Major Nerve Research Articles

Endoscopic Thyroidectomy Through Oro-Vestibular Route (ETOVR)

Nodular goitre is the most common endocrine disease requiring surgical thyroidectomy for its cure. Though surgical exploration is routinely performed through conventional open-neck approach, a wide range of minimal access and minimally invasive endoscopic techniques (gasless and with gas) have been attempted in the past two decades. In this context, we report the feasibility and safety of an innovative transoral endoscopic thyroidectomy technique, which marks a paradigm shift in the endocrine surgery. This is a prospective study conducted at a tertiary care endocrine surgery department in Southern India from May 2016 to November 2018. We employed a novel transoral, lower vestibular route for endoscopic thyroidectomy. All the clinical, investigative, operative, pathological and post-operative data were collected from our prospectively filled proformas. Statistical analysis was performed with SPSS 20.0 version. Descriptive analysis was done. Out of the 604 goitre cases operated during the study period, 123 (20.4%) were operated by this technique. Hemithyroidectomy was performed in 104 and total thyroidectomy in 19 cases respectively. Mean operative time was 124 ± 18 min (100–220). There was extended subcutaneous emphysema on to upper chest in one case. Otherwise, the post-operative course was uneventful with no major morbidity, hypocalcemia, or recurrent laryngeal nerve palsy. All the cases had benign histopathology. We conclude that this novel transoral vestibular route thyroidectomy is a comparably optimal approach for nodular thyroid goitres, especially in benign cases.

Comparing Shape Categorization to Circularity Measurement in the Evaluation of Median Nerve Compression Using Sonography.

This study aimed to develop a subjective categorization of nerve shape and to examine the relationship of shape categorizations to measurement of nerve circularity. Wrists were evaluated with sonography in healthy participants. Images of the median nerve were obtained in the transverse plane at the level of pisiform with the fingers resting, gripping, and pinching. Nerves were categorized as ovoid, angular, or irregular, and the cross-sectional area and perimeter were measured to calculate nerve circularity. Across 167 participants, the median nerve shifted from being primarily ovoid at rest to angular shaped when the fingers were in a full fist or pinching. Approximately three-quarters of subjects exhibited a shape change during dynamic movement. Irregular nerves had the lowest circularity values; however, the majority of nerves had similar circularity measures despite having different shapes. Subjective categorization of shape has the potential to be a valid technique for evaluation of the median nerve using sonography, and this evaluation may provide additional information regarding nerve compression that is not fully captured by a circularity measure. Further investigation is needed to determine how these two techniques may be best used individually or together to advance clinical diagnosis, prevention, and rehabilitative interventions.

Adenoid Cystic Carcinoma.

Sinonasal adenoid cystic carcinoma is a rare malignancy characterized by an insidious growth pattern and a tendency for perineural spread along major and minor nerves, resulting in invasion of the skull base and intracranial extension. Therefore, many patients present with advanced disease and involvement of critical structures, making treatment difficult and potentially associated with high morbidity. Surgery represents the mainstay of treatment of the primary tumor. Complete resection of the tumor with negative margins, whenever feasible, is associated with better survival outcomes. However, in the case of extensive involvement of vital structures (e.g., carotid artery, cavernous sinus, optic nerve, Meckel's cave) or when radical surgery could seriously affect the patient's quality of life, a function-preserving subtotal removal of the tumor followed by irradiation can be proposed. The role of surgery is limited to a biopsy in unresectable lesions that are more suitable for non-surgical treatments (e.g., exclusive chemoradiation). Given the difficulty in obtaining negative margins and the propensity for submucosal and perineural spread, adjuvant radiotherapy is strongly recommended. Recently, heavy-particle radiotherapy using protons or carbon ions has emerged as a promising treatment with improved local control. Local failures (60%) and distant metastases (40%) are common and can occur even decades after definitive treatment. The 5-year overall survival ranges from 55 to 70% and it exceeds that of other sinonasal malignancies, but dramatically drops down at 10 years (40%) and further decreases at 20 years (15%). Therefore, a prolonged follow-up of at least 15 years, and possibly lifelong, is mandatory.

