Left Anterolateral Thigh Research Articles

Navigation-guided endoscopic lumbar decompression on foramen and lateral recess in advanced scoliosis.

An 84-year-old woman presented with left leg radiating pain for 18 months and a numeric rating scale score of 8. From examination, motoric on left knee extension was grade 4, with dysesthesia and numbness along the left anterolateral thigh. Imaging showed left L3-4 foraminal and lateral recess stenosis with severe-degree scoliosis. The patient underwent navigation-guided endoscopic transforaminal foraminotomy and lateral recess decompression on the left L3-4 level with a good outcome. Three-years' follow-up showed a well-maintained clinical outcome and coronal sagittal balance. This video explores navigation-guided endoscopic lumbar decompression for neural compression in advanced scoliosis. Further research is encouraged to establish long-term efficacy. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23195.

A Rare Cause of Anterior Thigh Pain

BACKGROUND: Anterior thigh pain is frequent in rugby players, and hematomas are common. Most occur due to trauma; however, if swelling occurs with no mechanism of injury, these should always be investigated. CASE PRESENTATION: A 17-year-old male presented with a 6-month history of left anterolateral thigh pain and swelling with no mechanism of injury. Examination revealed that the area was hot to touch, no wounds were visible, and the patient reported no night pain or fever. He was urgently referred where an x-ray showed no findings, and then subsequently discharged. On recommendation from the original referring clinician, an ultrasound scan was ordered, which showed a 4.5-cm foreign body causing an infection. OUTCOME AND FOLLOW-UP: Subsequent surgery removed a twig with thorns from the area. The pain was relieved, and he returned to rugby 3 weeks later with no further complications. DISCUSSION: This case is a unique presentation of anterolateral thigh pain and highlights the importance of referral and follow-up when things do not fit a clinical picture. JOSPT Cases 2023;3(4):245-248. Epub 11 October 2023. doi:10.2519/josptcases.2023.11904

Posteriorly migrated epidural lumbar disc extrusion with contralateral neurodeficit: An unusual presentation

Abstract The posterior epidural migration of lumbar disc herniation is a rare condition, and the overall reported incidence is 0.4%–1.04%. Most of these cases present with cauda equina syndrome or polyradiculopathy on ipsilateral side. We report a case of posterior epidural migration of lumbar disc causing contralateral neurodeficit. A 66-year-old gentleman presented with axial pain radiating to the left anterolateral thigh since 15 days after heavy weight lifting. Neurological examination revealed hypoesthesia over left L3 dermatome and left knee extensor weakness (Medical Research Council grade 3/5). Magnetic resonance imaging with contrast showed L2–L3 right-side extruded disc fragment migrated posteriorly in epidural space. Contralateral monoradiculopathy was an unusual presentation. Interlaminar decompression and discectomy were able to achieve complete neurological recovery at three months. To the best of our knowledge, this is the second case with contralateral neurodeficit due to posteriorly migrated lumbar disc herniation.

Ultrasound-guided treatment of meralgia paresthetica: case report

Meralgia paresthetica (MP) or so-called as lateral femoral cutaneous nerve (LFCN) entrapment is a mononeuropathy characterized by a localized area of paresthesia, dysesthesia, tingling, burning, and numbness on the anterolateral aspect of the thigh, between the inguinal ligament and the knee without associated loss of reflexes and motor weakness. The incidence of MP increases with obesity and diabetes. Ultrasound-guided has been demonstrated useful for visualization of peripheral nerves, in particular very small nerves such as the LFCN. Hereby, we reported a case of 63-year-old man diagnosed with MP. The patient complained of numbness, and no pain when pinched in his anterolateral aspect of the left thigh since 3 weeks ago. On physical examination, his body mass index (BMI) was 27 (overweight) with normal vital signs. Neurological examination revealed normal motoric function and refleks; but decreased sensation to pinprick in the left anterolateral thigh in the LFCN distribution. No abnormal findings on plain radiographs of the pelvis and lumbar spine. Ultrasound-guided injection was performed in this patient.

