Digital Nerve Research Articles

Pudendal Nerve Blocks: An Introduction and How-to Guide

<h3>Study Objective</h3> To provide a stepwise description of the anatomy, evidence, and technique for performing pudendal nerve blocks for the treatment of pudendal neuralgia. <h3>Design</h3> Video demonstration with narrated description. <h3>Setting</h3> Academic tertiary care site. <h3>Patients or Participants</h3> Patients with pudendal neuralgia. <h3>Interventions</h3> Digital transvaginal pudendal nerve blocks and blocks of the terminal peripheral branches of the pudendal nerve, including the perineal and dorsal clitoral branches. <h3>Measurements and Main Results</h3> Pudendal neuralgia can be identified using the Nantes criteria, which includes pain in the distribution of the pudendal nerve, increased pain with sitting, not being awakened by pain, lack of sensory loss, and resolution of pain after pudendal nerve block. Pudendal nerve blocks have been shown to provide relief in over 75% of patients with pudendal neuralgia, with relief potentially lasting from days to months post-procedurally. This video presents both a transvaginal digital approach to pudendal nerve block as well as targeted blocks of the peripheral branches of the pudendal nerve, including the perineal and dorsal clitoral branches. A review of the relevant clinical anatomy, benefits and risks of the procedures, type and toxicity of injectate medications, procedural set up, procedural techniques, and post-procedural follow up care is presented. <h3>Conclusion</h3> Pudendal nerve blocks, when performed through a safe and standardized approach, are a beneficial therapeutic tool for clinicians caring for patients with pudendal neuralgia.

933 The Glass Half Full? A Case Of Cutaneous Neuroma Formation Post Laceration Of First Web-Space Of The Hand

Abstract Introduction neuromas are lesions resulting from abnormal nerve regeneration following a peripheral nerve injury and may cause severe pain. Method we present a case of a 54-year-old female who developed a painful cutaneous lesion over the first web-space of the hand following an untreated glass laceration 3 years previously. Results surgical resection revealed a 100% transection of ulnar digital nerve (UDN) of thumb with regeneration into the skin. A posterior interosseous nerve (PIN) nerve graft was required to bridge the resulting 15mm gap. Histopathology revealed a 12x12mm neuroma extending into dermis. Conclusions cutaneous neuroma is a rare consequence of penetrating trauma. This case highlights the need for prompt assessment of penetrating injuries to reduce risk of neuroma formation.

983 Digital Angioleiomyoma: A Rare Tumour Of the Hand

Abstract Introduction Angioleiomyoma is an unusual, benign tumour originating from the tunica media of blood vessels. They commonly occur in the face, neck and lower limb. It is rarely found in the hand and is not considered in the differential diagnoses of painful subcutaneous hand tumours. Case Report We present a case of a 40-year-old man with a several month history of a slow growing lump on his right middle finger. He complained of pain and difficulty flexing his finger. On examination, he had a solid tumour with normal overlying skin, on the volar ulnar border of middle phalanx with altered sensation and a positive Tinel’s along the ulnar digital nerve. Ultrasound and MRI reported a highly vascular subcutaneous tumour measuring 26x14x22mm with differential diagnoses of giant cell or peripheral nerve tumour. Intra-operatively the tumour was in continuity with the ulnar digital artery and solid in consistency. Tumour excision and microsurgical repair of the digital artery was required. Histology confirmed a well-defined nodule, composed of bundles of smooth muscle surrounding ectatic blood vessels, consistent with angioleiomyoma. On follow-up the patient reported return of full range of movement without hypersensitivity or evidence of recurrence. Conclusions Angioleiomyomas in the hand are rare. It should be considered in the differential diagnoses of painful subcutaneous tumours. Ultrasound and MRI are non-specific. Treatment is successful with excision biopsy and microsurgical repair of digital artery. Microvascular instruments should be available, and the patient consented for vein graft.

