Local Nerve Research Articles

Post-traumatic Trigeminal Neuropathic Pain: Factors Affecting Surgical Treatment Outcomes.

Post-traumatic trigeminal neuropathic pain (PTTNp) is a painful condition that may result from injury to the sensory division of the trigeminal nerve. Treatment of this condition is challenging and consensus on treatment to resolve neuropathic pain has yet to be standardized. Equally as challenging is the identification of surgical outcome variables to guide surgical treatment of PTTNp. This is partly due to the variability in pain characteristics, severity of nerve injury, location, and duration from injury to surgery. In those with neuropathic pain prior to microsurgical intervention, the incidence of neuropathic pain after microsurgical intervention is 67%. It is unclear why nerve repair surgery is effective in resolving or decreasing neuropathic pain in some patients, whereas it has no effect on pain relief in others. Psychological, medical, and age-related factors have been identified as risk factors for developing chronic post-surgical pain due to post-traumatic neuropathic pain. Two factors: injury to surgery time and preoperative visual analog scale score have recently been identified as variables that influence surgical outcomes in the treatment of PTTNp.

Translator use not associated with longer time to pain medication in initial evaluation of low-severity geriatric trauma

ObjectivesDetermine whether geriatric victims of blunt trauma who preferred to communicate in a language other than English waited longer for pain medication or received more imaging studies than English-speaking patients with the same age and injuries. Secondary outcomes were the type of medication administered and number of imaging studies. MethodsWe conducted a retrospective analysis of all trauma activations to a single academic urban medical center from January 2019 to October 2019. We included all hemodynamically stable patients older than 65, with head or torso trauma after a low energy injury, and on at least one medication that was an anti-coagulant, anti-platelet, or chemotherapeutic. ResultsWe identified 1,153 unique patients (17, 379 radiologic studies) performed from January 2019 to October 2019, with a median of 5 (4–6) radiologic studies per patient. We excluded 419 patients for whom the language used was not reported (n = 7), no imaging was not reported (n = 16), or no medication was recorded as given (n = 409), leaving 734 patients for further analysis. Of those 734 patients, 460 preferred to communicate in English, 84 in Mandarin Chinese, 64 in Spanish, 37 in Cantonese Chinese, and 35 in Korean, and 29 in Russian. Across all languages patient age and Injury Severity Score (ISS) were comparable. Those who preferred to communicate in Spanish, Russian, or Korean were more likely to be female than those who preferred English, Mandarin, or Cantonese, but this tendency was not statistically significant (χ2-test; p = 0.051, 0.15 after Bonferroni correction). We did not find a statistically significant association between preferred language and time to medication, fraction of opioids used as first-line pain medication, or number of imaging studies performed. Across all patients, the most common medications administered were acetaminophen (524/734, 71%), any opioid (111/734, 15%), followed by local infiltration or nerve block with lidocaine (49/734, 6.7%). ConclusionsA retrospective analysis of patients with low-risk blunt trauma found no relationship between preferred language, time to pain medication, use of opioids or number of imaging studies.

Apex of Triceps Aponeurosis: A Reliable Landmark to Localize the Radial Nerve.