Dermatofibrosarcoma protuberans of perianal region: a rare case report

Dermatofibrosarcoma protuberans (DFSP) is a rare locally aggressive slow growing soft tissue sarcoma with very low metastatic potential with high local recurrence rates. We presented a rare case of DFSP of left perianal region ulcerating into anal canal, we did wide excision with 3 cm margin along with abdominoperineal excision of rectum and permanent colostomy, defect is reconstructed with left pedicled antero-lateral thigh flap. DFSP has high chance of recurrence, it should be excised with at least 2-3 cm 3D margin and patient should be followed up for a long time.

Avascular necrosis of the femoral head following an occult femoral neck stress fracture

Introduction. Osteonecrosis (ON) of the femoral head (FH) ? (ONFH) is an intractable disease that causes progressive femoral head collapse, severe pain, and gait disturbance. We report a case of avascular necrosis of the femoral head following an occult femoral neck (FN) stress fracture. Case report. A 55-year-old woman presented to our department with a chief complaint of low back pain that radiated into the left anterolateral thigh over the period of two months. Her left anterolateral thigh became progressively more painful over the past two weeks. No abnormal findings indicative of ONFH or an occult fracture of the FN were detected by X-ray or computed tomography, but an occult insufficiency fracture of the left FN was identified on magnetic resonance imaging (MRI). The diagnosis of FN stress fracture was delayed, resulting in femoral head necrosis. The fracture was treated with total hip arthroplasty, and the resected FH was subjected to histopathology (HP). Based on the HP findings, the final diagnosis of this case was ONFH with an occult fracture of the left FN. Clinical symptoms were relieved postoperatively. Conclusion. An early MRI examination is recommended in patients presenting with a suspected stress fracture of the FN to avoid FH necrosis due to a delayed diagnosis.

A tricky trochanter

A 24-year-old previously well female presented with a discharging thigh abscess after travel to Ghana. She reported malaise but was otherwise systemically well. Further history revealed 2 years of intermittent left thigh pain, which had been attributed to a large trochanteric bursa identified on ultrasound in 2017. On examination she was afebrile with a deep, undermined ulcer discharging pus in the left antero-lateral thigh. Femoral X-ray was unremarkable. She underwent surgical debridement and intra-operatively infection was found to track to the greater trochanter. Tissue specimens grew Gemella morbillorum, Klebsiella pneumoniae, Enterobacter cloacae, Streptococcus anginosus and mixed anaerobes. She responded well to 4 weeks of ciprofloxacin, metronidazole and amoxicillin. Histological examination of the ulcer edge revealed non-necrotising granulomata (Ziehl-Neelsen stain negative).Mycobacterium tuberculosis(MTB) was subsequently isolated on mycobacterial culture from the same site. MRI demonstrated osteomyelitis of the greater trochanter with a 2cm intramedullary abscess and an adjacent soft tissue collection. Macroscopically caseous material was found on further debridement and tissue samples were AAFB smear negative but MTB complex was detected by PCR and culture of intra-medullary bone. This case demonstrates that bacteria and mycobacteria may be co-pathogens, and that M. tuberculosis bone infection may present with no systemic symptoms. It is a reminder of the importance of cross-sectional imaging and mycobacterial culture in deep soft tissue infections with a long or unusual history.

Extensive Degeneration of Vertebral Body Leading to Baastrup's Disease: A Radiographic Review of an Image.

Baastrup’s disease, known colloquially as “kissing spine disease”, is a degenerative process, most commonly occurring in the lumbar spine, in which adjacent spinous processes closely approximate or even touch (Filippiadis et al. in Insights Imaging. 10.1007/s13244-014-0376-7, 2015). We present the case of an 86-year-old woman presenting with left low back, hip, and anterolateral thigh pain. Magnetic resonance imaging noted an approximation of the L2/3 spinous processes, with degeneration of the vertebral processes. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors. Informed consent for publication was obtained from the participant.

