Protocolo de recuperación intensificada durante la cirugía del plexo braquial (RIPLEX) / ntensified Recovery Protocol during Brachial Plexus Surgery (RIPLEX)

La restauración de la función del miembro superior en los pacientes que sufren lesiones del plexo braquial para favorecer la mejoría en su calidad de vida. Así como su reinserción social y laboral, se puede optimizar mediante la implementación de programas de recuperación intensificada o mejorada, multimodales, multidisciplinarios, y de elevados estándares cualitativos, denominados protocolos ERAS (Enhanced Recovery After Surgery), se recomienda la utilización de métodos fundamentados en la mejor evidencia científica disponible. El protocolo que se expone, aplicado en el Complejo Científico Ortopédico Internacional "Frank Paísˮ, derivado de una investigación institucional en curso. Objetivos: Contribuir en el desarrollo del conocimiento científico imprescindible para favorecer la introducción y sistematización de los cuidados perioperatorios multimodales durante las intervenciones quirúrgicas del plexo braquial.

Introduction: Restoration of upper limb function in patients suffering from brachial plexus injuries, in view of favoring improvement in their quality of life or their social and labor reinsertion, can be optimized by means of implementing multimodal, multidisciplinary, intensified or enhanced recovery programs with high qualitative standards, called ERAS (enhanced recovery after surgery) protocols. The use of methods based on the best available scientific evidence is recommended. The protocol presented here is applied at Complejo Científico Ortopédico Internacional "Frank Paísˮ and derived from an ongoing institutional research. Objective: To contribute to the development of scientific knowledge essential to favor the introduction and systematization of multimodal perioperative care during brachial plexus surgical interventions.

Correlating nerve conduction studies with cross-sectional area measured using ultrasound in patients with neuromuscular disease / 中华神经科杂志

Objective:To determine whether there is a correlation between the cross-sectional area (CSA) and the parameters as measured on nerve conduction studies.Methods:Twenty-one patients with neuromuscular diseases in Beijing Tiantan Hospital from March 3, 2022 to May 4, 2023 underwent ultrasound measurement of the CSA of the median nerves and ulnar nerves at the wrist, elbow and the upper arm, followed by nerve conduction studies (NCS). A linear regression model was performed to compare NCS and CSA.Results:A total of 180 sets of motor nerve conduction velocity (MCV) and CSA at the different sites including 102 sets of median nerve and 78 sets of ulnar nerve, 220 sets of compound muscle action potential (CMAP) amplitude and CSA at the different sites including 104 sets of median nerve and 116 sets of ulnar nerve, 60 sets of sensory nerve conduction velocity (SCV) and CSA and sensory nerve action potential (SNAP) amplitude and CSA at the wrist including 32 sets of median nerve and 28 sets of ulnar nerve were recorded. The linear correlation between MCV and CSA was statistically significant both in median nerve ( r2=0.10,adjusted r2=0.09, P=0.001) and in ulnar nerve ( r2=0.18,adjusted r2=0.17, P<0.001).When CSA>10 mm 2, the linear correlation between CMAP amplitude and CSA was statistically significant both in median nerve ( r2=0.09,adjusted r2=0.08, P=0.024) and ulnar nerve ( r2=0.19,adjusted r2=0.17, P=0.004). The correlation between CMAP and CSA was not statistically significant when CSA≤10 mm 2. And the correlations between SCV and CSA and between SNAP and CSA were not statistically significant. Conclusions:CSA can better show the characteristics of changes in motor nerve conduction especially in motor conduction velocity. It is suggested that its application prospect in demyelinating peripheral neuropathy with motor nerve damage may be more extensive.

The key points in diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy / 中华神经科杂志

The diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy relies on clinical features, demyelinating changes on motor and sensory nerve conduction studies, elevated cerebrospinal fluid protein, peripheral nerve image, nerve pathology, and response to immune therapy. Each diagnostic proof should be interpreted in light of clinical background and other findings, to avoid misdiagnosis or overdiagnosis, treatment delay or unnecessary treatment with immunotherapy.

Analysis of electrophysiological characteristics and influencing factors of peripheral neuropathy in Parkinson's disease / 中华老年医学杂志

