Internal Neurolysis for Trigeminal Neuralgia: A Preliminary Single-institution Experience in Japan.

Internal neurolysis (IN) is a surgical procedure in which the trigeminal fibers are separated between the pons and porus trigeminus to relieve trigeminal neuralgia (TN). Recent investigations revealed that the number of nerve bundles made by IN varies, and immediate postoperative hypesthesia exceeded 90% and pain control rate at 1 year was 77%-93.5%. We present the preliminary experience of 18 patients who underwent IN for TN between June 2020 and June 2022. The Barrow Neurological Institute pain scale (BNI-PS) was recorded preoperatively and in June 2023, and the Barrow Neurological Institute hypesthesia scale (BNI-HS) was recorded preoperatively, immediate postoperatively and in June 2023. Intraoperatively, the number of bundles made by IN was reviewed. Preoperative BNI-PS ranged between VI and V. Two patients experienced BNI-HS II due to percutaneous procedure prior to IN. Intraoperatively, 3 bundles were made by IN in 7 patients, 4 bundles in 5, and 5 bundles in 6. Immediate postoperative BNI-HS I was recorded in 6 patients and II in 12 (66.7%). The last follow-up revealed that BNI-PS I and II were recorded in 13 patients (72.2%) and BNI-HS I and II in 6 patients, respectively. Our results demonstrated that the rates of immediate postoperative hypesthesia (66.7%) and pain control (72.2%) at 1 year or later were below those of previous reports. Therefore, we are currently combing to make at least 6 bundles. Detailed surgical technique and cardiac reflex alerts during the procedure are described.

Patient Questions Surrounding Posterior Nasal Nerve Ablation for Chronic Rhinitis.

Objective: In-office ablation of the posterior nasal nerve (PNN) has emerged as an effective treatment option for chronic rhinitis patients. This study explored questions patients commonly search online regarding this therapy and the quality of content available. Study Design: A retrospective analysis of online search criteria and sources was performed with subsequent analysis of results. Setting: Search and data acquisition was in September of 2023. Methods: Most common search terms related to cryotherapy and radiofrequency neurolysis of the PNN were identified with associated People Also Ask (PAA) questions. Questions were categorized and organized into subtopics and sources evaluated using readability and quality metrics. Results: A total of 255 unique PAA questions and 175 unique websites were identified. The most common subtopics were related to facts about chronic rhinitis (26.7%) and rhinitis treatment options (25.1%). Nearly a quarter (24.3%) of websites were from commercial sources. Quality metrics indicate difficult-to-read and low-quality materials. Conclusion: Existing online resources need improvement to provide patients material that is easier to read. Physicians counseling patients should be aware of these areas for adequate shared decision making.

Role of Endoscopic Ultrasound in Pancreatic Cancer Diagnosis and Management.

The emergence of endoscopic ultrasound (EUS) has significantly impacted the diagnosis and management of pancreatic cancer and its associated sequelae. While the definitive role of EUS for pancreatic cancer remains incompletely characterized by currently available guidelines, EUS undoubtedly offers high diagnostic accuracy, the precise staging of pancreatic neoplasms, and the ability to perform therapeutic and palliative interventions. However, current challenges to EUS include limited specialized expertise and variability in operator proficiency. As the technology and techniques continue to evolve and become more refined, EUS is poised to play an increasingly integral role in shaping pancreatic cancer care.

Meralgia paresthetica.

Meralgia paresthetica is a common but probably underrecognized syndrome caused by dysfunction of the lateral femoral cutaneous nerve. The diagnosis is based on the patient's description of sensory disturbance, often painful, on the anterolateral aspect of the thigh, with normal strength and reflexes. Sensory nerve conduction studies and somatosensory evoked potentials may be used to support the diagnosis, but both have technical limitations, with low specificity and sensitivity. Risk factors for meralgia paresthetica include obesity, tight clothing, and diabetes mellitus. Some cases are complications of hip or lumbar spine surgery. Most cases are self-limited, but a small proportion of patients remain with refractory and disabling symptoms. Treatment options include medications for neuropathic pain, neurolysis, neurectomy, and radioablation, but controlled trials to compare efficacy are lacking.

Buerger's Disease of Hand; my Experience with Phenol Chemical Neurolysis of Stellate Ganglion: Case Series of Six Patients.

