[A man with abdominal pain after esophageal surgery]. / Een man met buikpijn na een slokdarmoperatie.

A 66-year-old man is evaluated in the Emergency Department for abdominal pain and vomiting since 2 days. Medical history showed esophageal resection because of an esophageal carcinoma. On physical examination there was tenderness of the right hemi-abdomen. A CT-angiography-chest/abdomen proved intrathoracically located small intestines with signs of ischemia.

Resection of hepatic and pulmonary metastasis from metastatic esophageal and gastric cancer: a nationwide study.

The standard of care for gastroesophageal cancer patients with hepatic or pulmonary metastases is best supportive care or palliative chemotherapy. Occasionally, patients can be selected for curative treatment instead. This study aimed to evaluate patients who underwent a resection of hepatic or pulmonary metastasis with curative intent. The Dutch national registry for histo- and cytopathology was used to identify these patients. Data were retrieved from the individual patient files. Kaplan-Meier survival analysis was performed. Between 1991 and 2016, 32,057 patients received a gastrectomy or esophagectomy for gastroesophageal cancer in the Netherlands. Of these patients, 34 selected patients received a resection of hepatic metastasis (n = 19) or pulmonary metastasis (n = 15) in 21 different hospitals. Only 4 patients received neoadjuvant therapy before metastasectomy. The majority of patients had solitary, metachronous metastases. After metastasectomy, grade 3 (Clavien-Dindo) complications occurred in 7 patients and mortality in 1 patient. After resection of hepatic metastases, the median potential follow-up time was 54 months. Median overall survival (OS) was 28 months and the 1-, 3-, and 5- year OS was 84%, 41%, and 31%, respectively. After pulmonary metastases resection, the median potential follow-up time was 80 months. The median OS was not reached and the 1-, 3-, and 5- year OS was 67%, 53%, and 53%, respectively. In selected patients with gastroesophageal cancer with hepatic or pulmonary metastases, metastasectomy was performed with limited morbidity and mortality and offered a 5-year OS of 31-53%. Further prospective studies are required.

Omitting Postoperative Wound Drainage After Mastectomy With Skin-Flap Quilting.

BACKGROUND: Seroma is the most frequent complication after mastectomy (ME) and axillary lymph node dissection (ALND). The quilting suture technique, in which skin flaps are sutured to the underlying muscle, was previously investigated and found to reduce seroma incidence after ME and ALND. This study aimed to investigate whether postoperative wound drainage can safely be omitted when quilting sutures are applied. METHODS: Two groups with a total of 251 consecutive patients who underwent ME, ALND, or both were retrospectively compared. The first group underwent quilting sutures with wound vacuum drainage, and the second group underwent quilting sutures without wound drainage. The primary outcome was the incidence of postoperative clinically significant seroma (CSS). The secondary outcomes were the incidence of postoperative infection, bleeding complications, wound dehiscence, and flap necrosis. RESULTS: The group without a postoperative drain (n = 166) had a significantly lower CSS incidence (8.4%) than the group with a postoperative drain (n = 85, 21.2%) (p < 0.05). In the multivariate analysis, no significant predictors were found for seroma formation. Wound complications significantly decreased, from 31.8% in the group with a drain group to 17.5% in the group without a drain (p < 0.05). CONCLUSION: This study showed that the postoperative drain can be omitted when quilting sutures are applied in ME, ALND, or both. This facilitates day care mastectomy, eliminating drain-related care, discomfort, and related expenses.

Evolution of the surgical technique of minimally invasive Ivor-Lewis esophagectomy: description according to the IDEAL framework.

Totally minimally invasive Ivor-Lewis esophagectomy (Ivor Lewis TMIE) is a technically challenging procedure and is associated with a learning curve. Refinement of surgical technique is an important part of this learning curve. However, detailed descriptions of these refinements according to the idea, development, exploration, assessment, and long-term follow-up (IDEAL) framework are lacking and this study was undertaken to fill this knowledge gap. From 2010 until 2016, all consecutive patients (n = 164) were included from the first patient undergoing Ivor Lewis TMIE. Surgical reports were analyzed and surgeons were interviewed to determine surgical refinements. These data were used to describe the transition of the surgical technique from IDEAL stage IIB to stage III. The main findings were that four refinements were made to the surgical procedure in IDEAL stage IIB: (1) At case 9, the use of the 25 mm OrVil was abandoned, exchanged for a 28 mm EEA stapler and a large omental wrap around the anastomosis was introduced; (2) at case 27, the omental wrap was reduced in volume; (3) at case 60, the omental wrap was refined to cover the full 360° of the anastomosis and (4) at case 77, the fixation of the anvil with the Endostitch was replaced by fixation with two Endoloops®. During the transition from IDEAL stage IIB to stage III, the incidence of anastomotic leakage decreased from 26.0% to 4.6% (P < 0.001) and the incidence of textbook outcome increased from 31.2% to 47.1% (P = 0.039). In conclusion, this study describes the surgical refinements that were made during the progression of Ivor Lewis TMIE from IDEAL stage IIB to IDEAL stage III. During IDEAL stage IIB, postoperative outcome improved as surgical proficiency was gained and the technique was refined.