The course of posterior interosseous nerve in the wrist capsule. An anatomical study using the modified Sihler's staining.

Thirty dorsal wrist capsules were collected bilaterally from 15 donors (thirty capsules) within 12 hours of death. By the dorsal incision the capsules were collected in the same manner. The specimens were stained according to the protocol of modified Sihler's staining technique. The preserved capsules were analysed under 8-16× magnification of optical microscope for the presence of major posterior interosseous nerve trunks, their major and minor branches, and nerve connections. Three main types of nerve course were identified within the joint capsule. Type I - the most common, with the presence of a single trunk with the excursion of the first main branch on the radial side, two main branches on the ulnar side, the presence of the prevailing number of small branches on the radial side and the presence of 3-4 branches extending beyond the level of the carpo-metacarpal joints. Type II with the presence of two main nerve trunks, running almost in parallel with the first main branch on the radial side, two main branches on the ulnar side with presence of a predominant number of small branches on the radial side and the presence of 3-4 branches running beyond the level of carpo-metacarpal joints. Type III (least often) with the presence of crossed main nerve trunks. The modified Sihler's staining technique allows for transparent visibility of the nerves innervation the dorsal wrist capsule. However does not allow accurate assessment as histological examination, especially in evaluation of nerve endings, but it gives a significantly larger area of nerve observation.

The efficacy of the "no zone" approach for the assessment of traumatic neck injury: a case-control study.

PurposeRecently, several studies have demonstrated symptom-based, non-zonal algorithms for approaching penetrating neck injuries. The purpose of this study was to confirm the effectiveness of the “no zone” approach in traumatic neck injuries.MethodsMedical charts of patients with traumatic neck injuries who presented at the Regional Trauma Center in South Korea between January 2014 and December 2018 were retrospectively reviewed. Negative final neck findings (FNFs) were compared with positive FNFs (which include major vascular, aerodigestive, nerve, endocrine gland, cartilage, or hyoid bone injuries) using multivariate logistic regression analysis including values of the “zone” and/or no zone approach.ResultsOut of 168 trauma patients, 70 patients with a minor injury and 7 patients under the age of 18 years were excluded. Of the remaining 91 patients, 74 (81.3%) had penetrating neck injuries and 17 (18.7%) had blunt neck injuries. Initial diagnosis most frequently revealed external wounds in zone II (84.6%). Twenty (22.0%) and 36 (39.5%) patients had hard and soft signs, respectively, using the no zone approach. Further, there was a significant difference between the negative and positive FNFs in patients with hard signs (11.6% vs. 54.5%; P < 0.01, respectively). According to the multivariate logistic regression analysis, the hard signs were associated with an odds ratio (OR) for FNFs (OR, 18.92; 95% confidence interval, 3.55–157.60).ConclusionTraumatic neck injuries classified as having hard signs based on the no zone approach may be correlated with internal organ injuries of the neck.

The association between injury severity and psychological morbidity, hand function, and return to work in traumatic hand injury with major nerve involvement: A one-year follow-up study.

We aimed to investigate the association between the severity of the injury and psychological morbidities, hand functions, and return to work (RTW) in traumatic hand injury (THI) with major nerve involvement. Thirty-two patients had THI with major nerve involvement were enrolled in this study. The demographic and clinical characteristics of the patients were recorded after the injury. The severity of the injury was evaluated using the modified Hand Injury Severity Score (MHISS). The Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score and Duruöz Hand Index (DHI) were used to assess the hand function. Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and Impact of Event Scale-Revised (IES) were performed to assess psychological morbidity. These assessments were performed after injury and at the end of the first year. Time to RTW was recorded in the first year after the injury. Jamar Hand Dynamometer and pinch meter were used for the measurement of hand and finger grip strength at the end of the first year. There were significant improvements in IES-R, BDI, BAI, Q-DASH, and DHI scores at the end of the first year compared with baseline scores. We found a significant correlation between MHISS and time of RTW, Q-DASH, and pinch strengths. We found no significant correlation between MHISS and IES-R, BDI, BAI, and grip strength. The severity of the injury is significantly associated with hand functions, pinch strengths, and RTW in THIs with major nerve involvement. The findings showed that there was no association between the severity of the injury and psychological morbidities in the present study.