13. Idiopathic inflammatory myopathy, everything it should not be: asymmetrical, normal CK, high fever

IntroductionMyositis can be infective, metabolic or immune-mediated. Idiopathic inflammatory myopathy, which is immune-mediated, tends to be subacute, with symmetrical symptoms, overlap clinical features and positive autoimmune serology. We present a case of acute onset lower limb seronegative inflammatory myopathy with a normal creatinine kinase (CK), a marked acute phase response that responded promptly to immunomodulatory therapy.Case descriptionA 68-year-old man presented with a 2-week history of lower limb pain with subjective weakness, on a background of well-controlled type 2 diabetes mellitus and hypertension. He was admitted with worsening symptoms of marked left thigh pain, night sweats, and fevers.On admission, he had swinging pyrexia (above >39 °C) while remaining haemodynamically stable. He had focal tenderness over the left anterolateral thigh, with a good range of movement, normal power and no signs of focal collection or cellulitis. There were no extra-muscular features to suggest systemic infection or overlap connective tissue disease.Bloods showed C-reactive protein (CRP) 225, normal CK 212 and negative blood cultures. X-rays knee, femur and pelvis were normal. Magnetic resonance imaging (MRI) on T2, fat-suppressed STIR sequences demonstrated increased signal/oedema both thighs throughout the anterior muscle compartment and along the fascial plane, notably most severe in the left vastus lateralis. He was treated empirically for infective myositis. Despite 14 days of broad-spectrum antibiotics, he remained febrile with persistently elevated CRP. There was no focal collection, lymphadenopathy or occult malignancy on CT abdomen and pelvis. Trans-oesophageal echocardiogram showed no evidence of infective endocarditis but revealed incidental moderate aortic stenosis.The patient described persistent now bilateral thigh pain with continued normal CK and high CRP. Full autoimmune screen (ANA, ANCA, ACE and complement studies) was negative. Despite negative nuclear and cytoplasmic HEp-2 immunofluorence, extended myositis immunoblot was negative. Muscle biopsy from the left vastus lateralis demonstrated inflammation within the perimysium and perivasculature. In view of biopsy findings and no response to anti-microbial therapy, prednisolone (0.5mg/kg) with significant clinical response (resolution of fever and pain) with concurrent normalisation in CRP. The patient remains in remission following steroid reduction with no additional immunomodulatory therapy required.DiscussionWe report a case of idiopathic inflammatory myopathy presenting with predominantly asymmetrical symptoms, normal CK, marked inflammatory response and negative myositis autoantibodies. Diagnosis was confirmed on MRI and muscle biopsy. The normal CK can be explained by the histology demonstrating inflammation in perivascular regions and around muscle fibres, rather than inflammation or necrosis in the muscle fascicles and fibres themselves. Idiopathic inflammatory myopathy including sporadic inclusion-body myositis, dermatomyositis, overlap CTD myositis and polymyositis/necrotising myopathy subsets are distinguishable based on clinical features, autoantibodies, MRI and biopsy features. The table below summarises the atypical aspects of this case. Differential diagnoses for this case include atypical infection, sarcoid myopathy and amyloid myonecrosis secondary to diabetes. Table: Features of typical idiopathic inflammatory myopathy compared with this atypical case.Idiopathic inflammatory myopathiesOur patient- typical featuresOur patient- atypical featuresSymptomsPain, fever, weakness.Pain and fever.Normal power.Clinical distributionSymmetrical, proximal muscle groups.Predominantly asymmetrical (worse on left), only in thighs.AntibodiesMyositis associated autoantibodiesSeronegativeMuscle enzymesElevated CKNormal CK.Inflammatory markersNormal to slightly elevated CRPMarkedly raised CRP and WCC.MR imaging resultsFocal muscle oedema in affected musclesDiffuse and speckled muscle oedemaKey learning pointsEarly idiopathic inflammatory myopathy can have inflammation around the muscle fascicles in the perimysium. Normal CK does not rule out a diagnosis of idiopathic inflammatory myopathy.Idiopathic inflammatory myopathies can present atypically with fevers >39 °C, significantly raised inflammatory markers, and asymmetrical symptoms and MRI findings.In the absence of overlap features, normal CK and negative serology, MRI and biopsy can delineate the type of myositis and direct management.Conflicts of interestThe authors have declared no conflicts of interest.