The impact of COVID-19 on traumatic hand injuries: A Turkish survey

Aim: Our aim in the study is to perform a comparative analysis of traumatic hand injuries during the quarantine period of the COVID-19 pandemic with data of the previous year and to research the effect of quarantine on hand injuries. Material and Methods: We retrospectively analyzed patients who presented to the emergency department with traumatic hand injuries between 16.03.2020 and 01.06.2020 and within the same period of 2019. Patients’ age, gender, injury mechanism, length of hospitalization, ethnic origin, presence of major and digital nerve injuries, presence of bone injury, emergency or elective surgery data were recorded. The data were analyzed statistically in comparison with the previous year. Results: A total of 301 patients participated in the study. There were 117 patients in 2020, and 184 patients in 2019. When patients of both years were examined in terms of age, gender and length of hospitalization, there was no statistically significant difference between the patients who were operated for hand injuries between 2020 and 2019 (p>0.05). When patients who were operated due to hand injuries were examined in terms of differences in ethnic origin, operation under emergency conditions and accompanying bone injury between both groups, a statistically significant difference was found between them (p<0.05). Discussion: A decrease was observed in the number of traumatic hand injuries admitted to the emergency department during the COVID-19 pandemic;however, there were no changes in etiology. These reference data can help healthcare systems prepare for future outbreaks and similar restrictions.

Duration of skin desensitisation following palmar digital nerve blocks with lidocaine, bupivacaine, mepivacaine and prilocaine.

Objective comparative evidence of the time to onset and duration of effect provided by local anaesthetic (LA) agents for perineural blocks in the horse is lacking. Clear knowledge of these properties is required to guide clinically appropriate agent selection and aid interpretation of response to diagnostic blocks for lameness examinations. An interventional study, with complete, randomised crossover design was used to compare time to onset and duration of skin desensitisation provided by four LA agents applied to palmar digital nerve blocks in 12 horses. Effect at each time point was determined using a pressure gauge to measure the mechanical nociceptive threshold (MNT) over the heel bulbs. Complete desensitisation was defined when MNT was greater than four times the pre-block baseline. Onset and duration of complete desensitisation were recorded and compared across agents using a mixed linear model. When significant (P ≤ 0.05), post-hoc paired comparisons between agents were performed against a Tukey's corrected P ≤ 0.05. Onset of complete skin desensitisation for each agent was <5 min. Duration for lidocaine (mean 25 min; 95% confidence interval [CI] 9-42) was shorter than bupivacaine (53 min; 95% CI 39-65), which was shorter than both prilocaine (102 min; 95% CI 81-123) and mepivacaine (107 min; 95% CI 92-121), which were not different. Although onset of complete skin desensitisation was not different for the LA agents tested, duration varied from 25 min to nearly 2 h. Prilocaine and mepivacaine provided the most prolonged duration of effect, both exceeding bupivacaine.

An Epidermoid Cyst along the Sensory Branch of Digital Nerve with Focal Neuropathy: A Case Report

An epidermoid cyst is a slow-growing benign neoplasm that commonly occurs in the hand. Herein, we report a rare case of an epidermoid cyst with focal neuropathy in the left ring finger of a 38-year-old woman. Preoperatively, the patient complained of erythema, swelling, and paresthesia on her fingertips. On ultrasonography and magnetic resonance imaging, ulnar digital nerve thickening and inflammation around the nerve were observed, and a neurogenic tumor-like schwannoma was expected. An excisional biopsy with neurectomy of the involved sensory branch of the ulnar digital nerve was performed under brachial plexus block. During the operation, there is such an uncommon morphology, yellowish debris under the epineurium of the ulnar digital nerve sensory branch was involved with the epidermoid cyst and seemed to be propagating along the sensory branch from the skin surface. After the operation, the paresthesia and swelling resolved. Over the 6-month follow-up in the outpatient clinic, no complications and recurrences occurred. Thus, we reported a rare intraneural epidermoid cyst (occurred along the digital nerve) in the finger, and we believe that considering the anatomical characteristics and the surrounding structures is important during mass excision.

Fibrin Glue and Conduit Form a Composite Structure in Digital Nerve Repair.

