Nerve Distribution Research Articles

Self-maintaining macrophages within the kidney contribute to salt and water balance by modulating kidney sympathetic nerve activity

The kidney is critical in controlling salt and water balance, with the interstitium involved with a variety of components including immune cells in steady state. However, the roles of resident immune cells in kidney physiology are largely unknown. To help unravel some of these unknowns, we employed cell fate mapping, and identified a population of embryo-derived self-maintaining macrophages (SM-MØ) that were independent of the bone marrow in adult mouse kidneys. This kidney-specific SM-MØ population was distinctive from the kidney monocyte-derived macrophages in transcriptome and in their distribution. Specifically, the SM-MØ highly expressed nerve-associated genes; high-resolution confocal microscopy revealed that the SM-MØ in the cortex were in close association with sympathetic nerves and there was a dynamical interaction between macrophages and sympathetic nerves when live kidney sections were monitored. Kidney-specific depletion of the SM-MØ resulted in reduced sympathetic distribution and tone, leading to reduced renin secretion, increased glomerular filtration rate and solute diuresis, which caused salt decompensation and significant weight loss under a low-salt diet challenge. Supplementation of L-3,4-dihydroxyphenylserine which is converted to norepinephrine invivo rescued the phenotype of SM-MØ-depleted mice. Thus, our findings provide insights in kidney macrophage heterogeneity and address a non-canonical role of macrophages in kidney physiology. In contrast to the well-appreciated way of central regulation, local regulation of sympathetic nerve distribution and activities in the kidney was uncovered.

Anatomical analysis of the intramuscular distribution patterns of the levator scapulae and the clinical implications for pain management.

The present study aimed to demonstrate the intramuscular nerve distribution of the levator scapulae muscle that is responsible for pain and to use this anatomic data to propose possible injection sites. Twenty levator scapulae muscles were dissected from 16 Korean embalmed cadavers. The intramuscular nerve distribution of the levator scapulae muscle was identified by whole-mount nerve staining to preserve and stain the nerve fibers without damage. The posterior ramus of spinal nerves C3, C4, and C5 innervated the levator scapulae muscles. When the origin and insertion of the muscle were set to 0% and 100%, respectively, most of the intramuscular nerve terminals were located between 30 and 70%. This area may correspond to the cricoid cartilage of the sixth cervical vertebra. Most intramuscular nerve terminals can be found in the middle and distal portions of the levator scapulae muscle. Our findings improve our understanding of the intramuscular nerve distribution of the levator scapulae muscle and will aid in pain management in clinical practice.

Femoral nerve blockade during endovenous laser ablation of great saphenous vein decreases pain but does not affect the use of opioids during the procedure

BackgroundEndovenous laser ablation (EVLA) using tumescent anesthesia for treatment of an insufficient great saphenous vein (GSV) can be painful and require intravenous pain management and, sometimes, sedation with propofol. Femoral nerve blockade (FNB) anesthetizes the femoral nerve distribution and is usually used for anterior thigh and knee procedures. It is easy to inject with ultrasound guidance because the nerve is easy to visualize in the groin. The aim of the present double-blind, randomized controlled trial was to determine whether FNB before tumescent anesthesia decreases the pain of GSV EVLA combined with local phlebectomy. MethodsEighty patients who underwent GSV EVLA combined with local phlebectomy under tumescent anesthesia were randomized into two groups. The placebo group (control group; 40 patients) was given placebo FNB with 0.9% saline before tumescent injection. The FNB group (intervention group; 40 patients) received 1% lidocaine with adrenaline for FNB before tumescent injection. Only the study nurse, who performed the randomization, knew which patients were in which group. The patients and operating surgeon were unaware of the randomization group. FNB was performed under ultrasound guidance. The effectiveness of anesthesia was tested 10 minutes after injection using the pin-prick test and a numeric rating scale (NRS). The NRS was completed before and during tumescent anesthesia and during EVLA ablation and local phlebectomy. The motor function of the femoral nerve was tested at the end of the procedure and 1 hour after using the Bromage method. Patients had a follow-up visit 1 month after the procedure, and their need for pain medication and the duration of sick leave were recorded. ResultsNo differences were found in the gender distribution, age, or GSV dimensions at baseline. The mean length of the treated GSV segment was 28 cm and 30 cm and the mean energy used was 1911 J and 2059 J in the placebo and FNB groups, respectively. The median NRS score for pain during tumescent injection around the GSV was 2 (interquartile range [IQR], 1-4) in the placebo group compared with 1 (IQR, 1-3) in the FNB group. Very little pain was experienced during laser ablation. The median NRS score was 0 (IQR, 0-0) and 0 (IQR, 0-0.75) in the placebo and FNB groups, respectively. The most painful stage was injection of tumescence to the local phlebectomy sites in both groups. The median NRS score was 4 (IQR, 3-7) in the placebo group and 2 (IQR, 1-4) in the FNB group (P = .01). During local phlebectomy, the NRS score was 2 (IQR, 0-4) vs 1 (IQR, 0-3) in the placebo and FNB groups, respectively. Only the difference in pain during injection of tumescence before local phlebectomy was significant. ConclusionsFNB seems to decrease pain during EVLA combined with local phlebectomy. Patients experienced the highest pain when tumescence was injected before local phlebectomy, and those in the FNB group experienced significantly less pain than the placebo group. No indication for routine use of FNB is indicated. However, it could be used to decrease the pain for patients who experience strong pain during varicose vein surgery, especially if extensive local phlebectomies are required.