The patient is anesthetized and placed in the lateral decubitus position with the elbow of the operative limb hanging freely over a bolster. A posterior midline incision centered over the fracture is made on the posterior aspect of the arm. The superficial and deep fascia are incised. The triceps aponeurosis is formed by the convergence and fusion of the lateral and long heads of the triceps. The most proximal confluence can be termed the "apex of the triceps aponeurosis." The radial nerve can be isolated approximately 2.5 cm proximal to the apex by developing an intramuscular plane. The remainder of the intramuscular dissection for plate fixation can then be performed safely without risking injury to the radial nerve. Numerous studies have established the relationship of the radial nerve to a fixed osseous point such as the medial epicondyle, lateral epicondyle, and angle of the acromion4-9. Additionally, the wide range of measurements of these anatomic relationships, as reported in various studies, makes it difficult for the operating surgeon to locate the radial nerve, especially in the setting of a fractured humeral shaft. For example, the reported distance of the radial nerve from the lateral epicondyle ranges from 6 to 16 cm and the distance from the angle of the acromion ranges from 10 to 19 cm. Even identification of the superficial branch of the radial nerve has been shown to help intraoperative localization of the radial nerve10. However, these studies have been conducted on cadavers with intact humeri, and their accuracy has not been demonstrated on the patients in the clinical milieu of trauma. The described soft-tissue landmark, which lies approximately 2.5 cm proximal to the apex of the triceps aponeurosis, reliably locates the radial nerve intraoperatively11. It is based on the anatomical fact that the origins of the lateral head (oblique ridge corresponding to the lateral lip of the spiral groove) and long head (infraglenoid tubercle of the scapula) are well above fractures of the middle and distal thirds of the humerus. Hence, the relationship of the radial nerve to the soft point represented by the apex of the aponeurosis is not likely to be disturbed in the setting of fractures distal to it, in sharp contrast with previously described osseous landmarks. Employing this anatomical understanding resulted in early localization of the radial nerve (within 6 ± 1.5 minutes of skin incision) and less blood loss (188 ± 13 mL)11. Patients are likely to retain their ability to perform active dorsiflexion of the wrist and fingers and have sensory preservation in the distribution of autonomous zone of the radial nerve after the procedure. The relationship of the radial nerve to the soft point represented by the apex of the aponeurosis is not likely to be disturbed in the setting of typical fractures distal to it; however, this may differ in cases of severely displaced or comminuted fractures, and the surgeon should be aware of this fact.The surgeon should remain careful to protect the vena comitans.

P-67954085-235 - A new classification of inferior alveolar nerve repositioning procedure for dental implants placement presentation and illustrative cases.

<h3>Objectives</h3> Tooth loss is one of the most common causes of reduced quality of life in adults. Recently there is an increasing global interest in treatments involving the Inferior Alveolar Nerve (IAN) repositioning for dental placement but standardization and classification of the techniques is warranted. In the present paper, a new classification is suggested, illustrated, and discussed. <h3>Patients and Methods</h3> A retrospective analysis of the preoperative radiographic records and the documents of the surgical procedures during a ten year period between 2008 -2018 of patients who had been treated with implant placement in conjunction with IAN repositioning of posterior atrophic mandible was performed. The cases were categorized according to the available bone, the nerve location, and the surgical intervention into four groups. <h3>Results</h3> Overall, 132 edentulous posterior mandibles in 98 patients (72 women, 26 men; age range 20-75 years) were included in the analysis. Those sites were divided into four categories: Category 1, included 54 patients with 72 sites, and was treated by one surgery. Category 2; included 15 patients with 15 sites and was treated with two stages. Category 3, included 17 patients with 21 sites, and category 4, included 12 patients with 24 sites. The treated 132 sites with IAN repositioning received 379 dental implants. All the sites were restored by an implant-supported fixed prosthesis. The patients reported good function and improvement in their quality of life. <h3>Conclusions</h3> This new classification might enhance diagnosis and help predict the treatment stages of the patients requiring IAN repositioning for dental implant placement.

Telocytes' Role in Modulating Gut Motility Function and Development: Medical Hypotheses and Literature Review.

This review article explores the telocytes’ roles in inflammatory bowel diseases (IBD), presenting the mechanisms and hypotheses related to epithelial regeneration, progressive fibrosis, and dysmotility as a consequence of TCs’ reduced or absent number. Based on the presented mechanisms and hypotheses, we aim to provide a functional model to illustrate TCs’ possible roles in the normal and pathological functioning of the digestive tract. TCs are influenced by the compression of nearby blood vessels and the degree of fibrosis of the surrounding tissues and mediate these processes in response. The changes in intestinal tube vascularization induced by the movement of the food bowl, and the consequent pH changes that show an anisotropy in the thickness of the intestinal tube wall, have led to the identification of a pattern of intestinal tube development based on telocytes’ ability to communicate and modulate surrounding cell functions. In the construction of the theoretical model, given the predictable occurrence of colic in the infant, the two-layer arrangement of the nerve plexuses associated with the intestinal tube was considered to be incompletely adapted to the motility required with a diversified diet. There is resulting evidence of possible therapeutic targets for diseases associated with changes in local nerve tissue development.

