Triple neurectomía transperitoneal laparoscópica y con asistencia robótica para el tratamiento del dolor inguinal crónico: descripción de la técnica, nuestra experiencia y resultados preliminares / Robot-assisted laparoscopic triple neurectomy for chronic inguinal pain: Description of the technique, our experience and preliminary results

Introducción. El dolor inguinal crónico o inguinodinia posthernioplastia es una complicación relativamente común y que puede llegar a ser muy incapacitante. El tratamiento quirúrgico mediante triple neurectomía es una opción terapéutica ante el fracaso de tratamientos previos (terapia oral, local o neuromodulación).ObjetivoDescripción retrospectiva de la técnica quirúrgica y resultados de la triple neurectomía laparoscópica y con asistencia robótica en el tratamiento de la inguinodinia crónica.Material y métodosSe describen los criterios de inclusión/exclusión, así como la técnica quirúrgica empleada en 7 pacientes intervenidos en el Complejo Asistencial Universitario de León (Servicio de Urología) tras no responder a otras alternativas terapéuticas.ResultadosLos pacientes presentaban dolor crónico inguinal reportando una valoración en la escala EVA del dolor prequirúrgica de 7,43 sobre 10. Tras la cirugía, dicha valoración se redujo a 3,71 al primer día postoperatorio y a 4,2 puntos al año de la intervención. El alta hospitalaria se produjo a las 24h de la cirugía y no se reportaron complicaciones relevantes.ConclusionesLa triple neurectomía laparoscópica o con asistencia robótica es una técnica segura, reproducible y eficaz en el tratamiento del dolor inguinal crónico refractario a otros tratamientos. (AU)

Introduction. Chronic inguinal pain or inguinodynia following hernioplasty is a relatively common complication that can be very incapacitating. Surgical treatment by triple neurectomy is a therapeutic option when previous treatments (oral/local therapy or neuromodulation) have failed.ObjectiveRetrospective description of the surgical technique and results of laparoscopic and robot-assisted triple neurectomy for chronic inguinodynia.Material and methodsWe describe the inclusion/exclusion criteria as well as the surgical technique applied in 7 patients operated on at the University Health Care Complex of León (Urology Department) after failure of other treatment options.ResultsThe patients presented chronic groin pain, reporting a preoperative pain VAS of 7.43 out of 10. After surgery, this score was reduced to 3.71 on the first postoperative day and to 4.2 points one year after surgery. Hospital discharge occurred 24hours after surgery with no relevant complications being reported.ConclusionsLaparoscopic or robot-assisted triple neurectomy is a safe, reproducible, and effective technique for the treatment of chronic groin pain refractory to other treatments. (AU)

Involvement of Denervated Midbrain-Derived Factors in the Formation of Ectopic Cortico-Mesencephalic Projection after Hemispherectomy.

Neuronal remodeling after brain injury is essential for functional recovery. After unilateral cortical lesion, axons from the intact cortex ectopically project to the denervated midbrain, but the molecular mechanisms remain largely unknown. To address this issue, we examined gene expression profiles in denervated and intact mouse midbrains after hemispherectomy at early developmental stages using mice of either sex, when ectopic contralateral projection occurs robustly. The analysis showed that various axon growth-related genes were upregulated in the denervated midbrain, and most of these genes are reportedly expressed by glial cells. To identify the underlying molecules, the receptors for candidate upregulated molecules were knocked out in layer 5 projection neurons in the intact cortex, using the CRISPR/Cas9-mediated method, and axonal projection from the knocked-out cortical neurons was examined after hemispherectomy. We found that the ectopic projection was significantly reduced when integrin subunit ß three or neurotrophic receptor tyrosine kinase 2 (also known as TrkB) was knocked out. Overall, the present study suggests that denervated midbrain-derived glial factors contribute to lesion-induced remodeling of the cortico-mesencephalic projection via these receptors.SIGNIFICANCE STATEMENT After brain injury, compensatory neural circuits are established that contribute to functional recovery. However, little is known about the intrinsic mechanism that underlies the injury-induced remodeling. We found that after unilateral cortical ablation expression of axon-growth promoting factors is elevated in the denervated midbrain and is involved in the formation of ectopic axonal projection from the intact cortex. Evidence further demonstrated that these factors are expressed by astrocytes and microglia, which are activated in the denervated midbrain. Thus, our present study provides a new insight into the mechanism of lesion-induced axonal remodeling and further therapeutic strategies after brain injury.