Role of Physical Therapy in Trigeminal Neuralgia: A Case With 4-Year Follow-up

BACKGROUND: Trigeminal neuralgia presents with acute stabbing unilateral facial pain along the nerve distribution precipitated by innocuous sensory stimuli. Trigeminal neuralgia can be unrelenting and can lead to severe physical and emotional consequences. Medical and surgical intervention often has adverse effects, and reports of physical therapy treatment are uncommon. CASE PRESENTATION: The patient in this case presented for physical therapy with a history of head/neck surgery, migraines and headaches, joint pain, and depression, with severe sharp shock-like pain aggravated by innocuous oral activity in the trigeminal nerve distribution. Over 10 sessions, she received manual therapy for joint, myofascial, and nerve mobilization, and upper limb stretching and strengthening. OUTCOME AND FOLLOW-UP: Her pain level decreased substantially and interfered with only 1 oral activity at 4-year follow-up. DISCUSSION: Her presentation may inform the differential diagnosis of craniofacial pain. Her management integrating manual therapy with exercise and the positive clinical outcome suggest a new avenue for treatment of trigeminal neuralgia. JOSPT Cases 2023;3(2):119–126. Epub: 13 April 2023. doi:10.2519/josptcases.2023.11446

D61. Management of Recurrent Morton’s Neuromas with Targeted Muscle Reinnervation

PURPOSE: Morton’s interdigital neuroma is a common cause of severe foot pain that is detrimental to quality of life. Current operative interventions for this condition include neurolysis, decompression, or neurectomy, which may result in true neuroma formation, with failure rates reported up to 49%. The objective of this study was to evaluate the efficacy of targeted muscle reinnervation (TMR) for the treatment of Morton’s neuromas that have failed previous surgeries. METHODS: A retrospective chart review was performed between March 2018 and April 2021. Eight patients underwent TMR of the medial plantar nerve (MPN), lateral plantar nerve (LPN), and/or sensory plantar common digital nerves. All patients were non-amputees who had previously undergone surgery for Morton’s neuroma and now had recurrent symptoms. The operative techniques employed for TMR of neuromas in the foot were described, along with post-operative outcomes. RESULTS: Of the 8 patients reviewed receiving TMR for neuroma pain in the foot, all of whom had previously undergone excisions of digital nerve neuromas: 7 patients had complete or near complete resolution of their pain; 1 patient had no improvement upon follow-up. Of the successfully treated group, 4 had complete or near complete resolution of paresthesia, dysesthesia, and other neuropathic signs in the relevant nerve distribution. The remaining 3 had partial improvement of these symptoms. The mean follow-up period was 395 days. CONCLUSION: This study is the first to investigate TMR as a treatment and prevention option for the recurrence of Morton’s neuroma. Our technique revealed good clinical outcomes and no procedure-specific complications.

Postherpetic pruritus successfully treated with Onabotulinum toxin: A case report (P12-10.003)

