Management of chronic knee pain caused by postsurgical or posttraumatic neuroma of the infrapatellar branch of the saphenous nerve.

PURPOSE: Injury to the infrapatellar branch of the saphenous nerve (IBSN) is a relatively common complication after knee surgery, which can interfere with patient satisfaction and functional outcome. In some cases, injury to the IBSN can lead to formation of a painful neuroma. The purpose of this study was to report the results of surgical treatment in a series of patients with IBSN painful neuroma. METHODS: We retrospectively identified 37 patients who underwent resection of IBSN painful neuroma at our institution, after failure of non-operative treatment for a minimum of 6 months. Injury to the IBSN resulted from prior orthopedic surgery, vascular surgery, tumor resection, trauma, or infection. Leg pain and health-related quality of life were measured using the numeric rating scale (NRS) and EuroQol 5 dimensions (EQ-5D) questionnaire, respectively. Clinically meaningful improvement in leg pain was defined as reduction in NRS by at least 3 points. Predictors of favorable and unfavorable surgical outcome were investigated using multivariable logistic regression analysis. RESULTS: Patient-reported leg pain, health-related quality of life, and overall satisfaction with the surgical outcome were obtained at 94 ± 52.9 months after neuroma surgery. Postoperative patient-reported outcomes were available for 25 patients (68% of the cohort), of whom 20 patients (80.0%) reported improvement in leg pain, 17 patients (68.0%) reported clinically meaningful improvement in leg pain, and 17 patients (68%) reported improvement in health-related quality of life. The average NRS pain score improved from 9.43 ± 1.34 to 5.12 ± 3.33 (p < 0.01) and the average EQ-5D functional score improved from 10.48 ± 2.33 to 7.84 ± 2.19 (p < 0.01). Overall patient reported satisfaction with the surgical outcome was good to excellent for 18 patients (72.0%). Older age, multiple prior orthopedic knee surgeries, and failed prior attempts to resect an IBSN neuroma were associated with non-favorable surgical outcome. CONCLUSION: We conclude that surgical intervention is efficacious for appropriately selected patients suffering from IBSN painful neuroma.

Neurolysis for the treatment of sciatic nerve palsy associated with total hip arthroplasty.

Sciatic nerve palsy following total hip arthroplasty (THA) is a relatively rare yet potentially devastating complication. The purpose of this case series was to report the results of patients with a sciatic nerve palsy who presented between 2000 and 2010, following primary and revision THA and were treated with neurolysis. A retrospective review was made of 12 patients (eight women and four men), with sciatic nerve palsy following THA. The mean age of the patients was 62.7 years (50 to 72; standard deviation 6.9). They underwent interfascicular neurolysis for sciatic nerve palsy, after failing a trial of non-operative treatment for a minimum of six months. Following surgery, a statistically and clinically significant improvement in motor function was seen in all patients. The mean peroneal nerve score function improved from 0.42 (0 to 3) to 3 (1 to 5) (p < 0.001). The mean tibial nerve motor function score improved from 1.75 (1 to 4) to 3.92 (3 to 5) (p = 0.02).The mean improvement in sensory function was a clinically negligible 1 out of 5 in all patients. In total, 11 patients reported improvement in their pain following surgery. We conclude that neurolysis of the sciatic nerve has a favourable prognosis in patients with a sciatic nerve palsy following THA. Our findings suggest that surgery should not be delayed for > 12 months following injury.

Microsurgical management of penetrating peripheral nerve injuries: pre, intra- and postoperative analysis and results.