Repair of severed nerves without autograft or allograft has included suture, suture with glue alone, suture with conduit and suture with glue augmentation to conduit, where use of conduit is considered for separation of the nerve ends from 5 mm to 3 cm. Repairs must not only serve acutely to provide apposition of nerve ends but must enable the healing of the nerve. Using biological conduit can place suture at the ends of the conduit while fibrin glue alone eliminates suture but with limited strength. The combination of conduit and glue offers the growth guidance of conduit with sufficient strength from the glue to maintain the nerve within the conduit. The role of fibrin glue in the integrity of the repair remains an open question, however. We sought to determine the factors in the strength of a glue-conduit-nerve construct and include consideration of standard suture repair. Fresh-frozen cadaveric digital nerves were repaired with suture alone, with glue alone or with suture and glue together and then loaded to failure. Previously tested specimens with conduit, suture and glue were considered for comparison. The suture alone (2.02 N) and suture with glue (2.24 N) were not statistically different from each other but were statistically stronger than glue alone (0.15 N). When compared to the earlier results of the strength of conduit with glue (0.65 N), these simple results show that the glue and conduit act together. The increased area over which the glue adheres to the nerve and conduit creates a composite structure stronger than either alone.

Biological sex differences in afferent-mediated inhibition of motor responses evoked by TMS

Sensorimotor integration can be assessed by pairing electrical peripheral nerve stimulation with transcranial magnetic stimulation (TMS). The resulting afferent inhibition is observed when TMS precedes nerve stimulation by ∼ 20–25 ms, termed short-latency afferent inhibition (SAI), or by 200 ms, termed long-latency afferent inhibition (LAI). The purpose of this study was to determine whether biological sex influences the magnitude of SAI or LAI. SAI and LAI were assessed in fifteen males (21.5 ± 2.7 years) and fifteen females (20.2 ± 2.3 years). TMS was delivered to the primary motor cortex (M1) following stimulation of the contralateral median nerve at the wrist or digital nerve of the index finger, and motor-evoked potentials (MEPs) were obtained from the right first dorsal interosseous (FDI) muscle. SAI evoked by median and digital nerve stimulation, and LAI evoked by median nerve stimulation, were not different between males and females. LAI evoked by digital nerve stimulation was increased in females compared to males, but this difference between sexes was no longer present following the removal of datapoints where inhibition was not observed. This study is the first to investigate biological sex differences in afferent inhibition.

Effect on analgesia duration and pain intensity of adding dexamethasone to lidocaine in digital nerve block in patients with finger trauma

Digital nerve block is one of the multimodal analgesia methods used in finger trauma cases. According to some studies, dexamethasone needs further investigation before being used routinely. We therefore investigated dexamethasone’s effect on the parameters of digital nerve block. In this double-blind clinical study, 60 patients were allocated to two groups: lidocaine alone and lidocaine + dexamethasone. Groups were compared for pain intensity, analgesia duration and demographic characteristics. Patients in the intervention group received 3 cc 2% lidocaine + 1 cc (equivalent to 4 mg) dexamethasone and patients in the control group received 3 cc lidocaine 2% + 1 cc normal saline. The two groups were comparable for age and gender. In the lidocaine + dexamethasone group, postoperative pain severity was significantly lower and the pain-free period was longer (P < 0.05). Dexamethasone as an adjuvant in digital nerve block after trauma reduced the severity of postoperative pain and increased the pain-free period.

Comparison of nerve conduits and nerve graft in digital nerve regeneration: A systematic review and meta-analysis

The goal of this systematic review and meta-analysis was to compare nerve conduits and nerve graft for peripheral nerve regeneration. This type of lesion frequently causes disability due to pain, paresthesia and motor deficit. On the PICO process, “P” corresponded to patients with peripheral digital nerve lesions of any age, gender or ethnicity, “I” to interventions with nerve conduits or nerve graft, “C” to the control group with no treatment, placebo or receiving other treatment, and “O” to outcome assessment of nerve regeneration. Initial search found in 3859 studies, including 2001 duplicates. The remaining 1858 studies were selected by title and/or abstract; 1798 articles were excluded, leaving 60 articles for full-text review. Thirty-nine of these 60 reports were excluded as not meeting our inclusion criteria, and 21 articles were ultimately included in the systematic review. For patients older than 40 years, there was a greater mean improvement on S2PD and M2PD tests with grafting, which seemed to be the better surgical technique, positively impacting prognosis. On the M2PD test, there was significantly greater improvement in 11–17.99 mm defects with grafting (P < 0.001); this finding should guide surgical strategy in peripheral nerve regeneration, to ensure better outcomes.