Short term safety of oncoplastic breast conserving surgery for larger tumors.

BACKGROUND: Oncoplastic surgery (OPS) replaces lumpectomy as standard technique in breast conserving surgery (BCS). OPS has shown to give good cosmetic results, but is it as safe as standard lumpectomy? We conducted a retrospective cohort study to determine postoperative complications, resection margins and re-excision rates for OPS compared to standard lumpectomy. METHODS: Based on data from the 'Netherlands Cancer Registry' and medical records we scored patient, treatment and follow-up related variables. All consecutive patients, with an initially breast conserving operation for primary breast cancer, performed between January 2010 and December 2014 in a dedicated breast center were eligible. Breast surgeons performed the operations. Invasive and in situ tumors were included. Postoperative complications within 30 days after surgery and the need for additional treatment were classified using the Clavien Dindo classification. Involved margin rates and subsequent re-excision were compared. RESULTS: We included 828 women with 842 breast cancers, who had a standard lumpectomy (62.7%) or oncoplastic resection (37.3%). OPS was performed more often for larger tumors (17.5 mm vs 13.6 mm, p = 0.002) and for tumors in the caudal half of the breast (33.1% vs 16.9%, p < 0.001). There was no significant difference in postoperative complications. Positive surgical margins were similar (OPS 22.6%, lumpectomy 18.2%, p = 0.119), as were re-excision rates (p = 0.337). CONCLUSION: Oncoplastic breast surgery can be safely applied in larger tumors, resulting in comparable postoperative complications, resection margins and re-excision rates compared to standard lumpectomy.

[Acute abdominal pain in children caused by pneumonia]. / Acute buikpijn door longontsteking bij kinderen.

Three children presented with symptoms of an acute abdomen. In all three a diagnosis of pneumonia was subsequently established, and the patients made a full recovery following antibiotic therapy. When a paediatric patient presents with symptoms of an acute abdomen, the possibility of pneumonia should be considered. It can be difficult to differentiate between appendicitis and pneumonia because of the subtle clinical signs. Early recognition is, however, important in order to start the correct therapy and to avoid an unnecessary laparotomy.

Long-term follow-up of axillary recurrences after negative sentinel lymph node biopsy: effect on prognosis and survival.

As axillary recurrence (AR) after a negative sentinel lymph node biopsy (SLNB) is rare, the prognosis of these patients is unknown. Since treatment paradigms for patients with breast cancer are shifting toward less axillary surgery, the number of ARs might increase. In this study, we evaluated primary and salvage treatment as well as long-term survival of patients diagnosed with an AR. A retrospective analysis of the cancer registry of 16 breast cancer units in the Netherlands was used to identify patients who developed an AR after a negative SLNB performed between 2002 and 2004. Using local hospital records we recorded primary patient-, tumor-, and treatment-characteristics, as well as salvage treatment. We identified 54 patients with an AR, median 30 months (range 3-79) after SLNB. Eighteen patients (33 %) were initially treated with breast conserving therapy, 15 of whom received external beam radiation therapy (EBRT). Thirty-three patients (61 %) did not receive adjuvant systemic treatment. In 45 of the 54 (83 %) patients, a salvage axillary lymph node dissection was performed showing a median of three positive nodes (range 1-24). Nine patients (17 %) were not treated surgically: three were treated with salvage EBRT and six with salvage systemic therapy only. At time of detection of the AR, a total of 7 patients (13 %) had proven distant metastases. After a median follow-up of 47 months (range 3-118), the 5-year "post-recurrence" distant metastasis free survival was 50 % and overall survival was 58 %. Significant negative predictors of survival were negative estrogen receptor (ER) status and receiving adjuvant chemotherapy at initial treatment. AR following a negative SLNB is associated with a 58 % 5-year OS. Prognostic factors are ER- primary tumor and receiving adjuvant chemotherapy as a part of initial treatment, reflecting an aggressive phenotype. Adequate regional and systemic salvage therapy constitute a chance for long-term survival after AR.