Peripheral nerve sheath tumors in Neurofibromatosis Type 2: Surgical and histopathologic features

ObjectiveManagement of peripheral nerve sheath tumors (PNST) in Neurofibromatosis Type 2 (NF2) is complicated by frequent involvement of major peripheral nerves and concern that these tumors may be plexiform and/or involve multiple fascicles. Hybrid histologic features of both schwannoma and neurofibroma have been described in NF2-associated tumors, although the incidence of this phenotype in PNSTs is unknown. We sought to define the outcomes of surgery for tumors involving major peripheral nerves in NF2 and identify the rate of hybrid histology in PNSTs. Patients and methodsFunctional outcomes of surgery for patients with tumors on major (named) peripheral nerves were recorded. Histopathologic analyses were performed on all available excised tumors. ResultsNineteen operations were performed in 12 patients with NF2, for resection of 28 PNSTs. Among 11 tumors involving major peripheral nerves, 10 involved nerves related to motor function. Presenting symptoms in this group included pain (9) and weakness (4). Median tumor diameter was 3.4 cm (range:2.2–10.3 cm). Gross-total resection was achieved in 10 cases. Motor function was stable/improved in 10 cases but diminished after one case involving a small motor fascicle. All tumors involved a single fascicle. Histopathologic analyses of 21 available specimens revealed 19 pure schwannomas. In two cases (10 %) hybrid features of both schwannoma and neurofibroma were identified, with mast cells within regions consistent with neurofibroma. ConclusionsPNSTs can be resected safely in NF2, even if they involve major peripheral nerves. A small proportion (10 %) of these tumors harbor hybrid histologic features, which may explain reports of plexiform or multi-fascicular tumors in NF2.

Hindlimb motor responses evoked by microstimulation of the lumbar dorsal root ganglia during quiet standing

Somatosensory afferent pathways have been a target for neural prostheses that seek to restore sensory feedback from amputated limbs and to recruit muscles paralyzed by neurological injury. These pathways supply inputs to spinal reflex circuits that are necessary for coordinating muscle activity in the lower limb. The dorsal root ganglia (DRG) is a potential site for accessing sensory neurons because DRG microstimulation selectively recruits major nerve branches of the cat hindlimb. Previous DRG microstimulation experiments have been performed in anesthetized animals, but effects on muscle recruitment and behavior in awake animals have not been examined. Objective. The objective of the current study was to measure the effects of DRG microstimulation on evoking changes in hindlimb muscle activity during quiet standing. Approach. In this study, 32-channel penetrating microelectrode arrays were implanted chronically in the left L6 and L7 DRG of four cats. During each week of testing, one DRG electrode was selected to deliver microstimulation pulse-trains during quiet standing. Electromyographic (EMG) signals were recorded from intramuscular electrodes in ten hindlimb muscles, and ground-reaction forces (GRF) were measured under the foot of the implanted limb. Main results. DRG Microstimulation evoked a mix of excitatory and inhibitory responses across muscles. Response rates were highest when microstimulation was applied on the L7 array, producing more excitatory than inhibitory responses. Response rates for the L6 array were lower, and the composition of responses was more evenly balanced between excitation and inhibition. On approximately one third of testing weeks, microstimulation induced a transient unloading of the hindlimb as indicated by a decrease in GRF. Reciprocal inhibition at the knee was a prevalent response pattern across testing days which contributed to the unloading force on this subset of testing weeks. Significance. Results show that single-channel microstimulation in the lumbar DRG evokes stereotyped patterns of muscle recruitment in awake animals, demonstrating that even limited sensory input can elicit hindlimb behavior. These findings imply that DRG microstimulation may have utility in neural prosthetic applications aimed at restoring somatosensory feedback and promoting motor function after neurological injury.