Dorsally placed commercially available subpalpebral lavage systems have low complication rates in horses.

To retrospectively evaluate the complication rate following dorsal placement of a commercially available 1-hole subpalpebral lavage system (SPL) at a veterinary teaching hospital. 102 client-owned horses with ophthalmic disease. Medical records of horses (2010 to 2020) with ophthalmic disease were reviewed to determine whether a commercially available SPL system was dorsally placed. Data collected from the medical record included signalment, presenting complaint(s), diagnosis, ophthalmic procedures performed, SPL laterality, hospital service that placed the SPL, anesthetic technique for placement (general anesthesia or sedation with local nerve blocks), duration of SPL management while hospitalized or at home, type of enclosure for the horse, use of eye protection, duration of time the SPL was in place, location of SPL management (home vs hospital), types and numbers of medications administered, recorded complications, and outcome of the globe. Complications experienced during treatment were categorized as either ocular or nonocular. The χ2 test for independence test and Fisher exact test were performed to examine the relationship between the department that placed the SPL, method of anesthesia, antimicrobial administration, type of facial protection used, and complication type and rate. Overall complication rate for SPL systems was 29.1% (37/127), with 21.2% (27/127) being ocular complications and 7.9% (10/127) being nonocular complications. SPL complication rate was not affected by any variable that was examined. Commercially available SPL systems placed dorsally have a low ocular complication rate. These SPL systems may be placed by veterinarians with varied training backgrounds and managed at home without significantly increasing complication rate.

VIBRATION ORTHODONTICS: A SIMPLE METHOD TO PAINLESS ORTHODONTIC TREATMENT

Pain is an all too common experience of patients undergoing any form of dental treatment, to the extent that 77% of a patient population reported some degree of pain from a visit to the dentist. In orthodontics, a mechanical stimulus is introduced by placing fixed appliances on the teeth resulting in tooth movement. To achieve this movement, forces are applied to the dentoalveolar complex resulting in inflammation or ischemia to the periodontal ligament (PDL) with subsequent release of histamine, bradykinin, prostaglandins, substance P, and serotonin. These mediators stimulate local nerve endings and send pain signals to the brain. Many methods have been used to alleviate pain arising from orthodontic origins. Nonsteroidal anti-inflammatory drugs (NSAIDS) are the most common method employed for pain relief. Other methods include low-level laser therapy, acupuncture,transcutaneous electrical nerve stimulation, vibratory stimulation of the PDL,viscoelastic bite wafers, and even chewing gum. This paper highlights use of vibratory stimulation for reduction in perception of pain.

The Posterior Femoral Cutaneous Nerve and Branches are in Proximity to the Surgical Approach During Proximal Hamstring Repair

PurposeThe purpose of our study is to identify the location of the posterior femoral cutaneous nerve (PFCN) and its branches in relation to the proximal hamstring tendon.MethodsFifteen lower torso human cadaveric specimens were dissected in prone position. Skin and subcutaneous tissues were reflected to expose the gluteal and hamstring musculature. The distance between the ischial tuberosity and lateral border of the hamstring, PFCN, perineal branch of the PFCN, and descending femoral branch of the PFCN was measured with digital calipers. Measurements were repeated three times and averaged.ResultsThe PFCN was 30.5 ± 11.4 mm lateral to the central tip of the ischial tuberosity (range: 15.7 to 52.0 mm). The average longitudinal distance from the tip of the ischial tuberosity to the point where the perineal branch crossed the hamstrings was 24.1 ± 15.0 mm (range: 9.9 to 52.2 mm). The average longitudinal distance to the point where the descending cutaneous branch crossed the hamstrings was 83.3 ± 21.3 mm (range: 41.3 to 110.3 mm). The PFCN was nearest to the inferior border of the gluteus maximus 45.8 ± 13.6 mm lateral to the ischial tuberosity (range: 13.6 to 62.1 mm). Eleven specimens (73%) had one identifiable perineal branch; four (27%) had two distinct perineal branches.ConclusionsThe PFCN was in close proximity to the surgical approach used during proximal hamstring repair, with the perineal branch consistently crossing the surgical field transversely. The location of these nerves varied substantially among the specimens tested, with some nerves less than 1 cm from the ischial tuberosity and 27% of specimens with two perineal branches.