<h3>Objective:</h3> Postherpetic pruritus is an underreported but significant sequelae of Herpes zoster infection. It can present isolated or in conjunction with postherpetic neuralgia. <h3>Background:</h3> A 78-year-old woman who presented with Shingles in V1 dermatome distribution of the left trigeminal nerve developed postherpetic neuralgia and pruritus. Standard treatment with antivirals resolved the pain but the postherpetic itching persisted. Trials of antidepressant and nerve pain medications such as Duloxetine and Doxepin couldn’t alleviate the symptoms or were not tolerated. Topical corticosteroid cream provided the only relief at the time. However, it induced profound skin thinning. <h3>Design/Methods:</h3> Due to concomitant blepharospasm, the patient was injected with a pattern Onabotulinum toxin targeting the blepharospasm and additional units were added in the areas of pruritus on the scalp and forehead. <h3>Results:</h3> The result was complete resolution of blepharospasm and dramatic improvement of the itching. The symptoms reoccurred a few months later and subsequent treatments with Onabotulinum toxin were performed, and consistently had notable improvement. The only side effect was post injection bruising after the initial injections which subsided rapidly in the days following. <h3>Conclusions:</h3> In conclusion, Botulinum toxin administration might constitute a valuable option for symptomatic relief of postherpetic itching, especially after the failure of first-choice treatment. <b>Disclosure:</b> Ms. Stoilova has nothing to disclose. Mrs. Torres has received personal compensation in the range of $0-$499 for serving as a Panelist with IQVIA. The institution of Dr. Martinez has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Merz. The institution of Dr. Martinez has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biohaven. The institution of Dr. Martinez has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Amgen/Novartis. The institution of Dr. Martinez has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Abbott. The institution of Dr. Martinez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Abbvie/Allergan. The institution of Dr. Martinez has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Abbvie/Allergan. The institution of Dr. Martinez has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Merz. The institution of Dr. Martinez has received research support from Medtronic. The institution of Dr. Martinez has received research support from Boston Scientific. The institution of Dr. Martinez has received research support from Abbvie/Allergan.

Trigeminal Somatosensory Evoked Potentials During Neurosurgical Procedures Using Electrical Stimulation of the Lips Under General Anesthesia.

Background Intraoperative neurophysiology monitoring is rapidly evolving with the advent of newer modalities. Long latency sensory evoked potentials from the trigeminal nerve distribution have rarely been demonstrated during neurosurgical procedures. Trigeminal sensory evoked potential (TSEP) can be used to prevent nerve injury during surgical procedures, such as those for trigeminal neuralgia and tumors involving the trigeminal nerve and pathway. Methodology We attempted to record TSEP from 12 subjects who underwent various neurosurgical procedures with low doses of inhalational anesthetic agents. We stimulated the upper and lower lip and recorded from C6 and Fz locations. We used 14-17 mA current stimuli with a pulse width of 50-150 microseconds and a stimulation rate of2.1 Hz. Results We could obtain a clear, reproducible TSEP response in two out of 12 subjects. We observed a TSEP waveform with negative peaks at 13 and 27 milliseconds and a positive wave at around 19 milliseconds. Conclusions The TSEP produced by the electrical stimulation of the upper and lower lip can be detected from the scalp C5, C6, and Fz area even during neurosurgical procedures, even if inhalational anesthesia was used at induction, but only in a small proportion of cases. It appeared to reflect the activity of trigeminal cortical response. Avoiding the notch filter and turning off the inhalational agents are essential for a good response.

Research advances and trends in the surgical treatment of carpal tunnel syndrome from 2003 to 2022: A CiteSpace-based bibliometric analysis.

Carpal Tunnel Syndrome (CTS) is one of the most common peripheral neuropathies. The typical symptoms are tingling and numbness in the median nerve distribution of the hand. Current treatment for CTS includes general conservative treatment and surgical treatment. Surgical treatment plays a crucial role in the management of CTS, but little bibliometric analysis has been conducted on it. Therefore, this study aimed to map the literature co-citation network using CiteSpace (6.1 R4) software. Research frontiers and trends were identified by retrieving subject headings with significant changing word frequency trends, which can be used to predict future research advances in the surgical treatment of CTS. Publications on the surgical treatment of CTS in the Web of Science database were collected between 2003 and 2022. CiteSpace software was applied to visualize and analyze publications, countries, institutions, journals, authors, references, and keywords. A total of 336 articles were collected, with the USA being the major publishing power in all countries/regions. JOURNAL OF HAND SURGERY AMERICAN VOLUME was the journal with the most published and co-cited articles. Based on keyword and reference co-citation analysis, keywords such as CTS, surgery, release, median nerve, and diagnosis were the focus of the study. The results of this bibliometric study provide clinical research advances and trends in the surgical treatment of patients with CTS over the past 20 years, which may help researchers to identify hot topics and explore new directions for future research in the field.

Origin, course, and distribution of the posterior femoral cutaneous nerve and the spatial relationship among its branches