Origin and distribution of the brachial plexus of the Van cats.

Knowing the structure and variations of the plexus brachialis is important in neck and shoulder surgery. The knowledge of the brachial plexus reduces the injury rate of the nerves in surgical interventions to the axillary region. The major nerve trunks of the thoracic limb were the suprascapular, subscapular, axillary, radial, musculocutaneous, median and ulnar nerves. In Van cats, the brachial plexus was formed by the ventral branches of the spinal nerves, C6-C7-C8 and T1. The 7th cervical nerve was quite thick compared to the others. The subscapular nerve was the thinnest (on the right side, the average length was 6.55±0.60mm and on the left side was 6.50±0.60mm), and the radial nerve was the thickest (the average length on the right side was 28.48±0.44mm and on the left side was 29.11±0.55mm). The suprascapular nerve was formed by the ventral branch of the 6th cervical nerve. The subscapular nerves were formed by a branch originating from the 6th cervical nerve and the two medial and caudal branches originating from the 7th cervical nerve. No communicating branch between the ulnar nerve and the median nerve was observed in the palmar region. The axillary nerve was formed by the ventral branches of the 7th nerve, the musculocutaneous nerve was formed by ventral branches of the 6th and 7th cervical nerves, and the ulnar nerve was formed by ventral branches of the 8th cervical and the 1st thoracic nerves. The radial nerve was the thickest branch in the brachial plexus. In Van cats, the origin and distribution of nerves were similar to those reported in the literature for other species of cats, with the exception of the suprascapular, subscapular and axillary nerves.

Histologic Analysis of Sensory and Motor Axons in Branches of the Human Brachial Plexus.

The topographic distribution through histologic analysis of motor and sensory axons within peripheral nerves at the brachial plexus level is not clearly defined, as there has previously been little need to appreciate this microanatomy. A desire to better understand the topography of fascicle groups developed with the introduction of targeted muscle reinnervation. Fourteen bilateral brachial plexus specimens from seven fresh human cadavers were harvested at the time of organ donation, and immunofluorescent staining of motor and sensory nerves with choline acetyltransferase and Neurofilament 200 was performed to determine whether a consistent somatotopic orientation exists at the brachial plexus level. There was significant variability in the number of fascicles at the level of the brachial plexus. Qualitative analysis of choline acetyltransferase staining demonstrated that although motor axons tended to be grouped in clusters, there were high degrees of variability in somatotopic orientation across specimens. The radial nerve demonstrated the highest number of total myelinated axons, whereas the median nerve exhibited the greatest number of motor axons. The ulnar nerve contained only 13 percent motor axons, which was significantly lower than the median, radial, and musculocutaneous nerves. There was no consistent somatotopic organization of motor and sensory axons of the mixed major nerves of the arm just distal to the brachial plexus, but clustering of motor axons may facilitate the splitting of nerves into primarily "motor" and "sensory" fascicles.

Evaluation of functional outcomes after brachial plexus injury.

Major nerve injuries such as those of the brachial plexus present a significant challenge for both rehabilitation and evaluation of outcome. With these often complex and multi-faceted injuries, correct selection of outcome measures is important. Healthy nerve function in humans heightens our interactions with the world, creating quality and enjoyment through our experiences of movement and touch. Therefore, assessments should be holistic and representative of all of these features. This article considers the assessment and evaluation of all of the features of nerve injury: sensorimotor, sensation (including that of pain), function and the psychosocial aspects. Current practice is described and combined with clinical experience and research findings to provide suggestions and recommendations for the selection of the most appropriate tools for use with this patient group.

Stereotyped transcriptomic transformation of somatosensory neurons in response to injury.