Objective:To analyze the electrophysiological characteristics and influencing factors of peripheral neuropathy in Parkinson's disease(PD)patients.Methods:Totally 68 PD patients and 30 controls were selected for neuroelectrophysiological evaluation, including items such as limb motor nerve terminal latency(LP)and amplitude and sensory nerve conduction velocity(SCV)and amplitude.Age, sex, serum folate, vitamin B 12, homocysteine and hemoglobin levels were also recorded for the two groups.The Hoehn-Yahr scale was used to assess patients and levodopa daily doses and levodopa equivalent daily doses were calculated.According to the criteria for neuroelectrophysiological abnormalities, 31 PD patients were found to have peripheral neuropathy and 37 PD patients did not have peripheral neuropathy. Results:In PD patients, a total of 952 peripheral nerves were examined, with 21.7% having motor nerve involvement(118/544)and 72.8%(297/of 408)having sensory nerve involvement.In the control group, a total of 420 peripheral nerves were examined, with 4.2%(10/240)having motor nerve involvement and 26.1%(47/180)having sensory nerve involvement.Compared with the control group, the wave amplitudes of motor nerve terminals were reduced in the PD group for the ulnar nerve( t=2.172/2.345, right/left), median nerve( t=2.104/2.543, right/left), and tibial nerve( t=2.340/2.444, right/left)(all P<0.05); compared with the control group, the wave amplitudes of sensory nerve terminals of the ulnar nerve( Z=3.535/3.439, right/ left), median nerve( Z=3.076/2.937, right/left), and peroneal nerve( Z=2.795/2.795, right/left)were all reduced in the PD group(all P<0.05); compared with the control group, sensory conduction velocities of the ulnar nerve( t=2.326/2.487, right/left), median nerve( t=3.269/2.386, right/left), and peroneal nerve( t=2.551/2.418, right/left)were prolonged(all P<0.05). The rate of abnormalities with the sensory nerve terminal wave amplitude( χ2=149.814, P<0.001)was higher than that of abnormalities with motor nerve terminal wave amplitude in PD patients; the rate of abnormalities with the sensory nerve terminal wave amplitude( χ2=58.364, P<0.001)was higher than that of abnormalities with sensory conduction velocities.Logistic regression analysis showed that increased folic acid( OR=0.825, 95% CI: 0.637-0.990)and vitamin B 12( OR=0.996, 95% CI: 0.991-1.000)were protective factors for PD peripheral neuropathy; H-Y score, levodopa daily dose( OR=1.009, 95% CI: 1.003-1.015), and increased homocysteine( OR=1.151, 95% CI: 1.041-1.273)were risk factors for PD peripheral neuropathy.After excluding confounding factors, H-Y classification( OR=3.213, 95% CI: 1.342-7.713)remained an independent risk factor for peripheral nerve injury in PD patients. Conclusions:In PD patients with peripheral neuropathy, both motor nerves and sensory nerves are involved, sensory nerves are more significantly involved, and axonal damage is more important than myelin loss; increased H-Y classification is an independent risk factor for peripheral nerve injury in PD patients.

The use of adhesive radiopaque grids in genicular nerve block by radioscopy / O uso de máscara localizadora no bloqueio de nervos geniculares por radioscopia

ABSTRACT The performance of genicular nerve block requires an imaging method to guide the procedure. Radioscopy has the disadvantage of being radiation dependent. Objective: To assess whether the use of adhesive radiopaque grids reduce radiation exposure in these cases. Methods: This is a cross-sectional study conducted with 23 orthopedists in which needles were positioned in a model with and without the use of adhesive radiopaque grids. The number of fluoroscopy shots necessary for proper positioning in three points (superior lateral, superior medial, and inferior medial) were registered. Results: A statistical difference was observed in the three blocking points studied. The number of radioscopies required for these three points were 12.1 ± 2.5 in the group without grid and 5.0 ± 1.8 in the group with grid. The superior medial point presented the greatest numerical difference and the inferior medial point the smallest. Conclusion: The use of adhesive radiopaque grids led to a statistically significant reduction in the number of radioscopies/fluoroscopies required to perform the genicular block. The use of this device increases the safety of the physician and patient by reducing radiation exposure in this procedure. Level of Evidence III, Level of Evidence II, Random Clinical Trial.

RESUMO Para a realização do bloqueio de nervos geniculares é necessário guiar o procedimento por um método de imagem. A radioscopia possui a desvantagem de ser dependente de radiação. Objetivo: Avaliar se o uso de máscaras localizadoras diminui a exposição à radiação nesses casos. Métodos: Estudo transversal realizado com 23 ortopedistas, que realizaram o posicionamento de agulhas em um modelo com e sem o uso da máscara localizadora. Foi registrado o número de escopias necessárias para o posicionamento adequado em três pontos: superior lateral, superior medial e inferior medial. Resultados: Foi observada diferença estatística nos três pontos de bloqueio analisados. O número de radioscopias necessárias nos três pontos somados foi de 12,1 ± 2,5, no grupo sem máscara, e 5,0 ± 1,8, no grupo com máscara. O ponto superior medial foi o que apresentou a maior diferença numérica, e o inferior medial a menor. Conclusão: O uso da máscara localizadora reduziu de forma estatisticamente significativa o número de escopias necessárias para a realização do bloqueio genicular. O uso desse dispositivo aumenta a segurança do médico e do paciente por diminuir a exposição à radioscopia nesse procediment. Nível de Evidência III, Ensaio clínico randomizado aberto - Nível de recomendação B - nível de evidência 2b.