Clinical effects of neurocutaneous vascular flap innervated by terminal branch of lateral antebrachial cutaneous nerve in repairing finger tip or finger pulp wounds of the thumb

Objective: To investigate the clinical effects of neurocutaneous vascular flap innervated by terminal branch of lateral antebrachial cutaneous nerve in repairing finger tip or finger pulp wounds of the thumb. Methods: A retrospective observational study was conducted. From February 2016 to April 2019, a total of 21 patients (21 fingers) with finger tip or finger pulp wounds of the thumbs met the inclusion criteria and were admitted to the Second Hospital of Tangshan, including 13 males and 8 females, aged 21 to 65 years, with the defects located at the finger tips of 14 patients and the finger pulps of 7 patients, and all having exposed bones and/or tendons. The wound sizes of patients in this group after debridement ranged from 2.0 cm×1.5 cm to 4.0 cm×2.7 cm. All the wounds were repaired with the neurocutaneous vascular flap innervated by terminal branch of lateral antebrachial cutaneous nerve, with the flap sizes ranging from 2.3 cm×1.8 cm to 4.3 cm×3.0 cm. In surgery, the terminal branch of lateral antebrachial cutaneous nerve carried by the flaps was anastomosed with the end of the proper digital nerve of the wounds. The donor sites of flaps were sutured directly. The survival of flaps and healing of wounds in donor sites after operation were observed. The appearance of flaps and donor sites were observed during follow-up. At the final follow-up, the static two-point discrimination distances of the flaps were measured, and the degree of satisfaction of patients for the appearances of injured hands were evaluated based on Michigan Hand Function Questionnaire. The total action motion (TAM) of the injured and contralateral thumbs and the angle of thumb web of the injured and contralateral hands were measured. Data were statistically analyzed with paired sample t test. Results: All the flaps of the 21 patients survived with good blood supply and no infection. The wounds at the donor sites were all healed. All the patients were followed up, with the time ranging from 8 to 22 months. The appearances of flaps were good with their color and texture similar to the surrounding tissue. There was no pain in the finger tip or finger pulp, nor any ectopic sensation in flaps. There was only some linear scar left at the radial side of thumb. At the final follow-up, the static two-point discrimination distances of the flaps of the patients were 6 to 11 mm; 18 patients were very satisfied and 3 patients were satisfied with the overall appearance of the injured hand. The TAM of injured thumbs and the angle of thumb web of the injured hands of the patients were respectively (140±5)º and (94±9)°, which were similar to (141±5)º of the thumbs and (95±9)° of hands in the contralateral side, respectively (t=-2.024, -1.142, P>0.05). Conclusions: The neurocutaneous vascular flap innervated by terminal branch of lateral antebrachial cutaneous nerve has constant anatomy and is easy to perform. It can repair the finger tip or finger pulp wounds of the thumb achieving good appearance and function recovery. It provides a good option for repair of finger tip or finger pulp wounds of the thumb and is especially suitable for emergency application.

Translating morphology from bench side to bed side via neurophysiology: 8-min protocol for peripheral neuropathy research

BackgroundPeripheral neuropathy treatment is not always satisfactory. To fill this gap, inferences from bench side are warranted, where morphological and pathogenetic determinations can be performed. Nerve conduction studies (NCS) are ideal to translate results from preclinical to clinical setting. New methodsWe propose a comprehensive 8-minute protocol for sensory-motor neurophysiological assessment, similar to routine clinical practice: sensory proximal and distal caudal nerves, motor caudal nerve, and sensory digital nerve recordings were used and tested in 2 different experimental settings. In Experiment 1 we compared control (CTRL) animals to a severe sensory-motor polyneuropathy (animals treated with vincristine [VCR]), and in Experiment 2 CTRL animals were compared to a mild sensory polyneuropathy (animals treated with oxaliplatin [OHP]). NCS were performed after 1-month of chemotherapy and matched with confirmatory neuropathological analyses. ResultsVCR treated animals showed, at NCS, a relevant sensory-motor polyneuropathy ensued at the end of treatment; whereas, OHP animals showed a mild distal sensory neuropathy. These patterns were confirmed by neuropathological analysis. Comparison with existing methodsIn literature, the majority of proposed neurophysiological protocols relies mainly on a single nerve testing, rather than a combination of them, and only a few studies tested both caudal and sciatic nerve branches, nevertheless not aiming at fully reproduce clinical protocols (e.g., seeking for length-dependency); to provide evidence of appropriateness of our protocol we applied a gold standard: neuropathology. ConclusionThe simple and rapid protocol here presented can be suggested as a good translation outcome measure in preclinical setting.