This study aimed to elucidate the origin, course, and distribution of the branches of the posterior femoral cutaneous nerve, considering the segmental and dorsoventral compositions of the sacral plexus, including the pudendal nerve. The buttocks and thighs of five cadavers were analyzed bilaterally. The branches emerged from the sacral plexus, which was divided dorsally to ventrally into the superior gluteal, inferior gluteal, common peroneal, tibial, and pudendal nerves. It descended lateral to the ischial tuberosity and comprised the thigh, gluteal, and perineal branches. As for the thigh and gluteal branches, the dorsoventral order of those originating from the sacral plexus corresponded to the lateromedial order of their distribution. However, the dorsoventral boundary was displaced at the inferior margin of the gluteus maximus between the thigh and gluteal branches. The perineal branch originated from the ventral branch of the nerve roots. In addition, the pudendal nerve branches, which ran medially to the ischial tuberosity, were distributed in the medial part of the inferior gluteal region. These branches should be distinguished from the gluteal branches; the former should be classified as the medial inferior cluneal nerves and the latter as the lateral ones. Finally, the medial part of the inferior gluteal region was distributed by branches of the dorsal sacral rami, which may correspond to the medial cluneal nerves. Thus, the composition of the posterior femoral cutaneous nerve is considered necessary when considering the dorsoventral relationships of the sacral plexus and boundaries of the dorsal and ventral rami.

Abstract 3630: TrkA+ sensory neurons modulate macrophage phenotype in osteosarcoma

Abstract Introduction: Osteosarcoma (OS) is the most common primary malignancy of the skeleton, and inordinately affects young adults. Despite improved outcomes with current multimodal care, the prognosis for patients with metastatic disease is grim. Peripheral neural regulation of cancer growth has long been suggested by clinical observations in pancreatic and prostate cancers. Prior reports suggest peripheral nerve sprouting in osteosarcoma, but the functional roles of sensory nerves in osteosarcoma are unknown. Here, the role of TrkA+ sensory nerves in OS disease progression was assayed. Methods: All experiments were conducted under IACUC approval at Johns Hopkins University. TrkAF592A mice which are homozygous for a phenylalanine-to-alanine point mutation in exon 12 of Ntrk1 gene were crossbred with NOD scid mice (TrkAF592A/Scid). TrkA inhibition was performed by 1NMPP1 treatment. In vivo tumor growth was examined using a periosteal xenograft model. 1 million human 143B-luc OS cells were injected. Analysis was performed using serial measurements of tumor size and IVIS imaging. Nerve distribution and macrophage polarization within the tumor microenvironment was documented using immunostaining for Beta III Tubulin (TUBB3), CD86, CD206 and F4/80. Results: Inhibition of TrkA led to a significant reduction in Tubb3+ nerves (88.4%) within and around the OS xenografts. In addition, tumors within TrkAF592A/Scid animals demonstrated slower growth, including a 51.5% reduction in tumor size and 60.0% reduction in IVIS luciferase activity at 4 wks. Histologic examination showed a reduction in macrophage infiltration and reprogramming of macrophages from an M2-like to M1-like phenotype in tumors with chemical denervation. Remarkably, this was associated with a reduction in Ki67 proliferative index (80.1%) and CD31 immunofluorescent staining (60.8%) within the tumors. Overall survival of mice with TrkA inhibition was significantly prolonged (p=0.0003). Retrograde tracing identified the sensory nerve fibers innervating the periosteum originated from L3-L5 lumbar DRGs and RNA seq identified OS-derived neurotrophins and axon guidance molecules. Discussion: Disruption of TrkA+ nerves significantly mitigates OS disease progression in a mouse xenograft model, including a significant improved overall survival. These findings are associated with a reduction of macrophage infiltration and macrophage re-polarization. Ongoing studies are examining the molecular mechanisms that mediate nerve-to-macrophage interaction in peripheral nerves and DRG neurons using a combination of sequencing approaches. Significance/Clinical Relevance: Sensory neurons positively regulate osteosarcoma growth and disease progression. Use of chemical or microsurgical approaches to denervate tumors may represent a future adjunctive therapy to both improve pain and prognosis in high grade bone sarcomas. Citation Format: Qizhi Qin, Sowmya Ramesh Ramesh, Thomas L. Clemens, Aaron W. James. TrkA+ sensory neurons modulate macrophage phenotype in osteosarcoma. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3630.

Sensory innervation of the lumbar 5/6 intervertebral disk in mice.

