Endoscopic posterior nasal neurectomy for the treatment of allergic rhinitis: anatomy and analysis of clinical efficacy / 中华耳鼻咽喉头颈外科杂志

Objective: To propose total posterior nasal neurectomy with transection of sphenopalatine neurovascular bundle from anatomy for the treatment of allergic rhinitis, and to explore its clinical application. Methods: Two fresh cadaveric heads (4 sides) were dissected through endoscopic transnasal middle meatus approach at Otorhinolaryngology Anatomy Laboratory of China-Japan Friendship Hospital. The structures of the craniofacial bone related to the surgical approach were observed. Twelve patients with allergic rhinitis who treated in Department of Otorhinolaryngology, China-Japan Friendship Hospital from Feb. 1 2019 to Jun. 10 2021 were selected. All the patients were treated by posterior nasal neurotomy with the technique of complete transection of sphenopalatine neurovascular bundle and followed up for 1 year after sugery. During the follow-up, 2 patients were lost. The other 10 patients included 4 males and 6 females, aging from 29 to 69 years. Visual Analogue Scale (VAS) and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) were used to evaluate the effect of the surgery. SPSS 25.0 software was used for statistical analysis. Results: Important anatomic landmarks of transnasal middle meatus approach were obtained during anatomy, such as ethmoid crest, sphenopalatine foramen/notch, palatine orbital process and sphenopalatine process. The postoperative VAS scores of nose, eye, pharynx, ear and whole body and total VAS scores were significantly lower than those before operation, with statistically significant difference (nose 2.50±1.70 vs 6.47±2.17, eyes 1.15±0.89 vs 3.60±2.57, pharynx 1.30±1.36 vs 4.25±3.64, ear 1.10±1.03 vs 2.67±2.00, whole body 1.08±1.24 vs 3.60±1.17, total 7.13±4.31 vs 20.58±9.05, all P<0.05). The postoperative RQLQ scores of sleep, nose, eyes, practical problems, emotion, activity and the total RQLQ scores of patients were significantly lower than those before operation, with statistically significant difference (sleep 0.80±0.69 vs 2.93±1.33, nose 1.38±1.18 vs 3.93±1.50, eyes 0.58±0.66 vs 1.80±1.25, practical problems 1.10±1.22 vs 3.03±1.84, emotion 1.00±1.81 vs 2.58±2.00, activity 2.77±2.93 vs 6.00±1.85, total 8.99±8.92 vs 22.42±8.69, all P<0.05). There was no significant difference in preoperative and postoperative scores of non-nasal/ocular symptoms (1.37±1.60 vs 2.16±1.12, P=0.166). There was no other complication except 2 cases with short-term postoperative numbness. Conclusions: Total posterior nasal neurectomy with transection of sphenopalatine neurovascular bundle is a safe, effective and feasible method for the treatment of intractable allergic rhinitis, and its long-term efficacy needs further observation.

The anatomic analysis of the vidian canal and the surrounding structures concerning vidian neurectomy using computed tomography scans / Avaliação anatômica do canal vidiano e estruturas adjacentes por tomografia computadorizada para a neurectomia do vidiano

Abstract Introduction: The type of endoscopic approach chosen for vidian neurectomy can be specified by evaluating the vidian canal and the surrounding sphenoid sinus structures. Objective: The variations and morphometry of the vidian canal were investigated, focusing on the functional correlations between them which are crucial anatomical landmarks for preoperative planning. Methods: This study was performed using paranasal multidetector computed tomography images that were obtained with a section thickening of 0.625 mm of 250 adults. Results: The distributions of 500 vidian canal variants were categorized as follows; Type 1, within the sphenoid corpus (55.6%); Type 2, partially protruding into the sphenoid sinus (34.8%); Type 3, within the sphenoid sinus (9.6%). The pneumatization of the pterygoid process is mostly seen in vidian canal Type 2 (72.4%) and Type 3 (95.8%) (p < 0.001). The mean distances from the vidian canal to the foramen rotundum and the palatovaginal canal were greater in the vidian canal Type 2 and 3 with the pterygoid process pneumatization (p < 0.001). The prevalence of the intrasphenoid septum between the vidian canal and the vomerine crest and lateral attachment which ending on carotid prominence were much higher in vidian canal Type 3 than other types (p < 0.001). The mean angle between the posterior end of the middle turbinate and the lateral margin of the anterior opening of the vidian canal was measured as 33.05 ± 7.71°. Conclusions: Preoperative radiologic analysis of the vidian canal and the surrounding structures will allow surgeons to choose an appropriate endoscopic approach to ensure predictable postoperative outcomes.