Ultrasound reference values for peripheral nerve cross-sectional areas and indices in a sample of healthy individuals in Brazil / Valores de referência ultrassonográficos para áreas e índices de secção transversa de nervos periféricos em uma amostra de indivíduos brasileiros saudáveis

Abstract Objective: To establish peripheral nerve cross-sectional area (CSA) reference values (absolute values, measures of asymmetry, and measures of focality) for healthy individuals in Brazil. Materials and Methods: Sixty-six healthy volunteers underwent high-resolution ultrasound of the peripheral nerves. We obtained CSA measurements for three peripheral nerves, at specific locations: the median nerve, in the carpal tunnel (MT); the ulnar nerve, at the cubital tunnel site (UT) and at the pre-tunnel site (UPT); and the common fibular nerve, near the fibular head (FH). We calculated the CSA indices between the same sites on different sides (∆CSAs) and between the ulnar nerve tunnel and pre-tunnel sites on the same side (∆TPT). Results: A total of 132 neural sites were analyzed, and the following CSA values (mean ± SD, median) were obtained: MT (6.3 ± 1.9 mm2, 6.0 mm2); UT (6.2 ± 1.6 mm2, 6.1 mm2); UPT (5.6 ± 1.7 mm2, 5.4 mm2); and FH (10.0 ± 3.7 mm2, 9.9 mm2). The ∆CSA values (mean ± SD, median) were as follows: MT (0.85 ± 0.7 mm2, 0.95); UT (0.81 ± 0.62 mm2, 0.95); UPT (0.61 ± 0.51 mm2, 0.5); and FH (1.0 ± 0.77 mm2, 1.0). The ∆TPT (mean ± SD, median) was (1.0 ± 0.8 mm2, 1.0). Conclusion: Among individuals in Brazil, peripheral nerve CSA values tend to be higher among males and to increase with aging. However, the same does not appear to hold true for the ∆CSA or the ∆TPT, the exception being the difference between the right and left UT. Differences in CSA values greater than 2.5 mm2 between sides or between sites along the same nerve can indicate asymmetry or focal thickening in neuropathy, respectively.

Resumo Objetivo: Estabelecer valores de referência da área de secção transversa (AST) dos nervos periféricos (valores absolutos e medidas de assimetria e de espessamento focal) para amostra de indivíduos brasileiros saudáveis. Materiais e Métodos: Sessenta e seis voluntários brasileiros saudáveis foram submetidos a ultrassonografia de alta resolução de nervos periféricos. As medidas da AST dos seguintes nervos periféricos foram obtidas em: mediano no túnel do carpo (MT), ulnar no túnel cubital (UT), pré-túnel ulnar (UPT) e fibular comum na cabeça da fíbula (FH). Os índices CSA foram obtidos entre os mesmos sítios em lados diferentes (∆CSA) e entre os sítios distal e proximal do nervo ulnar (∆TPT). Resultados: As seguintes médias ± desvio-padrão e mediana da AST foram obtidas para os 132 sítios dos nervos periféricos analisados: MT (6,3 ± 1,9 mm2; 6,0 mm2), UT (6,2 ± 1,6 mm2; 6,1 mm2), UPT (5,6 ± 1,7 mm2; 5,4 mm2) e FH (10,0 ± 3,7 mm2; 9,9 mm2). A média ± desvio-padrão e as respectivas medianas do ∆CSA em mm2 foram: 0,85 ± 0,7 [0,95] para MT, 0,81 ± 0,62 [0,95] para UT, 0,61 ± 0,51 [0,5] para UPT, 1,0 ± 0,77 [1] para FH, e 1,0 ± 0,8 [1,0] para ∆TPT. Conclusão: Os valores de AST tendem a ser maiores no sexo masculino, aumentando os valores absolutos das medianas das ASTs com o envelhecimento, mas não nos seus índices, ∆CSA e ∆TPT, exceto a diferença entre a AST dos nervos ulnares nos lados direito e esquerdo. Diferenças de valores de AST entre lados ou pontos no mesmo nervo maior que 2,5 mm2 podem significar neuropatia com assimetria e espessamento focal.

The Effectiveness of Early Investigative Tools for Neural Lesions in Leprosy: An Observational Cohort Study

Leprosy can cause different lesions in peripheral nerves and inervatory structures. This study aims to analyze the effectiveness of evaluation protocols used to identify neural lesions in leprosy, such as Degree of Physical Disability (DPD), Simplified Neurological Assessment (SNA) and propose to use Neuro Dynamic Assessment (NDA). A descriptive analytical study was carried out in 27 individuals treated in two outpatient leprosy clinics in São Paulo State, between 2017 and 2019. A control group of age and sex matched 27 people, chosen from the population without a diagnosis of leprosy, was also evaluated. The Mann-Whitney, Multivariate Linear Regression, association between variables, and P<0.05 values were used. The test that most captured the neurological alterations was the SNA, with 22 (81.5%) in the upper limbs (ULs) and 25 (92.6%) in the lower limbs (LLs), followed by the NDA, with 20 (74.1%) in the ULs and 11 (40.7%) in the LLs. The DPD showed handicap in the hands of 16 (59.2%) individuals and in the feet of 17 (62.9%) individuals. The three assessment instruments can and should be used in combination to expand the monitoring of neural lesions in leprosy, as there are changes that are not perceptible with one instrument but can be confirmed by another. If there is an instrument to be chosen, it should be the SNA, because it identifies subtle changes that suggest neural distress.

