surgical intervention.MethodsFourteen OBPI patients were diagnosed with MRC of the shoulder and SD of the forearm along with SHEAR deformity during a 16 month study period, with eight patients available to long-term follow-up (age range 2.2 – 18 years). Surgical correction of the MRC was performed as a triangle tilt or humeral osteotomy depending on the age of the child, after which, the patients were treated with a radial osteotomy to correct the fixed supination deformity. Function was assessed using the modified Mallet scale, examination of apparent supination and appearance of the extremity at rest.ResultsSignificant functional improvements were observed in patients with surgical reconstruction. Mallet score increased by an average of 5.2 (p < 0.05). Overall forearm position was not significantly changed from an average of 5° to an average of 34° maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries.ConclusionThe simultaneous presence of two opposing deformities in the same limb will visually offset each other at the level of the wrist and hand, giving the false impression of neutral positioning of the limb. In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder. Both of these deformities require surgical attention, and the presence of concurrent MRC and SD should be monitored for in OBPI patients.

Topographic mapping of the superior transverse scapular ligament: a cadaver study to facilitate suprascapular nerve decompression.

&NA; Division of the superior transverse scapular ligament for decompression of suprascapular nerve entrapment can be curative. However, the superior transverse scapular ligament can be difficult to locate, and large incisions are often required. This study was designed to determine the topographic coordinates of the superior transverse scapular ligament to permit reproducible surgical localization and reduce incision size. In 20 cadavers, the superior transverse scapular ligament was identified through a superior approach. Measurements were obtained from the superior transverse scapular ligament to external landmarks. The superior transverse scapular ligament was located 1.3 ± 0.3 cm (± SD) posterior to the posterior border of the clavicle and 2.9 ± 0.8 cm from the acromioclavicular joint in a two‐dimensional surface plane. The depth of the superior transverse scapular ligament from the skin surface was 3.9 ± 0.7 cm. An incision (mean length, 6.3 ± 0.7 cm) derived from a novel system of planning marks facilitated access to the superior transverse scapular ligament. The authors conclude that the superior transverse scapular ligament can be located consistently through an incision located on the superior aspect of the shoulder on the basis of palpable topographic landmarks. The superior approach permits small incision size and the maintenance of local muscle anatomic integrity.