Femoral neuropathy following venoarterial-extracorporeal membrane oxygenation therapy: a case report.

BACKGROUND: Although life-threatening complications of extracorporeal membrane oxygenation (ECMO) are well described, non-life threatening complications are less known. Herein, we report a case of femoral neuropathy (FN) due to nerve compression caused by cannula compression and deep vein thrombosis (DVT) after successful ECMO therapy, which seriously undermined one's quality of life. CASE PRESENTATION: A 70-year old male presented to the emergency department for chest pain. The patient had cardiac arrest before percutaneous coronary intervention (PCI) and was inserted with ECMO. Although he was successfully weaned from ECMO 4 days after PCI, he consistently complained swelling, abnormal sensation, and weakness in his right lower extremity, where the cannulas were inserted. Imaging studies showed deep vein thrombosis (DVT) in his right leg, which was further treated with anticoagulants. Symptoms, however, remained after the regression of DVT. Nerve conduction study revealed femoral neuropathy, which may have been caused by ECMO cannula compression and tissue swelling. CONCLUSION: The current case proposes that non-life threatening complications of ECMO therapy can seriously affect quality of life. Venous drainage distant from the arterial cannula may prevent such complications.

Surgical Outcomes After Anterior Controllable Antedisplacement and Fusion Compared with Single Open-Door Laminoplasty: Preliminary Analysis of Postoperative Changes of Spinal Cord Displacements on T2-Weighted Magnetic Resonance Imaging.

OBJECTIVE: This retrospective cohort study aimed to investigate the change of spinal cord displacements and the occurrence of C5 palsy between anterior controllable antedisplacement and fusion (ACAF) (group A) and single open-door laminoplasty (group L). METHODS: From January 2016 to December 2017, a total of 80 patients with cervical ossification of the posterior longitudinal ligament (OPLL) were enrolled. All patients underwent computed tomography and magnetic resonance imaging. The types and extent of OPLL, spinal cord rotation, deviation angle, and distance between the vertebral arteries line and spinal cord (DVS) were measured. Patients with postoperative C5 palsy were recorded. Neurologic function was evaluated by Japanese Orthopaedic Association (JOA) score. RESULTS: Three days after surgery, patients in group A had better recovery (6.7° ± 2.4°) of spinal cord rotation than group L (3.1° ± 0.8°; P < 0.05). Deviation angle showed similar changes to spinal cord rotation. At the final follow-up, patients in group A had decreased DVS (11.0 ± 0.7 mm), whereas patients in group L had increased DVS (15.1 ± 0.8 mm) compared with preoperation (P < 0.05). Five patients (1 in group A and 4 in group L) developed postoperative C5 palsy (P > 0.05). Patients in group A had a higher JOA score at the final follow-up than those in group L (P < 0.05). CONCLUSIONS: ACAF could achieve in situ decompression in terms of spinal cord rotation, deviation angle, and spinal cord shift with better clinical outcomes and relatively lower incidence of C5 palsy compared with single open-door laminoplasty.

[Lo-back pain and compression-ischemic neuropathies: strategies for diagnosis, therapy and rehabilitation]. / Bol' v spine i kompressionno-ishemicheskie neiropatii: strategii diagnostiki, terapii i reabilitatsii.

The article discusses such a common pathology as pain syndrome in the lower back and limbs. A variety of etiological causes, anatomical features leading to the formation of this persistent algic disorder lead to therapeutic failures in clinical practice. The authors consider in detail the most common types of compression-ischemic neuropathy accompanying back pain, suggest diagnostic algorithms and practical recommendations. Results of foreign, Russian and own research are presented.

Efectividad de la movilización neurodinámica en el dolor y funcionalidad en sujetos con síndrome del túnel carpiano: revisión sistemática / Effectiveness of neurodynamic mobilization in pain and functionality in subjects with carpiano tunnel syndrome: systematic review