BACKGROUND AND METHODS: Clinical and electrophysiological motor function data were compared before and after microsurgical repair of penetrating peripheral nerve injuries. Sixty-four patients totaling 74 injured nerves (25 gunshot wounds, 49 stab wounds) were treated with external and interfascicular neurolysis and/or interfascicular nerve grafts. Microsurgery was performed 2-12 months after the injury (Group 1, 33 patients,) and 12 months-60 years after the injury (Group 2, 31 patients). The postoperative clinical and electrophysiological follow-up period ranged between 1 and 5 years. RESULTS: A statistically significant improvement in muscle strength occurred after the microsurgery, compared to before repair, gunshot wounds (p < 0.001), stab wounds (p < 0.001). Intraoperative and postoperative electrophysiological analysis showed statistically significant improvement. TIMING OF SURGERY: No statistically significant difference in muscle strength occurred between the 2 groups after the surgery, each showing statistically significant improvement, Group 1 (p < 0.001), Group 2 (p < 0.001). Patients above and below age of 40 showed an improvement in muscle strength after microsurgery, (p < 0.001) and (p < 0.001), respectively. CONCLUSION: Microsurgery can progressively improve nerve function in penetrating peripheral nerve injuries and lead to significant functional improvement, even when it is delayed for more than one year after the injury.

Thoracic outlet syndrome: a multidisciplinary problem with a perspective for microsurgical management without rib resection.

BACKGROUND: Thoracic outlet syndrome (TOS) refers to a group of complex symptoms in the upper extremity caused by compression of the brachial plexus, subclavian artery and vein. Different surgical approaches were described for the management of TOS. There is, however, no "gold standard" procedure for this complicated and multidisciplinary problem. OBJECTIVES: This study evaluated the effectiveness of a microsurgical neurovascular decompression in the treatment of TOS. METHODS: 11 patients suffering from TOS (for 1.3 to 15 years after the beginning of the symptoms) were selected for a treatment of the complex symptoms of pain (diffuse or irradiated to the arm and hand), aching or paresthesia in the neck, shoulder, anterior chest, upper extremity and hand. Four of the 11 patients were suffering from signs of vascular compression. Eight patients showed slow progressive neurological deterioration (distribution of the ulnar nerve) with partial muscle atrophy. Patients underwent a microsurgical treatment using a supraclavicular approach followed by brachial plexus neurolysis, scalenectomy and release of the subclavian artery and vein without rib resection. Postoperative results were classified, using Am. J. Surg. (176: 215-218, 1998) scale (4), as good, fair and poor. RESULTS: Surgical results were studied, with a follow-up of 24 to 48 months. Prior to surgery, all patients had partial or severe limitation in physical activities. Post-operative follow-up showed that 9 (82%) of the 11 patients returned to normal everyday physical activities with a complete or significant relief of the symptoms (good results). In 2 patients (18%) the pain decreased and the use of medication was reduced (fair results). Eight of the 11 patients returned to full or partial employment. There were no cases of poor results in the study. CONCLUSION: Microsurgical neurovascular decompression of TOS without a removal of the cervical or first rib using a supraclavicular approach is an effective treatment method for a relief or complete release from symptoms and allows most patients to return to an active normal life.

Development of a tissue-engineered composite implant for treating traumatic paraplegia in rats.

This study was designed to assess a new composite implant to induce regeneration of injured spinal cord in paraplegic rats following complete cord transection. Neuronal xenogeneic cells from biopsies of adult nasal olfactory mucosa (NOM) of human origin, or spinal cords of human embryos, were cultured in two consecutive stages: stationary cultures in a viscous semi-solid gel (NVR-N-Gel) and in suspension on positively charged microcarriers (MCs). A tissue-engineered tubular scaffold, containing bundles of parallel nanofibers, was developed. Both the tube and the nanofibers were made of a biodegradable dextran sulphate-gelatin co-precipitate. The suturable scaffold anchored the implant at the site of injury and provided guidance for the regenerating axons. Implants of adult human NOM cells were implanted into eight rats, from which a 4 mm segment of the spinal cord had been completely removed. Another four rats whose spinal cords had also been transected were implanted with a composite implant of cultured human embryonic spinal cord cells. Eight other cord-transected rats served as a control group. Physiological and behavioral analysis, performed 3 months after implantation, revealed partial recovery of function in one or two limbs in three out of eight animals of the NOM implanted group and in all the four rats that were implanted with cultured human embryonic spinal cord cells. Animals of the control group remained completely paralyzed and did not show transmission of stimuli to the brain. The utilization of an innovative composite implant to bridge a gap resulting from the transection and removal of a 4 mm spinal cord segment shows promise, suggesting the feasibility of this approach for partial reconstruction of spinal cord lesions. Such an implant may serve as a vital bridging station in acute and chronic cases of paraplegia.