Introduction: Buerger's disease is common in 74.70% of cases in the lower limb but in 20.20% of cases, it is found in the upper limb or hand. The disease usually starts from pain in the finger/thumb or hand and then to more centrally.Patients presented with pain in the hand with gangrene of fingers. Pain aggravated on lifting hand above the shoulder level or above heart level in upright or lying in the bed, respectively. Case Report: In almost all patients, there was a history of smoking except one and all patients had involvement of digits of the right or left hand. Diagnosis of Buerger's disease was made based on the history of smoking, weak or absent pulse, lack of bleeding, swelling, edema, blackening, stony hard fingers or thumb on clinical examination, and color Doppler study of the limb.In all patients, Stellate ganglion chemical neurolysis with 8% phenol was done at C7-T1 under fluoroscopic and radiocontrast dye (Iohexol 300) guidance.After successful neurolysis patients got excellent pain relief, their wounds started healing, the vascularity of the diseased part increased and the disease stopped progressing. Conclusion: Stellate ganglion chemical neurolysis with phenol in Peripheral vascular disease or Buerger's disease of hand is an effective method to stop the disease procession, promoting wound healing, controlling ischemic pain, and avoiding surgical amputation.

Pudendal nerve neurolysis outcomes for urogenital and rectal disorders in patients suffering from pudendal nerve entrapment: A systematic review.

PURPOSE: Pudendal neuropathy is an uncommon condition that exhibits several symptoms depending on the site of nerve entrapment. This study aims to evaluate the efficacy of pudendal nerve neurolysis (PNN) in improving lower urinary tract symptoms, anal and/or urinary incontinence, and sexual dysfunctions. MATERIALS AND METHODS: A systematic literature search was performed on 20 May 2023 using Scopus, PubMed, and Embase. Only English and adult papers were included. Meeting abstracts and preclinical studies were excluded. RESULTS: Twenty-one papers were accepted, revealing significant findings in the field. The study identified four primary sites of pudendal nerve entrapment (PNE), with the most prevalent location likely being at the level of the Alcock canal. Voiding symptoms are commonly exhibited in patients with PNE. PNN improved both urgency and voiding symptoms, and urinary and anal incontinence but is less effective in cases of long-standing entrapment. Regarding sexual function, the recovery of the somatic afferent pathway results in an improvement in erectile function early after neurolysis. Complete relief of persistent genital arousal disorder occurs in women, although bilateral PNN is necessary to achieve the efficacy. PNN is associated with low-grade complications. CONCLUSIONS: PNN emerges as a viable option for addressing urinary symptoms, fecal incontinence, erectile dysfunction, and female sexual arousal in patients suffering from PNE with minimal postoperative morbidity.

Pudendal Nerve Neurolysis in Patients Afflicted With Pudendal Nerve Entrapment: A Systematic Review of Surgical Techniques and Their Efficacy.

To assess the effectiveness and safety of various techniques of pudendal nerve neurolysis (PNN) in patients with pudendal nerve entrapment (PNE). A comprehensive literature search was conducted on May 20th, 2023, using Scopus, PubMed, and Embase databases. Only studies in English involving adults were accepted, while meeting abstracts and preclinical studies were excluded. A total of 34 papers were included. Transperineal PNN emerged as a promising technique, demonstrating significant potential in alleviating pain, restoring erectile function in males, and improving the resolution of urinary stress incontinence in females. Furthermore, the bilateral approach consistently yielded positive outcomes in addressing urinary symptoms. The transgluteal technique appeared particularly suitable for cases of posterior PNE, situated between the sacrospinous ligament and the lesser sciatic foramen. A progressive amelioration of painful symptoms was observed during follow-up. Minimally invasive PNN is evolving and enables decompression along the entire proximal tract up to the Alcock canal, minimizing the risk of comorbidities. In addition to reducing pudendal neuralgia, robot-assisted and laparoscopic approaches determined a reduction in lower urinary tract symptoms and an improvement in erectile function, though further studies are required to corroborate these findings. PNN emerges as an effective treatment for PNE with minimal morbidity. Therefore, PNN should be tailored according to the site of PNE to enhance functional outcomes and improve patient quality of life.

MRI findings correlate with difficult dissection during proximal hamstring repair and with postoperative sciatica.

