Nerve Distribution Research Articles

Iliopsoas bleeds in patients with hemophilia

Background: Iliopsoas bleed is a serious complication in people with hemophilia (PWH), with significant morbidity. Studies examining the profile, incidence, and outcomes in psoas bleeds are scarce and will shed more light and increase awareness about its management. Material and Methods: Data of 453 PWH with confirmed iliopsoas bleed treated at Bangalore Medical College were retrospectively analyzed. Results: Eighty-five (18.8%) PWH presented with total of 154 psoas bleeds. Their mean age was 21.96 years. Common symptoms were thigh/hip/groin pain (100.0%), hip flexion spasm (41.2%), numbness/tingling in quadriceps muscle (5.9%), abdominal tenderness (3.5%), hematuria, and anemia requiring blood transfusion in 2.4% each. Long-term complications were quadriceps atrophy (9.4%), permanent abnormal posture (10.6%), transient paresthesia in the distribution of femoral nerve (3.5%), and pseudo tumor in pelvis (1.2%). The overall average duration of therapy with clotting factor concentrate was 1.7 days with a mean duration of therapy of 1.4 days in patients without inhibitors and 2.8 days in patients with inhibitors (p = 0.010). The overall mean duration of hospitalization was 7.2 days with 5.3 days in PWH without inhibitors and 8.3 days in PWH with inhibitors (p = 0.342). Conclusion: Pain in hip joint/groin/hip flexion spasm suggests the possibility of an iliopsoas hematoma and early factor replacement therapy should be started to prevent complications. Early treatment at first sign of discomfort reduces the duration of treatment, and prevents severe complication and invasive interventions. Patients with inhibitors were overrepresented in the cohort who needed longer duration of factor replacement therapy.

Can India Let Go The Opportunity To Minimize Million Shingles Cases Annually? As India Launches Shingrix Zoster Vaccine in April 2023

Chickenpox is an incredibly uncomfortable common viral disease, rarely coming to the notice for the health system. After experiencing chickenpox or exposure to the varicella zoster virus, the virus stays dormant in the human body for life. When the immune system naturally weakens due to aging or chronic diseases like cancer, cardiac failures, chronic kidney diseases and immunodeficiency disease like HIV/AIDs etc., inactive virus reactivates, causing Shingles. Commonly seen among persons over 50 years though it can occur at any age. Most people have only one episode of the illness in their lifetime, second episodes are not uncommon, and third episodes are very rare and multiple episodes are also possible. In India, we see about a million cases of Shingles each year giving an incidence of 705 per million population per year. In USA approximately 1 out of 3 people develop herpes zoster during their lifetime Shingles, and about half of people over age 80 have had shingles. Most people with shingles in every episode start with Itching, Tingling, Burning and Pain over one or two dermatome areas to be followed by rashes on 3-5th day. Associated symptoms of fever and body ache are short lived. the blisters and pimples dry, form scabs and heal in 2-3 weeks not leaving any scar, but if get infected may take longer time of 4-5 weeks. But the tingling or a pins-andneedles feeling, itching, burning, and a deep pain due to the post-herpetic neuralgia, a severe painful condition may persist for months. The rashes often follow the distribution of nerves in the skin, a pattern called a dermatome. The most common dermatome affected are on the chest and back, around one side of the waistline but can involve any area like neck, face, butts, arms, and legs. There is no cure for shingles, but treatment with antivirals to shorten the length and severity of the illness, antihistamines NSAIDS and analgesics are used to provide comfort. Fortunately, shingles is not communicable to others. This article is based on primary cases seen by the in the context of. India has 260 million adults above 50 years of age at risk of shingles and its complications and this vaccine given in 2 doses becomes a boon for such population providing protection for 10 years. Materials and Methods: Three (including autobiographical) cases author managed since 2010 to March 2023 print media message of the launch of Shingrix Zoster Vaccine Recombinant, Adjuvanted vaccine in India on Monday the 16 April 2023 for the persons over 50 years and review of the literature.