Reconstruction of a subtotal upper lip defect with a facial artery musculomucosal flap, kite flap, and radial forearm free flap: a case report

BackgroundFor reconstructive surgeons, massive midface defects, including large, full-thickness wounds on the upper lip, can be very challenging. Although there are many methods for reconstruction of upper lip defects, it is difficult to obtain satisfactory restoration of oral functions and good cosmetic results.Case presentationThis case report presents a man with massive midface defects, including upper lip, left nose, and cheek defects. Over the previous 2 years, the patient had three reconstructions with sequential free flaps for the resection of recurrent tumors, the first of which was in March of 2016; this resulted in the patient having massive midface defects, including an upper lip defect, a defect on the left side of the nose, and one on the left cheek. The defects were reconstructed using a radial forearm free flap (RFFF), a facial artery musculomucosal (FAMM) flap, and a kite flap. In June 2016, he underwent a second reconstruction, this time of the left nose defect, using a left anterolateral thigh (ALT) flap. In March of 2017, the patient underwent a third reconstruction with the use of a free ALT on the left intraoral cheek and the defects on the neck. All flaps survived. No complications were encountered postoperatively. The patient regained good oral sphincter function with no reports of drooling. Although the patient underwent three surgeries, the reconstruction results were acceptable.ConclusionsFor massive midface defects, including large, full-thickness wounds on the upper lip, the combination of a FAMM flap, kite flap, and RFFF promotes the reconstruction of the complex midface structure and improves the resulting functionality.

Repair of a soft tissue defect of medial malleolus with cross-leg bridge free transfer of anterolateral thigh muscle flap: a case report

A 38-year-old man sustained a traffic accident injury to his right medial malleolus and leg. It was an open fracture of the right tibia and fibula accompanied by a large soft tissue defect of the right medial malleolus sized 12 cm multiply 4 cm. Doppler examination revealed that the tibialis posterior vessel was occluded due to thrombosis. The anterior tibial artery was patent. Three weeks after injury, the left anterolateral thigh muscle flap was harvested and transplanted to the right medial malleolus defect area for repair of the soft tissue defect, and an end-to-side anastomosis was performed between the posterior tibial vessel of the contralateral leg and the muscle flap's vascular pedicle. A split thickness free skin graft was used to cover the muscle flap and around the flap's vascular pedicle. The vascular pedicle was cut off after 28 days and the muscle flap survived completely. After 3-year follow-up postoperatively, the right tibia and fibula fractures were confirmed healing radiologically. The posterior tibial artery of contralateral leg was patent by clinical and Doppler examinations. This technique can be used to preserve the flow and patency of recipient arteries.

Safety and immunogenicity of the DTP/HB /Hib combination vaccine: phase I study

Background The World Health Organization (WHO) hasrecommended the introduction ofhepatitis B (HB) and Haemophilusinfluenza type b (Hib) vaccines into routine childhood vaccinationprograms. A new diptheria/tetanus/pertussis (DTP) /hepatitis B/Hibpentavalent combination vaccine has been developed.Objective To evaluate the safety and immunogenicity of a newcombination DTP/HB/Hib liquid vaccin e in infants.Met hods An open-label, uncontrolled, prospective interventionphase I study was con ducted on 30 healthy infants aged 6- 11weeks. Each subject received 3 doses of DTP/HB/Hib vaccine,formulated by Bio Fanna, 0.5 mL intramuscularly at the leftanterolateral thigh region using a 25-gauge n eedle of 25 mmlength . Subjects were followed for 1 month after administration ofeach vaccine dose to evaluate its safety, while serum anti-diphteria,tetanus, HB, Hib, and per tussis antibodies were measured priorto the l '' dose and 1 month after the Jtd dose.Results Among 30 vaccinated subjects, 18 infants had fever within24 hours after the first vaccination. Most cases of fever were mildin intensity and resolved within 24 hours. No other systemic orlocal reactions, or serious adverse events were observed in oursubjects during the study. The immunogenicity results after Jtdvaccine dose showed that the geometric mean titer of the antipolyribosylribitolphosphate (PRP) antibody levels increasedsignificantly from 0.0041μ,g/mL to 4.3 7 μ,g/mL after vaccination,and most infants h ad a fourfo ld or greater rise in antibody levelsover their pre-injection levels . All subjects who received DTP/HB/Hib liquid vaccine had seropro tective antibodies againsttetanus, diphtheria,a and hepatitis B, while 29/30 infants hadseroprotective antibodies against pertussis.Conclusion This new diphtheria/tetanus/pertusis/hepatitis B/Hibcombination vaccine has excellent safety profile and antibodyresponses in infants. These results encourage further clinicalevaluation in phase II.