Resumo Introdução: O tipo de abordagem endoscópica para a neurectomia do vidiano pode ser definido pela avaliação do canal do vidiano e das estruturas adjacentes aos seios esfenoidais. Objetivo: Investigar as variações e a morfometria do canal vidiano com enfoque nas suas correlações funcionais, pois são parâmetros anatômicos cruciais para o planejamento pré-operatório. Método: Esse estudo foi realizado utilizando-se imagens de tomografia computadorizada multidetectores dos seios paranasais com espessura de corte de 0,625 mm obtidas de 250 indivíduos adultos. Resultados: A distribuição das 500 variantes do canal vidiano foi categorizada da seguinte forma: Tipo 1, dentro do corpo ósseo esfenoidal (55,6%); Tipo 2, protrusão parcial no interior do seio esfenoidal (34,8%); Tipo 3, no interior do seio esfenoidal (9,6%). A pneumatização do processo pterigoide foi observada principalmente no canal vidiano Tipo 2 (72,4%) e Tipo 3 (95,8%) (p < 0,001). As distâncias médias do canal vidiano até o forame redondo e o canal palatovaginal foram maiores no canal vidiano do Tipo 2 e 3, com a pneumatização do processo pterigoide (p < 0,001). A presença do septo intraesfenoidal entre o canal vidiano e a crista vomeriana e a extensão lateral, que termina na proeminência da carótida, foi muito maior no canal vidiano Tipo 3 do que nos outros tipos (p < 0,001). A angulação média entre a cauda da concha média e a margem lateral da abertura anterior do canal vidiano foi de 33,05° ± 7,71°. Conclusões: A análise radiológica pré-operatória do canal do vidiano e das estruturas circunjacentes permitem ao cirurgião escolher uma abordagem endoscópica apropriada e prever resultados pós-operatórios.

Botulinum toxin as a treatment for short bowel syndrome in rats

Abstract Purpose: The denervation of the intestine with benzalkonium chloride (BAC) reduces mortality and improves weight gain in rats with short bowel syndrome (SBS). Nevertheless, translating these promising findings from bench to bedside is not feasible because BAC promotes peritonitis and irreversible denervation which may be followed by an uncontrolled dilatation of the viscera. The use of botulinum toxin (BT) instead of BAC to achieve the denervation of the remaining small intestine in SBS could be an interesting option because it leads to a mild and transient denervation of the intestine. Methods: Here we evaluated the effects of the ileal denervation with BT in rats with SBS by verifying the body weight variation and intestinal morphological parameters. Four groups with 6 animals each were submitted to enterectomy with an ileal injection of saline (group E) or BT (group EBT). Control groups were submitted to simulated surgery with an ileal injection of BT (group BT) or saline (group C - control). Results: We observed that the treatment of the remaining ileum with BT completely reversed the weight loss associated to extensive small bowel resection. Conclusion: This may provide a new promising approach to the surgical treatment of SBS.

Anatomical study of the transfer of flexor digitorum superficialis nerve branch of median nerve to restore wrist extension and forearm pronation / Estudo anatômico da transferência do ramo do nervo mediano destinado ao músculo flexor superficial dos dedos para restaurar a extensão do punho e a pronação do antebraço

Abstract Objective To analyze the anatomical variations of the innervation of the flexor digitorum superficialis muscle and to determine if the branch of the median nerve that supply this muscle is connected to the branches to the extensor carpi radialis brevis and the pronator teres muscles, without tension, and how close to the target-muscles the transfer can be performed. Methods Fifty limbs of 25 cadavers were dissected to collect data on the anatomical variations of the branches to the flexor digitorum superficialis muscle. Results This muscle received innervation from the median nerve in the 50 limbs. In 22 it received one branch, and in 28 more than one. The proximal branch was identified in 22 limbs, and in 12 limbs it shared branches with other muscles. The distal branch was present in all, and originated from the median nerve as an isolated branch, or a common trunk with the anterior interosseous nerve in 3 limbs, and from a common trunk with the flexor carpi radialis muscle and anterior interosseous nerve in another. It originated distally to the anterior interosseous nerve at 38, in 5 on the same level, and in 3 proximal to the anterior interosseous nerve. In four limbs, innervation came from the anterior interosseous nerve, as well as from the median nerve. Accessory branches of the median nerve for the distal portion of the flexor digitorum superficialis muscle were present in eight limbs. Conclusion In 28 limbs with two or more branches, one of them could be connected to the branches to the extensor carpi radialis brevis and pronator teres muscles without tension, even during the pronation and supination movements of the forearm and flexion-extension of the elbow.

RESUMO Objetivo Analisar as variações anatômicas da inervação do músculo flexor superficial dos dedos e determinar se o ramo do nervo mediano destinado a esse músculo pode ou não ser conectado aos ramos para os músculos extensor radial curto do carpo e pronador redondo sem tensão, e quão próximo dos músculos-alvo a transferência pode ser realizada. Métodos Foram dissecados 50 membros de 25 cadáveres para coletar dados sobre as variações anatômicas dos ramos para o músculo flexor superficial dos dedos. Resultados O referido músculo recebeu inervação do nervo mediano nos 50 membros. Em 22 recebeu um ramo, em 28 mais que um. O ramo proximal foi identificado em 22 membros e em 12 compartilhava ramos com outros músculos. O ramo distal estava presente em todos e desprendeu-se do nervo mediano como um ramo isolado ou de um tronco comum com o nervo interósseo anterior em 3 membros, e de um tronco comum com músculo flexor radial do carpo e nervo interósseo anterior em outro. Originou-se distalmente ao nervo interósseo anterior em 38, em 5 no mesmo nível e em 3 proximal ao nervo interósseo anterior. Em quatro recebeu inervação do nervo interósseo anterior, além daquela recebida pelo mediano. Ramos acessórios do nervo mediano para a porção distal do músculo flexor superficial dos dedos estavam presentes em oito membros. Conclusão Nos 28 membros em que existam 2 ou mais ramos, 1 desses poderia ser conectado aos ramos para o músculo extensor radial curto do carpo e pronador redondo sem tensão, mesmo durante os movimentos de pronossupinação do antebraço e flexão-extensão do cotovelo.