Preclinical nerve conduction: Nerve battery options for primate studies

Electrophysiological neurodiagnostic tests of nerve conduction (NC) are key assays included in preclinical safety and toxicology programs to assess the peripheral neuropathy (PN) liability of a new drug. Despite their increased use, standardization of nerve conduction studies (NCS) is lacking in the preclinical space, with limited regulatory guidelines stipulating type and number of nerves or minimum combinations appropriate for each stage of drug development or indication. Detection of subtle peripheral toxicities depends on choosing appropriate nerve targets for testing, especially when functional changes remain above the lower limit of normal values. To support robust preclinical toxicology study designs, the current short communication provides options and recommendations for selecting peripheral nerves for clinically translatable nerve conduction batteries applicable to toxicology and gene therapy, with a focus on primate models. A comprehensive compilation of accessible nerve locations is offered including lower and upper extremity motor nerves, and sensory nerves with origin at multiple DRG levels. Rankings of technique difficulty and repeatability across serial collections are presented for each assay informed by serial nerve conduction from 500 adult primates. The goal of this communication is to support the standardization and preclinical implementation of this important assay.

Ameliorative Potential of Hot Compress on Sciatic Nerve Pain in Chronic Constriction Injury-Induced Rat Model.

Hot compress modalities are used to ameliorate pain despite prevalent confusion about which modality should be used and when. Most recommendations for hot compresses are based on empirical experience, with limited evidence to support its efficacy. To obtain insight into the nerve transmission mechanism of hot compresses and to identify the nerve injury marker proteins specifically associated with sciatic nerve pain, we established a rat model of chronic constriction injury (CCI) and performed mechanical allodynia, electrophysiology, and histopathological analysis. All CCI rats exhibited geometric representation of the affected hind paw, which indicated a hyper-impact on both mechanical gait and asymmetry of gait on day 28. The CCI model after 28 days of surgery significantly reduced compound muscle action potential (CMAP) amplitude, but also significantly reduced latency. Administration of hot compress for 3 weeks (heated at 40–42°C, cycle of 40 min, and rest for 20 min, three cycles each time, three times per week) significantly increased the paw withdrawal thresholds in response to stimulation by Von Frey fibers and reversed the CCI-induced reduced sciatic functional index (SFI) scores. Hot compress treatment in the CCI model improved CMAP amplitude and latency. The S100 protein expression level in the CCI+Hot compression group was 1.5-fold higher than in the CCI group; it dramatically reduced inflammation, such as tumor necrosis factor alpha and CD68 expression in nerve injury sites. Synaptophysin (Syn) expression in the CCI+Hot compression group was less than threefold in the CCI group at both nerve injury sites and brain (somatosensory cortex and hippocampus). This finding indicates that local nerve damage and inflammation cause significant alterations in the sensorimotor strip, and hot compress treatment could significantly ameliorate sciatic nerve pain by attenuating Syn and inflammatory factors from local pathological nerves to the brain. This study determines the potential efficacy and safety of hot compress, and may have important implications for its widespread use in sciatic nerve pain treatment.

Lesion Localization and Prognosis Using Electrodiagnostic Studies in Facial Diplegia: A Rare Variant of Guillain-Barre Syndrome.