Application of 18F-FDG PET/CT metabolic parameters in the prediction of perineural invasion in non-metastatic rectal cancer / 中华核医学与分子影像杂志

Objective:To investigate the value of 18F-FDG PET/CT metabolic parameters in predicting perineural invasion (PNI) in patients with non-metastatic rectal cancer. Methods:From August 2012 to April 2020, 81 patients (51 males, 30 females, median age: 63 years) who received PET/CT examination and pathologically confirmed as rectal cancer in the Affiliated Hospital of Qingdao University were retrospectively analyzed. The 18F-FDG PET/CT metabolic parameters including SUV max, metabolic tumor volume (MTV) and total lesion glycolysis (TLG), and clinicopathological factors including gender, age, carcinoembryonic antigen (CEA), carbohydrate antigen (CA)19-9, maximum tumor diameter, degree of differentiation, T stage, lymph node metastasis, and TNM stage were recorded. Mann-Whitney U test and χ2 test were used to compare the differences of each parameter between PNI positive group and PNI negative group. Multivariate logistic regression was used to analyze the independent predictor of positive PNI. ROC curve was used to analyze its predictive efficacy. Results:Of 81 patients, 32(39.51%) were PNI positive and 49(60.49%) were PNI negative. There were significant differences of T stage ( χ2=10.73, P=0.010), lymph node metastasis ( χ2=6.21, P=0.013), TNM stage ( χ2=7.61, P=0.022), MTV (14.6(10.4, 24.7)and 9.0(5.4, 14.5) cm 3; U=-3.48, P=0.001) and TLG (108.588(72.749, 182.707) and 65.365(35.593, 117.682) g; U=-2.79, P=0.005) between PNI positive group and PNI negative group. Multivariate logistic regression analysis showed that MTV was the independent predictor of positive PNI in non-metastatic rectal cancer patients (odds ratio ( OR)=1.130, 95% CI: 1.025-1.245, P=0.014). The optimal threshold of MTV was 9.53 cm 3 and AUC was 0.73 with the sensitivity of 81.82%(27/33) and the specificity of 59.18%(29/49). Conclusion:18F-FDG PET/CT metabolic parameter MTV can predict PNI in non-metastatic rectal cancer with high sensitivity.

Research progress on cerebellar ataxia, neuropathy, vestibular areflexia syndrome / 中华神经科杂志

Cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS) is an autosomal recessive hereditary disorder characterized by cerebellar ataxia, sensory neuropathy and bilateral vestibulopathy. Recently a biallelic intronic AAGGG repeat expansion in the replication factor C1 (RFC1) gene was identified as the cause of this disorder. Clinical studies of genetically-confirmed CANVAS in the past 2 years have significantly expanded the clinical phenotype of the disease and the concept of RFC1-related disease was proposed. The clinical manifestations, characteristic auxiliary examination, genetic changes of CANVAS were reviewed and the new diagnostic criteria to improve clinicians′ awareness of the disease was discussed in this paper.

Cerebellar ataxia, neuropathy, vestibular areflexia syndrome with replication factor C subunit 1 gene mutation: a case report and literature review / 中华神经科杂志

Objective:To investigate the clinical and genetic characteristics of cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS) with replication factor C subunit 1 (RFC1) gene mutation to improve the understanding of this disease.Methods:A case of CANVAS diagnosed in the Peking University Third Hospital in January 2021 was reported. Detailed genetic analyses of ataxia were performed with DNA extracted from the peripheral blood of the patient. Studies including pathogenic variants of RFC1 gene causing CANVAS were reviewed and the clinical and genetic characteristics of the disease were summarized.Results:The patient was a 51-year-old female with the prominent manifestation of progressive walking instability. And the clinical data met the diagnostic criteria of CANVAS. The genetic tests excluded other hereditary ataxia mutations and identified the biallelic expansion of the pathogenic variant structure (AAGGG)exp repeat amplification in RFC1 gene. A total of 14 studies on CANVAS with RFC1 gene mutation were reviewed. The overall mutation rate of RFC1 gene in CANVAS was 68%-100%, and it varied in sporadic and familial CANVAS. And the mutation had ethnic differences.Conclusions:Among adult patients with late-onset ataxia, the combination of brain magnetic resonance imaging, electrophysiology tests and vestibular function examination is beneficial to the identification of CANVAS. And the genetic test of RFC1 gene has significant value in the diagnosis of this disease. This patient with CANVAS expands the disease spectrum of ataxia in China, and confirms that RFC1 gene mutation is of great significance in the screening of ataxia disorders in the Chinese population.