OBJECTIVE: This study examines the correlation between MRI findings and difficult dissection during proximal primary hamstring repair and postoperative sciatica. MATERIALS AND METHODS: A total of 32 cases of surgically repaired hamstring tendon tears that underwent preoperative and postoperative MRI were divided into sciatica (n = 12) and control (n = 20) groups based on the presence or absence of postoperative sciatica. Cases were scored by two blinded musculoskeletal radiologists for imaging features associated with difficult surgical dissection and the development of subsequent sciatica. Intra- and interrater agreements, as well as correlation of MRI findings with symptoms (odds ratio, OR), were calculated. RESULTS: On preoperative MRI, diffuse hamstring muscle edema pattern suggestive of active denervation (OR 9.4-13.6), and greater sciatic perineural scar circumference (OR 1.9-2) and length (OR 1.2-1.3) were significantly correlated with both difficult dissection and postoperative sciatica. Preoperatively, a greater number of tendons torn (OR 3.3), greater tear cross-sectional area (CSA, OR 1.03), and increased nerve T2-weighted signal (OR 3.2) and greater perineural scar thickness (OR 1.7) were also associated with difficult dissection, but not postoperative sciatica. On postoperative MRI, hamstring denervation, sciatic nerve tethering to the hamstring tendon, and development of perineural scar and greater perineural scar extent were all significantly correlated with postoperative sciatica. CONCLUSION: Preoperative hamstring MRI demonstrates findings predictive of difficult sciatic nerve dissection; careful MRI evaluation of the nerve and for the presence and extent of perineural scar is important for preoperative planning. Preoperative and postoperative MRI both depict findings that correlate with postoperative sciatica.

Bone marrow stem cells with or without superparamagnetic iron oxide nanoparticles as a magnetic targeting tool: Which is better in regeneration of neurolysed facial nerve? An experimental study.

Aim: This study was performed to evaluate neural regenerative capacities of bone marrow stem cells (BMSCs) with or without superparamagnetic iron oxide nanoparticles (SPIONs) as a magnetic targeting tool after neurolysis of the facial nerve (FN) in albino rats. Methods: Thirty-eight male albino rats were selected. Two of them were euthanized for normal FN histology assessment. Thirty-six rats were injected with ethanol in the FN nerve for neurolysis induction and assessed one week post-operatively by eye blinking test. Animals were divided into three groups, each containing twelve rats: Group I (positive control) was injected with Dulbecco Modified Eagle's medium (DMEM-F12), group II was injected with BMSCs in DMEM-F12, and group III was injected with BMSCs in DMEM-F12 with poly l-lysine coated SPIONs (0.5 mmol/mL). Monitoring of SPIONs in the rat's body was carried out by MRI. A circular neodymium magnet N52 (0.57 T, 2 × 5 mm) was placed on each rat in group III just below the right ear at the site of surgery to attract SPIONs labeled BMSCs, left in place for 24 h, and then removed. From each group, six rats were euthanized at the end of the 4th and 8th week of treatment, respectively. The right FN trunks were extracted for routine histological examination using H&E stain. Immunohistochemical examination by anti-S100B was performed to characterize the thickness of the myelin sheath formed by the Schwann cells. Ultra-structural examination was performed to study changes in axons, myelin sheaths, and Schwann cells. Results: Regeneration of nerve fibers, Schwan cells, and myelin sheaths was better in group II than in groups I and III histologically, immunohistochemically, and ultra-structurally. Conclusion: BMSCs alone could ameliorate FN regeneration better than magnetic targeting treatment using BMSCs labeled with SPIONs.

Spasticity Treatment Beyond Botulinum Toxins.

Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity management. In this paper, we focus on innovative and revived treatment options that can be alternative or complementary to BoNT therapy, including phenol neurolysis, cryoneurolysis, and extracorporeal shock wave therapy.

Does prophylactic decompression of distal nerves following nerve repair improve functional recovery? A systematic review.