Patellar denervation for Anterior Knee Pain Management in Knee Arthroplasty / Denervação patelar para tratamento da dor anterior na artroplastia total do joelho

OBJECTIVE: To compare the effectiveness of patellar denervation versus non-patellar denervation in reducing anterior knee pain on a follow-up period of at least one year after total knee arthroplasty. METHOD: Data from 84 patients, who underwent total knee arthroplasty were analyzed. Participants were divided into 2 groups; group A: 42 patients who previously underwent total knee arthroplasty with patellar denervation; and group B: 42 patients who previously underwent total knee arthroplasty without patellar denervation. Results were evaluated using WOMAC and KSS questionnaires, and the VAS pain measurement. Knee ranges of motion were measured. Preoperative clinical conditions of both groups were similar. RESULTS: Postoperatively, the following results were observed. (a), the WOMAC scores for group A were significant better when compared to group B (27.95 ± 5.89 vs. 33,55 ± 6.23; (b) better results were also found in KSS scores for group A vs. group B (86.19 ± 7.10 vs. 83,07 ± 4.88); (c) the range of knee flexion was smaller than in group A vs. group B (119.0 ± 10.7 vs 125.5 ± 11.0 degrees); (d) there was no significant difference between the mean of range of knee extension between the two groups groups; (e) in terms pain referred by the patient, no difference was observed according to VAS pain. CONCLUSION: Patellar denervation does not show better effect in pain reduction compared with TKA with non-patellar denervation. However, it had a better beneficial effect on knee function score, as measured through the KSS and WOMAC questionnaires.

OBJETIVO: Comparar a eficácia de denervação patelar em relação à não-denervação patelar na redução da dor anterior do joelho em um período de acompanhamento de no mínimo um ano após a artroplastia total do joelho (ATJ). MÉTODO: Foram analisados dados de 84 pacientes, submetidos a ATJ e divididos em 2 grupos: grupo A formado por 42 pacientes submetidos à ATJ com denervação patelar (PD) e grupo B formado por 42 pacientes submetidos a ATJ sem a denervação (ND). Os resultados foram avaliados utilizando os questionários WOMAC e KSS, além da escala analógica visual da dor (EVA). Também foi avaliada a amplitude de movimento em graus. As condições clínicas pré-operatórias dos dois grupos foram semelhantes. RESULTADOS: Comparando a pontuação do questionário WOMAC, o grupo A apresentou melhores resultados, com media de 27,95 ± 5,89, enquanto o grupo B apresentou média de 33,55 ± 6,23. Melhores resultados foram também observados no KSS para o grupo A, apresentando média de 86,19 ± 7,10, em comparação ao grupo B, com média de 83,07 ± 4,88. Observou-se menor amplitude de flexão do joelho no grupo A, 119,0 ± 10,68 graus, em comparação com o grupo B, com média de 125,5 ± 11,02 graus. Analisando exclusivamente a dor, não foi observada diferença entre a dor referida pelo paciente, de acordo com a escore da escala EVA. CONCLUSÕES: A DP não demonstrou melhores efeitos na redução da dor em comparação com ND na ATJ. No entanto um melhor efeito da denervação nos escores de função, através dos questionários KSS e WOMAC sugerem que a denervação pode ser benéfica neste cenário.

Abordaje intervencionista del síndrome facetario lumbar: denervación con radiofrecuencia / Interventional approach for lumbar facet syndrome: radio frequency denervation

Lumbar pain is a common and frequent chronic condition. It is estimated that facet joint pain represents 15-31% of all consultations for low back pain. In suspected facet joint pain, it is recommended to perform nerve blocks to establish the diagnosis. Percutaneous continuous radiofrequency is the most effective treatment to date. We describe the current evidence on the minimally invasive treatment of lumbar facet syndrome and our experience with image guidance with CT and fluoroscopy by means of rhizolysis of the medial branch of the dorsal primary ramus of the spinal nerve.

El dolor lumbar es una entidad común y frecuente crónica. Se estima que el dolor de causa articular facetaria representa el 15-31% de todas las consultas por dolor lumbar. En sospecha de dolor articular facetario se recomienda realización de bloqueos nerviosos para establecer el diagnóstico. La radiofrecuencia continua percutánea es el tratamiento más efectivo hasta la fecha. Se describe la evidencia actual en el tratamiento mínimamente invasivo del síndrome facetario lumbar y nuestra experiencia con las guías de imagen con TC y fluoroscopía mediante rizolisis de la rama medial del ramo primario dorsal del nervio espinal.