Effect of hyperbaric oxygen therapy on nerve regeneration in rats / Efeito da terapia hiperbárica de oxigênio na regeneração nervosa em ratos

ABSTRACT Objective: To evaluate histological changes in peripheral nerves of rats after sciatic nerve neurorrhaphy, according to the time of exposure to hyperbaric oxygen chamber treatment. Methods: Twenty-five Wistar rats were divided into 5 groups according to the amount of exposure to hyperbaric oxygen chamber treatment. Group 1 was the control and there was no use of hyperbaric oxygen chamber; group 2 received one week of therapy; group 3, two weeks; group 4, three weeks; and group 5, four weeks. After the fourth postoperative week, the animals were submitted to euthanasia and a sciatic nerve sample sent for histological analysis. Axons proximal and distal to the neurorrhaphy were counted with axonal regeneration index measurement. Results: We observed that the number of axons distal to neurorrhaphy increases with the amount of hyperbaric oxygen chamber exposure, the results were more expressive from the third week of treatment. However, the statistical analysis found no significant difference between the groups. Conclusion: The descriptive analysis suggests benefit of using hyperbaric oxygen chamber directly proportional to the time of therapy. The study, however, did not present statistically relevant results, probably due to the reduced sample size. Subsequent studies with more significant sampling would be of great value. Level of Evidence II, Prospective Comparative Study.

RESUMO Objetivo: Avaliar as alterações histológicas nos nervos periféricos após neurorrafia do nervo ciático de ratos, de acordo com o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. Métodos: Vinte e cinco ratos da raça Wistar foram divididos em cinco grupos conforme o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. O grupo 1 não recebeu o tratamento; o grupo 2 recebeu uma semana de terapia; o grupo 3, duas semanas; o grupo 4, três semanas; e o grupo 5, quatro semanas. Após quatro semanas de pós-operatório, os animais foram submetidos à eutanásia e uma amostra do nervo ciático foi enviada para análise histológica. Foram feitas contagens do número de axônios proximalmente e distalmente à neurorrafia, com medição do índice de regeneração axonal. Resultados: Observamos que o aumento do número de axônios distais à neurorrafia foi diretamente proporcional ao tempo de exposição à câmara hiperbárica de oxigênio, sendo mais expressivo a partir da terceira semana de tratamento. Entretanto, a análise estatística não encontrou diferença significativa entre os grupos. Conclusão: A análise descritiva sugere benefício do uso da câmara hiperbárica de oxigênio. Porém, devido à amostra reduzida, o estudo não apresentou resultados estatisticamente relevantes, sendo necessária a realização de estudos subsequentes com amostragem mais significativa. Nível de Evidência II, Estudo Prospectivo Comparativo.

Comparison of two volumes for sciatic perineural injection using 1% methylene blue in rabbit cadavers / [Comparação de dois volumes para injeção perineural no nervo isquiático utilizando azul de metileno 1% em cadáveres de coelhos]

The purpose of this study was to assess the efficacy of a blind technique for sciatic and femoral nerve block in rabbit cadavers by evaluating the spread of 1% methylene blue at two different volumes. Nine recently euthanized rabbits weighing 2.5(0.3kg were used. The sciatic (SN) and femoral (FN) nerves of each limb were randomly assigned for injection with 1% methylene blue at 0.2mL/kg (G0.2) or 0.3mL/kg (G0.3). Nerves were dissected and measured for depth and extension of staining (cm). Mean comparisons were performed using paired t test. The relation between volume and nerve staining ( 2cm was assessed using chi-square test. The mean depth of SN was 1.9±0.2 and 1.6±0.3cm and staining 1.9±1.4 and 2.0±1.2cm, respectively in G0.2 and G0.3. No relation was found between depth and dye spread and there was no association between nerve staining ( 2.0cm and volume of solution. The FN failed to be stained in all subjects. In conclusion, SN injection can be successfully performed without guidance in rabbits. The lower volume (0.2mL/kg) is recommended to avoid systemic toxicity.(AU)

O objetivo deste estudo foi avaliar a eficácia de uma técnica para bloqueio às cegas dos nervos isquiático e femoral em cadáveres de coelhos, por meio da avaliação da dispersão de azul de metileno 1% em dois volumes distintos. Nove coelhos recém-eutanasiados, com peso 2,5(0,3kg, foram utilizados. Os nervos isquiático (NI) e femoral (NF) de cada membro foram aleatoriamente designados para injeção com azul de metileno 1% a 0,2mL/kg (G0,2) ou 0,3mL/kg (G0,3). Em seguida, foram dissecados e mensurados em relação à sua profundidade e extensão corada (cm). As médias foram comparadas por meio de teste t pareado. A relação entre volume e extensão corada ( 2cm foi avaliada utilizando-se teste de qui-quadrado. A profundidade média do NI foi 1,9±0,2 e 1,6±0,3cm, e a extensão corada 1,9±1,4 e 2,0±1,2cm, respectivamente, no G0,2 e no G0,3. Não houve relação entre a profundidade e a extensão corada ou entre a extensão corada ( 2,0cm e o volume de solução. Não foi observada coloração do NF em nenhum cadáver. Concluiu-se que a injeção do NI pode ser realizada com sucesso sem auxílio de tecnologias em coelhos. O menor volume (0,2mL/kg) é recomendado para evitar toxicidade sistêmica.(AU)

Late follow-up of peripheral neural decompression in leprosy: functional and clinical outcomes / Seguimento tardio da descompressão neural periférica na hanseníase: resultados funcionais e clínicos