Outpatient Neuromodulation May Avert the Need for Surgery in Patients with Painful Cutaneous Neuromas.

Background: Traumatic neuromas are a result of abnormal neural regeneration after nerve injury. Neuropathic pain arising from neuroma can be debilitating. Methods: This was a retrospective review of a consecutive series of patients who presented with a painful cutaneous neuroma secondary to direct trauma or surgery. The diagnosis was made by the presence of neuropathic symptoms in the dermatome of a cutaneous nerve and a positive Tinel sign. Local anaesthetic injection was performed for confirmation of diagnosis. Each patient was offered optimisation of medical therapy and physiotherapy for desensitisation. Outpatient neuromodulation was offered as an alternative to neuroma surgery. The primary aim of treatment was symptom reduction such that neuroma surgery was no longer required. Results: This study included 50 patients with painful cutaneous neuromas. Surgery was the commonest cause. The most frequently injured nerves were superficial radial nerve, digital nerve and dorsal ulnar cutaneous nerve, together comprising over 60% of cases. After receiving neuromodulation, 18 (36%) patients experienced sufficient symptom relief and did not wish to pursue neuroma surgery. Conclusions: Surgery is the commonest cause of a painful cutaneous neuroma. Following optimisation of pharmacotherapy and physiotherapy, neuromodulation may offer symptom relief such that neuroma surgery may be avoided in approximately one third of cases.

Fascial Manipulation Technique in the Conservative Management of Morton's Syndrome: A Pilot Study.

Background and Objective: Morton’s syndrome (MS) is a common cause of neuropathic chronic forefoot pain, characterised by the development of a swelling of the common digital plantar nerve, whose aetiology is not fully known. There is currently no gold standard of treatment; nonoperative management commonly involves manual therapies, orthoses therapy and infiltrative techniques, while surgery is indicated after failure of conservative measures. The present preliminary study prospectively evaluates patients affected by MS treated by Fascial Manipulation technique (FM), a noninvasive manual therapy, focused on the release of the deep fascia, reducing its stiffness. Materials and Methods: Patients with clinical and sonographic diagnosis of MS with at least a 4-month history of neuropathic symptoms underwent a cycle of three weekly FM sessions. Clinical follow-up, including VAS and AOFAS scores, was performed 21 days (T1) and 3 months (T2) after treatment. Results: Nine patients, among 28 recruited initially, completed the manual therapy sessions and relative follow-up points. This noninvasive pain treatment led to significant improvement of VAS (p = 0.0034) and AOFAS scores (p = 0.0240) at the first follow-up (T1). At 3-month follow-up (T2), both scores decreased slightly, remaining however superior to the pre-treatment values. Only VAS was still significant (p = 0.0184). Conclusions: Despite the small size of the case series, this pilot study is unique in supporting Fascial Manipulation in the nonoperative treatment of MS. Further studies are needed with a large cohort of gender balanced patients to confirm the encouraging results obtained.

Long-term sensibility outcomes of secondary digital nerve reconstruction with sural nerve autografts: a retrospective study

BackgroundRecovery of sensibility after digital nerve injury is crucial for restoring normal hand function. We evaluated long-term outcomes of digital nerve reconstruction with autografts.MethodsThis retrospective study included patients who underwent secondary reconstruction of digital nerves with nerve autografting. Recovery of sensibility was evaluated based on the following: patient self-assessment, two-point discrimination (2PD), and a total sensation score (sum of proprioception, temperature sensation, and sharp/dull discrimination). Mixed models regression was used to study predictors of sensibility outcomes. The predictors analyzed were age, sex, smoking status, number of fingers involved in a patient (as a measure of injury severity), time to reconstruction, and time to follow-up.ResultsIn 61 patients, 174 digital nerves in 126 fingers were reconstructed after an average of 33.1 weeks from injury. The mean follow-up was 6.4 years from reconstruction. The mean graft length was 3.6 cm. Self-rated sensibility in the affected area was very good in 13% of patients, good in 33%, satisfactory in 40%, and poor in 24%. 2PD at 6 mm was present in 17% of patients, at 10 mm in 12%, and at 15 mm in 18% (mean 2PD was 10.8). Proprioception was preserved in 107 (85%) fingers, sensation of temperature was preserved in 99 (75%) of fingers, and sharp/dull discrimination in 88 (70%) fingers. Time from injury to reconstruction was the only significant predictor of the total sensation score.ConclusionOur data indicate that earlier reconstruction is associated with a favorable outcome.