El síndrome del túnel del carpo (STC) es la neuropatía periférica más común y de mayor porcentaje, afectando principalmente más a mujeres que a hombres. La técnica de movilización neural es una intervención que está dirigida a las estructuras neurales mediante el posicionamiento y el movimiento de múltiples articulaciones, para descomprimir la zona y liberar la presión del nervio afectado. Se realizará una síntesis de la evidencia a través de una revisión sistemática de ensayos clínicos aleatorizados que hayan comparado la técnica de movilización neural por sí sola con otros tipos de intervenciones. Nuestro objetivo es determinar si existe evidencia científica que avale la efectividad de la técnica de movilización neurodinámica en pacientes diagnosticados con síndrome del túnel carpiano. La estrategia de búsqueda incluyó ensayos clínicos aleatorizados y ensayos clínicos controlados. Las bases de datos usadas fueron: Medline, LILACS, Central, CINAHL, SPORTDiscus y PEDro. Se obtuvieron cuatro artículos que cumplían con los criterios de elegibilidad. Se concluye que existe moderada evidencia, que la técnica de movilización neural en comparación con placebo, cuidados estándar y agentes físicos podría ayudar a disminuir el dolor y mejorar la funcionalidad a sujetos con síndrome del túnel del carpo. La decisión de aplicar este tipo de tratamientos también debe basarse en costos, preferencias y seguridad del tratamiento (AU)

Carpal Tunnel Syndrome (STC) is the most common peripheral neuropathy with a higher percentage, affecting mainly women than men. The technique of neural mobilization is an intervention that is directed at neural structures by positioning and moving multiple joints, to decompress the area and release the pressure of the affected nerve. A synthesis of the evidence was done through a systematic review of randomized clinical trials that was compared with the technique of neural mobilization with other types of interventions. Our objective is to determine if there is scientific evidence to support the effectiveness of the neurodynamic mobilization technique in patients diagnosed with carpal tunnel syndrome. The search strategy included randomized clinical trials and controlled clinical trials. The databases used were: Medline, LILACS, Central, CINAHL, SPORTDiscus and PEDro. Four items were obtained that met the eligibility criteria. We conclude that there is moderate evidence that the neural mobilization technique compared with placebo, standard care and physical agents, could help decrease pain and improve the functionality of subjects with carpal tunnel syndrome. The decision to apply this type of treatment should also be based on costs, preferences and treatment safety (AU)

Late Peroneal Neuropathy after Open Surgical Treatment of Popliteal Artery Aneurysm.

We report the case of a 71-year-old man complaining of swollen left limb and progressively worsening pain. He underwent surgery 12 years ago for popliteal artery aneurysm with proximal and distal ligation and venous bypass grafting. The patient was diagnosed as having left peroneal neuropathy caused by a 10.5 cm expanded aneurysmal sac compressing the peroneal nerve in the popliteal fossa. The patient underwent open repair with opening of the aneurysmal sac, removal of the thrombus, and sewing of the left genicular artery responsible for back-bleeding. Postoperative range of motion exercises and physical therapy allowed resolving foot drop 1 year after surgery.

Back extension exercises decompress the spinal root and improve standing mobility in patients with sub-acute lumbosacral radiculopathy.

PURPOSE: Repeated back extension exercises (RBEEs) have been reported to cause changes in the distribution and intensity of radicular symptoms. Therefore, the objective of this study was to investigate the effects of RBEEs on the neurophysiology of the compromised nerve root and on standing mobility and pain intensity in patients with sub-acute and chronic lumbosacral radiculopathy (LSR). SUBJECTS AND METHODS: A total of 40 patients with unilateral sub-acute/chronic LSR voluntarily participated in the study; the patients performed three sets of 10 RBEEs in the prone position with 1 min of rest between the sets. The soleus H-reflex, standing mobility, and pain intensity were recorded before and after the RBEEs. RESULTS: The results of the study showed that the RBEEs significantly improved the H-reflex, standing mobility, and pain intensity in patients with sub-acute LSR (p < .01); there was not a significant improvement in the patients with chronic LSR (p < .61). CONCLUSION: RBEEs in the prone position are recommended for improving the neurophysiological function of the compromised nerve root and standing mobility in patients with sub-acute LSR.

Differential Diagnosis and Intervention of Proximal Median Nerve Entrapment: A Resident's Case Problem.