Over the years, most back pain-related biological studies focused on the pathogenesis of disk degeneration. It is known that nerve distributions at the outer layer of the annulus fibrosus (AF) may be an important contributor to back pain symptoms. However, the types and origins of sensory nerve terminals in the mouse lumbar disks have not been widely studied. Using disk microinjection and nerve retrograde tracing methods, the current study aimed to characterize the nerve types and neuropathway of the lumbar 5/6 (L5/6) disk in mice. Using an anterior peritoneal approach, the L5/6 disk of adult C57BL/6 mice (males, 8-12 weeks) disk microinjection was performed. Fluorogold (FG) was injected into the L5/6 disk using the Hamilton syringe with a homemade glass needle driven by a pressure microinjector. The lumbar spine and bilateral thoracic 13 (Th13) to L6 DRGs were harvested at 10 days after injection. The number of FG+ neurons among different levels was counted and analyzed. Different nerve markers, including anti-neurofilament 160/200 (NF160/200), anti-calcitonin gene-related peptide (CGRP), anti-parvalbumin (PV), and anti-tyrosine hydroxylase (TH), were used to identify different types of nerve terminals in AF and their origins in DRG neurons. There were at least three types of nerve terminals at the outer layer of L5/6 AF in mice, including NF160/200+ (indicating Aβ fibers), CGRP+ (Aδ and C fibers), and PV+ (proprioceptive fibers). No TH+ fibers (sympathetic nerve fibers and some C-low threshold mechanoreceptors) were noticed in either. Using retrograde tracing methods, we found that nerve terminals in the L5/6 disk were multi-segmentally from Th13-L6 DRGs, with L1 and L5 predominately. An immunofluorescence analysis revealed that FG+ neurons in DRGs were co-localized with NF160/200, CGRP, and PV, but not TH. Intervertebral disks were innervated by multiple types of nerve fibers in mice, including Aβ, Aδ, C, and proprioceptive fibers. No sympathetic nerve fibers were found in AF. The nerve network of the L5/6 disk in mice was multi-segmentally innervated by the Th13-L6 DRGs (mainly L1 and L5 DRGs). Our results may serve as a reference for preclinical studies of discogenic pain in mice.

MP80-07 MICROSCOPICAL ANALYSIS OF FRESH PROSTATE SPECIMENS: PRELIMINARY FINDINGS ABOUT NERVE DISTRIBUTION ON PROSTATE APEX

MP80-07 MICROSCOPICAL ANALYSIS OF FRESH PROSTATE SPECIMENS: PRELIMINARY FINDINGS ABOUT NERVE DISTRIBUTION ON PROSTATE APEX

MP27-12 FUNCTIONAL ERECTOGENIC NERVE MAPPING OF THE ENTIRE RAT PROSTATE WITH OPTICAL CLEARING

You have accessJournal of UrologyCME1 Apr 2023MP27-12 FUNCTIONAL ERECTOGENIC NERVE MAPPING OF THE ENTIRE RAT PROSTATE WITH OPTICAL CLEARING Selman Unal, Biljana Musicki, Ahmet Hoke, and Arthur Burnett Selman UnalSelman Unal More articles by this author , Biljana MusickiBiljana Musicki More articles by this author , Ahmet HokeAhmet Hoke More articles by this author , and Arthur BurnettArthur Burnett More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003255.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Erectile dysfunction is an important complication of radical prostatectomy (RP) due to cavernous nerve (CN) injury, which is in part a result of the unknown exact distribution of the CN branches (CNBs) on the prostate. We hypothesized that preserving functional pro-erectile CNBs promotes the success of retaining erectile function after RP. The aim of this study was to determine the functional erectogenic nerve distribution surrounding the entire prostate using a rat model. METHODS: Submaximal electrical stimulation of the CN was performed in male rats to induce penile erection by stimulating nNOS phosphorylation on Ser-1412 (functional nNOS). For localization of the P-nNOS (Ser-1412)-containing and nNOS-containing nerves, whole mount immunofluorescence staining was performed on the prostate, using ß-III-tubulin, a non-specific nerve marker, as control. Furthermore, the staining was combined with optical clearing with benzylalcohol/benzylbenzoate (BABB), which removes lipids and minimizes light scattering, allowing imaging of the tissue in situ. Because the BABB clearing technique has not been used previously for the CN or the whole prostate, we first modified it by optimizing stringency of lipid removal. RESULTS: We achieved optimum staining signal and prostate transparency by modification of BABB clearing technique to include shortening dehydration to prevent fluorescence quenching, followed by incubation with tert-butanol and BABB (1:2) at decreased acidity for 1.5 hour (Figure 1a). Microscopic examination localized nNOS and P-nNOS (Ser-1412)-containing cell bodies in the major pelvic ganglia, CN, and CNBs on the prostate. All nerves stained with nNOS/P-nNOS were also stained with ß-III-tubulin (Figure 1b, c). While there was no background noise in ß-III-tubulin staining, a minor signal of the nNOS and P-nNOS (Ser-1412) staining was observed in other tissues such as vascular smooth muscles. CONCLUSIONS: This study presents the first mapping of the pro-erectile nerves, in contrast to all nerves, surrounding the anatomically preserved whole rat prostate. This approach allows a dimensional shift from 2D to 3D histology of the whole intact prostate, providing further information about the distribution of pro-erectile CNBs in penile erection. Source of Funding: This study was supported by the Patrick C. Walsh Prostate Cancer Research Grant. Selman Unal was supported by The Scientific and Technological Research Council of Turkey (TÜBİTAK) for this study © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e366 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Selman Unal More articles by this author Biljana Musicki More articles by this author Ahmet Hoke More articles by this author Arthur Burnett More articles by this author Expand All Advertisement PDF downloadLoading ...