BackgroundThe etiology of facial nerve palsy is diverse and includes herpes zoster virus, Guillain-Barre syndrome (GBS), otitis media, Lyme disease, sarcoidosis, human immunodeficiency virus, etc. The lower motor neuron type facial nerve palsy is usually caused by an ipsilateral facial nerve lesion; however, it may be caused by a central lesion of the facial nerve nucleus and tract in the pons. Facial diplegia is an extremely rare condition that occurs in approximately 0.3% to 2.0% of all facial palsies. Electrodiagnostic studies including direct facial nerve conduction, facial electromyography (EMG), and blink reflex studies are useful for the prognosis and lesion localization in facial nerve palsy.MethodologyThis retrospective, observational study was conducted at the Neurophysiology Unit, Hamad General Hospital, Doha, Qatar. This study included 11 patients with bilateral facial weakness who visited for electrodiagnostic studies in the neurophysiology laboratory.ResultsIn total, eight (72.7%) patients had facial diplegia, eight (72.7%) had hypo/areflexia, seven (63.6%) had facial numbness, and five (45.5%) had cerebrospinal fluid albuminocytological dissociation. The most frequent cause of facial diplegia in this study was GBS (81.9%). Direct facial nerve conduction stimulation showed that nine (81.8%) patients had bilateral facial nerve low compound muscle action potential amplitudes. The bilateral blink reflex study showed that eight (88.8%) patients had absent bilateral evoked responses. Finally, the EMG study showed that five (55.5%) patients had active denervation in bilateral sample facial muscles.ConclusionsBilateral facial nerve palsy is an extremely rare condition with a varied etiology. Electrodiagnostic studies are useful in detecting the underlying pathophysiologic processes, prognosis, and central or peripheral lesion localization in patients with facial diplegia.

Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review.

ObjectiveManagement of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesic properties and side effects. The objective of this review is to discuss the efficacy and safety of multimodal analgesia (MMA) for these patients.MethodsPubmed, Cochrane, Embase, Scopus, and clinicaltrials.gov were systematically searched for all comparative studies of patients receiving MMA (nonsteroidal anti‐inflammatory drugs (NSAIDs), acetaminophen, anticonvulsants, local anesthetics, and corticosteroids) for head and neck cancer surgeries. The primary outcome was additional postoperative opioid usage, and secondary outcomes included subjective pain scores, complications, adverse effects, and 30‐day outcomes.ResultsA total of five studies representing 592 patients (MMA, n = 275; non‐MMA, n = 317) met inclusion criteria. The most commonly used agents were gabapentin, NSAIDs, and acetaminophen (n = 221), NSAIDs (n = 221), followed by corticosteroids (n = 35), dextromethorphan (n = 40), and local nerve block (n = 19). Four studies described a significant decrease in overall postoperative narcotic usage with two studies reporting a significant decrease in hospital time. Subjective pain scores widely varied with two studies reporting reduced pain at postoperative day 3. There were no differences in surgical outcomes, medical complications, adverse effects, or 30‐day mortality and readmission rates.ConclusionMMA is an increasingly popular strategy that may reduce dependence on opioids for the treatment of postoperative pain. A variety of regimens and protocols are available for providers to utilize in the appropriate head and neck cancer patient.

The anatomy of the obturator nerve and its branches in a South African cadaver sample

PurposeSeveral surgical and clinical procedures are performed in the area of the medial compartment of the thigh. This places the obturator nerve and its branches in potential danger of injury. This study aimed to provide a clear description of the anatomy and course of the obturator nerve and its branches. Methods: One hundred and one formalin-fixed cadavers were dissected just lateral to the lumbar vertebra to describe the origin and course of the obturator nerve, as well as its relation to other anatomical structures. The location of the obturator nerve within the obturator foramen was quantified by measuring the distance from three bony landmarks of the obturator foramen to the nerve. Findings: In 20% of cases the obturator nerve originated from L3 and L4 rather than L2 to L4 in the combined sample. The bifurcation of the nerve occurred intrapelvically in 2% of cases, within the obturator canal in 93% of cases and extrapelvically in 5% of the sample. Regarding the course in the abdomen, the L3 root joined the L4 root more distally after exiting the psoas major muscle. In all cases on the left (n = 97) and 99% on the right, the anterior branch innervated the muscles of the medial thigh, in one case on the right the anterior branch innervated the pectineus muscle. The posterior branch assisted the anterior branch in the innervation adductor brevis in 10% on the left and 11% on the right sides. ConclusionThe results of this study may be used in the pre-operative preparation of surgeons that are to perform surgery in the area of the obturator foramen such as obturator nerve blocks for pain relief of adductor muscle contractions, prevention of adduction of the thigh during transurethral bladder surgery, additional analgesia after knee surgery, chronic hip pain, as well as postoperative analgesia after hamstring harvest for anterior cruciate ligament reconstruction.