In mice, spared nerve injury replicates symptoms of human neuropathic pain and induces upregulation of many genes in somatosensory neurons. Here we used single cell transcriptomics to probe the effects of partial infraorbital transection of the trigeminal nerve at the cellular level. Uninjured neurons were unaffected by transection of major nerve branches, segregating into many different classes. In marked contrast, axotomy rapidly transformed damaged neurons into just two new and closely-related classes where almost all original identity was lost. Remarkably, sensory neurons also adopted this transcriptomic state following various minor peripheral injuries. By genetically marking injured neurons, we showed that the injury-induced transformation was reversible, with damaged cells slowly reacquiring normal gene expression profiles. Thus, our data expose transcriptomic plasticity, previously thought of as a driver of chronic pain, as a programed response to many types of injury and a potential mechanism for regulating sensation during wound healing.

To report trans-cranial magnetic stimulation to describe the NORMAL LATENCIES OF major nerve with central conduction time among Saudi Arabian population; a hospital based study

To report trans-cranial magnetic stimulation to describe the NORMAL LATENCIES OF major nerve with central conduction time among Saudi Arabian population; a hospital based study

2652 Primary Malignant Peripheral Nerve Sheath Tumor of Small Bowel and Colon Presenting With Metastases to Bone, Lung, Liver, Spleen, and Brain

INTRODUCTION: Malignant Peripheral Nerve Sheath Tumor (MPNST) is a rare diagnosis, with an incidence of 1:100,000 per year and 4–10% of soft tissue sarcoma, contains properties both neural crest cells and mesenchymal cells. Gastrointestinal MPNSTs are rare disease conditions with only 10 cases reported worldwide in the literature. CASE DESCRIPTION/METHODS: A 71-year old Portuguese male, presented with 8-week history of abdominal pain, anorexia with 20Ib weight loss. Vital signs were normal. On physical examination, a firm, tender, fixed abdominal mass in the RLQ was palpated. CT scan of the abdomen showed a 10 cm necrotic mass on the right side of the abdomen with communication to the small bowel was detected with a suggestion of a walled off perforation. Colonoscopy revealed a flattening of the terminal ileum suggesting an extrinsic compression. Biopsy of tumor consisting of mixed spindle and pleomorphic cells with focal rhabdoid features, high grade nuclear features and brisk mitotic activity. A week later, he presented with symptoms of small bowel obstruction, the CT scan at this time showed a 8 cm left sided abdominal mass with communication to the small bowel with dilation of the jejunum suggesting a new partial obstruction in addition. The patient underwent a palliative debulking of the tumor. Multiple large obstructive masses were found in the Ligament of Treitz,significant portion of the small bowel, right colon, left upper quadrant and omentum. For palliation purposes, these masses were resected and anastomosis was performed. Gross examination of the surgical specimens revealed grayish-tan cystic masses filled with brownish tan hemorrhagic material. Histology of the masses were similr to previous mass. On immunohistochemistry, showed patchy weak S100 immunoreactivity and focal BCL-2 and Neuron Specific Enolase stain immunoreactivity. Ki-67 proliferation index was 70%. The pathologic diagnosis of MPNST was established. He developed multiple bone, pulmonary, liver, splenic and hemorrhagic brain metastases. He died under hospice care within six months of his initial presentation. DISCUSSION: MPNST, occurs mostly in association with Neurofibromatosis Type 1 (8–13%). The tumor typically originates from the nerve sheaths of the major nerves in the extremities (40%), trunk/ retroperitoneal (38%) and head and neck region (21%). However, recent case reports have also documented MPNST of the liver, thyroid gland, skin, eighth cranial nerve and rarely the greater omentum without a history of radiation or NF1.

Clinical Efficacy of Three Surgical Approaches for the Treatment of Cervicothoracic Tuberculosis: A Multicenter Retrospective Study.