Pain Relief With Peripheral Nerve Stimulation of Superficial Cervical Plexus: A Case Report and Literature Review

BACKGROUND: Neuropathic head and facial pain are relatively common and difficult to treat pain syndromes encountered in pain clinics throughout the world. Atypical syndromes with overlapping nerve distributions can be particularly frustrating for patients and providers. In recent years, as providers search for alternatives to medications, advances in neuromodulation technology, including spinal cord stimulation and peripheral nerve stimulation (PNS), have shown promise in treating neuropathic pain confined to specific nerve distributions, such as the greater and lesser occipital nerves. However, there is limited literature describing the use of PNS for atypical facial pain. We report the first known case of PNS to the superficial cervical plexus in a 45-year-old woman with bilateral ear and postauricular pain. CASE REPORT: A 45-year-old woman presented with over 6 years of bilateral ear and periauricular pain in the auriculotemporal and lesser occipital nerve distribution. Conservative management, including neuropathic pain agents, ketamine infusions, nasal sprays, opioids, nonsteroidal anti-inflammatory medications, ice, heat, and transcutaneous neurostimulation, provided limited relief. She had excellent pain control with a series of nerve blocks to the superficial cervical plexus; however, relief was short term. In an attempt for a more long-term solution, she underwent implantation of the SPRINT PNS (MicroLead, SPR Therapeutics, Cleveland, OH), which resulted in 100% pain relief, improved function at work, and improved sleep tolerance throughout the 60-day treatment. Unfortunately, her symptoms returned shortly after treatment course completion. CONCLUSIONS: To our knowledge, this is the first case utilizing PNS of the superficial cervical plexus to treat atypical facial pain. The 60-day trial resulted in 100% pain relief of previously debilitating and functionally limiting pain symptoms during the treatment phase suggesting that the superficial cervical plexus may be a reasonable target for permanent PNS implants. KEY WORDS: Peripheral nerve stimulator, peripheral nerve stimulation, superficial cervical plexus, atypical facial pain, anesthetic blockade, pain relief, neuropathic pain, neuromodulation, SPRINT

Prevalence of Carpal Tunnel Syndrome and its Associated Risk Factors among Workers of Marble Industries of Abbottabad

Background: Carpal tunnel syndrome occurs when the median nerve that passes through the carpal tunnel is compressed due narrowing of the tunnel at the wrist. Pain, tingling and numbness, at median nerve distribution on fingers and hands are the symptoms of carpal tunnel syndrome.&#x0D; Objective: The objective of this study is to find out the prevalence of Carpal Tunnel Syndrome and its associated risk factors in workers of Marble industries of Abbottabad&#x0D; Methodology: This descriptive cross sectional study was completed within 6 months. A total of 150 workers were recruited to collect the data. Convenience sampling technique was used. inclusion criteria of this study was only industrial workers of age between ages 20-60 years, Work related carpal tunnel syndrome, Only males were included in this study, so convenient sampling approach was applied for data collection within research time period. The exclusion criteria of this study were those who were unable to complete the questionnaire and particularly those who were diabetic along with carpal tunnel syndrome, Women’s are excluded, Neoplasm, Any systemic disease, Peripheral nerve injury. Boston carpal tunnel syndrome questionnaire were used as tool. Data was collected with the help of questionnaire in Abbottabad. Data was collected from Jadoon marble industry, Taj marble industry, Hazara marble industry and Janzib marble industry Data is entered and analyzed using SPSS 20.0.&#x0D; Results: The results of total participant showed age range from 21 to 56, whereas the mean age was 36.52. Prevalence of CTS via Phalen's and Tinnel's test for all the samples was positive for with 11 participant. Statistically, age, work experience and types of work showed significant (P vale&gt;0.05), whereas type of activities had shown highly significant (P value &gt; 0.01) association with CTS. Further, study showed that prevalence of CTS increased with increase in age, experience and increase in force activities.&#x0D; Conclusion: The study concluded that marble factory works who work more for 6 hours or having greater year of work experience, increased age, those using repetitive movements or vibratory tools were at high risk of developing carpal tunnel syndrome. Hence awareness campaign needs to be arranged for marble industries worker about awareness of hands posture and management of carpal tunnel syndrome.