Inverted human umbilical artery as a 3D scaffold for sciatic nerve regeneration in rats

Treatment of peripheral nerve injuries (PNIs) remains a challenge. Interposing a graft delivers better regenerative outcomes. Autografts present major drawbacks which have given rise to the development of alternatives such as artificial scaffolds, some of which are very promising. This study was designed to investigate the potential use of an inverted human umbilical cord artery (iHUA) as a 3D scaffold nerve chamber, for nerve regeneration after transection of the sciatic nerve (SN) in rats. Rats underwent surgical SN transection in their right hindlimb, followed by suture of the device at the resected stumps. Local tolerance, insert biodegradability and nerve reconstruction over time were thoroughly studied by histopathological and morphometric analysis, completed by functional test assessment of sensitivity and motricity recovery. We have demonstrated that nerve reconstruction in the presence of an iHUA insert is effective. The device is well tolerated and highly biodegraded. Although the regenerated nerve is still immature at the end of our study, signs of sensitivity and partial functional recovery were witnessed, confirming our histological findings. Our results support the potential clinical use of iHUA as a 3D scaffold to bridge nerve discontinuity and guide axonal regrowth in selected cases of PNIs.

Nerves of the Thorax: Anatomy, Clinical Signs, and Imaging Findings of Pathological Conditions.

Radiological diagnosis of thoracic nerve diseases is difficult because they are rare, and nerves cannot be seen directly on radiological images. The major nerves of the thorax can be listed as the phrenic, vagus, recurrent laryngeal, long thoracic nerve pairs, sympathetic chains, costal nerves, and brachial plexus. Diseases of thoracic nerves have various causes, including traumatic injury, neuromuscular diseases, infection, compression, radiation, drugs, and tumors. This pictorial review aims to describe the anatomic locations of the major thoracic nerves on radiological images, comprehensively describe the causes of thoracic nerve diseases and define the clinical signs and primary and secondary imaging findings of dysfunction of the thoracic nerves. This paper was designed to illustrate primary and secondary imaging findings of nerve diseases. Firstly, the normal anatomy of nerves is shown with diagrams. Secondly, we explained primary and secondary imaging features with variable radiological methods, including chest X-Ray, magnetic resonance imaging, and computed tomography. Primary findings of nerve diseases can be detected if radiologists are familiar with the courses of the nerves on radiological images. Knowledge of the normal functions of the nerves can aid in diagnosing thoracic nerve diseases identified from secondary imaging findings such as diaphragmatic elevation, muscular atrophy, and winged scapula. It is essential to know the normal anatomy, function, and possible causes of thoracic nerve diseases to make a correct diagnosis and apply the prompt treatment.

Surgical Anatomy of the Cavernous Sinus, Parasellar Region, and Orbit

The cavernous sinus, para-sellar region, and orbit have intricately intertwined cranial nerves, blood vessels, and dura mater. In surgery, anatomical understanding is very important. Recognizing the location(depth)of the cranial nerves running on the lateral and upper wall of the cavernous sinus is vital and is directly linked to postoperative complications. In addition, understanding the dural ring in the clinoid segment of the internal carotid artery is important. The periosteum on the upper surface of the anterior clinoid is the distal dural ring of the internal carotid artery, and the periosteum on the lower surface is the proximal dural ring. The orbit is filled with adipose tissue and is completely different from other intracranial parts. However, understanding the anatomy from the orbital apex to the superior orbital fissure is important in the pterional approach.