ObjectiveTo evaluate the efficacy of three surgical approaches for the treatment of cervicothoracic tuberculosis.MethodsThis is a multicenter retrospective study. We analyzed 74 patients with cervicothoracic tuberculosis who were treated in six institutions between January 2000 and January 2015. There were 37 male and 37 female patients, with an average age of 24 years (range, 5–62 years). The operative method was selected according to the indications. A total of 33 patients underwent one‐stage anterior surgery (group A); 16 underwent a combined anterior and posterior surgery (group B) and 25 underwent one‐stage posterior surgery (group C). Clinical outcomes, laboratory indexes, and radiological results were analyzed.ResultsAll cases were followed up for approximately 36–96 months post‐surgery (average, 39 months). At the last follow‐up, patients in all three groups had achieved bone fusion, with pain relief and neurological recovery. No major vessel and nerve injuries were found during the operation. There were significant differences before and after treatment for visual analogue scale (VAS), neck disability index (NDI), and Japanese Orthopedic Association (JOA) score (P < 0.001). Three surgical strategies significantly improved kyphosis (P < 0.001).ConclusionThe choice of operation for cervicothoracic tuberculosis should be selected based on the pathological changes, scope, and general physical condition of the patient. The indication for a posterior approach is narrow and it should be used selectively. The combined anterior and posterior approach involved a longer operating time, larger blood loss, and greater trauma, and also required a higher level of surgical skill. Therefore, the indications for this approach should be strictly controlled. Anterior approach surgery for the treatment of cervicothoracic tuberculosis showed excellent efficacy and fewer complications.

Chronic neuropathic pain after traumatic peripheral nerve injuries in the upper extremity: prevalence, demographic and surgical determinants, impact on health and on pain medication.

Background and aims Aside from the long term side effects of a nerve injury in the upper extremity with devastating consequences there is often the problem of chronic neuropathic pain. The studies concerning the prevalence of persistent pain of neuropathic origin after peripheral nerve injuries are sparse. The prevalence and risk factors associated with chronic neuropathic pain after nerve injuries in the upper extremity were assessed. Methods A standardized data collection template was employed prospectively and retrospectively for all patients with traumatic nerve injuries accepted at the Hand Surgery Department, Uppsala, Sweden between 2010 and 2018. The template included demographic data, pain diagnosis, type of injured nerve, level of injury, date of the lesion and repair, type of procedure, reoperation, time since the procedure, S-LANSS questionnaire (Self report-Leeds Assessment of Neuropathic Symptoms and Signs), RAND-36 (Item short form health survey), QuickDASH (Disability of Shoulder, Arm and Hand) and additional questionnaires concerned medication, pain intensity were sent to 1,051 patients with nerve injuries. Partial proportional odds models were used to investigate the association between persistent pain and potential predictors. Results More than half of the patients undergoing a surgical procedure developed persistent pain. Prevalence of neuropathic pain was 73% of the patients with pain (S-LANSS ≥ 12 or more). Multivariate analysis indicated that injury of a major nerve OR 1.6 (p = 0.013), years from surgery OR 0.91 (p = 0.01), younger age OR 0.7 (p < 0.001), were the main factors for predicting pain after surgery. The type of the nerve injured was the strongest predictor for chronic pain with major nerves associated with more pain (p = 0.019). Conclusions A high prevalence of chronic pain and neuropathic pain with a negative impact on quality of life and disability were found in patients after traumatic nerve injury. Major nerve injury, younger age and less time from surgery were predictors for chronic pain.

Pain and small-fiber affection in hereditary neuropathy with liability to pressure palsies (HNPP).