WS7.5. Neuromuscular ultrasound of the lower extremities

Neuromuscular ultrasound is rapidly evolving as an excellent diagnostic tool in the evaluation of peripheral neuropathies, especially so in focal neuropathies. It can be of use in understanding the underlying pathological mechanism of neuropathies. Focal neuropathies are more likely to be associated with structural abnormalities that can be easily recognized by imaging modalities. Certain subtypes of polyneuropathies are also associated with morphological changes. Point of care ultrasound helps with rapid examination of long segments of multiple nerves in the out-patient setting. This can result in early triaging of patients and rapid management decisions. Other advantages include easy patient tolerability when compared to nerve conduction studies and lower cost. The sonographic abnormalities that are commonly associated with neuropathies include focal or diffuse enlargement, hour-glass constriction, change in neural architecture, decreased mobility of the nerve and increased vascularity of the nerves. It can also be of use in detecting extra-neural abnormalities like tenosynovitis, soft tissue tumors, entrapment or compression from metallic implants. Peripheral nerves of the lower extremities that can be commonly assessed by sonographic studies include the sciatic, peroneal and tibial nerve. Other less common nerves that are assessed include the lateral femoral cutaneous nerve, the superficial and deep peroneal nerves and the sural nerves. It can also be of value in the evaluation of the digital nerves in the feet. Clinical conditions where sonographic studies can be of paramount importance include evaluation of the peroneal nerve at the fibular head in patients presenting with foot drop and assessment of the tibial nerve in the tarsal tunnel in those presenting with unilateral foot numbness. Its use as a diagnostic tool has extended beyond focal neuropathies to include polyneuropathies secondary to metabolic, inherited and inflammatory causes. Other uses of lower extremity ultrasound include its role as a tool in guiding with therapeutic interventions like steroid injections and detection of morphological changes within cutaneous nerves prior to consideration of nerve biopsy.

Use of a Percutaneous Needle Release Technique for Trigger Thumb: A Retrospective Study of 11 Patients from a Single Center.

BackgroundTrigger finger is a very common disorder that occurs in both adults and children. Trigger finger presents mainly as pain and limited movement of the affected digit. This report describes a modified percutaneous needle release and an evaluation of its clinical efficacy to treat trigger thumb.Material/MethodsTrigger thumb of 11 patients was released percutaneously using a specially designed needle (0.8×100 mm) with a planus tip. Complete release was ensured when no more grating sound was heard and the needle moved freely at the tip. Pain-related functional score was evaluated preoperatively and at 3 months postoperatively. Resolution of Notta’s node, triggered or locked, Quinnell’s criteria, and patient satisfaction were also assessed at 3 months after the operation.ResultsAfter the percutaneous trigger thumb release, the overall visual analog scale (VAS) and pain-related functional scores declined significantly (P<0.01). There was no recurrence of thumb locking or triggering or Notta’s node. Only the first patient had incomplete release of the first annular pulley, and all patients showed high satisfaction with the procedure at 3 months after their operation. During the study, patients did not experience any complications such as inflammation, edema, or digital nerve injury.ConclusionsThis study demonstrated that the percutaneous technique is effective, less time-consuming, and safe for treating trigger thumb. Our release technique using a specially designed percutaneous needle is a valuable treatment for trigger thumb.

Metabolic syndrome and anthropometric indices in CTS hands: an electrophysiological study.