Study Design Resident's case problem. Background Entrapment neuropathies represent a diagnostic challenge and require a comprehensive understanding of the nerve's path and the anatomical structures that may cause compression of the nerve. This resident's case problem details the evaluation and differential diagnosis process for median nerve entrapment resulting from forceful and repetitive pronation/supination motions. Diagnosis Median nerve compression syndromes include pronator syndrome, anterior interosseous nerve syndrome, and carpal tunnel syndrome. A cluster of clinical special tests were performed to determine the anatomical site of median nerve entrapment. Based on the patient's history and clinical test results, a diagnosis of pronator syndrome was determined. Provocation testing specific to pronator syndrome assisted with further localizing the site of entrapment to the pronator teres muscle, which guided effective management strategies. Discussion This resident's case problem illustrates the importance of detailed anatomical knowledge and a differential diagnostic process when evaluating a patient with signs and symptoms of an entrapment neuropathy of the median nerve. Electrodiagnostic studies are useful in ruling out carpal tunnel and anterior interosseous nerve syndromes, but are often inconclusive in cases of pronator syndrome. Therefore, a diagnosis of pronator syndrome in this case problem was based on a detailed understanding of median nerve anatomy, potential sites of compression, and unique clinical features associated with this condition. Level of Evidence Differential diagnosis, level 4. J Orthop Sports Phys Ther 2016;46(9):800-808. Epub 5 Aug 2016. doi:10.2519/jospt.2016.6723.

Interventional and multimodal pain rehabilitation in a child with meralgia paresthetica.

Meralgia paresthetica is a chronic pain syndrome that is extremely rare in the pediatric population. It is manifested by hypesthesia or pain in the distribution of the lateral femoral cutaneous nerve (LFCN) and is typically caused by entrapment as the nerve passes deep to the inguinal ligament. This sensory mononeuropathy is rare in children and diagnosis is typically delayed, often leading to prolonged functional impairment and unnecessary medical testing. A 9-year-old girl presented to the pain clinic with a 6-week history of right anterolateral thigh pain first noticed after a nontraumatic cheerleading practice. Comprehensive laboratory and radiographic evaluation by multiple prior specialists revealed no clear nociceptive source of pain. History and examination were consistent with a diagnosis of idiopathic, compressive meralgia paresthetica. Conservative management including physical therapy was followed for 2 weeks with only mild improvement noted. To facilitate physical therapy, an ultrasound-guided LFCN block was performed which confirmed the diagnosis by providing complete analgesia. The patient reported overall 25% improvement from multimodal therapy at another 2 weeks. A second LFCN block was performed with complete resolution of symptoms and restoration of function. The patient remains pain-free and has returned to walking, running, and competitive sports. The primary goal of pediatric chronic pain management, regardless of pain etiology, is early restoration of function to avoid prolonged absence from school, sports, or other productive activities and limit the psychological burden of chronic disease.

Entrapment of the deep peroneal nerve and anterior tibial vessels by a spiral tibial fracture causing partial non-union: a case report.

We report a case of entrapment of the deep peroneal nerve as well as the anterior tibial artery and vein by a spiral distal tibial shaft fracture, causing partial non-union. The authors describe the utility of MRI in making the diagnosis of this post-traumatic complication, which may potentially result in a permanent neurovascular deficit and adverse functional outcome if left undetected. The importance of recognizing the distinct possibility of entrapment and injury to the deep peroneal nerve as well as the anterior tibial vessels, when managing a fracture involving the distal third of the tibial shaft is emphasized. Absence of clinical symptoms or signs of neurovascular entrapment should not deter one from performing the relevant investigations to exclude this complication, in particular when surgical fixation is being contemplated, or in the presence of a non-healing fracture.

Swimming does not alter nociception threshold in obese rats submitted to median nerve compression.

OBJECTIVES: We, herein, analyzed the effect of swimming on nociception threshold and peripheral nerve regeneration in lean and obese rats submitted to median nerve compression. METHODS: To induce obesity, newborn male Wistar rats received injections of monosodium glutamate (MSG), whereas the control (CTL) group received saline. The animals were separated into 6 groups; control and obese (CTL and MSG), control and obese with lesion (CTL LES and MSG LES), and control and obese with lesion submitted to physical exercise (CTL LES PE and MSG LES PE). RESULTS: Median nerve compression reduced nociception threshold in CTL LES and MSG LES rats. Swimming effectively altered nociception only in CTL LES PE animals. Lean and obese animals displayed histological differences, when compared to sedentary animals, and exercise improved axon regeneration in both groups. The brain-derived neurotrophic factor and GAP 43 protein expression was greater in animals submitted to nervous compression without alteration by exercise. DISCUSSION: In conclusion, swimming, a conservative treatment for peripheral nerve lesions, was not able to improve the nociception threshold in obese rats.

A case of Vernet syndrome associated with internal jugular phlebectasia.