"Axillary recurrences after sentinel lymph node biopsy: a multicentre analysis and follow-up of sentinel lymph node negative breast cancer patients".

INTRODUCTION: The objective of this study was to conduct a multicentre data analysis to identify prognostic factors for developing an axillary recurrence (AR) after negative sentinel lymph node biopsy (SLNB) in a large cohort of breast cancer patients with long follow-up. PATIENTS AND METHODS: The prospective databases from different hospitals of clinically node negative breast cancer patients operated on between, 2000 and 2002 were analyzed. SLNB was performed and pathological analysis done by local pathologists according to national guidelines. Adjuvant treatment was given according to contemporary guidelines. Multivariate analysis was performed using all available variables, a p-value of <0,05 was considered to be significant. RESULTS: A total of 929 patients who did not undergo axillary lymph node dissection were identified. After a median follow up of 77 (range 1-106) months, fifteen patients developed an isolated AR (AR rate 1,6%). Multivariate analysis showed that young age (p = 0.007) and the absence of radiotherapy (p = 0.010) significantly increased the risk of developing an AR. Distant metastasis free survival (DMFS) was significantly worse for patients with an AR compared to all other breast cancer patients (p < 0,0001). CONCLUSION: Even after long-term follow up, the risk of developing an AR after a negative SLN in breast cancer is low. Young age and absence of radiation therapy are highly significant factors for developing an axillary recurrence. DMFS is worse for AR patients compared to patients initially diagnosed with N0 or N1 disease.

Modified core wash cytology (CWC), an asset in the diagnostic work-up of breast lesions.

AIM: A quick and reliable preliminary diagnosis is essential in the management of a same-day breast clinic. In a preclinical study we developed an alternative method of core wash cytology (CWC). This study is an evaluation of this new CWC method introduced into the clinical setting. METHODS: From April 2008 to April 2009, biopsies were taken from lesions in the breast. CWC was obtained from core needle biopsy (CNB) with a modified technique and classified into the categories: malignant, suspicious for malignancy, atypical, benign and inadequate. CWC and CNB diagnoses were correlated with the histopathology of subsequently obtained resection specimens. The sensitivity and specificity were calculated. RESULTS: CWC was obtained from 226 breast lesions. In 167 of these cases subsequent resection of the lesion was performed revealing 149 carcinomas and 18 benign lesions. Of the 149 malignant cases, 136 were considered as either malignant or suspicious for malignancy by CWC, 7 as atypical, 4 as benign and 2 as inadequate. None of the 18 benign lesions were classified as suspicious or malignant on CWC. Eight out of 149 resected carcinomas were not recognized as malignant by histological analysis of the CNB, while 7 of these cases the CWC was considered malignant. The sensitivity and specificity were 97% and 100%, respectively. CONCLUSIONS: In the vast majority of patients the modified CWC technique can provide a quick and reliable diagnosis of malignant breast lesions. Furthermore, combining CWC with CNB histology can improve adequate, preoperative recognition of the malignant character of breast lesions.

[Diagnostic image (180). A woman with painful erythema after breast -conserving surgery. Erysipelas caused by group B Streptococcus agalactiae]. / Diagnose in beeld (180). Een vrouw met pijnlijk erytheem na een borstsparende operatie. Erysipelas door hemolytische streptokokken uit Lancefield-groep B.

A 60-year-old woman presented a year after breast-conserving surgery with severe erysipelas caused by a group-B Streptococcus agalactiae. She recovered after treatment with intravenous penicillin.

[Intracystic carcinoma of the breast: diagnosis and treatment in retrospective investigation and published literature]. / Intracystisch mammacarcinoom: diagnostiek en behandeling in retrospectief onderzoek en literatuurgegevens.