Immunohistochemical staining for nerve fibers in normal tissues with frozen sections: Structure and Function Relationship

Small nerve fibers are difficult to immunostain with routinely formalin-fixed and paraffin- embedded sections. Normal tissues except central nervous system are not densely innervated compared to densely distributed lymphatic and blood vessels and nerve fibers are not properly preserved in the routinely formalin-fixed and paraffin-embedded tissues. Nerve density technique with skin punch biopsy is an established method using 50 µm tissue sections, which are initially preserved in fixative. The fixed tissues are frozen sectioned and floating tissue sections are immunostained for nerve fiber markers. We had developed an alternative method using unfixed frozen sections mounted on glass slides. We had previously used this frozen section method for lymphatic and blood vessel immunohistochemistry and extended to nerve fiber immunostaining using neurofilament and CD56 as nerve fiber markers. Immunostained tissues with frozen sections were compared to formalin-fixed and paraffin-embedded colon and kidney sections. The normal tissues from rhesus monkey included heart, intestines, diaphragm, pancreas, spleen, kidney, thyroid, urinary bladder and others. Frozen section immunostained sections clearly depicted much more fine nerve fibers especially using CD56 as a nerve marker than with paraffin-embedded tissues. This technique is more labor-intensive but provides more precise distribution of fine nerve fibers than with routinely paraffin-embedded tissues. This immunostaining with frozen sections validated usefulness to depict more detailed nerve distribution and will shed light on normal histology and histopathology.

Giant Lipofibromatous Hamartoma of Median Nerve in a Child

Lipofibromatous hamartoma (LFH) is a rare fibrofatty tumor of adipocytes within peripheral nerves, affecting mainly children. It typically presents as a palpable mass surrounding the nerves of the upper limbs, causing pain and neurological deficits in the affected nerve distribution. We report the case of a child with a 2-years presentation of a mass in the right wrist associated with pain and paresthesia, who underwent investigation with magnetic resonance imaging (MRI). It showed thickening of the median nerve with spaghetti-like appearance associated with lipomatous tissue in a coaxial cable-like pattern, both features characteristic of LFH. This case illustrates the importance of MRI in the differential diagnosis of limb masses in the pediatric population.

Chronic Musculocutaneous Nerve Injury: An Important Differential in Progressive Arm Atrophy

An isolated musculocutaneous nerve (MCN) injury is a rare condition that can be easily missed if it presents late. A 28-year-old man reported painless and progressive wasting of the right arm for 6 months. On examination, there was visible wasting of the right biceps brachii muscle along with its slight weakness, depressed biceps jerk, and an impaired pinprick sensation in the lateral antebrachial cutaneous nerve distribution. He described a history of a road traffic accident 14 months beforehand. Based on the history and clinical examination, the differential diagnosis included an isolated MCN injury, upper trunk plexopathy, lateral cord plexopathy, C5/6 radiculopathy, and monomelic amyotrophy involving the C5/6 myotomes on the right side. The results of nerve conduction studies and electromyography were consistent with chronic proximal MCN neuropathy (right). In cases of arm wasting without pain or numbness, MCN injury should be included in the differential diagnosis, even in the presence of good power of the elbow flexors. The importance of detailed history-taking and clinical correlation cannot be over-emphasized in such cases.

Glossopharyngeal neuralgia as a postoperative complication of tonsillectomy: a case report

Tonsillectomy is one of the most common procedures performed by otolaryngologists. Post-operative complications commonly include temporary pain, infection, and bleeding. Glossopharyngeal neuralgia is a rare complication that has been previously documented in the literature. Glossopharyngeal neuralgia is a rare type of facial pain syndrome that is characterised by radiating pain in the sensory distribution of the glossopharyngeal nerve. It can cause sharp shooting pain in the face, ears and/or back of the throat. Pain is exacerbated with repetitive movements such as chewing, speaking, and swallowing. The majority of glossopharyngeal neuralgia is idiopathic in origin; however, we report a case of a 37-year-old lady that developed glossopharyngeal neuralgia immediately after tonsillectomy. Her condition was managed with intraoral injection of alcohol and saline preparation in the tonsillar fossa with good effect.