BACKGROUND: Peripheral nerve injuries are burdensome on healthcare systems, individuals and society as a whole. The current standard of treatment for neurotmesis is primary neurorrhaphy or nerve grafting. However, several patients do not recover their full function. There has been a suggestion that primary distal neurolysis at common entrapment sites maximises surgical outcomes; however, no guidelines exist on this practice. This scoping review aims to ascertain the existing evidence on prophylactic distal decompression of peripheral nerves following repair. METHODS: A literature search was performed using Ovid Medline, PubMed, Embase and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews for studies published in the past 50 years. Studies were screened using a selection criteria and study quality was assessed using standardised tools. Furthermore, thematic content analysis was performed. RESULTS: Six studies were eligible for inclusion after screening; all studies were retrospective and at most level 3 evidence. No studies were designed specifically to assess the efficacy of distal neurolysis following proximal repair, thus no comparative data with control cohorts are available. All studies that recommended distal decompression of proximally repaired nerves based their conclusions on cases observed by the authors in practice or from theories on nerve regeneration. CONCLUSIONS: This systematic review suggests that the evidence on the role of immediate distal neurolysis in primary neurorrhaphy is inadequate. Recommendations are limited by the lack of large-scale and generalisable data. Further research is needed with definitive objective outcomes and patient-related outcome measures.

Functional outcomes of different surgical treatments for common peroneal nerve injuries: a retrospective comparative study.

BACKGROUND: This study aims to assess the recovery patterns and factors influencing outcomes in patients with common peroneal nerve (CPN) injury. METHODS: This retrospective study included 45 patients with CPN injuries treated between 2009 and 2019 in Jing'an District Central Hospital. The surgical interventions were categorized into three groups: neurolysis (group A; n = 34 patients), nerve repair (group B; n = 5 patients) and tendon transfer (group C; n = 6 patients). Preoperative and postoperative sensorimotor functions were evaluated using the British Medical Research Council grading system. The outcome of measures included the numeric rating scale, walking ability, numbness and satisfaction. Receiver operating characteristic (ROC) curve analysis was utilized to determine the optimal time interval between injury and surgery for predicting postoperative foot dorsiflexion function, toe dorsiflexion function, and sensory function. RESULTS: Surgical interventions led to improvements in foot dorsiflexion strength in all patient groups, enabling most to regain independent walking ability. Group A (underwent neurolysis) had significant sensory function restoration (P < 0.001), and three patients in Group B (underwent nerve repair) had sensory improvements. ROC analysis revealed that the optimal time interval for achieving M3 foot dorsiflexion recovery was 9.5 months, with an area under the curve (AUC) of 0.871 (95% CI = 0.661-1.000, P = 0.040). For M4 foot dorsiflexion recovery, the optimal cut-off was 5.5 months, with an AUC of 0.785 (95% CI = 0.575-0.995, P = 0.020). When using M3 toe dorsiflexion recovery or S4 sensory function recovery as the gold standard, the optimal cut-off remained at 5.5 months, with AUCs of 0.768 (95% CI = 0.582-0.953, P = 0.025) and 0.853 (95% CI = 0.693-1.000, P = 0.001), respectively. CONCLUSIONS: Our study highlights the importance of early surgical intervention in CPN injury recovery, with optimal outcomes achieved when surgery is performed within 5.5 to 9.5 months post-injury. These findings provide guidance for clinicians in tailoring treatment plans to the specific characteristics and requirements of CPN injury patients.

Applications of Cryoneurolysis in Chronic Pain Management: a Review of the Current Literature.

PURPOSE OF REVIEW: The purpose of this review is to evaluate and summarize the literature investigating cryoneurolysis in the treatment of various chronic pain pathologies. RECENT FINDINGS: There is an increasing amount of interest in the use of cryoneurolysis in chronic pain, and various studies have investigated its use in lumbar facet joint pain, SI joint pain, post-thoracotomy syndrome, temporomandibular joint pain, chronic knee pain, phantom limb pain, neuropathic pain, and abdominal pain. Numerous retrospective studies and a more limited number of prospective, sham-controlled prospective studies suggest the efficacy of cryoneurolysis in managing these chronic pain pathologies with a low complication rate. However, more blinded, controlled, prospective studies comparing cryoneurolysis to other techniques are needed to clarify its relative risks and advantages.

Neuralgic amyotrophy with multiple hourglass-like constrictions of anterior interosseous nerve: a case report.