A 36-year-old woman presented with right shoulder weakness after a left parotid tumor resection. The overall clinical presentation included severe paralysis and atrophy of the right sternocleidomastoid and upper trapezius, an absent right gag reflex, and diminished right posterior tongue pinprick sensation. A diagnosis of right-sided Vernet syndrome (cranial nerve IX, X, XI lesions) was made, presumably from compression of cranial nerves by internal jugular vein phlebectasia. To our knowledge, this is the first case report of spontaneous Vernet syndrome associated with internal jugular vein phlebectasia in the absence of other lesions of the jugular foramen.

Conservative management of a saphenous nerve entrapment in a female ultra-marathon runner.

Entrapment of the saphenous nerve is a frequently overlooked cause of medial knee pain. Delayed or misdiagnosis is a result of a lack of detailed reporting of the vastoadductor membrane, and by direct visualization of the entrapment only being accomplished at the time of surgical decompression. To date there are no documented conservative interventions discussed in the literature. This is a case of diagnosis and conservative resolution of a spontaneous saphenous nerve entrapment in a competitive female ultra-marathon runner. In-office Active Release Technique(®) combined with an at-home rehabilitative exercise program relieved the patient's subjective pain and paresthesia with two treatments provided over a one week period of time.

Nerve compression syndromes of the upper extremity: diagnosis, treatment, and rehabilitation.

Nerve compression syndromes of the upper extremity, including carpal tunnel syndrome, cubital tunnel syndrome, posterior interosseous syndrome and radial tunnel syndrome, are common in the general population. Diagnosis is made based on patient complaint and history as well as specific exam and study findings. Treatment options include various operative and nonoperative modalities, both of which include aspects of hand therapy and rehabilitation.

The anterior recurrent peroneal nerve entrapment syndrome: a patellar tendinopathy differential diagnosis case report.

Patellar tendinopathy which is a cause of pain in the inferior patellar region is a relatively common pathology among sports enthusiasts. This paper describes a new pain syndrome identified from clinical observations which is a differential diagnosis to patellar tendinopathy. The pattern is specific and recognizable among many individuals, and it should be considered as its own entity. The new syndrome is discussed in terms of the pain experienced, the diagnostic criteria, treatment and the rationale to explain it. As it is a differential diagnosis to patellar tendinopathy, many sports enthusiasts might benefit from this diagnosis. If identified correctly, treatment might be directed to the correct structures and with the appropriate modalities, ensuring the patients a fast return to their past occupations without pain and without unwarranted treatments.

Fear of movement/(re)injury and activity avoidance in persons with neurogenic versus vascular claudication.

BACKGROUND CONTEXT: Activity avoidance and fear of movement/(re)injury are increasingly being recognized as important factors in the rehabilitation of persons suffering from chronic low back pain, yet these factors have not been thoroughly explored in persons suffering from neurogenic claudication resulting from lumbar spinal stenosis. PURPOSE: To determine, compare, and explain differences in the degree of fear of movement/(re)injury and activity avoidance in persons with neurogenic claudication, vascular claudication, and asymptomatic volunteers. STUDY DESIGN: Prospective controlled cohort study at an academic medical center. PATIENT SAMPLE: Eighty-two adults aged between 55 and 90 years with neurogenic claudication, vascular claudication, or no back and leg symptoms. METHODS: Subjects completed a visual analog scale for pain, the Center for Epidemiological Studies Depression Scale, the Quebec Back Pain Disability Scale, Short Form 36 (SF-36), and the 13-item version of the Tampa Scale for Kinesiophobia (Tampa). They were also asked to estimate their maximum walking distance. OUTCOME MEASURES: The difference in the level of fear of movement/(re)injury and activity avoidance in the two symptomatic populations, as well as the predictive validity of self-reported measures such as pain level, functional impairment, and depression in determining fear avoidance. RESULTS: The total Tampa score was significantly higher in individuals with neurogenic claudication (M=31.68; standard deviation [SD]=7.56; N=39) than vascular claudication (M=24.07; SD=6.57; N=15) (p=.002), whereas both symptomatic groups were significantly different from controls (M=18.71; SD=6.3; N=28) (p<.001 vs. neurogenic; p<.05 vs. vascular). Tampa scores were strongly correlated to the Center for Epidemiological Studies Depression Scale score (r=0.515; p<.001), SF-36 Physical Functioning score (r=-0.632; p<.001), and the visual analog scale average level of pain in a week (r=0.461; p<.001). Using a standard multiple regression model (R²=0.406; F(3,62)=13.47; p<.001), the amount of functional impairment, that is, the SF-36 Physical Functioning score, was the strongest contributor to the variance in the Tampa total score (ß=-0.371; p=.014). The average level of pain did not make a significant or unique contribution in predicting the Tampa total score. Functional impairment as measured by the SF-36 Physical Functioning was strongly correlated with both pain (r=-0.740; p<.001) and depression (r=-0.488; p<.001). CONCLUSIONS: Persons with neurogenic claudication have important elevations in fear and avoidance, higher than those with claudication from another source (vascular insufficiency). The impact of fear and avoidance along with other factors such as depression on pain, disability, and quality of life for persons with claudication and spinal stenosis need to be explored.