Regeneration of sensory nerve branches in extraction socket and surrounding alveolar bone in rat: immunohistochemical observation of the axon and myelin sheath changes

The purpose of this study was to investigate the process and derivation of the distribution of the sensory nerves that appear in the extraction socket and surrounding alveolar bone following tooth extraction. The right mandibular first molar of rats and periodontal ligament were extracted as a single mass, and the mandible was harvested after days 1, 3, 5, and 7 after extraction. Serial sections of 7 µm thickness were prepared for the proximal root (Section A), buccolingual root (Section B), and centrifugal root (Section C) of the first molar. H–E staining and immunohistochemical staining with anti-S100 antibody and anti-NF-L antibody were carried out. The presence of nerve fiber bundles in the blood clot was already evident on post-extraction day 3, and on post-extraction day 7. On day 3, the number of axons in Sections B and C had greatly decreased, indicating that, after extraction, the connection between peripheral nerve tissue and the trigeminal ganglion was temporarily markedly reduced in the region of the alveolar branch. Although the myelin sheaths were regenerating on day 5, the majority of the axons of the alveolar branches extending from the inferior alveolar nerve were seen to be extremely thin and scattered, despite their further regeneration. The above results suggest that the newly myelinated nerves are actually derived from the bone marrow to the extraction socket, so few nerves, rather than being derived from the alveolar branches that had innervated the extracted tooth.

Yuna Gloves, Sarung Tangan Anti Carpal Tunnel Syndrome (CTS)

<em>Carpal Tunnel Syndrome (CTS) is a symptom of compression neuropathy of the median nerve at the wrist. Characterized by increassed pressure in the carpal tunnel and decreased nerve function. The Most Common Complain are pain, numbness and tingling along the distribution of the median nerve. The prevalence of carpal tunel syndrome in the adult population ranges from 0.7 – 9.2%, 0.4% in women and 2.1% in men. Women have a riskof developing CTS 3 times higher in pregnant women then in non-pregnant women. The purpose of this study was tu produce yuna gloves which were effective in reducing the incidence of CTS in pregnant women at the Cipanas Health Center in 2021. This study was conducted using the case control method, which is to campare existing Products with research products. This researche process lasted for 3 months. The population in this study were all pregnant women in the third trimester at the Cipanas Public Health, which amaunted to 150 people, the sample in this study amounted 33 people. From the results of the case study, its expected to further improve the quality of service delivery for health workers, aspecially in handling cases of CTS in pregnant women at the Cipanas Health Center.</em>

Modeling the Impact of the Variation in Peripheral Nerve Anatomy on Stimulation.

The peripheral nervous system has a complex anatomical structure. Stimulation of nerve fibers in the peripheral nervous system depends on the fiber diameter and myelination as well as its location within the nerve, packing fraction and fascicle distribution within the nerve bundle. This paper analyzes the impact of the variation in peripheral nervous system anatomy and the distance of the stimulating electrodes on the probability of generating an action potential. A mathematical model for effective fascicle conductivity has been developed to capture the variation in the packing fraction and fiber diameter. A linear activating function is utilized to analyze the impact of this effective conductivity and fascicle distribution as an indicator of generating an action potential. Finite element simulations are performed for the nerve-electrode configuration to evaluate the electric field. The simulation results are used to analyze the activating function for different packing fractions and type of nerve fibers. The effect of electrode distance on activating function and the total current through a nerve bundle has also been studied. The simulation results indicate that the peripheral nerve anatomy and electrode distance have a significant effect on the action potential generation.

Bone marrow-derived vasculogenesis leads to scarless regeneration in deep wounds with periosteal defects

Deep skin wounds with periosteal defects, frequently caused by traffic accidents or radical dissection, are refractory. Transplant surgery is frequently performed, but patients are subjected to stress for long operation periods, the sacrifice of donor regions, or several complications, such as flap necrosis or intractable ulcers. Even if the defects are covered, a scar composed of fibrous tissue remains in the body, which can cause itching, dysesthesia, or repeated ulcers because of the lack of distribution of peripheral nerves or hair follicles. Thus, treatments with the aim of regenerating lost tissue for deep wounds with periosteal defects are needed. Here, we show that the use of gelatin sponges (GS), which have been used as haemostatic materials in clinical practice, allowed the regeneration of heterogeneous tissues, including periosteum, skin, and skin appendages, when used as scaffolds in deep wounds with periosteal defects in rats. Bone marrow transplantation in rats revealed the mechanism by which the microenvironment provided by GS enabled bone marrow-derived cells (BMDCs) to form a vascular niche, followed by regeneration of the periosteum, skin, or skin appendages such as hair follicles by local cells. Our findings demonstrated that vascular niche formation provided by BMDCs is crucial for heterogeneous tissue regeneration.