Emergency department diagnosis of a quadriceps intramuscular loculated abscess/pyomyositis using dynamic compression bedside ultrasonography

IntroductionA 73-year-old man with a past medical history of myelodysplastic syndrome and recent chemotherapy presented to the emergency department with a 1-week history of progressively increasing left thigh pain and swelling. His physical examination revealed left anterolateral diffuse thigh swelling with no erythema or warmth to palpation. The anterolateral quadriceps was markedly tender to palpation. Emergency department bedside dynamic compression ultrasonography that was performed on the left anterolateral thigh revealed a quadriceps intramuscular abscess with loculated yet movable pus.ConclusionBedside dynamic compression ultrasonography can assist the emergency or critical care physician in the diagnosis of quadriceps intramuscular abscess or pyomyositis.

“Donʼt Let Your Flap Get HITT”

INTRODUCTION: Heparin induced thrombocytopenia and thrombosis (HITT) may compromise the success of microsurgical procedures. In 2009, the Plastic Surgery team at the Montreal General Hospital treated a patient suffering from a chronic 8x9cm wound of the right medial malleolus. The wound was treated with a left anterolateral thigh perforator free flap complicated by multiple thrombotic events. Despite multiple salvage attempts including thrombolysis, popliteal AV loop, and a second free flap procedure, all microvascular attempts at correction failed. HITT was diagnosed six days postoperatively, and due to the significant impact of HITT on this flap, we reviewed literature and found few reports describing HITT in microsurgery. We present a comprehensive review of HITT in microsurgery and how HITT might be identified earlier to promote improved flap viability. METHODS: We performed a literature review (PUBMED, MEDLINE, Cochrane Reviews) to determine how HITT affects flap viability. RESULTS: HITT is estimated to occur in up to 5% of patients treated with heparin. HITT could also be under-diagnosed, highlighting the importance of recognition of HITT in plastic surgery. Suspicion of HITT should prompt immediate cessation of heparin and implementation of non-heparin anti-coagulants. Of the 7 diagnosed cases of HITT in free-flaps we reviewed, only one reported flap salvage, likely due to immediate substitution of heparin with agatroban therapy. CONCLUSION: HITT is a significant threat to free-flap survival. In patients with thrombotic events, previous heparin exposure, and post-operative decline of platelets, HITT should be considered as a cause of failing flaps. We recommend using the “4T” algorithm to assess pre-test probability of HITT, and to measure CBC counts daily after flap placement to follow platelet levels. On suspicion of HITT, heparin treatment should be discontinued and replaced with an alternative anti-coagulant such as agatroban or lepirudin to enhance flap viability and reduce patient mortality.

Comparison of Complications of Anterolateral and Lateral TransPsoatic Retroperitoneal Approaches to the Th12-L5 Intervertebral Disks. Experience with 208 Patients