Facial Asymmetry of Italian Children: A Cross-Sectional Analysis of Three-Dimensional Stereophotogrammetric Reference Values

Reference data on the asymmetry of facial thirds of children is still scarce, although it can offer meaningful comparative information for clinical studies. This study aims to provide reference data on the facial asymmetry of Italian children using a 3D analysis of facial thirds divided according to the trigeminal nerve distribution (upper, middle, and lower). A 3D surface-based approach was conducted on the digital models of the faces of 135 children (74 M, 61 F), acquired by stereophotogrammetry. In addition to sex, two different age classes were analyzed (4–8 years and 9–12 years). For each facial third, the asymmetry was expressed as root-mean-square distance (RMS) by calculating the point-to-point distances between the original and the reflected 3D models. A 3-way ANOVA test verified significant differences between the two sexes, the two age classes, and the three facial thirds (p-value &lt; 0.05), and also their interaction. Significant differences were found between the sexes (females were more symmetric, p = 0.005) and the two age groups (younger were more symmetric p &lt; 0.001). According to Tukey’s HSD post-hoc test, among the thirds, the middle one proved to be significantly more symmetrical (p &lt; 0.001). No significant interaction impacting the asymmetry was found when the main factors were considered in any combination. Reference data on the “normal” facial asymmetry of Italian children was provided for further clinical purposes. Normal children have low average RMS values (0.30–0.51 mm) and younger, in particular females, proved more symmetrical than older children, while among the facial surfaces, the middle proved most symmetrical in both sexes, although with little clinical relevance. Since there is no consensus on the amount of symmetry deemed clinically acceptable, further studies on larger randomized samples are auspicial.

Paresthesia Is Predictive of Symptom Recurrence After Fasciotomy for Exertional Compartment Syndrome of the Leg.

Exertional compartment syndrome (ECS) is an underdiagnosed cause of lower extremity pain among athletes. The condition can be managed operatively by fasciotomy to relieve excess compartment pressure. However, symptom recurrence rates after fasciotomy are considerable, ranging from 3% to 17%. Leg paresthesia and its distribution during ECS episodes would be a significant predictor of outcomes after fasciotomy. Retrospective cohort study. Level 4. We conducted a retrospective chart review of patients who underwent fasciotomy for ECS at our center from 2010 to 2020 (institutional review board no. 21-00107). We measured postoperative outcomes including pain frequency and severity, Tegner activity level, and return to sport. Significant predictors of outcomes were identified using multivariable linear and logistic regression. P values <0.05 were considered significant. A total of 78 legs (from 42 male and 36 female participants) were included in the study with average follow-up of 52 months (range, 3-126 months); 33 participants (42.3%) presented with paresthesia. Paresthesia was an independent predictor of worse outcomes, including more severe pain at rest (P = 0.05) and with daily activity (P = 0.04), reduced postoperative improvement in Tegner scores (P = 0.04), and lower odds of return to sport (P = 0.05). Those with paresthesia symptoms in the tibial nerve distribution had worse outcomes than those without paresthesia in terms of preoperative-to-present improvement in pain frequency (P < 0.01), pain severity at rest (P < 0.01) and with daily activity (P = 0.04), and return to sport (P = 0.04). ECS patients who present with paresthesia have worse pain and activity outcomes after first-time fasciotomy, but prognosis is worst among those with tibial nerve paresthesia. Paresthesia among ECS patients is broadly predictive of more severe recurrent leg pain, reduced activity level, and decreased odds of return to sport after fasciotomy.

Three-dimensional visualization of neural networks inside bone by Osteo-DISCO protocol and alteration of bone remodeling by surgical nerve ablation

Bone is one of the largest organ systems in humans and is considered to regulate whole-body homeostasis in cooperation with other organs. We have previously reported that a sympathetic or sensory nervous system inside bone regulates bone homeostasis. However, the detailed regulatory mechanism, including the distribution of nerves inside bone, remains unknown. Although a two-dimensional histological analysis has been widely used to evaluate the structure of nerves or blood vessels, the actual structure is more complex, suggesting that it should be evaluated three-dimensionally. Here, we established a novel bone tissue clearing technique (Osteo-DISCO) for murine bones which enabled us to visualize the detailed distribution of nerves or blood vessels inside bone. Interestingly, we found that there is a specific nerve entry site in each long bone and that surgical ablation of the specific nerve fibers entering bone tissue led to decreased bone formation and impaired bone regeneration. Furthermore, we revealed that the administration of calcitonin gene-related peptide (CGRP), which is primarily released from sensory nerves, suppressed the bone loss caused by surgical nerve ablation. An in vitro study also indicated that CGRP directly promotes osteoblast activity, suggesting that sensory nerves inside bone can regulate osteogenesis via the secretion of CGRP.

Hyperselective neurectomy of thoracodorsal nerve for treatment of the shoulder spasticity: anatomical study and preliminary clinical results.