Primary Melanocytoma Arising From Trigeminal Nerve.

A 12-year-old girl presented with a 3-week history of left-sided hemifacial pain. Physical examination revealed hemifacial numbness, hypesthesia, and chewing weakness without signs of nevus of Ota. Neuroradiologic examinations showed a dumbbell-shaped lesion in middle and posterior fossa along the distribution of the trigeminal nerve (Figure 1). Intraoperatively, a well-defined black extra-axial lesion firmly attached to the trigeminal nerve was observed. Pathologic examination confirmed a melanocytoma (Figure 2). Extra-axial melanocytoma may have a tendency to distribute along the trigeminal nerve similar to nevus of Ota. For lesions involving the trigeminal nerve with hyperdensity on CT and hyperintensity on T1 and hypointensity in T2 imaging, melanocytoma should be considered.1

Sural hypersensitivity after nerve transection depends on anatomical differences in the distal tibial nerve of mice and rats

IntroductionVarious mouse and rat models of neuropathic pain after nerve injury exist. Whilst some models involve a proximal nerve lesion or ligation of the sciatic trifurcation in mice and rats, others consists of a transection or ligation of distal nerves at the tibial bifurcation in mice or rats. The level of nerve cut directly affects the magnitude of hypersensitivity, and anatomical differences between mice and rats might therefore impact the development of hypersensitivity after distal tibial nerve transection as well. MethodsThe bifurcation of the distal tibial nerve into the medial and lateral plantar nerve (MPN and LPN), and the presence of anatomical differences in sural and tibial nerve distribution between mice and rat was evaluated. Sural mechanical sensitivity after transection of the MPN or whole tibial nerve was assessed using von Frey test until 8 weeks after surgery in 48 rats and 16 mice. ResultsThe bifurcation of the tibial nerve into the MPN and LPN is situated proximal to the ankle in both mice and rats. The sural nerve joins the LPN in mice, but not in rats. A proximal communicating branch is present between the LPN and MPN in rats, but not in mice. MPN transection in mice caused hypersensitivity of the hindpaw innervated by the sural nerve, but not in rats. In rats, sural hypersensitivity only developed when both MPN and LPN were cut. ConclusionInter-species variation in nerve anatomy should be taken in consideration when performing surgery to induce plantar hypersensitivity in rodents.

Evaluation of the efficacy of therapeutic ultrasound in the treatment of migraine.

This study aims to evaluate the efficacy of therapeutic pulsed ultrasound (US) applied to the occipital nerve distribution area in chronic migraine patients. This prospective, randomized, double-blind, placebo-controlled, study was conducted on 58 patients diagnosed with migraine at the University of Health Sciences Bursa Yüksek Ihtisas Training and Research Hospital, Department of Physical Medicine and Rehabilitation between January 2018 and October 2018. The patients were randomly divided into two groups as sham and pulsed US group. Pulsed US was applied in Group 1 (n=29), and sham US was used in Group 2 (n=29) for 5 min for a total of 10 sessions in each group. The evaluation was made at pre-treatment, post-treatment first month (week six) and third month (week 14) using the numeric rating scale, and the Migraine Disability Assessment Scale (MIDAS). The final analysis was conducted with 52 patients (7 males, 45 females; mean age: 38.3±7.9 years; range, 20 to 65 years) due to drop-outs, with 27 patients in Group 1 and 25 patients in Group 2. A statistically significant improvement was found in all parameters at week six and week 14 compared to pre-treatment values in Group 1. A statistically significant worsening was detected in MIDAS 1, 4, 5, total questions, and a significant improvement was found in MIDAS A and B at week six compared to pre-treatment values in Group 2. A statistically significant worsening was found only in MIDAS total score at week 14 compared to pre-treatment values. In the comparison of the difference scores of the two groups, all parameters in Group 1 showed significant improvement at week six and week 14. The findings obtained in this study show that pulsed US applied to the occipital nerve distribution region in migraine patients can be effective on headache frequency, severity, and disability.