Update of Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain from 2000 to 2018 in the US Fee-for-Service Medicare Population.

BACKGROUND: Interventional techniques for managing spinal pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic spinal pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009. OBJECTIVES: The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic spinal pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018. STUDY DESIGN: The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic spinal pain from 2000 to 2018 in the FFS Medicare population in the United States. METHODS: Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. RESULTS: Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018. LIMITATIONS: This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate. CONCLUSIONS: Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%. KEY WORDS: Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.

Experiencia inicial con catéter multielectrodo en denervación renal. ¿Una técnica que ha vuelto para quedarse? / Initial experience with a multi-electrode catheter in renal denervation. A technique that has come back to stay?

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Renal Denervation Update From the International Sympathetic Nervous System Summit: JACC State-of-the-Art Review.

Three recent renal denervation studies in both drug-naïve and drug-treated hypertensive patients demonstrated a significant reduction of ambulatory blood pressure compared with respective sham control groups. Improved trial design, selection of relevant patient cohorts, and optimized interventional procedures have likely contributed to these positive findings. However, substantial variability in the blood pressure response to renal denervation can still be observed and remains a challenging and important problem. The International Sympathetic Nervous System Summit was convened to bring together experts in both experimental and clinical medicine to discuss the current evidence base, novel developments in our understanding of neural interplay, procedural aspects, monitoring of technical success, and others. Identification of relevant trends in the field and initiation of tailored and combined experimental and clinical research efforts will help to address remaining questions and provide much-needed evidence to guide clinical use of renal denervation for hypertension treatment and other potential indications.

Antifibrillatory effects of renal denervation on ventricular fibrillation in a canine model of pacing-induced heart failure.

NEW FINDINGS: What is the central question of this study? In the present study, we investigated the effects of renal denervation on the vulnerability to ventricular fibrillation and the ventricular electrical properties in a rapid pacing-induced heart failure canine model. What is the main finding and its importance? Renal denervation significantly attenuated the process of heart failure and improved left ventricular systolic dysfunction, stabilized ventricular electrophysiological properties and decreased the vulnerability of the heart to ventricular fibrillation during heart failure. Thus, renal denervation can attenuate ventricular electrical remodelling and exert a potential antifibrillatory action in a pacing-induced heart failure canine model. In this study, we investigated the effects of renal denervation (RDN) on the vulnerability to ventricular fibrillation (VF) and the ventricular electrical properties in a canine model of pacing-induced heart failure (HF). Eighteen beagles were divided into the following three groups: control (n = 6), HF (n = 6) and HF+RDN (n = 6). Heart failure was induced by rapid right ventricular pacing. Renal denervation was performed simultaneously with the pacemaker implantation in the HF+RDN group. A 64-unipolar basket catheter was used to perform global endocardial mapping of the left ventricle. The restitution properties and dispersion of refractoriness were estimated from the activation recovery intervals (ARIs) by a pacing protocol. The VF threshold (VFT) was defined as the maximal pacing cycle length required to induce VF using a specific pacing protocol. The defibrillation threshold (DFT) was measured by an up-down algorithm. Renal denervation partly restored left ventricular systolic function and attenuated the process of HF. Compared with the control group, the VFT in the HF group was decreased by 27% (106 ± 8.0 versus 135 ± 10 ms, P < 0.01). However, RDN increased the VFT by 13% (135 ± 10 versus 118 ± 7.5 ms, P < 0.05) and decreased the DFT by 27% (30 ± 6.3 versus 21.8 ± 4.7 J, P < 0.05) in the treated hearts compared with the failing hearts. Renal denervation significantly flattened the ventricular ARI restitution curve by 15% (1.48 ± 0.2 versus 1.26 ± 0.11, P < 0.05) and decreased the dispersion of ARI by 25% (0.08 ± 0.02 versus 0.06 ± 0.01, P < 0.01) in the treated group compared with the HF group. The findings of this study suggest that RDN can attenuate ventricular electrical remodelling and exert a potential antifibrillatory action on VF in a canine model of pacing-induced HF.

Spasticity and hyperselective neurectomy in the upper limb.