Hourglass-like constrictions (HLCs) of peripheral nerves in the upper extremity were a rare form of neuralgic amyotrophy, often characterized by the sudden onset of pain in the shoulder or arm, followed by muscle weakness and amyotrophy, with limited sensory involvement. We present a case of multiple HLCs of the anterior interosseous nerve (AIN) in a 22-year-old female with left upper arm pain, finger numbness, and limited activity for 1 month. Physical examination showed weakness of the left index flexor digitorum profundus and flexor pollicis longus, with mild hypoesthesia in the first three fingers and the radial half of the ring finger. Electromyography suggested a median nerve (mainly AIN) lesion. Ultrasonographic imaging of the median nerve shows AIN bundle swelling and multiple HLCs at left upper arm. Despite conservative treatment, which included 15 days of steroid pulse therapy, Etoricoxib, and oral mecobalamin, the patient still complained of extreme pain at night without relief of any symptoms. Operation was recommended for this patient with thorough concerns of surgical advantages and disadvantages. During surgery, a total of 7 HLCs were found in her median nerve along and above the elbow joint. Only Interfascicular neurolysis was performed because the nerve constrictions were still in the early stage. The pain was almost relieved the next day. One month after surgery, she could bend her thumb and index fingers, although they were still weak. 4 months after the surgery, she was able to bend affected fingers, with muscle strength M3 level. At the same time, her fingers had fewer numbness symptoms. There was still controversy regarding treatment strategy; however, early diagnosis and surgical treatment for nerve HLCs might be a better choice to promote nerve recovery.

Neuralgic Amyotrophy and Hourglass Nerve Constriction/Nerve Torsion: Two Sides of the Same Coin? A Clinical Review.

Neuralgic amyotrophy, also called Parsonage-Turner syndrome, in its classic presentation is a brachial plexopathy or a multifocal neuropathy, involving mainly motor nerves of the upper limb with a monophasic course. Recently, a new radiological entity was described, the hourglass constriction, which is characterized by a very focal constriction of a nerve, or part of it, usually associated with nerve thickening proximally and distally to the constriction. Another condition, which is similar from a radiological point of view to hourglass constriction, is nerve torsion. The pathophysiology of neuralgic amyotrophy, hourglass constriction and nerve torsion is still poorly understood, and a generic role of inflammation is proposed for all these conditions. It is now widely accepted that nerve imaging is necessary in identifying hourglass constrictions/nerve torsion pre-surgically in patients with an acute mononeuropathy/plexopathy. Ultrasound and MRI are useful tools for diagnosis, and they are consistent with intraoperative findings. The prognosis is generally favorable after surgery, with a high rate of good motor recovery.

Temperature-controlled radiofrequency ablation for the treatment of chronic rhinitis: Two-year outcomes from a prospective multicenter trial.

BACKGROUND: Minimally invasive temperature-controlled radiofrequency (TCRF) ablation of the posterior nasal nerve (PNN) demonstrated a significant larger treatment effect on the symptom burden of chronic rhinitis patients than a sham control (no energy delivery) at the 3-month primary endpoint of this trial. METHODS: Two-year posttreatment outcomes for patients treated in a prospective, multicenter, patient-blinded randomized controlled trial were determined by combining the index active treatment-arm and index control-arm crossover patients into a single group (after the primary endpoint) to evaluate the treatment effect durability and long-term effects on concomitant chronic rhinitis medication usage. RESULTS: The mean baseline reflective total nasal symptom score (rTNSS) was 8.2 (95% confidence interval [CI], 7.9-8.6; N = 104). At 2 years (N = 79), the mean change in rTNSS was -5.3 (95% CI, -5.8 to -4.8; p < 0.001; 64.6% improvement). The 2-year responder rate (≥30% improvement in rTNSS) was 87.3% (95% CI, 78.0-93.8). All four components of the rTNSS (rhinorrhea, congestion, sneezing, and nasal itching) showed significant improvement over baseline, with rhinorrhea and congestion showing the most improvement. Postnasal drip and cough symptoms were also significantly improved. At 2 years, 81.0% (95% CI, 70.6-89.0) reported a minimal clinically important difference of ≥0.4-point improvement in the mini-rhinoconjunctivitis quality of life questionnaire score. Of 56 patients using chronic rhinitis medications at baseline, 25 of 56 (44.6%) either stopped all medication use (7/56 [12.5%]) or stopped/decreased (18/56 [32.1%]) use of ≥1 medication class at 2 years. No serious adverse events related to the device/procedure were reported over 2 years. To determine the potential effect of patients who left the trial over 2 years on the responder rate, the responder statuses of the 14 patients with follow-up data who were lost to follow-up/withdrew/died were imputed by the last observation carried forward and the responder statuses of all nine patients who had an additional nasal procedure were imputed to nonresponder, resulting in a 2-year responder rate of 79.4% (95% CI, 70.3-86.8). CONCLUSION: TCRF ablation of the PNN is safe and resulted in a significant and sustained reduction in chronic rhinitis symptom burden through 2 years and a substantial reduction in concomitant medication burden.