Pronator Quadratus: A Preferable Recipient for Targeted Muscle Reinnervation of Neuromas in the Hand.

Targeted muscle reinnervation (TMR) has emerged as a useful solution to the problem of painful neuromas and is increasingly being applied in many clinical circumstances. Relatively little has been written about TMR for painful neuromas of the hand, and what has been written describes use of the intrinsic muscles as recipients for the nerve transfer. Except in cases of amputation, intrinsic muscle sacrifice carries morbidity. Furthermore, TMR to intrinsic muscles will place the nerve coaptation in areas subject to pressure with loading of the palm. For these reasons, the pronator quadratus may be a preferable target muscle when performing TMR for painful neuromas of the hand. In this report, we describe the rationale for its use and demonstrate the surgical technique and outcomes with case examples.

NCMP-20. NUMB CHIN SYNDROME: ATYPICAL PRESENTATION OF METASTATIC BREAST CANCER

Abstract OBJECTIVES 1. To report a variation of Numb Chin Syndrome (NCS) 2. Raise awareness and early localization of NCS to more efficiently develop a targeted treatment plan to prevent tumor spread and potentially improve clinical outcomes and survival. INTRODUCTION/BACKGROUND NCS is an uncommon but known complication of cancer. Prompt recognition is imperative to directed treatment. In some instances, numb chin may be complicated by other findings. CASE REPORT A 53-year-old female with past medical history of estrogen receptor positive invasive ductal breast carcinoma underwent partial mastectomy, chemotherapy, and radiation. After 6 years remission, new lung and liver metastases occurred, and chemotherapy resumed. Imaging was negative. Eight weeks later, she developed left chin numbness followed by progressive difficulty retaining food and drink. Her left lower lip weakened. Neurological examination revealed left lower lip weakness (showing a “droop” with attempted smile). The area of decreased sensation to sharp touch had expanded from the left chin to the nasolabial fold. The remainder of her neurological examination was unremarkable. Contrast-enhanced MRI was repeated which revealed a 1.9 cm enhancing left parotid mass. SUMMARY/ CONCLUSION NCS is defined as an ipsilateral loss of chin sensation. If there is no history of trauma or dental injury and especially if the presentation is atypical, then cancer is the most likely etiology. This case began as an uncomplicated NCS that rapidly expanded to involve a greater portion of the trigeminal nerve distribution, in addition to a branch of the facial nerve. Thus, each focal deficit was not the result of separate distal nerve lesions, but rather partial proximal cranial neuropathies at their parotid gland propinquity.

Post-ablation augmentation of skin sympathetic nerve activity predicts a poor outcome of idiopathic ventricular arrhythmias

BackgroundThe neuromodulation effect after ventricular arrhythmia (VA) ablation is unclear. The study aimed to investigate skin sympathetic nerve activity (SKNA) changes in patients receiving catheter ablations for idiopathic VA. MethodsOf 43 patients with drug-refractory symptomatic VA receiving ablation, SKNA was continuously recorded for 10 min during resting from electrocardiogram lead I configuration and bipolar electrodes on the right arm 1 day before and 1 day after ablation. ResultsTwenty-two patients with acute procedure success and no recurrence during follow-ups were classified as sustained success group (group 1). Other 21 patients were classified as failed ablation group (group 2). Baseline SKNA showed no significant difference between the two groups. Post-ablation SKNA in group 2 was significantly higher than in group 1. In patients with ablation involved right ventricular outflow tract (RVOT), the post-ablation SKNA was also significantly higher in group 2. In contrast, there was no difference in post-ablation SKNA between groups in patients receiving non-RVOT ablation. ConclusionThe neuromodulation response after RVOT ablation may correspond to the sympathetic nerve distribution at RVOT. Augmentation of sympathetic activity after VA ablation indicates an unsuccessful VA suppression, especially in patients receiving ablation of RVOT VA.