Spasticity is a complex pathology, both in terms of assessment and treatment. This article focuses on the clinical examination (objective, capacity, performance and function), which is key for choosing a treatment and can be helped by botulinum toxin injections. The treatment involves physical therapy, occupational therapy, medications and surgery. Neurectomy has been used in the upper limb since 1912 and is one of the therapeutic options for spasticity. This treatment is usually reserved for nonfunctional hands. Cadaver studies have helped us better understand nerve anatomy and improve the hyperselective neurectomy (HSN) technique. This article describes the history of neurectomy, how anatomical dissections apply to surgery, the HSN technique in the musculocutaneous nerve, median nerve and ulnar nerve and results of preliminary prospective studies. Spasticity, mobility, performance and function were evaluated a few months after HSN and about 12 months later to assess the permanence of the results in children and adult spastic patients. No matter the nerve or function targeted (elbow extension, wrist extension, or supination), spasticity was reduced with improvements in the functional House score and appeared stable at the last follow-up. HSN seems to be a good, reliable therapeutic option for spasticity, including functional hands.

Determinants of denervation-independent depletion of putamen dopamine in Parkinson's disease and multiple system atrophy.

BACKGROUND: Severe putamen dopamine depletion characterizes Parkinson's disease (PD) and multiple system atrophy (MSA). The extent of the depletion is greater than can be accounted for by loss of nigrostriatal dopaminergic terminals alone. We used putamen tissue levels and ratios of cysteinyl and parent catechols to explore possible denervation-independent abnormalities of dopamine synthesis and fate in PD and MSA. 5-S-Cysteinyldopa (Cys-DOPA) is produced from spontaneous oxidation of DOPA and 5-S-cysteinyldopamine (Cys-DA) from spontaneous oxidation of DA. METHODS: Post-mortem putamen tissue samples from 17 PD and 25 MSA patients and 30 controls were assayed for endogenous catechols including DA, its cytoplasmic metabolites (Cys-DA, 3,4-dihydroxyphenylacetic acid, 3,4-dihydroxyphenylethanol, and 3,4-dihydroxyphenylacetaldehyde), and tyrosine hydroxylation products proximal to DA (DOPA and Cys-DOPA). RESULTS: The PD and MSA groups did not differ in mean values of parent or cysteinyl catechols, and the data for the two groups were lumped. In the patients an index of vesicular storage of DA (the ratio of DA to the sum of its cytoplasmic metabolites) averaged 54% of control (p = 0.001), and an index of L-aromatic-amino-acid decarboxylase (LAAAD) activity (the ratio of DA and the sum of its cytoplasmic metabolites to the sum of DOPA + Cys-DOPA) averaged 21% of control (p < 0.0001). An index of innervation (the sum of DOPA + Cys-DOPA) averaged 63% of control (p = 0.01). INTERPRETATION: Based on patterns of parent and cysteinyl catechols in putamen, PD and MSA involve decreased vesicular uptake and decreased LAAAD activity in the residual dopaminergic terminals. The combination seems to contribute importantly to dopamine depletion in these diseases.

[Renal denervation. Current developments]. / Renale Denervation. Aktuelle Entwicklungen.

UNLABELLED: METHODICAL INNOVATION: Renal denervation is a catheter-based, endovascular procedure for the treatment of drug-resistant hypertension. The aim of the therapy is to lower the blood pressure < 140/90 mmHg. PERFORMANCE: Even after successful minimally invasive therapy patients usually continue to take three or more antihypertensive drugs. Currently there is no evidence that renal denervation is a good option for the treatment of well-controlled hypertension in order to dispense with antihypertensive drugs. In carefully selected patients the mean reduction in systolic and diastolic blood pressure after renal denervation is 25-30 mmHg and 10-15 mmHg, respectively. ACHIEVEMENTS: Procedure-related or device-related complications are rare. Ablation catheters from different manufactures differ greatly in handling properties; however, up to now there is no evidence for relevant differences in safety and efficacy between the devices available.

Antegrade transsphenoidal vidian neurectomy: short-term surgical outcome analysis.