Hyperselective neurectomy is a reliable treatment for spasticity. This research was designed to quantify the surgical parameters of hyperselective neurectomy of thoracodorsal nerve for shoulder spasticity through anatomical studies, as well as to retrospectively assess patients who underwent this procedure to provide an objective basis for clinical practice. On nine embalmed adult cadavers (18 shoulders), we dissected and observed the branching patterns of thoracodorsal nerve, counted the number of nerve branches, measured the distribution of branch origin point, and determined the length of the surgical incision. Next, we selected five patients who underwent this procedure for shoulder spasticity and retrospectively evaluated (ethic committee: 2022-37) their shoulder function with active/passive range of motion (AROM/PROM) and modified Ashworth scale (MAS). The anatomical study revealed that the main trunk of thoracodorsal nerve sends out one to three medial branches, with the pattern of only one medial branch being the most common (61.1%); there were significant variations in the branch numbers and nerve distributions; the location of thoracodorsal nerve branches' entry points into the muscle varied from 27.2 to 67.8% of the length of the arm. Clinical follow-up data showed significant improvement in shoulder mobility in all patients. AROM of shoulder abduction increased by 39.4° and PROM increased by 64.2° (P < 0.05). AROM and PROM of shoulder flexion increased by 36.6° and 54.4°, respectively (P < 0.05). In addition, the MAS of shoulder abduction (1.8) and flexion (1.2) was both significantly reduced in all patients (P < 0.05). Hyperselective neurectomy of thoracodorsal nerve is effective and stable in the treatment of shoulder spasticity. Intraoperative attention is required to the numbers of the medial branch of thoracodorsal nerve. We recommend an incision in the mid-axillary line that extends from 25 to 70% of the arm length to fully expose each branch.

Diffusion Tensor Imaging of Ulnar Neuropathy Caused by an Accessory Anconeus Muscle.

HomeRadiologyRecently Published PreviousNext Reviews and CommentaryFree AccessImages in RadiologyDiffusion Tensor Imaging of Ulnar Neuropathy Caused by an Accessory Anconeus MuscleTeodoro Martín-Noguerol , Antonio LunaTeodoro Martín-Noguerol , Antonio LunaAuthor AffiliationsFrom the Department of Radiology, MRI Unit, HT Médica, Clínica Las Nieves, Calle Carmelo Torres 2, 23007 Jaén, Spain.Address correspondence to T.M.N. (email: [email protected]).Teodoro Martín-Noguerol Antonio LunaPublished Online:Mar 21 2023https://doi.org/10.1148/radiol.221854MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In A 29-year-old woman presented with complaints of progressive numbness in the left ulnar nerve territory. Physical examination demonstrated left ring and little finger weakness and hypoesthesia with positive flexion elbow test. MRI of the elbow with diffusion tensor imaging (DTI) neurography was performed and revealed extrinsic compression of the ulnar nerve by an accessory anconeus epitrochlearis muscle (Figure). DTI neurography scan showed deformity of the ulnar nerve with corresponding focal decrease in fractional anisotropy (FA) values at the compression site (0.3). FA values were also slightly decreased distally to the compression level (0.41), with normal appearance of the rest of the ulnar nerve (1).MRI scans show the left elbow in a 29-year-old woman with progressive numbness in the left ulnar nerve distribution. (A, B) Axial proton density–weighted images with spectral fat suppression show an accessory anconeus epitrochlearis muscle (arrow) with entrapment of the ulnar nerve (arrowhead). (C) Three-dimensional neurography reconstruction of diffusion tensor imaging with use of directional encoding color fused with proton density with spectral fat suppression shows deformity of the ulnar nerve at the site of extrinsic compression (arrowhead). A focal decrease in the fractional anisotropy values of the ulnar nerve (black arrow) is seen below the level of compression by the anconeus epitrochlearis muscle (white arrow).Download as PowerPointOpen in Image Viewer The anconeus epitrochlearis muscle is an accessory muscle located at the medial aspect of the elbow, originated at the inferior surface of medial epicondyle, and inserted at the medial cortex of the olecranon (2). The relationship between the accessory anconeus muscle and prevalence of ulnar neuropathy remains unknown (3). By providing quantitative information, DTI neurography allows detection of subtle changes in ulnar nerve morphologic conditions (4) and may prove helpful in diagnosis and treatment monitoring in ulnar neuropathy caused by accessory anconeus muscle. In the presented case, the patient was treated conservatively with a favorable clinical outcome.Disclosures of conflicts of interest: T.M.N. No relevant relationships. A.L. Royalties or licenses from Springer; fee to institution as lecturer from GE; Digital Oncology board member for Siemens Healthineers.