ABSTRACT Background: Peripheral neural surgical decompression (PNSD) is used as a complementary therapy to the clinical treatment of neuritis to preserve neural function. Objective: To evaluate the long-term (≥ 1 year) clinical and functional results for PNSD in leprosy neuritis. Methods: This cross-sectional study included leprosy patients who were in late postoperative period (LPO) of surgical decompression of ulnar, median, tibial, and fibular nerves. Socioeconomic, epidemiological, and clinical data were collected. The following instruments were used in this evaluation: visual analogue pain scale (VAS), Douleur Neuropathique en 4 Questions (DN4), SALSA scale, and simplified neurological assessment protocol. The preoperative (PrO) and 180-day postoperative (PO180) results were compared. Results: We evaluated 246 nerves from 90 patients: 56.6% were on multidrug therapy (MDT) and 43.3% discharged from MDT. Motor scores and pain intensity showed statistically significant improvement (p<0.01). There was an increase in sensory scores only for bilateral ulnar nerves (p<0.05). Of the operated cases, 26.0% of patients were referred for surgery of ulnar neuritis and 23.6% of tibial neuritis. Neuropathic pain was reported in 41% of cases. Daily dose of prednisone reduced from 39.6 mg (±3.0) in PrO, 16.3 mg (±5.2) in PO180, to 1.7 mg (±0.8) in LPO. The SALSA scale results showed mild activity limitation in 51% and moderate in 34% of patients. Eighty percent of individuals reported that the results reached their expectations. Conclusions: PNSD in leprosy was effective in the long term to decrease the prevalence and intensity of pain, improve motor function, and reduce the dose of corticosteroids, which is reflected in the patients' satisfaction.

RESUMO Antecedentes: A descompressão cirúrgica neural periférica (DCNP) é usada como uma terapia complementar ao tratamento clínico da neurite hansênica para preservar a função neural. Objetivo: Avaliar a longo prazo (≥ 1 ano) os resultados clínicos e funcionais da DCNP na neurite hansênica. Métodos: Este estudo transversal incluiu pacientes que estavam no pós-operatório tardio (POT) de cirurgia de descompressão dos nervos ulnares, medianos, tibiais e fibulares. Foram coletados dados socioeconômicos, epidemiológicos e clínicos. Os instrumentos utilizados foram: escala visual analógica de dor (EVA), questionário de dor neuropática 4 (DN4), escala SALSA e protocolo de avaliação neurológica simplificada. Os resultados obtidos foram comparados com os do pré-operatório (PrO) e pós-operatório de 180 dias (PO180). Resultados: Foram avaliados 246 nervos de 90 pacientes: 56,6% estavam em poliquimioterapia (PQT) e 43,3% em alta da PQT. Escores motores e intensidade da dor apresentaram melhora significante (p<0,01). Houve aumento nos escores sensitivos nos nervos ulnares bilaterais (p<0,05). Neurite ulnar foi indicação cirúrgica em 26,0% dos casos operados, seguida pela neurite tibial (23,6%). Dor neuropática foi relatada em 41% dos casos. Dose diária de prednisona reduziu de 39,6 mg (±3,0) na PrO, 16,3 mg (±5,2) na PO180, para 1,7 mg (±0,8) na POT. Escala SALSA mostrou limitação leve da atividade em 51% e moderada em 34% dos pacientes. 80% dos indivíduos relataram que os resultados atingiram suas expectativas. Conclusão: DCNP na hanseníase foi eficaz a longo prazo na redução da prevalência e intensidade da dor, na melhora da função motora e redução da dose de corticosteroides, refletindo na satisfação do paciente.

Leprosy case series in the emergency room: A warning sign for a challenging diagnosis

ABSTRACT Leprosy can be considered a dissimulated disease, mainly when presented as atypical cases leading to mistaken diagnosis at the emergency setting. Herein we report six patients referred to the emergence room with hypotheses of acute myocardial infarction and arterial and venous thrombosis, although with chronic neurological symptoms; the seventh patient was referred with a wrong suspicion of infected skin ulcer. Positive findings included hypo-anesthetic skin lesions and thickened nerves; 100% were negative for IgM anti-phenolic glycolipid-I, while 71.4%, 100% and 42.8% were positive for IgA, IgM and IgG Mce1A. RLEP-PCR was positive in all patients. Ultrasound of peripheral nerves showed asymmetric and focal multiple mononeuropathy for all patients. Unfortunately, in many patients leprosy is often misdiagnosed as other medical conditions for long periods thus delaying initiation of specific treatment. This paper is intended to increase physicians' awareness to recognize leprosy cases presented as both classical and unusual forms, including in emergency department.

Retrospective Analysis of 20 Patients Affected by Schwannomas in the Upper and Lower Limbs / Análise retrospectiva de 20 pacientes acometidos por schwannoma nos membros superior e inferior

Abstract Objective To analyze the epidemiological profile and evolution of 20 patients diagnosed with upper- and lower-limb schwannomas. Methods A group of patients was defined for a retrospective evaluation comprising the period between February 2002 and June 2018, in which we studied and evaluated 20 medical records of patients undergoing surgery due to schwannoma; the diagnosis was confirmed by an anatomopathological examination. Results Male and female patients were equally affected. The average age was 50.85 years, ranging from 12 to 77 years. There was a predominance of the upper limb and of the flexor face. The most affected nerve was the ulnar nerve. In total, 6 (30%) patients had transient postoperative complications. No cases of tumor recurrence were identified. Conclusion Schwannoma is a rare and difficult-to-diagnose lesion. It should always be considered as a hypothesis when facing a soft-tissue tumor affecting the limbs. The Tinel sign should be regarded, given its higher correlation with complications. The patients should be informed of the possible postoperative complications, which are frequent but usually transient.