OBJECTIVE: To describe policy and prognosis of patients with a cystic mammary lesion caused by an intracystic mammary carcinoma (ICMC). DESIGN: Retrospective, descriptive. METHOD: The study concerned retrospective analysis of 17 patients presenting with intracystic carcinoma of the breast in an educational clinic in the period 1988-2000, who were selected by searching the national pathology database (PALGA). None of the patients was on hormone replacement therapy. In addition a literature search was carried out in the Medline system. RESULTS: The patients with an intracystic carcinoma of the breast were 10 years older compared to the other breast cancer patients and presented themselves with a palpable mass. Mammography showed a single, well-defined and lobulated mass. Microcalcifications were uncommon. Ultrasound investigation showed a well-defined, inhomogenous and hypoechoic mass. 6 patients had encysted lesions and in 3 a solid, hypoechoic component within the cystic mass was found. Cytology of the cystic fluid is false negative in 36% (5/14). All patients were treated surgically, varying from excisional biopsy to modified radical mastectomy. In 15 patients an intracystic papillary carcinoma (ICPC) was found. 5 patients show a 'pure' ICPC. In the other 10 patients, 5 had an ICPC with a component of DCIS and 5 patients an ICPC with an invasive component. The median follow-up was 84 months (range: 28-165). In 15 patients no evidence of disease was found at follow-up; 2 patients developed local recurrence. The survival was 100%. CONCLUSION: Based on the investigation and on the available literature it is concluded that cysts in breasts of postmenopausal women, who do not use hormone replacement therapy, are malignant until proved otherwise. Ultrasound is invaluable in the diagnostic pathway of intracystic carcinoma of the breast. When ICPC is suspected excisional biopsy with sentinel node biopsy is the treatment of choice. The prognosis is good.

[Diagnostic image (153). A boy with chronic hereditary pancreatitis and nocturnal abdominal pain. Multiple, large pseudo-cysts of the pancreas, caused by chronic hereditary pancreatitis]. / Diagnose in beeld (153). Een jongen met chronische hereditaire pancreatitis en nachtelijke buikpijn. Multipele grote pseudo-cysten van het pancreas, bij chronische hereditaire pancreatitis.

A 14-year-old boy with chronic hereditary pancreatitis developed nocturnal episodes of pain in the back and abdomen. CT revealed two large pseudocysts of the pancreas and one smaller pseudocyst near the hilus of the spleen. The two largest pseudocysts were surgically drained into the stomach and the jejunum.

Impact of spinal cord stimulation on sensory characteristics in complex regional pain syndrome type I: a randomized trial.

BACKGROUND: A randomized trial was performed to assess the effect of spinal cord stimulation (SCS) on detection and pain thresholds for pressure, warmth, and cold and on the extent of mechanical hyperalgesia in patients with chronic complex regional pain syndrome type I. METHODS: Fifty-four chronic complex regional pain syndrome type I patients were randomized to receive both SCS and physical therapy (SCS+PT; n = 36), or to receive only physical therapy (PT; n = 18). Twenty-four SCS+PT patients responded positively to trial stimulation and underwent SCS implantation. During a 12-month follow-up period, six quantitative sensory testing sessions were performed. The main analysis compared 24 SCS patients with 29 nonimplanted patients--one PT patient was excluded. RESULTS: SCS showed no effect on detection thresholds for warmth and cold or on pain thresholds for any sensation. The pressure detection threshold initially increased by SCS, but after 3 months, pressure detection thresholds returned to normal. Mechanical hyperalgesia, both dynamic and static, was reduced slightly with SCS. CONCLUSIONS: Although SCS has previously been shown to cause a significant pain reduction in complex regional pain syndrome type I, the treatment has no long-term effect on detection and pain thresholds for pressure, warmth, or cold. The treatment seems to have only minimal influence on mechanical hyperalgesia.

Thermal thresholds in complex regional pain syndrome type I: sensitivity and repeatability of the methods of limits and levels.

OBJECTIVES: To study whether the method of levels (MLE) or the method of limits (MLI) is preferable as a method of measuring thermal perception thresholds in patients with complex regional pain syndrome type I (CRPS I). METHODS: Perception thresholds for warmth and cold were measured twice, with both MLE and MLI, at a 1 month interval, both at unaffected and affected wrists (n=33) or feet (n=20) of patients with CRPS I of one extremity. RESULTS: (1) Sensitivity for pathology was equal for both methods. (2) The agreement between thresholds measured by both methods was low at all locations, except for the unaffected wrist. Since thresholds measured with the MLI always contain reaction time artefacts, this lack of agreement favours the MLE. (3) At both unaffected and affected wrists, the MLE showed significantly better coefficients of repeatability as compared to the MLI for both sensations. However, at both unaffected and affected feet, there was no preference for either method as far as threshold measurement repeatability was concerned. CONCLUSIONS: Abnormal thermal perception thresholds occurred in 20% (foot) to 36% (wrist) of the CRPS I patients on the affected side and in 15% (foot, wrist) on the unaffected side. The MLE is considered to be the preferable method to assess thermal perception thresholds in CRPS I.

Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy.

BACKGROUND: Chronic reflex sympathetic dystrophy (also called the complex regional pain syndrome) is a painful, disabling disorder for which there is no proven treatment. In observational studies, spinal cord stimulation has reduced the pain associated with the disorder. METHODS: We performed a randomized trial involving patients who had had reflex sympathetic dystrophy for at least six months. Thirty-six patients were assigned to receive treatment with spinal cord stimulation plus physical therapy, and 18 were assigned to receive physical therapy alone. The spinal cord stimulator was implanted only if a test stimulation was successful. We assessed the intensity of pain (on a visual-analogue scale from 0 cm [no pain] to 10 cm [very severe pain]), the global perceived effect (on a scale from 1 [worst ever] to 7 [best ever]), functional status, and the health-related quality of life. RESULTS: The test stimulation of the spinal cord was successful in 24 patients; the other 12 patients did not receive implanted stimulators. In an intention-to-treat analysis, the group assigned to receive spinal cord stimulation plus physical therapy had a mean reduction of 2.4 cm in the intensity of pain at six months, as compared with an increase of 0.2 cm in the group assigned to receive physical therapy alone (P<0.001 for the comparison between the two groups). In addition, the proportion of patients with a score of 6 ("much improved") for the global perceived effect was much higher in the spinal cord stimulation group than in the control group (39 percent vs. 6 percent, P=0.01). There was no clinically important improvement in functional status. The health-related quality of life improved only in the 24 patients who actually underwent implantation of a spinal cord stimulator. Six of the 24 patients had complications that required additional procedures, including removal of the device in 1 patient. CONCLUSIONS: In carefully selected patients with chronic reflex sympathetic dystrophy, electrical stimulation of the spinal cord can reduce pain and improve the health-related quality of life.

Electrical spinal cord stimulation in reflex sympathetic dystrophy: retrospective analysis of 23 patients.

OBJECT: The aim of the study was to assess retrospectively the clinical efficacy and possible adverse effects of electrical spinal cord stimulation (SCS) for the treatment of patients with reflex sympathetic dystrophy (RSD). METHODS: Twenty-three patients who suffered severe pain due to RSD were included in the study. The SCS system was implanted only after a positive 1-week test period. The visual analog scale (VAS) score for pain (1-10) was obtained in all patients prior to treatment, 1 month postimplantation, and at last follow up. At final follow-up examination, patients were asked to rate the effect of their treatment on the 7-point global perceived effect scale. Eighteen (78%) of 23 patients treated between 1991 and 1997 reported improvement during the test period. Permanent implantation of SCS system was not performed in the other five patients. Complications occurred in nine (50%) of 18 patients. The system was removed in three patients after implantation (17%). At the end of follow up (mean 32 months) 15 patients still had an implanted system. The mean pain score had decreased from 7.9 to 5.4 (p<0.001). In the other eight patients the pain score had not changed significantly. In 13 patients (57%) in whom the SCS system was implanted, clinical status had much improved or improved; these cases were regarded as successful. CONCLUSIONS: In this retrospective series, the majority of patients with RSD reported a subjective improvement after implantation of an SCS system.

Low-level laser therapy in ankle sprains: a randomized clinical trial.