Introduction Anterior lumbar interbody fusion using supportive cage is a common surgical method for treating degenerative lumbar spinal diseases. Improved surgical techniques and better results have led to renewed interest in this procedure and to the development of new lateral transPsoatic minimally invasive access to the lumbar disks. The aim of this study was to compare the rate of complications during traditional anterolateral and new lateral transPsoatic retroperitoneal approaches to the intervertebral disks (IVD) at levels Th12-L5. Materials and Methods We reviewed all cases of the IVD anterolateral and lateral surgery at level Th12-L5, treated at the Department of Neurosurgery from January 1996 to June 2011. The ALIF (Anterior Lumbar Interbody Fusion) group consisted of 120 patients: 53 women and 67 men, average age 44 years, range 17 to 76 years; and the XLIF (Extreme Lateral Interbody Fusion) group consisted of 88 patients: 50 women and 38 men, average age 51 years, range 17 to 74 years. They suffered from low back pain (LBP) and usually radiculopathy itself and conservative treatment was not effective for a minimum of 6 months. The diagnosis was established using generally accepted methods including history-taking and physical examination, radiography, and magnetic resonance imaging (MRI) of the lumbosacral (LS) spine. The preoperative diagnosis of ALIF group was degenerative disk disease at 39 levels, failed back surgery syndrome (FBSS) at 27, spondylolisthesis at 27, and posttraumatic disk injury at 35 levels. The preoperative diagnosis of XLIF group was DDD at 39, FBSS at 22, spondylolisthesis at 17, retrolisthesis at 5, and posttraumatic disk injury at 9 levels. The whole surgery, including surgical approach in the lateral decubitus position, was performed by an experienced neurosurgical team. The surgical steps in the minimally invasive anterolateral retroperitoneal approach and lateral retroperitoneal transPsoatic approach from the left side to disks Th12-L5 are described. Intraoperatively during XLIF procedure, the surgeon identified the lumbar nerve roots with stimulator to prevent their injury. All surgical intraoperative and postoperative complications directly related to the spinal surgery were documented. Both study groups were compared to each other. Results In both the groups, we had no serious complications such as death, excessive intra- or postoperative bleeding, thromboembolism, infection, visceral injury, injury of ureter or kidney, ileus, retrograde ejaculation, or sterility. In ALIF group, intra- and postoperative minor complications were found in 35 patients (29%), the main intraoperative complication was the necessity to perform sympathectomy of lumbar sympathetic chain to obtain wide access to the disks in 19 patients (16%). For all of these patients with symptoms of sympathectomy the thermography was done as a sensitive test. The main postoperative complications were numbness of left anterolateral thigh or groin or transient pain of left groin in 16 patients (13%). In XLIF group, we had partial and transient injury of L5 nerve root (just the first patient) during implant insertion at level L4/5 (one patient, 1%), without using an intraoperative neuromonitoring (IOM). Since this major complication, we started using IOM strictly and didnát have more nerve injuries. In XLIF group, intra- and postoperative minor complications were found in 20 patients (23%), mainly transient pain of left groin in 11 patients and sympathectomy in 4 patients. At follow-up, we found no hardware failure on X-ray (implant displacement). Total 198 patients were satisfied with the surgery and reported improvement, 10 patients were neither improved nor worsened. Conclusion Rate of minor complications was similar in both groups, in ALIF group 29% and in XLIF group 23% of treated patients. Only one major complication, nerve root injury, was due to underestimation of XLIF procedure in the beginning. Retroperitoneal access and surgery at levels Th12-L5 disk space is a safe procedure when performed by a knowledgeable and experienced spine team. IOM during XLIF surgery is fully recommended. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared Crock HV. Anterior lumbar interbody fusion: indications for its use and notes on surgical technique. Clinical Orthopaedics 1982;165:157–163 Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L. The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. Spine 1995;20:1592–1599 Mayer HM. A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine 1997;22:691–700 Mehren C, Mayer HM, Siepe C, Grochulla F, Korge A. The minimally invasive anterolateral approach to L2-5. Oper Orthop Traumatol 2010;22:221–228 Zdeblick TA, David SM. A prospective comparison of surgical approach for anterior L4-L5 fusion. Spine 2000;25:2682–2687

Meralgia parestésica secundária a laparoscopia cirúrgica para miomectomia. Relato de caso

BACKGROUND AND OBJECTIVES: Meralgia paresthetica is a disesthetic and / or anesthetic syndrome in the distribution of the lateral femoral cutaneous nerve. It is a compressive or traumatic mononeuropathy, characterized by burning pain and / or discomfort in the anterolateral thigh, without motor or muscle strength changes, with preserved reflexes. It has been described after several surgical procedures, including laparoscopies. This study aimed at reporting a case of meralgia paresthetica after gynecological laparoscopy and its treatment, as well as at reviewing relevant literature. CASE REPORT: Female patient, 52 yeas old, submitted to laparoscopic miomectomy who presented in the immediate postoperative period anesthesia in left anterolateral thigh. Seven days later she reported paroxysmal and disesthetic pain and pain at touch in the same topography. She was medicated with analgesics and anti-inflammatory drugs without improvement. After evaluation in the pain outpatient setting, clinical and electroneuromyographic diagnosis of meralgia paresthetica was established and treatment was started with gabapentin. There has been significant symptoms improvement so that 90 days later she presented just occasional paroxysmal pain. CONCLUSION: Meralgia paresthetica is a possible complication of laparoscopic miomectomy, the diagnosis of which is seldom considered. Conservative treatment with α2-δ calcium channel blocker anticonvulsants was effective for this patient.