This study aims to evaluate the effect of metabolic syndrome (MetS) and anthropometric indices on carpal tunnel syndrome (CTS). Forty-three healthy controls and 41 CTS patients were enrolled. Complaints of patients were assessed by Boston Questionnaire (BQ). MetS components were investigated. Wrist circumference, wrist depth, wrist width, palm width, and palm length were measured. Routine nerve conduction studies of median and ulnar nerves as well as the "sensitive" comparison tests were performed. Cutaneous silent period (CuSP) was studied by stimulating both second and fifth digital nerves while recording over thenar muscles. The vast majority of the participants were female and right-handed. CTS was bilateral in 61% of patients. Data of 109 hands were analyzed. MetS was more frequent in CTS patients. BQ scores were not related to MetS. Waist circumference, serum TG, and fasting glucose levels were higher in CTS patients. CTS hands with MetS had lower median CMAP amplitudes and increased sensory thresholds. Sensory thresholds were increased with both median and ulnar nerve stimulations suggesting a wider spread of peripheral nerve excitability changes in MetS presence. CuSPs were recorded from all 109 hands. CuSP latencies and durations were similar between controls and CTS patients. Wrist ratio was the only anthropometric index that was a statistically significant predictor for CTS development. MetS was more prevalent in CTS patients. Some clinical and electrophysiological features (mainly sensory thresholds) may worsen in presence of MetS, but not the wrist ratio.

Surgical Management of Macrodystrophia Lipomatosa, a rare case report of the left hand middle finger macrodactyly

IntroductionMacrodystrophia Lipomatosa is a rare congenital non-hereditary disorder, characterized by the presence of gigantism of a small part of the limb or the whole limb due to an overgrowth and disproportionate growth of fibroadipose tissue, causing macrodactyly.Case presentationOne case of the 14-year-old girl presented with an enlarged middle finger of her left hand since birth, discomfort during the last 6 months, and resistance to flex, was underwent surgery by performing debulking procedure and a yellow cord-like mass was obtained from the digital nerve covered and enlarged by fibrofatty tissue to the palm area, could be cut off completely. Imaging and histopathological examination revealed to macrodystrophia lipomatosa. We follow up the patient for the finger's range of motion, the neurological disturbance and re-enlargement of the tumor.DiscussionSince there were compression of the nerves, functional impairment due to enlarge fingers and cosmesis problems, the surgery was indicated. Types of surgery may include debulking of soft tissue, especially adipose tissue. The mass size was decrease, motor function and movement of the middle finger were normal post operatively, but sensory deficits persisted according to the distribution of the digital nerves. Three months and six years after surgery, no enlargement of the middle finger, normal motor function, normal finger movements but sensory deficit still persisted according to the distribution of the digital nerves.ConclusionSurgical management in macrodactyly due to macrodystrophia lipomatosa of the finger give the satisfactory result.

Adjuvant Drugs for Peripheral Nerve Blocks: The Role of NMDA Antagonists, Neostigmine, Epinephrine, and Sodium Bicarbonate.

The potential for misuse, overdose, and chronic use has led researchers to look for other methods to decrease opioid consumption in patients with acute and chronic pain states. The use of peripheral nerve blocks for surgery has gained increasing popularity as it minimizes peripheral pain signals from the nociceptors of local tissue sustaining trauma and inflammation from surgery. The individualization of peripheral nerve blocks using adjuvant drugs has the potential to improve patient outcomes and reduce chronic pain. The major limitations of peripheral nerve blocks are their limited duration of action and dose-dependent adverse effects. Adjuvant drugs for peripheral nerve blocks show increasing potential as a solution for postoperative and chronic pain with their synergistic effects to increase the duration of action and decrease the required dosage of local anesthetic. N-methyl-d-aspartate (NMDA) receptor antagonists are a viable option for patients with opioid resistance and neuropathic pain due to their affinity to the neurotransmitter glutamate, which is released when patients experience a noxious stimulus. Neostigmine is a cholinesterase inhibitor that exerts its effect by competitively binding at the active site of acetylcholinesterase, which prevents the hydrolysis of acetylcholine and subsequently retaining acetylcholine at the nerve terminal. Epinephrine, also known as adrenaline, can potentially be used as an adjuvant to accelerate and prolong analgesic effects in digital nerve blocks. The theorized role of sodium bicarbonate in local anesthetic preparations is to increase the pH of the anesthetic. The resulting alkaline solution enables the anesthetic to more readily exist in its un-ionized form, which more efficiently crosses lipid membranes of peripheral nerves. However, more research is needed to show the efficacy of these adjuvants for nerve block prolongation as studies have been either mixed or have small sample sizes.