Long-term follow-up in sacroiliac joint pain patients treated with radiofrequency ablative therapy / Seguimento longo em pacientes com sacroileíte submetidos a terapia de radiofrequência ablativa

Sacroiliac joint (SIJ) pain is responsible for up to 40% of all cases of lumbar back pain. Objective Report the long-term efficacy of radiofrequency denervation for sacroiliac joint pain at six, twelve and eighteen months.Method Third-two adults’ patients with sacroiliac join pain diagnosis were included for a prospective study. Primary outcome measure was pain intensity on the Numeric Rating Scale (NRS). Secondary outcome measure was Patient Global Impression of Change Scale (PGIC).Results Short-term pain relief was observed, with the mean NRS pain score decreasing from 7.7 ± 1.8 at baseline to 2.8 ± 1.2 at one month and to 3.1 ± 1.9 at six months post-procedure (p < 0.001). Long-term pain relief was sustained at twelve and eighteen months post-procedure, with NRS pain remaining at 3.4 ± 2.1 and 4.0 ± 2.7, respectively.Conclusion Radiofrequency denervation of the SIJ can significantly reduce pain in selected patients with sacroiliac syndrome.

A Sacroileíte pode ser responsável por até 40% dos casos de dor lombar crônica. Objetivo Análise da eficácia da denervação por radiofrequência na articulação sacro-ilíaca em seis, doze e dezoito meses.Método Trinta e dois pacientes com diagnóstico de sacroileíte foram incluídos em estudo prospectivo. O prognóstico primário foi avaliado pela escala visual analógico (NRS). O prognóstico secundário foi avaliado pela escala de impressão global de mudança pelo paciente (PGIC).Resultados Melhora a curto prazo da dor foi observada, com redução media na NRS de 7,7 ± 1,8 para 2,8 ± 1,2 após 1 mês e para 3,1 ± 1,9 em 6 meses do procedimento (p < 0,001). Após 12 e 18 meses, o NRS manteve-se 3,4 ± 2,1 e 4,0 ± 2,7, respectivamente.Conclusão A denervação da articulação sacro-ilíaca por radiofrequência pode reduzir significativamente a dor em pacientes com sacroileíte.

Denervação renal na hipertensão resistente: onde estamos e para onde vamos? / Renal denervation in resistant hypertension: where are we, and where are we headed?

Apesar dos grandes avanços no tratamento farmacológico da hipertensão arterial, uma porcentagem considerável de pacientes hipertensos não consegue um controle adequado da pressão arterial, sendo reconhecidos como hipertensos resistentes. Para esta população desenvolveram-se técnicas intervencionistas para atuação no sistema nervoso simpático renal, um dos mecanismos fisiopatológicos importantes da hipertensão arterial. A denervação renal por ablação de radiofrequência mostrou-se uma terapia promissora, com elevada segurança e redução significativa da pressão arterial em estudos preliminares em pacientes com hipertensão resistente. Recentemente, resultados de estudos randomizados não mostraram benefício na redução da pressão com o procedimento, e puseram em dúvida a eficácia da denervação renal. Neste artigo revisamos as bases fisiopatológicas da denervação renal, os resultados dos principais estudos iniciais e os mais recentes, e quais as perspectivas futuras a partir destes resultados.

Despite the great advances in the pharmacological treatment of hypertension, a considerable percentage of hypertensive patients do not manage to achieve proper controlof their blood pressure, and are recognized as resistant hypertensive patients. For this population, interventionist techniques were developed for procedures involving the renal sympathetic nervous system, one of the important pathophysiological mechanisms of hypertension. Renal denervation by radiofrequency ablation has proven to be a promising therapy, with good safety and resulting in a significant reduction in blood pressure in preliminary studies on patients with resistant hypertension. Recently, results of randomized studies have shown no benefit of the procedure in reducing the blood pressure, placing in doubt the effectiveness of renal denervation. In this article, we review the pathophysiological bases of renal denervation, the results of the main preliminary studies and morerecent studies, and future forecasts based on these results.

Effect of renal denervation procedure on left ventricular hypertrophy of hypertensive rats and its mechanisms / Efeito da denervação renal na hipertrofia do ventrículo esquerdo de ratos hipertensos e seu mecanismo

PURPOSE: To investigate the effect of renal denervation (RDN) on the blood pressure, left ventricular hypertrophy and myocardial expression of TLR4/NF-κB in spontaneously hypertensive rats (SHR). METHODS: A total of 36 SHR were randomly assigned into control group (D0), RDN group (D) and sham group (S). 12 WKY rats of same age served as controls (WKY group). Rats in the D0 and WKY groups were sacrificed, but rats in the D and S group were sacrificed at one week and six weeks after surgery. The heart was collected and the left ventricle weighted followed by calculation of left ventricular mass index (LVMI). RESULTS: In the D0 group, the blood pressure, LVMI and protein expression of TLR4, NF-κB, TNF-α and IL-6 in the myocardium were markedly higher than that in the WKY group (p<0.05). In the D1 and D2 group, the LVMI, NE and protein expression of TLR4, NF-κB, TNF-α and IL-6 in the myocardium were significantly reduced (p<0.05). CONCLUSION: Renal denervation can significantly delay the progression of left ventricular hypertrophy in spontaneously hypertensive rats, which may be attributed to the not only the suppression of sympathetic activity and attenuation of pressure load but the improvement of myocardial immuno-inflammation.