Efficacy and Safety of Celiac Plexus Neurolysis Versus Splanchnic Nerve Neurolysis in the Management of Abdominal Cancer Pain: A Meta-analysis of 359 Patients.

BACKGROUND: Splanchnic nerve neurolysis (SNN) is commonly used as an alternative pain control technique to celiac plexus neurolysis (CPN) in patients with distortion of anatomy, but the analgesic effect and relative risks of the 2 procedures remain controversial in general condition. OBJECTIVES: The aim of this study was to evaluate the pain condition, safety, and symptom burden of SNN compared with CPN. STUDY DESIGN: A systematic review and meta-analysis of neurolysis therapy for intractable cancer-related abdominal pain. METHODS: A systematic search was performed for randomized controlled trials comparing SNN and CPN using the PubMed, Medline, Cochrane Library, Web of Science, Google Scholar, and China National Knowledge Infrastructure databases. Meta-analysis was performed using Stata Version 15.0. Outcomes included pain condition, opioid consumption, adverse effects, quality of life (QOL), and survival rate. Standardized mean difference (SMD) was calculated for continuous outcomes with its corresponding 95% CI. LIMITATIONS: Study limitations include challenges to make subgroup analysis by intervention measures and addressing inevitable heterogeneity. Larger studies are needed for survival rates and further insights. RESULTS: Seven studies involving 359 patients were included. No significant difference was found in pain condition at 2 weeks [SMD = 0.75, 95% CI (-0.25, 1.74), P > 0.05], 2 months [SMD = 1.10, 95% CI (-0.21, 2.40), P > 0.05] and 6 months [SMD = 0.53, 95% CI (-0.02, 1.08), P > 0.05] between SNN and CPN. Opioid consumption was comparable at 2 weeks [SMD = 0.57, 95% CI (-1.21, 2.34), P > 0.05] and one month [SMD = 0.37, 95% CI (-1.33, 2.07), P > 0.05]. However, SNN was associated with a statistically significant reduction in the opioid consumption at 2 months postoperatively [SMD = 0.99, 95% CI (0.68, 1.30), P < 0.05]. A systematic review was performed for adverse effects and QOL. CONCLUSIONS: Our evidence supports that the analgesic effect of SNN is equivalent to that of CPN, independent of changes in the anatomical structure of the abdominal nerve plexus. SNN requires less use of opioids at 2 months and does not show greater improvement in pain burden compared to CPN.

Dexmedetomidine in Fluoroscopic Guided Splanchnic Nerve Neurolysis for Pain Control: A Randomized, Controlled Trial.

BACKGROUND: Splanchnic nerve neurolysis (SNN) shows beneficial effects in reducing malignancy-associated refractory abdominal pain. Using adjuvants, such as dexmedetomidine to improve the pain was studied. OBJECTIVE: To detect any role of dexmedetomidine as an additive to local anesthetics with an alcohol injection in the chemical SNN process to improve pain in patients having upper-abdominal cancer. STUDY DESIGN: Double-blinded, prospective randomized study. SETTING: Department of Anesthesia and Intensive Care, faculty of medicine, Minia University,Egypt. METHODS: Forty patients with upper-abdominal malignancy-associated refractory abdominal pain underwent fluoroscopic guided SNN were divided into 2 groups. The SNN was performed by using 1.5 mL lidocaine 1%, dexmedetomidine 2 µg/kg, and then an injection of 4.5 mL of ethanol 96% on each side in group D and without dexmedetomidine in group C is done. Patients gave the score of abdominal pain expressed by the Visual Analog Scale (VAS), which measures the pain intensity. Scors were recorded prior to injection, during injection, after injection by 5 min, and after 2, 6, 12, 24, 72 hours, one week (W), 2 W, one month (M), and 2 M. Also, we recorded the amount of morphine required to relieve the residual pain after injection, the effect of procedure on quality of life (QOL), and any complication after injection. RESULTS: VAS scores showed a significant increase in group C in comparison to group D during injection, after injection by 5 min, 2, 6, 12, 24 hours, one and 2 months (P < 0.0001, 0.0001, 0.029, 0.031, 0.025, 0.040, 0.020, 0.015), respectively. The morphine requirement was significantly increased at one W, one M, and 2 M in group C in comparison to Group D (P < 0.044, 0.017, 0.033) with no significant change in the QOL observed between groups. LIMITATIONS: The limitations of this study were a relatively small sample size and short period of follow-up. CONCLUSIONS: This study revealed that using dexmedetomidine in the chemical SNN process improves the pain results from injection of alcohol and refractory cancer related pain with reduction in the consumption of morphine in patients with upper-abdominal malignancy.