Molecular structure of the bony tissue after experimental trauma to the mandibular region followed by laser therapy.

OBJECTIVE: We investigated the therapeutic efficiency of laser irradiation and Bio-Oss, both and separately, on the post-traumatic regeneration of bone tissue in rats using infrared spectroscopy as an informative and accurate measuring method. BACKGROUND DATA: The therapeutic effect of low-power laser irradiation on bone tissue regeneration processes in animal models has been studied using morphogenic, biochemical, roentgenographic and electron microscopic measurements. Natural bone minerals, such as Bio-Oss collagen, were recommended for the reconstruction of bone defects in the alveolar process. MATERIALS AND METHODS: 29 male Wistar rats, divided into four random groups in a blinded manner were operated on the right alveolar process. A bone defect was made by penetrating the right alveolar process of the mandible bone using a 3-mm drill. The rats were divided into four groups as follows: Group I, left side served as intact bone and right injured side as the control; Group II, right injured side was treated by organic bovine bone (Bio-Oss); Group III, right side bone defect was treated by HeNe laser (632.8 nm, 35 mW) applied transcutaneously for 20 min to the injured area daily for the following 14 consecutive days; and Group IV, Bio-Oss was placed loosely in the right side defect followed by laser treatment. After 2 weeks, the intact bone and bone replicas of the trauma area were removed and analyzed by infra-red spectroscopy technique. The composition and the structure of the bone tissue mineral substances were determined and compared among the four groups. For quantitative analysis of the regenerative bone process, the Mineralization index was used. An increase in this index indicates regenerative bone processes. RESULTS: The normal state analysis of the IR spectra of the normal alveolar bone tissue within the intervals of 400 to 4000 cm(-1) revealed characteristic absorption bands for the inorganic bone component in spectrum regions 450-1480 cm(-1), and the organic component at 1540-3340 cm(-1). In the case of trauma, the intensity of absorption of the inorganic component was decreased by 54%, and the absorption band became narrow, which can be interpreted as quantitative changes of the bone tissue mineral content. The wavelength characteristics of the inorganic component remained unchanged; that is, the induced trauma under these experimental conditions did not provoke alterations in the structure of the phosphate framework. The organic component showed decreased absorption by 10-15%, compared to the normal bone, and slight displacement of the wavelength, which can be interpreted as changes occurring in the quality of the organic content of the bone tissue. In the Bio-Oss-treated group, the intensity of absorption of the inorganic component increased by 43%, compared to the control injured area; however, there was a decrease of 22.6% in the normal bone. The wavelength characteristics of the inorganic component remained unchanged. The organic component showed similar absorption results in the injured non-treated group and absorption was 10-15% less than in the normal bone. Mineralization Index in the Bio-Oss-treated group was 0.93, compared to 0.63 in the control group and 2.04 in the normal bone. In the laser-treated group, the intensity of absorption of the inorganic component increased by 62, compared to the control injured area, and decreased only 11.4% in the normal bone. The wavelength characteristics of the organic component remained unchanged; that is, the organic component was similar to that of normal bone. Mineralization Index in the laser-treated group increased significantly to 1.86, compared to 0.63 in the control group and 2.04 in the normal bone. In the combined laser and Bio-Oss-treated groups, the intensity of absorption of the inorganic component and organic component was similar to that of normal bone. Mineralization Index in this group increased significantly to 1.98, compared to 0.63 in the control group and 2.04 in the normal bone. CONCLUSION: The results suggest that low-power laser irradiatults suggest that low-power laser irradiation alone and in combination with Bio-Oss enhances bone healing and increases bone repair.

Microsurgical anatomy of the facial nerve trunk.