BACKGROUND: Vidian neurectomy was an option for treating allergic rhinitis in the past but outcomes varied. A modified transsphenoidal approach is proposed to simplify endoscopic vidian neurectomy. The postoperative evaluation of rhinorrhea, sneezing, and recurrence was investigated. METHODS: A total of 317 patients with refractory allergic rhinitis underwent 414 transsphenoidal vidian neurectomies from September 2006 to December 2010. A rigid nasal endoscope was used through a transsphenoidal approach to reach the vidian canal inside the sphenoid sinus (type I) or through its anterior opening into the pterygopalatine fossa (type II) and to cut or cauterize the vidian nerve. The surgical outcomes were analyzed for patients with at least 6 months of follow-up. RESULTS: Our approach was successful in 90.3% of the 414 vidian neurectomies. Vidian neurectomy was successful via the type I approach in 27 sides and type II approach in 347 sides. The short-term surgical outcomes of 163 patients who underwent a total of 236 vidian neurectomies with at least 6 months of follow-up were analyzed. Immediate, complete cessation of sneezing and rhinorrhea occurred uniformly. Three recurrences were detected during the 1-2 years of follow-up. The symptom of dry eye was reported for 172 surgical sides, but only 6 had persistent symptoms for >6 months. CONCLUSION: The transsphenoidal approach in a vidian neurectomy is a simple method that removes the need for sphenopalatine artery ligation and causes less surgical morbidity. However, the possibility of recurrence of this condition in the long term needs further investigation.

Pulsed radiofrequency denervation for the treatment of sacroiliac joint syndrome.

OBJECTIVE: Current therapies for sacroiliac joint (SIJ) dysfunction offer discouraging results in alleviating low back pain. The innervation and target nerves for radiofrequency denervation (RFD) of the SIJ remain unclear. We present a prospective case series on the treatment of intractable SIJ dysfunction with pulsed radiofrequency denervation (PRFD) of lateral branches from L4-S3. INTERVENTIONS: A total of 126 patients with presumptive SIJ dysfunction based on history and physical examination underwent arthrographically confirmed steroid/local anesthetic SIJ injection. Fifty-two patients (41.3%) had >75% pain relief after two consecutive injections, physical therapy, repeated SIJ injections, and/or analgesics. Twenty-two patients failed to respond. These patients underwent PRFD of the medial branch of L4, posterior primary rami of L5, and lateral branches S1 and S2. OUTCOME MEASURES: Visual analog score (VAS) and quality of life (QOL) assessments were performed prior to and after treatment. RESULTS: Sixteen patients (72.7%) experienced "Good" (>50% reduction in VAS), or "Excellent" (>80% reduction in VAS) pain relief following PRFD. Duration of pain relief range was 6-9 weeks in four patients, 10-16 weeks in five patients, and 17-32 weeks in seven patients. In addition, QOL scores improved significantly in all measured categories. Six patients (26.1%) did not respond to PRFD and had less than 50% reduction in VAS and were considered failures. CONCLUSIONS: PRFD of the lateral branch of the medial branch of L4, posterior primary rami of L5, and lateral branches S1 and S2 is an effective treatment for some patients with SIJ pain unresponsive to other forms of therapy.

A case of pulsed radiofrequency lesioning for occipital neuralgia.

OBJECTIVE: This report describes a case where pulsed radiofrequency lesioning (RFL) of the greater occipital nerve (GON) offered a valuable and safe treatment for the management of greater occipital neuralgia. The case is considered in relation to a review of the medical literature on greater occipital neuralgia and RFL interventions. CASE REPORT: A 62-year-old man with a 43-year history of left suboccipital pain underwent pulsed RFL of the left GON (20-millisecond bursts at intervals of 0.5 second for 4 minutes at 42 degrees C) after failing to achieve substantial analgesia with naproxen, a transcutaneous electrical nerve stimulator (TENS) unit and a greater occipital nerve blockade (GONB) utilizing local anesthetic and steroid. After obtaining 4 months of 70% pain relief, pulsed RFL was repeated and resulted in an additional 5 months of 70% pain relief. CONCLUSIONS: Pulsed RFL of the GON is an alternative to continuous RFL with the proposed advantage of mitigating pain, as in continuous RFL, but without the potential risk of causing deafferentation pain. While placebo and other nonspecific analgesic effects cannot be ruled out, the apparent safety profile and potential efficacy of pulsed RFL suggests it may be a compelling option to consider before irreversible neuroablative therapies are applied.