Pronação excessiva e varismos de pé e perna: relação com o desenvolvimento de patologias músculo-esqueléticas: revisão de literatura / Excessive pronation and varus alignment of foot and shank: relationship with development of musculoskeletal pathologies: literature review

A literatura propõe mecanismos biomecânicos que relacionam a pronação subtalar excessiva ao desenvolvimento de diversas patologias músculo-esqueléticas. A presença dos desalinhamentos anatômicos antepé varo, retropé varo e tíbia vara pode levar à ocorrência da pronação subtalar excessiva. Entretanto, não existe um consenso sobre a contribuição do padrão de movimento e da presença desses desalinhamentos para o desenvolvimento de patologias. O objetivo deste estudo foi realizar uma revisão da literatura para investigar a influência de varismos aumentados de antepé, retropé e tíbia e da pronação subtalar excessiva no surgimento de patologias músculo-esqueléticas. Foi realizada uma pesquisa bibliográfica sistematizada nas bases Medline, ISI – Web of Science, Lilacs e SciELO, tendo sido selecionados 13 estudos analíticos. Do total de 13 estudos, 10 encontraram associação de patologias no membro inferior com um ou mais dos desalinhamentos anatômicos analisados ou com um ou mais parâmetros cinemáticos relacionadas à pronação subtalar excessiva. A análise dos estudos sugere que a pronação subtalar excessiva e/ou a presença de desalinhamentos que podem levar a esse padrão de movimento são possíveis fatores de risco para o desenvolvimento de patologias músculo-esqueléticas no membro inferior.

The literature proposes biomechanical mechanisms that link excessive subtalar joint pronation to the development of several musculoskeletal pathologies. The presence of forefoot varus, rearfoot varus and tibiofibular varum can lead to the occurrence of excessive subtalar pronation. However, there is no consensus about the contribution of the movement pattern and/or the presence of these anatomical misalignments to the development of pathologies. The aim of the present study was to conduct a literature review in order to investigate the influence of increased varus alignment of forefoot, rearfoot and shank and of excessive subtalar pronation on the development of musculoskeletal pathologies. A systematic literature search was performed in the databases Medline, ISI – Web of Science, Lilacs and SciELO, and 13 analytic studies were selected. Ten studies found significant associations of lower-limb musculoskeletal pathologies with one or more of the anatomical misalignments analyzed or with one or more kinematic parameters related to excessive subtalar pronation. The analysis of the studies suggests that excessive pronation and/or the presence of these anatomical misalagniments should be regarded as possible risk factors for the development of musculoskeletal pathologies in the lower limb.

Immediate and long-term effects of selected physiotherapy methods in patients with carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome is a serious therapeutic problem and it considerably impairs the patients' quality of life. Despite many studies, the effectiveness of conservative treatment is still debatable. This study aimed to evaluate the immediate and long-term effects of conservative treatment involving ultrasound therapy combined with massage and kinesiotherapy for carpal tunnel syndrome. MATERIAL AND METHODS: A total of 61 patients with carpal tunnel syndrome were assessed with regard to such symptoms as pain, numbness, tingling sensation, morning stiffness, and self-care difficulties. We used provocation tests and investigated sensory impairments, autonomic disturbances, and Lüthy's sign. Conduction in the median nerve fibres was assessed during a nerve conduction study. We performed computer-aided measurement of the hand joint range of motion and global grip strength. The tests were conducted before and on completion of a rehabilitation programme. The hands were re-examined one year later. The treatment involved ultrasound therapy, massage, and kinesiotherapy. RESULTS: The treatment outcomes confirmed the effectiveness of the therapeutic programme. Significant improvements concerning the majority of the symptoms were observed between the first and second examination as well for the entire follow-up period. We observed significant improvement in the quality of sensation, the hand range of motion and muscle strength. CONCLUSIONS: Ultrasound therapy combined with massage and kinesiotherapy brings the expected, long-term effects in patients with carpal tunnel syndrome.