OBJETIVO: Investigar o efeito da denervação renal na pressão sanguínea, na hipertrofia do ventrículo esquerdo e a expressão miocárdica de TLR4/NF-kB em ratos espontaneamente hipertensos. MÉTODOS: Trinta e seis SHR ratos foram aleatoriamente distribuídos em grupo controle, grupo denervação renal (D) e grupo sham(S). 12 WKY ratos de mesma idade serviram de controle. Os ratos controles foram sacrificados, mas os ratos com denervação renal e sham foram sacrificados uma semana e seis semanas após a cirurgia. O coração foi retirado e o ventrículo esquerdo pesado seguido pelo cálculo da massa ventricular (LVMI). RESULTADOS: No grupo DO, a pressão sanguínea, LVMI e a expressão proteica de TLR4, NF-κB, TNF-α e IL-6, no miocárdio foram marcadamente maiores do que o grupo WKY (p<0,05). Nos grupos D1 e D2, o LVMI, NE e a expressão proteica de TLR4, NF-κB, TNF-α e IL-6 no miocárdio foi significantemente reduzido (p<0,05). CONCLUSÃO: A denervação renal pode significantemente retardar a progressão da hipertrofia ventricular esquerda em ratos espontaneamente hipertensos, o que pode ser atribuído não apenas pela supressão da atividade simpática e atenuação da pressão, mas pela melhora na imunoinflamação miocárdica.

Denervación de cordón espermático asistida con lupas para el tratamiento del dolor testicular crónico idiopático / Spermatic cord denervation assisted with magnifying glasses in the treatment of idiopathic cronic testicular pain

Presentar una serie clínica de doce pacientes sometidos a denervación de cordón espermático asistida con lupas como tratamiento del Dolor Testicular Crónico ldiopático (DTCI). Pacientes y métodos: Diecisiete pacientes (rango de edad 18 a 70 años) con DTCI no respondedores a analgésicos orales fueron enrolados prospectivamente en la primera etapa del estudio. Se realizó un bloqueo del cordón espermático con Bupivacaína a todos los pacientes. Aquellos pacientes que respondieron al bloqueo (n= 12) fueron sometidos a denervación del cordón espermático asistida con lupas (magnificación 3. 5x) por via subinguinal. El seguimiento incluyó un ecodoppler testicular a los siete días post cirugía y Escala Visual Análoga (EVA) del dolor a los 3 y 6 meses. Resultados: La duración promedio de la cirugía fue de 70 minutos (rango: 50 a 90 minutos). En el control de los siete días los doce pacientes presentaron un ecodoppler normal sin evidencias de isquemia en ninguna de las unidades testiculares sometidas a cirugía (n= 13). Respecto de la EVA a los tres y seis meses, nueve pacientes (75 por ciento) estaban completamente libres de dolor con un EVA igual a O. Tres pacientes persistían con molestias, dos con un EVA de 1 que no requerían analgésicos, y uno con EVA de 2 que requería analgésicos de manera intermitente. Dos pacientes fueron reoperados 6 y 8 semanas después de la cirugía primaria, uno por un hematocele y el segundo por un linfocele, ambos evolucionaron de manera favorable con ecodoppler normal después de la segunda cirugía. Conclusión: La denervación de cordón espermático asistida con lupas es una alternativa eficaz para el tratamiento del DTCI y puede constituirse en una buena alternativa terapéutica para el manejo de estos pacientes...

To present a clinical series of twelve patients that underwent loupe assisted spermatic cord denervation as a treatment for idiopathic Chronic Testicular Pain (ICTP). Patients and methods: Seventeen non responders to oral analgesics patients (age range 18 - 70 years) with ICTP were prospective/y enrolled in the first stage of the study. A spermatic cord block with bupivacaine was performed in all patients. Twelve patients who responded to the bupivacaine cord block underwentloupe assisted (3. 5x magnification) spermatic cord denervation through a subinguinal/ approach. Postoperative follow-up included color doppler ultrasound of the testes seven days after surgery and Visual Analog Scale (VAS) pain questionnaire at 3 and 6 months. Results: The median operation time was 70 minutes (range 50 - 90 min). Seven days after surgery all patients had a normal color Doppler ultrasound without evidence of ischemia in any of the operated testes (n=13). At three and six months after surgery nine patients (75 percent) were absolutely pain free (VAS=O). Three patients remained with pain; two had a VAS 1 that did not interfere with daily activities and required no analgesics, the third patient had a VAS 2 and occasionally required analgesics to manage pain. Two patients needed reoperations, 6 and 8 weeks after primary surgery, one for hematocele and another for lymphocele, both had a favorable outcome and normal color doppler ultrasounds after the second surgery. Conclusion: Loupe assisted spermatic cord denervation is an efficient alternative for the management of ICTP and may become a good therapeutic option for these patients...

Denervación de la articulación sacroilíaca por radiofrecuencia: una descripción de las técnicas disponibles / Sacroiliac joint denervation radiofrequency: an overview of available techniques

La articulación sacroilíaca es una fuente de dolor lumbar y dolor referido en la extremidad inferior. Aún no existen rasgos históricos, clínicos o radiológicos definitivos para hacer un diagnóstico preciso del dolor originado en la articulación sacroilíaca. La inervación de esta articulación continúa siendo objeto de debate y en la literatura se describen muchos abordajes diferentes. Los bloqueos diagnósticos son la herramienta diagnóstica más precisa pues la reducción del dolor confirma el rol de la articulación sacroilíaca como generadora del mismo. En muchos pacientes, cuando la reducción del dolor se logra luego de bloqueos intraarticulares únicos o consecutivos, se realiza una denervación por radiofrecuencia, con el objetivo de obtener una analgesia de larga duración. El propósito de este artículo es describir las técnicas disponibles actualmente para la denervación por radiofrecuencia.

