Treatment of Peripheral Neuropathy in Leprosy: The Case for Nerve Decompression.

Plastic surgery has a tradition of caring for patients with facial deformity and hand deformity related to leprosy. The approach, however, to the progressive deformity and disability related to chronic nerve compression is underappreciated in the world today. A cohort of patients with leprous neuropathy from an indigenous area of leprosy in Ecuador was evaluated for the presence of chronic peripheral nerve compression, and 12 patients were chosen for simultaneous upper and lower extremity, unilateral, nerve decompression at multiple levels along the course of each nerve. The results at 1 year of follow-up show that 6 patients improved into the excellent category and 4 patients improved into the good category for improved function. Based on the early results in this small cohort of patients with leprous neuropathy, an approach to peripheral nerve decompression, encompassing the concept of multiple crush at multiple levels of each nerve, seems to offer optimism to improve upper and lower extremity limb function. Long-term studies with quality-of-life outcomes would be welcome.

Prevalence of leprous neuropathy determined by neurosensory testing in an endemic zone in Ecuador: Development of an algorithm to identify patients benefiting from early neurolysis.

The success of a microneurosurgical intervention in leprous neuropathy (LN) depends on the diagnosis of chronic compression before irreversible paralysis and digital loss occurs. In order to determine the effectiveness of a different approach for early identification of LN, neurosensory testing with the Pressure-Specified Sensory Device™ (PSSD), a validated and sensitive test, was performed in an endemic zone for leprosy. A cross-sectional study was conducted to analyze a patient sample meeting the World Health Organization (WHO) criteria for Hansen's disease. The prevalence of LN was based on the presence of ≥1 abnormal PSSD pressure threshold for a two-point static touch. A total of 312 upper and lower extremity nerves were evaluated in 39 patients. The PSSD found a 97.4% prevalence of LN. Tinel's sign was identified in 60% of these patients. An algorithm for early identification of patients with LN was proposed using PSSD testing based on the unilateral screening of the ulnar and deep peroneal nerves.

Intraneural hematoma with extrinsic compression: experimental study in rats and therapeutic options.

Intraneural hematoma can result in the median nerve in the carpal tunnel after trauma or coagulation disorders. The decision for expectant management or decompressive surgical techniques is still controversial. Fifty male Wistar rats were divided into five groups. The sciatic nerve was wrapped around with a silastic device in four groups. In group A, the sciatic nerve was just wrapped by the silastic tube. In group B, an intraneural injection of autologous blood was added. In group C, after the hematoma creation, the silastic device was removed and a longitudinal epineurotomy was performed. In group D, the silastic device was removed after the hematoma, but the nerve was not opened. In group E (sham-operated), the sciatic nerve was exposed without hematoma or compression. Nerve function recovery was assessed periodically over 61 days using the Bain-Mackinnon-Hunter Sciatic Function Index (SFI). Group A (extrinsic compression) presented initial SFI of -26.29 +/- 2.89, with return to baseline values on the fifth postoperative day. Group B (hematoma and extrinsic compression) exhibited the poorest function (SFI of -85.23 +/- 3.51) after surgery and recovery in 23 days. Group C (liberation of silastic and hematoma drainage through epineurotomy) and group D (only removal of the silastic tube) presented similar initial SFI values of -32.78 +/- 7.45 and -45.13 +/- 6.84, respectively. In both the groups, the SFI values returned to baseline level on fifth postoperative day. The statistical analysis of SFI identified a significant difference (P < .0001) between the expectant management (group B) and the descompressive surgery approach (groups C and D) by 1st to 19th postoperative day. The number of degenerative fibers and density of degenerative fibers were statistically significantly longer in group B when compared with the other groups. There was no statistical difference between the other groups when these parameters were analyzed. Thus, immediate decompressive procedures of the intraneural hematoma provide a faster functional recovery and reduce the damage to the axon fibers.

Infraorbital nerve injury associated with zygoma fractures: documentation with neurosensory testing.

Persistent sensibility abnormalities after correction of zygoma fractures indicate injury to the infraorbital nerve and may produce pain. To investigate this, a retrospective study of 25 patients who had undergone surgical correction of a zygoma fracture was performed. Bilateral neurosensory measurements were obtained with the Pressure-Specified Sensory Device (Sensory Management Services, Baltimore, Md.). Seven of the 25 patients had required orbital floor reconstruction. Each patient had undergone fracture correction at least 6 months earlier and was interviewed, at the time of sensibility testing, regarding symptoms related to the fracture. The data were evaluated by a blinded examiner, from a separate clinical facility, who attempted to predict the side of the fracture and the degree of zygoma displacement on the basis of measurements of sensibility of the paranasal, upper lip, and zygomaticotemporal areas. Seventy-six percent of patients demonstrated abnormal sensibility on the side of the zygoma fracture, compared with the contralateral side. Sensibility was abnormal for 100 percent of the patients who required orbital floor reconstruction. Seventy-four percent of patients with abnormal sensibility reported symptoms related to the fracture. Eighty percent of the zygoma fractures were correctly identified, with respect to the side of the fracture, by the blinded examiner on the basis of the neurosensory measurements alone (p < 0.005). Predictions proved correct for 91 percent of the patients with widely displaced fractures and none of the patients with nondisplaced fractures. The results of this study suggest that neurosensory testing is an important clinical adjunct for the evaluation of patients with facial pain or dysesthesia after facial fracture reconstruction. The results suggest the need to develop algorithms for the diagnosis and treatment of trigeminal nerve injuries after craniofacial trauma. This approach could also be applicable to dysesthesia or pain after aesthetic facial surgical procedures.