This Month in Anesthesiology

This Month in Anesthesiology

Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction can cause moderate to severe acute postoperative pain. Despite advances in our understanding of knee innervation, consensus regarding the most effective regional anaesthesia techniques for this surgical population is lacking. This network meta-analysis compared effectiveness of regional anaesthesia techniques used to provide analgesia for anterior cruciate ligament reconstruction. Randomised trials examining regional anaesthesia techniques for analgesia following anterior cruciate ligament reconstruction were sought. The primary outcome was opioid consumption during the first 24 h postoperatively. Secondary outcomes were: rest pain at 0, 6, 12 and 24 h; area under the curve of pain over 24 h; and opioid-related adverse effects and functional recovery. Network meta-analysis was conducted using a frequentist approach. A total of 57 trials (4069 patients) investigating femoral nerve block, sciatic nerve block, adductor canal block, local anaesthetic infiltration, graft-donor site infiltration and systemic analgesia alone (control) were included. For opioid consumption, all regional anaesthesia techniques were superior to systemic analgesia alone, but differences between regional techniques were not significant. Single-injection femoral nerve block combined with sciatic nerve block had the highest p value probability for reducing postoperative opioid consumption and area under the curve for pain severity over 24 h (78% and 90%, respectively). Continuous femoral nerve block had the highest probability (87%) of reducing opioid-related adverse effects, while local infiltration analgesia had the highest probability (88%) of optimising functional recovery. In contrast, systemic analgesia, local infiltration analgesia and adductor canal block were each poor performers across all analgesic outcomes. Regional anaesthesia techniques that target both the femoral and sciatic nerve distributions, namely a combination of single-injection nerve blocks, provide the most consistent analgesic benefits for anterior cruciate ligament reconstruction compared with all other techniques but will most likely impair postoperative function. Importantly, adductor canal block, local infiltration analgesia and systemic analgesia alone each perform poorly for acute pain management following anterior cruciate ligament reconstruction.

Tumor microenvironment adrenergic nerves blockade liposomes for cancer therapy.

Adrenergic nerves, which are innervated in the tumor, regulate tumor initiation, angiogenesis, and the establishment of the tumor immunosuppressive microenvironment. The study aimed to evaluate the effectiveness of propranolol liposomes (Lipo pro) in inhibiting adrenergic nerve signaling in cancer therapy. Lipo pro significantly regulated the distribution of tumor microenvironment adrenergic nerves, tumor blood vessels, and immunosuppressive microenvironment. Furthermore, it displayed considerable therapeutic effects on prostatic cancer, pancreatic ductal adenocarcinoma, and melanoma. The combination therapeutic regimen, in which Lipo pro was the primary treatment and was supplemented by chemotherapy, showed significant advantages over any single treatment, effectively restraining tumor growth in situ and metastasis, thereby prolonging the survival of mice. This study established a proof-of-concept by targeting tumor adrenergic nerve signaling for cancer therapy.

NOT ALL RASHES ASSOCIATED WITH INFANT FEEDING ARE FROM COW MILK PROTEIN ALLERGY!

<h3>Introduction</h3> Cow's milk protein allergy (CMPA) is the most common food allergy in the infancy period. The prevalence of CMPA in the United States has been increasing rapidly over the last decade. CMPA can be IgE-mediated or non-IgE-mediated. Non-IgE mediated reactions are often difficult to diagnose as there is no substantiative test. Many diagnoses of non-IgE mediated reactions are thus unconfirmed and may be incorrect. Facial rashes could occur because of other disorders too. <h3>Case Description</h3> Our patient is a 4-month-old infant, who presented with a facial rash that sometimes spread to the torso after feeds. The patient was born at term via prolonged vaginal delivery due to facial presentation. He was breastfed until two months, then switched to formula due to colic. Subsequently, the mother noticed a facial rash with feeds that resolved quickly without intervention. He was tried on different formulae, but the symptoms persisted. Upon admission, he was noted to develop facial flushing on the cheeks and forehead even with Pedialyte administration, along the distribution of the auriculotemporal nerve. Laboratory investigations (CBC, IgE for milk and soy, tryptase) were within normal limits. <h3>Discussion</h3> The infant was suspected immediately of having CMPA, but the presentation was inconsistent with an allergic reaction (absence of hives, itching, discomfort, other system involvement, and quick resolution without intervention). On the contrary, he developed flushing even with Pedialyte, which was more suggestive of a nervous system-related phenomenon, such as Frey's syndrome. He was transitioned back to cow milk-based formula, and the facial flushing improved over time.