The sacroiliac joint is a source of low back pain and referred pain in the lower extremity. There are still no definite historical, clinical or radiological features to make a precise diagnosis of pain originating from the sacroiliac joint. The innervation of the sacroiliac joint remains a subject of much debate and different approaches are described in the literature. Diagnostic blockades are the most accurate diagnostic tool, since pain reduction confirms the role of sacroiliac joint as a generator of it. In many patients, when pain reduction is achieved after single or consecutive intra-articular blockades, a radiofrequency denervation is performed for the purpose of obtaining a long term analgesia. The purpose of this paper is to describe the techniques currently available for radiofrequency denervation.

An improved strategy for evaluating the extent of chronic arterial baroreceptor denervation in conscious rats

There is no index or criterion of aortic barodenervation, nor can we differentiate among rats that have suffered chronic sham, aortic or sino-aortic denervation. The objective of this study was to develop a procedure to generate at least one quantitative, reproducible and validated index that precisely evaluates the extent of chronic arterial barodenervation performed in conscious rats. Data from 79 conscious male Wistar rats of about 65-70 days of age with diverse extents of chronic arterial barodenervation and used in previous experiments were reanalyzed. The mean arterial pressure (MAP) and the heart rate (HR) of all rats were measured systematically before (over 1 h) and after three consecutive iv bolus injections of phenylephrine (PHE) and sodium nitroprusside (SNP). Four expressions of the effectiveness of barodenervation (MAP lability, PHE ratio, SNP ratio, and SNP-PHE slope) were assessed with linear fixed models, three-level average variance, average separation among levels, outlier box plot analysis, and overlapping graphic analysis. The analysis indicated that a) neither MAP lability nor SNP-PHE slope was affected by the level of chronic sodium intake; b) even though the Box-Cox transformations of both MAP lability [transformed lability index (TLI)] and SNP-PHE slope [transformed general sensitivity index (TGSI), {((3-(ΔHRSNP-ΔHRPHE/ΔMAPSNP-ΔMAPPHE))-0.4-1)/-0.04597}] could be two promising indexes, TGSI proved to be the best index; c) TLI and TGSI were not freely interchangeable indexes for this purpose. TGSI ranges that permit differentiation between sham (10.09 to 11.46), aortic (8.40 to 9.94) and sino-aortic (7.68 to 8.24) barodenervated conscious rats were defined.

Microsurgical testicular denervation for the treatment of chronic testicular pain initial results

INTRODUCTION: Chronic testicular pain remains an important challenge for urologists. Currently, the treatment plan is primarily empirical, with the first approach consisting of clinical measures. However, some patients remain in pain despite a conservative treatment protocol and, for them, it is possible to perform a surgical procedure that involves severing the scrotal and spermatic branches of the genitofemoral and ilioinguinal nerve fibers. METHODS: In our institution, 60 patients were evaluated and treated for idiopathic chronic testicular pain between January 2003 and July 2007. Priority was give to clinical treatment, which evolved from simple to more complex measures. Microsurgical treatment was performed on those who experienced no considerable pain relief (10 individuals in our study). RESULTS: Over a twenty-four-month follow-up period, 70 percent of patients showed complete remission and 20 percent exhibited partial relief from pain.

Denervação acetabular cranial e dorsal no tratamento da displasia coxofemoral em cães: 360 dias de evolução de 97 casos / Cranial and dorsal acetabular denervation technique in treatment of hip dysplasia in dogs: 360 days evaluation of 97 cases

Realizou-se a pesquisa com o intuito de avaliar os resultados clínicos da denervação acetabular cranial e dorsal por curetagem em cães com displasia coxofemoral. Foram estudados, para tanto, 97 cães, sem predileção racial ou sexual, de 1-7 anos de idade, com diagnóstico clínico e radiográfico de displasia coxofemoral. Para avaliação dos resultados da técnica cirúrgica, de curetagem das fibras nervosas do periósteo acetabular cranial e dorsal, exames clínicos foram realizados no momento pré-operatório (exame inicial), e pós-operatório, nos dias dois, sete, 14, 21, 30, 60, 180 e 360. Todos os animais foram avaliados quanto à claudicação, dor à movimentação e toque, grau de atrofia muscular, sensibilidade dolorosa ao teste de Ortolani, e qualidade de vida. A denervação reduziu a claudicação, e dor à movimentação e toque à partir de dois dias de pós-operatório, reduziu atrofia muscular aos 60 dias pós-operatórios, e melhorou a qualidade de vida dos pacientes tratados, sob a ótica dos proprietários e veterinários aos 360 dias de pós-operatório. A dener-vação acetabular dorsal é técnica factível no tratamento da dor conseqüente à displasia coxofemoral em cães, com decréscimo significativo desta após dois dias da intervenção cirúrgica, aumenta qualidade de vida e proporciona maior atividade aos pacientes com proprietários satisfeitos quanto aos resultados do procedimento. A técnica cirúrgica deve incluir a curetagem das fibras nervosas do periósteo acetabular tanto da região cranial quanto dorsal.