Massage application to increase the spread of local anesthesia in sciatic nerve blocks: A cadaveric study

IntroductionSciatic nerve blocks are essential for surgical treatment of various lower limb pathologies. Due to the complexity and variation of anatomical landmarks, ultrasound (US) guided injection of local anesthesia has become common practice. In patients with thicker thigh girth (i.e., obese patients) excess tissue may distort US penetration thereby diminishing efficacy of the nerve block and/or cause severe post‐operative pain. Dye tracing techniques have been used to test the effectiveness of nerve blocks, but there is little research on using massage to manipulate anesthetic spread. Therefore, the aim of this study is to assess the effects of massage to manipulate local anesthesia spread in sciatic nerve blocks. We hypothesize massaging after injection will increase the spread of local anesthesia compared to non‐massage post injection.MethodsForty un‐fixed cadaveric legs were injected with a mixture of methylene blue dye and 2% Lidocaine Hydrochloride. Specimens were divided into non‐massage (control) (n=20) and massage (n=20) groups. Sciatic nerve blocks were performed by a nurse anesthetist using US guidance at the popliteal fossa traveling proximally until the sciatic nerve was identified and the location was tagged. Immediately following, massage group specimens received five repeated proximally directed massages with the US transducer head. Specimens from both groups were then dissected to expose the sciatic nerve. Measurements of the distance traveled from marked site of injection to proximal end of dyed area were measured and compared.ResultsSpread of local anesthesia in the inferior‐superior direction was significantly higher in the massage group than the control group (p≤0.05).ConclusionsMassaging post‐injection caused a greater spread of local anesthesia during sciatic nerve block.SignificanceSciatic nerve block techniques often utilize nerve stimulation to identify the sciatic nerve location. This may be due to lack of US penetration through the gluteus maximus muscle. In patients with thicker thigh girth due to subcutaneous fat, imaging visibility may be more difficult as well. Our findings suggest that clinicians may block the sciatic nerve at a more distal location with US guidance and manipulate the anesthesia to the region of interest.

MP59-13 BLADDER TUMOR ACCURATE RADIOFREQUENCY RESECTION: 38 CASES REPORTS

You have accessJournal of UrologyCME1 May 2022MP59-13 BLADDER TUMOR ACCURATE RADIOFREQUENCY RESECTION: 38 CASES REPORTS Shengkun Sun, Guangfu Chen, Weijun Fu, and Xu Zhang Shengkun SunShengkun Sun More articles by this author , Guangfu ChenGuangfu Chen More articles by this author , Weijun FuWeijun Fu More articles by this author , and Xu ZhangXu Zhang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002642.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bladder cancer is the fourth most frequently diagnosed malignancy in males and the 12th most common malignancy in females. Transurethral resection of bladder tumor (TURBT) remains the mainstay of diagnosis and initial treatment of bladder neoplasms. TURBT is performed conventionally with an electrocautery loop. The piecemeal resection specimens are inappropriate for tumor pathological evaluation because of poor anatomic orientation and evaluation of the pathological depth is not necessarily accurate. Also, tumor cells are scattered as the tumor is fragmented so that the possibility of implantation cannot be excluded. The objective of this study is to optimize the surgical method of transurethral bladder tumor resection. METHODS: 38 patients with non-muscle invasive bladder cancer received transurethral accurate resection of the tumor with a novel β electrode with a radiofrequency energy platform. Normal bladder mucosa 0.5 to 1 cm from the tumor base was marked with the tip of β electrode with an electrocautery energy. The needle of the β electrode was insert into the submucosa, and tissue of the bladder wall was pulled towards the midline of the bladder, followed by electro-cutting. Tumor blood vessels were cauterized with the needle tip. After en bloc resection of the tumor bulk, a novel β basket, which could be opened and trapped the tumor in bladder, was introduced into the bladder to retrieve the tumor en bloc or sub-en bloc. RESULTS: Tumors exceeded T2 stage or tumors with a maximum diameter of less than 1 cm were excluded. 38 patients underwent accurate transurethral radiofrequency resection of bladder tumors, and a total of 47 tumors were removed. The maximum diameter of the tumor is 2.4cm (range from 1 to 5cm). Tumors less than 3cm could be retrieved through the resection sheath or be taken out with the β basket. 12 tumors with a maximum diameter of >3cm were divided into 2-3 large pieces by the β basket and then taken out. During the operation, there was no obturator nerve reflex, no bladder perforation or urine extravasation. The intraoperative bleeding was less than 2ml in every patient. The bladder was flushed with normal saline for 24 hours post operation. Postoperative pathology showed Ta in 27cases and T1 in 11 cases. No second TURBT was performed in this group. No operative complications occurred. All patients received intravesical irrigation of BCG or chemotherapy agent periodically. 2 patients had tumor recurrence in the bladder during the mean follow-up of 8.7 months (range from 3 to 11 months). CONCLUSIONS: A novel β electrode was used to remove the tumor during accurate transurethral radiofrequency resection of bladder tumors. There are several advantages of this novel method. First, the blood supply of the tumor was occluded to avoid bleeding. Second, the obturator nerve reflex could be prevented completely and local nerve blockage was not necessary. Third, accurate radiofrequency resection of bladder tumor improved the resection quality and the en bloc resection helped make accurate TNM stage which was significant for postoperative treatment strategy. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1007 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shengkun Sun More articles by this author Guangfu Chen More articles by this author Weijun Fu More articles by this author Xu Zhang More articles by this author Expand All Advertisement PDF DownloadLoading ...