Dissection and manipulation of the facial nerve (FN) trunk between its exit from the cranial base through the stylomastoid foramen (SMF) and its bifurcation is a critical step in various otologic, plastic and neurosurgical procedures. This study demonstrates the anatomical relationships and variability of the FN trunk with emphasis on some important morphometric data, particularly with relevance to hypoglossal-facial nerve anastomosis (HFA). Bilateral microsurgical dissection was performed on twenty-three human cadavers fixed with formalin. The whole trunk of the FN was exposed, its diameter at the SMF and its length were measured, its branches were observed and the site of its bifurcation was determined. Anastomotic connections with other nerves and blood supply of the trunk were studied. The FN invariably emerged from the cranial base through the SMF. Its diameter upon its emergence from the foramen was 2.66 +/- 0.55 mm. Two branches consistently originated from the trunk: the posterior auricular nerve and the nerve to the digastric muscle. Less consistent were the communicating branch with the glossopharyngeal nerve and the nerve to the stylohyoid muscle. The bifurcation of the FN occurred before its penetration into the parotid gland in 15% of cases and within the gland in 85%. The length of the FN trunk was 16.44 +/- 3.2 mm. Anastomoses between the FN and other nerves were observed in one-third of the dissections. The blood supply to the FN trunk was provided by the stylomastoid artery that was identified in 91% of cases. Understanding the microsurgical anatomy of the FN trunk is essential for performing any surgical procedure in the relevant region. Surgical implications of this study are presented with emphasis on HFA surgery.

Double-blind randomized study evaluating regeneration of the rat transected sciatic nerve after suturing and postoperative low-power laser treatment.

This double-blind randomized study evaluated the therapeutic effect of low-power laser irradiation (LPLI) on peripheral nerve regeneration, after complete transection and direct anastomosis of the rat sciatic nerve. After this procedure, 13 of 24 rats received postoperative LPLI, with a wavelength of 780 nm laser, applied transcutaneously, 30 min daily for 21 consecutive days, to corresponding segments of the spinal cord and to the injured sciatic nerve. Positive somatosensory evoked responses were found in 69.2 percent of the irradiated rats (p = 0.019), compared to 18.2 percent of the non-irradiated rats. Immunohistochemical staining in the laser-treated group showed an increased total number of axons (p = 0.026), and better quality of the regeneration process, due to an increased number of large-diameter axons (p = 0.021), compared to the non-irradiated control group. The study suggests that postoperative LPLI enhances the regenerative processes of peripheral nerves after complete transection and anastomosis.

Effects of laser irradiation on the spinal cord for the regeneration of crushed peripheral nerve in rats.

BACKGROUND AND OBJECTIVE: The purpose of the present study was to examine the recovery of the crushed sciatic nerve of rats after low-power laser irradiation applied to the corresponding segments of the spinal cord. STUDY DESIGN/MATERIALS AND METHODS: After a crush injury to the sciatic nerve in rats, low-power laser irradiation was applied transcutaneously to corresponding segments of the spinal cord immediately after closing the wound by using 16 mW, 632 nm He-Ne laser. The laser treatment was repeated 30 minutes daily for 21 consecutive days. RESULTS: The electrophysiologic activity of the injured nerves (compound muscle action potentials--CMAPs) was found to be approximately 90% of the normal precrush value and remained so for up to a long period of time. In the control nonirradiated group, electrophysiologic activity dropped to 20% of the normal precrush value at day 21 and showed the first signs of slow recovery 30 days after surgery. The two groups were found to be significantly different during follow-up period (P < 0.001). CONCLUSION: This study suggests that low-power laser irradiation applied directly to the spinal cord can improve recovery of the corresponding insured peripheral nerve.

Paraganglioma of the pituitary fossa: diagnosis and management.

Paraganglioma of the sellar area is extremely rare with only six cases having been reported in the literature. Surgical removal of these tumors is difficult, and the transsphenoidal approach usually results in limited resection. Most authors who published reports on this tumor recommended radiation therapy after partial removal of the tumor. However, considering the benign nature of these tumors, the risk of radiation-induced endocrine insufficiency and optic neuropathy and the lack of proven effectiveness of radiotherapy, its value remains controversial. We describe a 48-year-old woman with parasellar paraganglioma who presented with headaches, visual loss and oligomenorrhea. Magnetic resonance imaging (MRI) showed an invasive tumor in the sellar and parasellar areas which extended to both cavernous sinuses and compressed the optic chiasm and the left internal carotid artery. Surgery by the transsphenoidal approach enabled only limited biopsy of the tumor. The patient was reoperated by an extended pterional approach which resulted in a subtotal removal of the tumor and adequate decompression of the adjacent structures. She received no adjuvant treatment during the 8-year postsurgical follow-up and remained in good health. A repeated MRI showed no change in the size of the residual tumor. Contrary to the therapeutic recommendations described in previous reports, we favor postoperative adjuvant therapy only if the symptoms or signs of cranial nerve compression persist following maximal tumor removal, or if there is evidence of subsequent growth of residual tumor.