The aim was to evaluate the clinical results of cranial and dorsal acetabular denervation using curettage in dysplastic dogs. Ninty seven dogs without distinction of breed and sex, 1 to 7 years of age, were analyzed for diagnosis and treatment of hip dysplasia, based on physical examination, clinical signs and radiographic findings. For evaluation of results of the surgical denervation technique, clinical examinations were performed preoperatively (initial exam) and postoperatively at days 2, 7, 14, 21, 30, 60 180 and 360. All animals were evaluated for lameness, pain to movement and touch, muscular atrophy degree, pain sensivity to Ortolani's test and assessment of life quality. The surgical denervation procedure decreases lameness, pain to movement and touch after 2 days of procedure, decreases muscular atrophy after 60 days of procedure, and improves quality of life from the owner's and veterinarian's point of view even after 1 year of the treatment. Dorsal acetabular denervation is a feasible surgical technique in treatment of pain secondary to hip dysplasia in dogs, with significant decrease of pain after 2 days of treatment, improvement of quality of life, decrease of lameness, and consequently joyful animals and owners extremely satisfied with the results obtained by the proposed treatment. The surgical technique must include the curettage of nerve fibers from the cranial-dorsal and dorsal region of the acetabular periosteum.

Abordagem cirúrgica inédita para denervação acetabular em cães / A new surgical approach to acetabular denervation in dogs

Este artigo tem por objetivo demonstrar nova abordagem cirúrgica para denervação seletiva das fibras sensitivas do periósteo acetabular, para tratamento da displasia coxo femoral em cães, conduzidas em 189 articulações. Para tanto, é descrita abordagem da região cranial e dorso-lateral do acetábulo de cães por incisão em forma de meia lua de aproximadamente de três centímetros de extensão, iniciando trocânter maior do fêmur e em direção ao corpo do ílio. Após rebatimento dorsal do músculo glúteo médio, secciona-se parcialmente a inserção do m. glúteo profundo para acesso às regiões citadas. Com auxílio de cureta foi removido, em todos os pacientes, periósteo na margem acetabular cranial e dorso lateral, até a exposição da cortical óssea. Em todos os animais foi possível a abordagem, tanto da face cranial como também acesso para a curetagem da face dorsal do acetábulo, com a técnica descrita, com incisão de pele de aproximadamente 3,2cm. A curetagem da porção cranial do acetábulo foi, em todos os casos realizados, sem visualização do osso, mas de fácil confecção e sem intercorrências de lesão de nervos ou músculos. Em todas as abordagens foi possível visualizar a cápsula articular da articulação coxo femoral, e em nenhum dos animais esta estrutura foi incisada por erro de técnica. Conclui-se que a abordagem cirúrgica descrita no presente trabalho é factível para este tipo de procedimento cirúrgico em cães, promovendo acesso adequado, com mínima invasão e sem complicações de qualquer natureza.

The purpose of this study is to demonstrate a new surgical approach for the selective denervation of the sensitive fibers of the acetabular periosteum, for the treatment of hip dysplasia in dogs, conducted in 189 joints.The surgical approach of the cranial and dorso-lateral regions of the acetabular joint in dogs, by moon-shaped incision of approximately 3cm in extension, starting from the greater trocanter of the femur, in direction of the ileum body. After dorsal opening of the middle gluteal muscle, the insertion of the deep gluteal muscle is inserted for the access to the mentioned regions. With the help of a curette, the periosteum of the cranial and dorso-lateral acetabular margin was removed until the bone cortex was exposed, in all patients. In all animals, the approach was possible, both in the cranial as well as in the caudal faces for the access and curettage of the acetabulum, with the technique described, with a skin incision of about 3.2cm. The curettage of the cranial portion of the acetabulum was, in all cases, realized without the visualization of the bone, but of easy achievement and without intercurrences of nervous or muscular injuries. In all the approaches, it was possible to visualize the articular capsule of the coxo-femoral joint, and in none of the animals, this structure was incised for a technique mistake. The surgical approach described in the present study is feasible for this kind of surgical procedure in dogs, promoting adequate access, with minimal invasion and with no complications of any nature.

Abordagem cirúrgica inédita para denervação acetabular em cães / A new surgical approach to acetabular denervation in dogs

Este artigo tem por objetivo demonstrar nova abordagem cirúrgica para denervação seletiva das fibras sensitivas do periósteo acetabular, para tratamento da displasia coxo femoral em cães, conduzidas em 189 articulações. Para tanto, é descrita abordagem da região cranial e dorso-lateral do acetábulo de cães por incisão em forma de meia lua de aproximadamente de três centímetros de extensão, iniciando trocânter maior do fêmur e em direção ao corpo do ílio. Após rebatimento dorsal do músculo glúteo médio, secciona-se parcialmente a inserção do m. glúteo profundo para acesso às regiões citadas. Com auxílio de cureta foi removido, em todos os pacientes, periósteo na margem acetabular cranial e dorso lateral, até a exposição da cortical óssea. Em todos os animais foi possível a abordagem, tanto da face cranial como também acesso para a curetagem da face dorsal do acetábulo, com a técnica descrita, com incisão de pele de aproximadamente 3,2cm. A curetagem da porção cranial do acetábulo foi, em todos os casos realizados, sem visualização do osso, mas de fácil confecção e sem intercorrências de lesão de nervos ou músculos. Em todas as abordagens foi possível visualizar a cápsula articular da articulação coxo femoral, e em nenhum dos animais esta estrutura foi incisada por erro de técnica. Conclui-se que a abordagem cirúrgica descrita no presente trabalho é factível para este tipo de procedimento cirúrgico em cães, promovendo acesso adequado, com mínima invasão e sem complicações de qualquer natureza.