Background and aims Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal - dominant hereditary neuropathy caused by a deficiency in the peripheral protein PMP-22, due to deletion on chromosome 17p11,2 or in some rare cases point mutations in the PMP-22 gene. The clinical picture is characterized by recurrent mononeuropathies in nerves which frequently may be exposed to pressure, such as the median, ulnar, radial and peroneal nerves or also a more general neuropathy. Although pain is reported to be an unusual clinical symptom, there have been reports of pain in a surprisingly high proportion of these patients. Since pain may be explained by mechanisms in afferent small unmyelinated C- nerve fibers, an assessment of the function of small nerve fibers has been requested. The purpose of the present study was to investigate the presence of pain and the possible affection of afferent small nerve-fibers, A-δ and C-fibers, by quantitative sensory testing (QST)-assessment of thermal thresholds, as well as quantitative sudomotor axon reflex (QSART), a quantitative, validated assessment of efferent postganglionic sumodotor function. QST values were compared to values of age- and sex matched healthy subjects. Methods The 19 patients were investigated clinically, with an emphasis on pain characteristics, with nerve conduction studies (NCS) of major nerves in upper- and lower extremity, small fiber testing (QST, measurement of thermal thresholds) and with QSART. Results A total of 10 patients reported numbness in some extremity, suggesting entrapment of individual nerves as well as a general neuropathy, as verified by NCS in nine patients. A total of 15 patients had findings compatible with a general polyneuropathy. A total of eight patients reported pain, seven patients with pain in the feet, described as burning, aching, shooting and six with severe pathological QST values, mainly cold detection, but also four patients with elevated thresholds to warmth. Four of the patients had signs of a severe sensory neuropathy on NCS, with no sural findings. One patient had only pain in the arms, with only minor changes on NCS and with normal QST-values. Cold detection thresholds (CD) were significantly elevated (reduced sensibility) on the dorsum of the foot (mean of two feet), in patients [26.0 °C (19.7-28.0)] as compared with healthy subjects [28.6 °C (27.4-29.6) p = 0.000]. There were also significantly elevated warmth detection thresholds (WD) in feet in patients 39.5 °C (36.4-42.9) compared to healthy subjects [37.7 °C (36.1-39.4) p = 0.048]. However, there were no significant differences in QST values between patients with and without pain. Conclusions Of a total of 19 patients with verified HNPP, eight patients (42.1%) suffered from neuropathic pain, mainly in both feet. Implications Due to the high percentage of pain in HNPP, it is important not to disregard this diagnosis in a patient presenting with pain. Since there are no significant differences in QST values in patients with and without pain, routine QST studies in HNPP do not seem necessary.

Clinical techniques in Veterinary Dermatology: Regional anaesthesia of the canine ear.

Video otoscopy is a valuable tool for the diagnosis and treatment of otitis externa (OE) and otitis media (OM) in dogs. Procedures performed by video otoscopy often are painful and it can be challenging to maintain steady anaesthetic depth and provide smooth anaesthetic recovery. A multimodal approach to analgesia and anaesthesia is ideal to minimize complications associated with high doses of anaesthetic drugs while providing the patient with adequate analgesia. To describe a technique for regional anaesthesia of the canine ear. One canine cadaver, obtained as part of a teaching laboratory class for other clinical techniques, with institutional approval, was used for illustration purposes. Clinical technique for regional anaesthesia of the canine ear. Nerve blocks for regional anaesthesia are an important aspect of a multimodal anaesthetic approach. A technique for blocking the two major sensory nerves to the canine ear is described.

Nomogram to Predict Survival Benefit of Postoperative Radiotherapy for Major Salivary Gland Cancers