Microsurgical management of old injuries of the peripheral nerve and brachial plexus.

A prospective study was carried out in patients suffering from old peripheral nerve and brachial plexus injuries to attempt to validate that functional improvement was possible after microsurgical management. Fifty patients underwent operative procedures, of whom 35 were peripheral-nerve injury cases, from 1.2 to 50 years after injury, and 15 were brachial-plexus injury cases, from 1.2 to 12 years after injury. The patients were treated by external and interfascicular neurolysis and/or autogenous nerve grafts. In cases of preganglionic nerve injury, neurotization from C3, C4 roots was done for reinnervation of trunks or cords. During external and interfascicular neurolysis in 19 of the 35 peripheral-nerve injuries, significant improvement was found in amplitude (p = 0.0001) and latency (p = 0.01) of compound muscle action potentials (CMAPs) at the end of the surgery, compared to the onset of surgery. Twenty (57 percent) of the 35 showed functional motor improvement up to M4-or M4. Electrophysiologic analysis of amplitude of CMAPs 1 year after surgery showed statistically significant improvement (p = 0.0003). Five (33 percent) of the 15 patients with upper brachial-plexus injuries showed functional motor improvement up to M4-(active movements against gravity and slight resistance) or M4 (active movements against gravity and moderate resistance) after surgery and of these, 11 also had lower brachial-plexus injuries, with four (36 percent) showing antigravity function M3 (active movement against gravity). Statistical analysis of recruitment 1 year after surgery demonstrated the appearance of or significant voluntary muscle activity in 45 percent of the muscles. Intraoperative electrophysiologic findings after external and interfascicular neurolysis confirmed that the viability of nerve tissue is of longer duration than previously considered. This study suggests that the use of microsurgical techniques results in the functional improvement of patients suffering from old injuries of the peripheral nerve and brachial plexus.

In vitro cellular processes sprouting in cortex microexplants of adult rat brains induced by low power laser irradiation.

The effect of He-Ne low power laser irradiation on the growth of cellular processes of microexplants of the brain cortex of adult rats in tissue culture was studied. Two 8-min doses of direct laser irradiation, 3.6 J/cm2 each given on two successive days, caused a significant amount of sprouting of cellular processes outgrowth in microexplants compared to small amounts produced by nonirradiated controls. This preliminary observation suggests that low power laser irradiation applied to the area of an experimentally injured nerve may induce neurite processes sprouting, thereby improving nerve tissue recovery.

Effect of low-power laser irradiation on the mechanical properties of bone fracture healing in rats.

BACKGROUND AND OBJECTIVE: Low-power laser irradiation (LPLI) has been found to have a positive effect on bone fracture healing in animal models, based on morphogenic, biochemical, roentgenographic, and electron microscopic measurements. We investigated the effect of LPLI on bone fracture healing in rats using biomechanical methods. STUDY DESIGN/MATERIALS AND METHODS: Two groups of male Wistar rats, divided in a randomized block design in a blinded fashion, each consisting of 25 animals, were subjected to anesthesia and tibial bone fracture with internal fixation. The first group was treated with LPLI (HeNe laser 632.8 nm, 35 mW), applied transcutaneously over 30 minutes to the area of the fracture daily for 14 days. The second group served as a control. After 4 weeks, the tibia was removed and tested at tension up to failure (by a Lloyd LR 50K testing apparatus, U.K.) in 16 rats from group I and 15 from group II. The maximal load at failure, the structural stiffness of the tibia (callus stiffness), and the extension maximal load were measured. RESULTS: The maximal load at failure and the structural stiffness of the tibia were found to be elevated significantly in the irradiated group (P = .014 and P = .0023, respectively), whereas the extension maximal load was reduced (P = .015). In addition, gross non-union was found in four fractures in the control group, compared to none in the irradiated group. CONCLUSION: These results suggest that LPLI treatment may play a role in enhancing bone healing.