Resumo Objetivo Analisar o perfil epidemiológico e a evolução de 20 pacientes diagnosticados com schwannoma nos membros superiores e inferiores. Métodos Definiu-se um grupo de pacientes para avaliação retrospectiva, compreendendo o período entre fevereiro de 2002 e junho de 2018, no qual foram estudados e avaliados 20 prontuários de pacientes submetidos a procedimento cirúrgico devido a schwannoma; a confirmação diagnóstica foi feita pelo exame anatomopatológico. Resultados Tanto os pacientes do sexo masculino quanto do feminino foram igualmente acometidos, e a média de idade foi de 50,85 anos, variando de 12 a 77 anos. Houve predomínio do membro superior e da face flexora. O nervo mais acometido foi o ulnar, e 6 (30%) pacientes apresentaram complicações pós-operatórias transitórias. Não foi identificado nenhum caso de recidiva tumoral. Conclusão O schwannoma é uma lesão rara e de difícil diagnóstico. Deve sempre ser considerada como hipótese quando se estiver diante de um tumor de partes moles acometendo os membros. O sinal de Tinel deve ser levado em consideração por conta de sua maior correlação com as complicações. Os pacientes devem ser informados quanto às possíveis complicações pós-operatórias, que são frequentes, mas, geralmente, transitórias.

Ultrasonographic Examination of Peripheral Nerves in Diabetic Peripheral Neuropathy.

Diabetes has been a major problem in India. Its slow growth is associated with many complications, most common being peripheral neuropathy. An easy and cheap investigation to diagnose the neuropathy may help in early diagnosis and decrease the economic burden on the society. The purpose of the study was to assess the usefulness of ultrasonography (USG) in the evaluation of diabetic peripheral neuropathy (DPN).METHODSFifty adult diabetic patients with clinically diagnosed DPN and 50 diabetics without DPN were included in the study. USG of the medial, ulnar, and common peroneal nerves was done. The mean cross-sectional area (CSA) of the involved nerves was measured in the two groups at identical positions. The CSA was compared between the two groups, and Student t-test was applied to assess statistical significance.RESULTSThe mean thickness of median nerve among diabetics without DPN was significantly less at 5 cms proximal to wrist (7.34 ± 1.24 vs 11.12 ± 1.56, p<0.0001); was significantly less at mid-forearm (6.84 ± 0.77 vs 10.36 ± 1.72, p<0.0001); and was significantly less at elbow (7.36 ± 0.75 vs 10.2 ± 1.64, p<0.0001). The mean thickness of ulnar nerve among diabetics without DPN was significantly less at wrist joint (6.98 ± 0.89 vs 8.44 ± 1.34, p<0.0001); and was significantly less behind medial epicondyle (7.44 ± 0.93 vs 9.36 ± 0.98, p<0.0001). The mean thickness of common peroneal nerve among diabetics without DPN was significantly less at neck of fibula (7.26 ± 1.34 vs 9.3 ± 1.67, P<0.0001); and the mean thickness of posterior tibial nerve was also significantly less at 5 cms above medial malleolus (7.06 ± 1.25 vs 9.16 ± 1.61, P<0.0001). There was a significant increase in the CSA of the median, ulnar, posterior tibial and common peroneal, in DPN patients as compared to diabetics without DPN (p<0.05).CONCLUSIONSUSG demonstrates a morphological change in patients with DPN in the form of an increase in CSAs, which was statistically significant. USG can objectively complement other diagnostic investigations such as nerve conduction studies. High resolution ultrasonography of peripheral nerves has the potential to become the investigation of first choice for the evaluation of DPN.

Stem cells in end-to-side neurorrhaphy. Experimental study in rats

Abstract Purpose: To evaluate the influence of mesenchymal stem cells from adipose tissue in the end-to-side neurorrhaphy, focusing in the nerve regeneration and the muscle reinnervation in acute trauma. Methods: 140 animals were randomly divided in seven groups: control, denervated, end-to-side neurorrhaphy between distal stump of common peroneal nerve and tibial nerve (ESN), ESN wrapped in fascia, ESN wrapped in fascia and platelet gel, ESN wrapped in platelet gel, ESN wrapped in fascia and platelet gel within stem cells (without culture) removed from the adipose tissue. Mass measurements of the animal and of cranial tibial muscles, electromyography, walking track analysis tests and histological examinations of the nerves and muscles after 180 days was performed. Results: In the groups where the ESN was performed, the results were always better when compared to the denervated group, showing reinnervation in all ESN groups. The most sensitive methods were walking track and histological analysis. Only the group with stem cells showed values similar to the control group, as well as the functional indices of peroneal nerve and the number of nerve fibers in the peroneal nerve. Conclusions: Stem cells were effective in ESN according with the functional index of the peroneal nerve, evaluated by walking track analysis and the number of nerve fibers in the peroneal nerve.