Treatment of Meralgia Paresthetica with Ultrasound‐Guided Pulsed Radiofrequency Ablation of the Lateral Femoral Cutaneous Nerve

A 23-year-old female with an 18-month history of left anterolateral thigh paresthesias and burning pain consistent with meralgia paresthetica was referred to our clinic after failing trials of physical therapy, nonsteroidal anti-inflammatories, gabapentin, and amitriptyline. We performed 3 lateral femoral cutaneous nerve blocks with corticosteroid over a 4-month period; however, each block provided only temporary relief. As this pain was limiting the patient's ability to perform her functions as an active duty service member, we elected to perform a pulsed radiofrequency treatment of the lateral femoral cutaneous nerve with ultrasound guidance and nerve stimulation. After locating the lateral femoral cutaneous nerve with ultrasound and reproducing the patient's dysthesia with stimulation, pulsed radiofrequency treatment was performed at 42°C for 120 seconds. The needle was then rotated 180° and an additional cycle of pulsed radiofrequency treatment was performed followed by injection of 0.25% ropivacaine with 4 mg of dexamethasone. At 1.5 and 3 month follow-up visits, the patient reported excellent pain relief with activity and improved ability to perform her duties as an active duty service member. ▪

Anterolateral thigh flap harvested from paralytic lower extremity in a patient with late polio sequel

Free flap reconstruction is the treatment of choice after extensive head and neck tumour resection. When treating a patient with a previous disability, such as lower extremity paralysis secondary to poliomyelitis, it is important to offer the best reconstruction whilst preserving healthy extremities. We report the case of a 51-year-old man with a squamous cell carcinoma (SCC) of the right tongue and a left lower extremity paralysis secondary to an acute poliomyelitis during childhood in which reconstruction was successfully achieved with a left anterolateral thigh (ALT) free flap.

Cervical Metastasis in Parotid Squamous Cell Carcinoma

With over half of our patient cohort having neck node metastasis, parotidectomy with simultaneous neck dissection appears to be mandatory for the optimum surgical treatment of this disease. The majority of our patient cohort had primary SCC and did not have facial nerve palsy. One of the 14 patients who had two primary invasive tumours, in the pinna and external auditory meatus, with secondary regional metastasis to the parotid gland. He underwent a left total pinnectomy, lateral temporal bone resection, radical parotidectomy, excision of the temporomandibular joint, type I modified radical neck dissection and reconstruction using a left anterolateral thigh free flap.

Connection between herniated nucleus pulposus and nerve roots in far lateral lumbar disc herniation

Background: Far lateral lumbar disc herniation (FLLDH) compresses the nerve root or dorsal ganglion outside the spinal canal at the same level as the herniation, producing severe pain on the anterolateral thigh. The pain is so severe that many patients cannot even walk. The severity of pain is attributed not only to compression, but also some chemical inflammation. Objective: To report a case of FLLDH whose nerve root was depicted during discography.Case report: A 55-year-old-man presented with severe pain from the left buttock to the left anterolateral thigh and leg. Abnormal shadowing suggested left FLLDH at the L5/S1 level on magnetic resonance imaging. During discography, a shadow suggestive of the left fifth lumbar nerve sheath was depicted. Comparing the computed tomography (CT) after discography and CT after rootgraphy, the root sheath-like shadow on discography was confirmed as the nerve root sheath. After nerve root block, pain decreased and the patient was discharged. Conclusions: The combination of mechanical compression and chemical inflammation by the herniated nucleus pulposus is considered responsible for severe pain in the disc herniation and also in FLLDH. Depiction of the nerve root during discography of FLLDH means that a connection exists between the herniated nucleus pulposus and affected nerve root sheath. Inflammation around the extruded nucleus pulposus penetrates the contacted nerve root sheath; this inflammation is thought to be one of the causes of severe pain in FLLDH. We recommend conservative therapies such as intradiscal or foraminal injection of local anesthetics with steroid for patients with radicular symptoms of FLLDH.