Real-time detection of the recurrent laryngeal nerve in thoracoscopic esophagectomy using artificial intelligence.

Artificial intelligence (AI) has been largely investigated in the field of surgery, particularly in quality assurance. However, AI-guided navigation during surgery has not yet been put into practice because a sufficient level of performance has not been reached. We aimed to develop deep learning-based AI image processing software to identify the location of the recurrent laryngeal nerve during thoracoscopic esophagectomy and determine whether the incidence of recurrent laryngeal nerve paralysis is reduced using this software. More than 3000 images extracted from 20 thoracoscopic esophagectomy videos and 40 images extracted from 8 thoracoscopic esophagectomy videos were annotated for identification of the recurrent laryngeal nerve. The Dice coefficient was used to assess the detection performance of the model and that of surgeons (specialized esophageal surgeons and certified general gastrointestinal surgeons). The performance was compared using a test set. The average Dice coefficient of the AI model was 0.58. This was not significantly different from the Dice coefficient of the group of specialized esophageal surgeons (P = 0.26); however, it was significantly higher than that of the group of certified general gastrointestinal surgeons (P = 0.019). Our software's performance in identification of the recurrent laryngeal nerve was superior to that of general surgeons and almost reached that of specialized surgeons. Our software provides real-time identification and will be useful for thoracoscopic esophagectomy after further developments.

The Transgluteal Approach for Decompression of Sciatic Nerve Entrapment (Piriformis Syndrome) with Intraoperative Neurophysiology: A Technical Note

Although the transgluteal approach splitting the gluteus maximus muscle has been reported as a posterior approach for sciatic nerve entrapment (piriformis syndrome), detailed descriptions of the surgical steps and intraoperative findings have not been published. Thus, the objective of this study was to present the transgluteal approach for decompression surgery of sciatic nerve entrapment in the subgluteal space. A method of circumferentially decompressing the sciatic nerve from the surrounding piriformis muscle was devised by decompressing it to the level of the sacrotuberous ligament, which was more proximal than the existing decompression range. Surgical findings are presented step-by-step in the stages of localization, exposure, and decompression of the sciatic nerve during surgery. We also emphasize the importance of intraoperative nerve monitoring to identify the sciatic nerve and its branches and the inferior gluteal nerve during surgery performed under general anesthesia. Our observations of intraoperative electromyographic responses by individual nerve stimulation are summarized and reported.