Correlation of Peripheral Nerve Injury to Motor Function of Upper Limb in Convalescent Patients with Peripheral Paralysis after Stroke / 中国康复理论与实践

Objective:To evaluate peripheral nerve injury in convalescent patients with peripheral paralysis after stroke, and explore the correlation between injured nerve and upper limb motor function. Methods:From December, 2015 to October, 2019, 77 stroke patients were examined motor nerve conduction, F wave, skin sympathetic response (SSR) and electromyography (EMG) on the affected side upper limbs. They were divided into the normal group and the injured group, according to motor nerve conduction. They were assessed with simplified Fugl-Meyer Assessment-Upper Extremities (FMA-UE), and the correlation between the neuroelectrophysiological parameters and FMA-UE score was analyzed. Results:There were 41 patients (53.25%) with peripheral nerve injury (injured group). FMA-UE score was less in the injured group than in the normal group (t = 2.193, P < 0.05), with lower amplitude and occurrence rate of F wave (t > 2.002, P < 0.05), and lower amplitude and shorter latency of SSR (t > 3.140, P < 0.01), although the occurrence rate of F wave and latency of SSR was in the reference range. There was correlation between numbers of injured nerves and FMA-UE score (r = -0.858, P < 0.001). Multivariate linear regression analysis showed that the amplitudes of ulnar, radial and musculocutaneous nerves affected the FMA-UE score (B > 0.317, P < 0.05). Conclusion:There may be peripheral nerves injury for patients with upper limb peripheral paralysis after stroke, which may impair the outcome of motor recovery, and need to be avoided and treated.

Establishment and evaluation of traumatic neuroma model / 中国组织工程研究

BACKGROUND: Traumatic neuroma is a common complication of peripheral nerve injury, and basic research on peripheral nerve repair and regeneration through a traumatic neuroma model is rarely reported. OBJECTIVE: To establish and identify a traumatic neuroma model. METHODS: The study was approved by the Laboratory Animal Ethical Committee of Chinese PLA General Hospital. Fifteen healthy Sprague-Dawley rats aged 8 weeks old were selected to expose the sciatic nerve under microscope, and the sciatic nerve was cut 1 cm away from the posterior gluteal muscle branch using microscissors. The proximal nerve was sutured to the surrounding muscle with 11-0 microlines, and the distal nerve was left open and reflexed. After 3 weeks, ultrasonic and histological examinations were used to verify the formation of neuroma. RESULTS AND CONCLUSION: (1) Ultrasound: After 3 weeks of modeling, the proximal nerve showed obvious spindle enlargement, which was a hypoechoic parenchymal nodule without echo. (2) Gross observation: The proximal nerves were enlarged and slightly stiffened, with fibrous connective tissue hyperplasia and adhesion to the surrounding tissues. (3) Hematoxylin-eosin staining indicated hyperplasia of fibrous tissue and disorderly growth of nerve fibers in the tumor. Immunofluorescence staining (S100, NF200) revealed irregular hyperplasia of Schwann cells and nerve axons in the tumor. (4) These results suggest that the model of traumatic neuroma is successfully constructed.

Clinical and electrophysiological features and treatment of acrylamide-induced toxic peripheral neuropathy / 中华劳动卫生职业病杂志

Objective@#To investigate the clinical manifestations, electrophysiology results, treatment and prognosis of acrylamide-induced toxic peripheral neuropathy.@*Methods@#The clinical data of 9 patients with acrylamide-induced toxic peripheral neuropathy, who were collected in Jinhua Municipal Central Hospital from January 2015 to August 2018, were retrospectively reviewed.@*Results@#This disease was characterized by distal limb numbness, some patients with hypoalgesia or allergy, deep sense loss, reduction or disappearance of tendon reflexes, and peeling. One case had muscle weakening and another case had cerebellar ataxia. Examination of electromyography showed only one case had spontaneous potential. Examination of nerve conduction showed that the amplitude decreased by 34 (38.6%) and the velocity decreased by 2 (2.3%) , the percentage of amplitude decreased was significantly higher than that of velocity decreased. The amplitude of sensory nerve decreased by 30 (57.7%) and motor nerve decreased by 4 (11.1%) , the percentage of sensory nerve amplitude decreased was significantly higher than that of motor nerve. After the treatment of nutrition, circulation improvement, numbness relief, glucocorticoid and other drugs, the numbness of the patients was relieved, but it did not completely disappear. Poor recovery of pain, deep sensation and tendon reflex in all patients. The results of reexamination of electromyography in 3 cases were worse than before. Therefore, it is suggested that peripheral nerve damage is irreversible.@*Conclusion@#This disease is characterized by distal limb numbness. Electrophysiological results suggest that the damage of sensory nerve axon is the main cause of the disease. Up to now, there is no effective drug to treat this disease, therefore, it is very important to do a good job of protection.