The purpose of this study is to demonstrate a new surgical approach for the selective denervation of the sensitive fibers of the acetabular periosteum, for the treatment of hip dysplasia in dogs, conducted in 189 joints.The surgical approach of the cranial and dorso-lateral regions of the acetabular joint in dogs, by moon-shaped incision of approximately 3cm in extension, starting from the greater trocanter of the femur, in direction of the ileum body. After dorsal opening of the middle gluteal muscle, the insertion of the deep gluteal muscle is inserted for the access to the mentioned regions. With the help of a curette, the periosteum of the cranial and dorso-lateral acetabular margin was removed until the bone cortex was exposed, in all patients. In all animals, the approach was possible, both in the cranial as well as in the caudal faces for the access and curettage of the acetabulum, with the technique described, with a skin incision of about 3.2cm. The curettage of the cranial portion of the acetabulum was, in all cases, realized without the visualization of the bone, but of easy achievement and without intercurrences of nervous or muscular injuries. In all the approaches, it was possible to visualize the articular capsule of the coxo-femoral joint, and in none of the animals, this structure was incised for a technique mistake. The surgical approach described in the present study is feasible for this kind of surgical procedure in dogs, promoting adequate access, with minimal invasion and with no complications of any nature.

Clinical Efficacy of Radiofrequency Cervical Zygapophyseal Neurotomy in Patients with Chronic Cervicogenic Headache

The purpose of the present study was to assess the clinical efficacy of radiofrequency (RF) cervical zygapophyseal joint neurotomy in patients with cervicogenic headache. A total of thirty consecutive patients suffering from chronic cervicogenic headaches for longer than 6 months and showing a pain relief by greater than 50% from diagnostic/prognostic blocks were included in the study. These patients were treated with RF neurotomy of the cervical zygapophyseal joints and were subsequently assessed at 1 week, 1 month, 6 months, and at 12 months following the treatment. The results of this study showed that RF neurotomy of the cervical zygapophyseal joints significantly reduced the headache severity in 22 patients (73.3%) at 12 months after the treatment. In conclusion, RF cervical zygapophyseal joint neurotomy has shown to provide substantial pain relief in patients with chronic cervicogenic headache when carefully selected.

Comparison between percutaneous retrogasserian glycerol rhizolysis and percutaneous radiofrequency trigeminal gangliolysis for management of trigeminal neuralgia

Approximately 70% of trigeminal neuralgia [TN] patients are well controlled by medical management. Although they are well controlled initially, many of them will become non-responders and the majority of patients will eventually fail medical management. The aim of this work is to study the difference between 2 of the minor surgical procedures used for treatment of trigeminal neuralgia, namely, percutaneous retrogasserian glycerol rhizolysis [PRGR] and percutaneous radiofrequency trigeminal gangliolysis [PRTG]. Thirty two patients with intractable trigeminal neuralgia, had failed medical treatment were included in the study. The patients were divided into 2 equal groups according to the procedure used, PRGR group and PRTG group under fluoroscopic guidance. It was found that PRTG had faster onset of action, higher success and lesser failure rates than PRGR. Recurrence rates after 6 months and one year were 6.25% and 18.75% for PRTG and 12.5% and 25% for PRGR. The incidence of keratitis was higher with PRTG than PRGR while no case of anaesthesia dolorosa was reported in both techniques. In conclusion, both techniques are effective with relative advantages and disadvantages to each. PRTG disadvantages include requirements for a cooperative patient and access to radiofrequency equipment. Its great merits include high initial success rates and modest rate of recurrence. PRGR has a lesser initial success rate and a higher rate of recurrence than with the thermal therapy. It requires less patient cooperation and minimal equipment and appears to be associated with lower incidences of corneal anaesthsia and keratitis

Estudo histológico da placa de crescimento após a denervaçäo periférica / Histological changes of the growth plate after peripheral denervation

Um estudo experimental foi realizado utilizando-se 25 ratos da raça Wistar com 30 dias de vida. Procedeu-se a uma neurotomia ciática esquerda, ao nível do 1/3 proximal da coxa, seguida de estudo histológico da placa de crescimento dos metatarsais após três, sete, 14, 28 e 56 dias do procedimento. O lado direito foi utilizado como controle de normalidade. Foram observadas alteraçöes estruturais na placa epifisária no lado desnervado, localizadas principalmente ao nível da zona proliferativa. Essas alteraçöes foram mais acentuadas no período de sete dias após a desnervaçäo. Concluem que a desnervaçäo ciática provocou alteraçöes na estrutura da placa de crescimento dos metatarsais