Low power laser irradiation enhances migration and neurite sprouting of cultured rat embryonal brain cells.

We used fetal brain cells grown in tissue culture to study some basic features of the interaction between low-power laser irradiation and biological systems. Seven- to nine-day-old rat fetal brain cell aggregates in culture were subjected to direct focused irradiation of low-power helium-neon laser (0.3 mW, 632.8 nm). An 8-minute dose of laser irradiation enhanced the appearance of brain cells around the treated aggregates, as monitored under the microscope of the stained cultures. Two and three doses of laser irradiations were correlated with 97% and 142% respective increases of the numbers of cells surrounding the aggregates. To identify the type of cells grown in the outgrowth of the treated aggregate, specific tetanus-anti-tetanus antibodies were used. Rhodamine-labeled antibodies bound to receptors on cells indicated massive neurite sprouting and outgrowth of migrating brain cells in culture.

Giant thoracolumbosacral teratoma in an infant.

A case of sacrococcygeal teratoma with unusually high intraspinal extension is reported and the symptomatology and treatment are discussed. A 7-month-old male presented at birth with a prominent mass of the right gluteal region preventing him from straightening his legs and causing undue effort during defecation. Magnetic resonance T1-weighted imaging revealed a thoracolumbosacrococcygeal, partly cystic tumor with intraspinal extension up to the mid-thoracic spine. During two-staged surgery, a cystic tumor containing fragments of hair, teeth, and bone and adherent to its surroundings was completely removed. The histologic examination confirmed the presence of a benign teratoma. A neurogenic bladder of the lower-motor-neuron type and constipation improved spontaneously. No further neurological deficits before and during a 3-year postoperative follow-up period were recorded.

Low velocity gun shot wounds of the brachial plexus.

28 patients with low velocity gunshot wounds of the brachial plexus were treated at Groote Schuur Hospital from 1980 to 1991. Delayed exploration of the brachial plexus (up to 7 months after injury) was performed in nine (30%) of the patients. The other 19 patients did not have exploration of the plexus; most of these patients showed signs of recovery within 2 to 4 weeks of injury. Injury to the subclavian or axillary artery occurred in nine (30%) of the cases. The average length of follow-up of the patients was 19 months (range 2-90 months). Of the 19 patients treated non-operatively, 15 (79%) had an excellent or good result and four (21%) a fair result. The indications for surgery were the absence of improvement within 3 months of injury or persistent pain. Surgery was indicated for significant pain in five of the nine patients; postoperatively two had complete relief of pain, two improvement in the pain and one no improvement. Of the nine surgically treated patients, three (33%) had a good result, two (22%) a fair result and four (45%) a poor result. The potential for recovery was not dependent on the severity of the injury at presentation or the presence of vascular injury but on the appearance of signs of recovery within 4 weeks of injury.

Muscle fiber formation in vitro is delayed by low power laser irradiation.

The myogenic cell culture provides a good in vitro model for studying the differentiation process of the muscle tissue. Although the growth of the mononucleated myoblasts is predetermined, in that they will fuse to form multinucleated muscle fibers, some control on the process of fusion can be achieved in vitro. The low power laser irradiation (LPLI) has been shown to enhance in cultured mammalian cells DNA synthesis and motility of cells. In our rat myogenic cell line (L8) system the LPLI induced a delay of 5 to 6 hours in the onset of fusion of the myoblasts compared to the nonirradiated cells. The creatine kinase activity and the incorporation of labelled thymidine of the irradiated cultures were similar to the pattern of behaviour of these parameters in the control cultures. Thus, we have extended the longevity of the myoblasts population. We assume that the delay in fusion was induced by the increase of the motility of the myoblasts in culture, so that rearrangements of physical contacts or of membrane components were needed to resume fusion.