There are no randomized data to support the use of postoperative radiotherapy (PORT) for major salivary gland malignancies. Our objective was to develop and validate a nomogram to estimate overall survival (OS) with and without PORT. Adults in the National Cancer Database diagnosed with invasive non-metastatic major salivary gland cancer between 2004-2015 were identified. Exclusion criteria included prior malignancy, pT1N0, no/unknown surgery, neoadjuvant therapy, PORT dose <50 Gy or >75 Gy, PORT to a non-head/neck site, PORT started >9 weeks from surgery, and PORT duration >9 weeks. Ratio of nodal positivity (N+ ratio) was defined as number of nodes positive among nodes resected. Cox proportional hazards models determined the effect of covariates on OS. A multivariate regression model was used to generate a nomogram to predict 2-, 5-, and 10-year OS. Cross-validation using 500 random 50-50 hold-out samples was performed. All p-values are two-sided. There were 18,400 subjects who met inclusion criteria, of which 9,721 (53%) received PORT. Subjects who received PORT had significantly worse adverse pathologic features compared to those treated with surgery alone: pT3-4 (54% vs 39%, p<0.01), high grade (60% vs 35%, p<0.01), lymphovascular invasion (34% vs 17%, p<0.01), >0.1 N+ ratio (36% vs 23%, p<0.01), extranodal extension (23% vs 15%, p<0.01), major nerve involvement (12% vs 6%, p<0.01), and positive margin (45% vs 25%, p<0.01). Median age at diagnosis for both cohorts was 65 (p=0.07). Distribution of gland involvement was 86% parotid, 13% submandibular, and 1% sublingual. Median follow-up for living subjects was 4.9 years. PORT was significantly associated with improved OS for the following subgroups by log-rank test: pT3 (p<0.01), pT4 (p<0.01), high grade (p<0.01), node positive (p<0.01), and positive margin (p<0.01). The variables listed in the table below were incorporated into a nomogram using data from 6,138 subjects. The resulting nomogram demonstrated good accuracy in predicting OS, with a concordance index of 0.719. Our cross-validated nomogram predicts the 2-, 5-, and 10-year differences in OS based on receipt of PORT for major salivary gland cancers using readily available clinicopathologic features. The nomogram will be made publicly available online.Abstract 1147; Table 1VariableHR95% CIPAge at diagnosis1.041.03 – 1.04<0.01Male sex (ref: female)1.281.17 – 1.39<0.01Charlson-Deyo comorbidity score (ref: 0)11.191.08 – 1.31<0.0121.581.32 – 1.90<0.01≥31.801.33 – 2.44<0.01Primary site (ref: parotid)Submandibular1.311.16 – 1.48<0.01Sublingual0.680.38 – 1.230.21Pathologic T-stage (ref: 1)21.140.96 – 1.350.1331.591.35 – 1.88<0.0141.891.60 – 2.23<0.01N+ ratio (ref: 0)>0 and ≤0.101.451.29 – 1.63<0.01>0.1 and <0.51.741.58 – 1.93<0.01≥0.52.131.91 – 2.37<0.01Tumor grade (ref: low)Intermediate1.701.43 – 2.02<0.01High2.091.77 – 2.47<0.01Positive margin (ref: negative)1.281.18 – 1.38<0.01Yes PORT (ref: no PORT)0.630.58 – 0.68<0.01 Open table in a new tab

Anatomically safe sites for intramuscular injections: a cross-sectional study on young adults and cadavers with a focus on the thigh

ABSTRACTThe anatomical safety of intramuscular injections at the deltoid and ventrogluteal sites has been investigated; however, the anatomical relationship between intramuscular injection sites in the thigh and major blood vessels and nerves remains unclear. We aimed to compare intramuscular injection sites in the rectus femoris and vastus lateralis with those at the deltoid and ventrogluteal sites and identify safe intramuscular injection sites in the thigh. Twenty-seven young adult volunteers were recruited, and the thicknesses of subcutaneous tissue and muscle as well as the number of blood vessels present were evaluated at two sites on the deltoid, ventrogluteal, and thigh using ultrasound equipment. The right thighs of 24 cadavers were used, and the thickness of muscle, number of blood vessels or nerves present, and the distance between each examined site and major blood vessels or nerves were evaluated in the rectus femoris and vastus lateralis. A major blood vessel was observed in the middle of the rectus femoris in young adults. In cadavers, the descending branch of the lateral circumflex femoral artery and muscle branch of the femoral nerves to the vastus lateralis were observed at the middle point, distal two-thirds point, and middle point between the middle and distal two-thirds points of the rectus femoris, but not at the middle of the vastus lateralis. The middle of the vastus lateralis is an appropriate site for intramuscular injections because of the low risk of vascular or nerve damage. The present results support good practices for site selection for intramuscular injections.