OBJECTIVE: To test the efficacy of low-level laser therapy on lateral ankle sprains as an addition to a standardized treatment regimen, a trial was conducted in which high-dose laser (5J/cm2), low-dose laser (0.5J/cm2), and placebo laser therapy (0J/cm2) at skin level were compared. DESIGN: Randomized, double-blind, controlled clinical trial with a follow-up of 1 year. Patients, therapists, assessors, and analysts were blinded to the assigned treatment. SETTING: An ambulatory care setting. PATIENTS: After informed consent and verification of exclusion criteria, 217 patients with acute lateral ankle sprains were randomized to three groups from September 1, 1993, through December 31, 1995. INTERVENTIONS: Twelve treatments of 904nm laser therapy in 4 weeks as an adjunct to a standardized treatment regimen of 4 weeks of brace therapy combined with standardized home exercises and advice. The laser therapy device used was a 904nm Ga-As laser, with 25-watt peak power and 5,000 or 500Hz frequency, a pulse duration of 200nsec, and an irradiated area of 1cm2. PRIMARY OUTCOME MEASURES: Pain and function as reported by the patient. RESULTS: Intention-to-treat analysis of the short-term results showed no statistically significant difference on the primary outcome measure, pain (p = .41), although the placebo group showed slightly less pain. Function was significantly better in the placebo group at 10 days (p = .01) and 14 days (p = .03) after randomization. The placebo group also performed significantly better on days of sick leave (p = .02) and at some points for hindrance in activities in daily life and pressure pain, as well as subjective recovery (p = .05). Intention-to-treat analysis showed that total days of absenteeism from work and sports were remarkably lower in the placebo group than in the laser groups, ranging from 3.7 to 5.3 and 6 to 8 days, respectively. The total number of relapses at 1 year in the low-dose laser group (n = 22) was significantly higher (p = .04) than in the other two groups (high laser, n = 13; placebo, n = 13). Subgroup analysis to correct for possible confounders did not alter these findings. CONCLUSIONS: Neither high- nor low-dose laser therapy is effective in the treatment of lateral ankle sprains.

Motor dysfunction and reflex sympathetic dystrophy. Bilateral motor denervation in an experimental model.

Reflex sympathetic dystrophy (RSD) is a neuropathic pain condition most often occurring in relation to trauma to, or surgery on, an extremity. It is characterized among other things by motor disturbances such as joint stiffness and tremor. Signs and symptoms can be induced in a rat model through chronic constriction of a sciatic nerve (CCI-model). In this study the CCI-model was used to evaluate the extent of bilateral peripheral motor nerve-fiber involvement in relation to ligature localization. In 12 Lewis rats, the common sciatic nerve was loosely ligated with four chromic catgut ligatures at the midthigh level just proximal to the right sciatic trifurcation. Acetylcholinesterase (CE) histochemistry of sciatic (distal and proximal to ligation) and corresponding contralateral nerve biopsy specimens was performed at 21 days after ligation. An additional 12 rats were sham-operated and served as controls. As compared to sham-operated controls or contralateral nonligated sciatic nerves, CE histochemistry after 21 days revealed a marked decrease of CE-positive fibers in cross-sections taken from distal and proximal sciatic nerve biopsies ipsilateral to the ligatures. In addition, as compared to sham-operated controls, there was a decrease of CE-positive fibers in cross-sections taken from contralateral nonligated sciatic nerves. The present findings indicate profound motor denervation, distal as well as proximal to the ligatures. Motor denervation also affected the contralateral nonligated sciatic nerve. The evident usefulness of the CCI-model for the study of RSD places the present results in line with the concept of central nervous system involvement in the pathophysiology of RSD.

Motor denervation induces altered muscle fibre type densities and atrophy in a rat model of neuropathic pain.

Loose ligation of a sciatic nerve in rats (chronic constriction injury; CCI) provokes sensory, autonomic, and motor disturbances like those observed in humans with partial peripheral nerve injury. So far, it is unknown whether these motor disturbances result from (mechanical) allodynia or from damage to the motor neuron. These considerations prompted us to assess, in CCI rats, the density of motor axons in both the ligated sciatic nerve and the ipsilateral femoral nerve. To this end, we determined the number of cholinesterase positive fibres. It has been demonstrated previously that muscle fibre type density may be used as a measure of motor denervation and/or hypokinesia. Therefore, the myofibrillar ATPase reaction was employed to assess fibre type density in biopsies obtained from the lateral gastrocnemius muscle (innervated by sciatic nerve) and rectus femoris muscle (innervated by femoral nerve). We observed axonal degeneration of motor fibres within the loosely ligated sciatic nerve, both at an intermediate (day 21) and at a late stage (day 90) after nerve injury. The reduction in the number of motor nerve fibres was more pronounced distal to the site of the ligatures than proximal. A (less pronounced) reduction of motor fibres was observed in the ipsilateral (non-ligated) femoral nerve. In line with these findings, we observed altered fibre type densities in muscle tissue innervated by the ligated sciatic nerve as well as the non-ligated femoral nerve indicative of motor denervation rather than hypokinesia. The findings of this study suggest that the motor disorder induced by partial nerve injury involves degeneration of motor nerve fibres not only within the primarily affected nerve but also within adjacent large peripheral nerves. This spread outside the territory of the primarily affected nerve suggests degeneration of motor neurons at the level of the central nervous system.