Internal Neurolysis for Trigeminal Neuralgia: Technical Nuances and a Single-Institution Experience.

BACKGROUND: Trigeminal neuralgia is a facial pain syndrome most commonly caused by a neurovascular compression (NVC) of the trigeminal nerve. Microvascular decompression (MVD) is the most durable surgical treatment; however, patients without an NVC are not candidates for this procedure. Alternative treatments such as percutaneous rhizotomy and radiosurgery are effective but with higher recurrence rates. Internal neurolysis (IN) is a less frequently used procedure that aims to provide long-term relief to patients without NVC. OBJECTIVE: We present the surgical techniques for IN developed at our institution. We also discuss the technical nuances related to nerve consistency and present a new classification based on these findings. We provide pain and numbness outcomes for our cohort of patients stratified by the extent of neurolysis and nerve consistency. METHODS: Patients with medically intractable trigeminal neuralgia eligible for posterior fossa exploration are eligible for MVD and possible IN. If no NVC or a mild NVC is encountered, IN is performed. We have divided the procedure into 4 main steps: opening the outer connective sheath, fascicular dissection, inside-out dissection and the fascicular irrigation technique. Trigeminal nerve consistency has been classified into 3 main types: type 1 is soft and friable; type 2 is intermediate consistency and ideal for neurolysis; and type 3 is firm and presents a more challenging dissection. CONCLUSIONS: In the absence of microvascular compression, we advocate for a thorough neurolysis using the techniques described in our article.

Postnasal drip and chronic cough in patients with chronic rhinitis treated with temperature-controlled radiofrequency neurolysis.

OBJECTIVE: To evaluate the contribution of postnasal drip (PND) and chronic cough (CC) to symptoms of patients with chronic rhinitis treated with temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN), and correlate PND and CC scores with components of the reflective total nasal symptom score (rTNSS). METHODS: Pooled data from three prospective studies: two single-arm studies and the index active treatment arm of a randomized controlled trial. Adult patients with baseline rTNSS ≥6 were treated with TCRF neurolysis at nonoverlapping regions of the PNN. PND and CC symptoms were evaluated on a 0 (none) to 3 (severe) scale. RESULTS: Data from 228 patients (57.9% women, 42.1% men) were included. The mean baseline rTNSS was 8.1 (95% confidence interval [CI], 7.8-8.3), which decreased to 3.2 (95% CI, 2.9-3.5) at 6 months. At baseline, 97.4% of patients had PND and 80.3% had CC. Median baseline PND and CC symptom scores were 3 (interquartile range [IQR], 2-3) and 2 (IQR, 1-2), respectively. At 6 months, this decreased to 1 (IQR, 0-2) and 0 (IQR, 0-1), respectively, showing significant improvement from baseline (both p < 0.001). Spearman correlation coefficients with components of rTNSS (rhinorrhea, congestion, itching, sneezing) were 0.16 to 0.22 for CC and 0.19 to 0.46 for PND, indicating only a weak to moderate correlation. CONCLUSION: PND and CC contribute to the symptomatology of chronic rhinitis and are significantly improved after TCRF neurolysis of the PNN. The inclusion of PND and CC symptoms in a chronic rhinitis assessment instrument could provide important additional information for the characterization of the disease state and outcomes after any therapeutic treatment.