Postoperative Neuralgia Research Articles

Clinical exploration of the international society of limb salvage classification of endoprosthetic failure using Henderson in the application of 3D-printed pelvic tumor prostheses.

The use of 3D-printed pelvic prosthesis for postoperative reconstruction after pelvic tumor resection has become one of the primary reconstruction methods the incidence of complications related to postoperative prosthesis reconstruction is high. Drawing on the failure of the type of bone tumor reconstruction in Henderson,the occurrence of postoperative complications was explored to take advantage of the design improvement of the 3D-printed prosthesis of subsequent pelvic tumors. The data for patients who underwent 3D-printed pelvic tumor prostheses in the Department of Bone and Soft Tissue Surgery at the Affiliated Cancer Hospital of Guangxi Medical University from January 2019 to October 2022 were collected and analyzed. The median follow-up time for all patients was 15.99 months (1.33-31.16 months). At the most recent follow-up,all patients were alive,with an average Musculoskeletal Tumor Society (MSTS) score of 21.46 (17 to 26 points). Local recurrence occurred in two cases (15.3%), metastasis in four cases (30.7%), and complications in 10 cases (76.9%). Early complications after surgery were primarily local wound fissure, deep tissue infection, and postoperative neuralgia. Later complications included loose dissolution of internal fixation, postoperative prosthetic dislocation, and postoperative gluteal middle muscle gait. 3D printing personalized design pelvic tumor prosthesis is an effective way to reconstruct, and designing pelvic 3D printed tumor prosthesis with the help of Henderson's bone tumor reconstruction failure concept may help bone tumor surgeons develop better pelvic tumor prosthesis.

Laparoscopic mesh placement during inguinal hernia repair: a meta-analysis of two methods of repair.

There are several modifications in the technique for the placement of mesh during laparoscopic inguinal hernia repair. One of these is a slit on the mesh to surround the cord structures which proponents of it suggest that it decreases the recurrence rate due to better anchoring of the mesh and lower risk of displacement. There is only low-level evidence in current literature examining the two methods. The present study aimed to provide stronger evidence in establishing whether the slit mesh technique is superior to the non-slit mesh technique. The reporting of this systematic review was guided by the standards of the preferred reporting items for systematic review and meta-analysis statement and registered with PROSPERO (ID: CRD42022300629). Eligible studies had to compare the two methods of mesh placement slit Vs nonslit in laparoscopic Inguinal hernia repair and also report on at least one outcome. The outcomes were expressed in odd ratios with their 95% confidence intervals. Where significant heterogeneity existed a random effects model was used otherwise a fixed effects model was used. Five studies met the criteria for inclusion in quantitative analysis. Overall, there were 10 (1.5%) recurrences in the slit group compared to 12 (2.5%) in the non-slit group OR 0.62, 95% CI (0.27-1.41). There was no difference in the incidence of post-operative bleeding (OR 1.21, 95%CI 0.4-3.66), seroma formation (OR1.5, 95% CI 0.81-2.76), or post-operative neuralgia (OR 0.98, 95%CI 0.11-8.92) between the two groups. There was no difference between the two methods.

OC-026 PERFORMING A SLIT ON THE MESH TO ENCIRCLE THE CORD STRUCTURES DURING LAPAROSCOPIC INGUINAL HERNIA REPAIR - A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Aim There are several modifications in the technique for the placement of mesh during laparoscopic inguinal hernia repair. The present study aimed to provide stronger evidence in establishing whether the slit mesh technique is superior to the non-slit technique (the most common practice). The primary outcome was recurrence and secondary outcomes were postoperative groin pain, bleeding, seroma formation and duration of surgery. Material & Methods Eligible studies had to compare the two methods of mesh placement slit Vs non slit in laparoscopic TEP or TAPP inguinal hernia repair. Databases searched were Embase, Medline, Cochrane collaboration, NICE guidelines search. The meta-analysis was conducted using Review Manager software 5:4. The outcomes were expressed in odd ratios with their 95% confidence intervals. Where significant heterogeneity existed (I2>75%) a random effects model was used otherwise a fixed effects model was used. Results Five studies included, all were single centre studies, 4 retrospective and one prospective observational studies. 1076 patients included, 633 in the slit group and 434 in the non-slit group. The male to female ration was 9:1. There were 10 (1.5%) recurrences in the slit group compared to 12 (2.5%) in the non-slit group 0.62, 95% CI (0.27–1.41). There was no difference in the incidence of post-operative bleeding (1.21, 95%CI 0.4–3.66), seroma formation (1.5, 95% CI 0.81–2.76), or post-operative neuralgia (0.98, 95%CI 0.11–8.92). Conclusion There is no advantage in performing a slit on the mesh to encircle the cord structures during laparoscopic inguinal hernia repair.

P-044 LEARNING AND DATA FROM OUR TEP LEARNING CURVE

Abstract Aim Laparoendoscopic techniques for inguinal repair (TEP) offers advantages such as less postoperatory pain, less local complication rates and early comeback to work activities. We describe the TEP learning curve in our unit and we present a preliminary analysis of our results. Material and Methods We present the retrospective analysis of patients who underwent TEP inguinal hernioplasty between 2018 and 2021 in a Wall Surgery Unit of Navarra Hospital. We perform a descriptive analysis of the collected data. Results 182 patients were analysed, including 91.6% male with an average age of 57.1 years. 11patients required conversion from TEP to another technique (mainly TAPP and open preperitoneal surgery) due to surgical or anesthetic problems, with a conversion rate of 6%. 4 patients (2%) presented early recurrence and 6 patients (3%) late recurrence. 16 patients (8.8%) had moderate pain (VAS < 5) while 7 patients (3.8%) had severe pain (VAS ≥5). All the patients who presented postoperative pain were reviewed and none presented postoperative neuralgia. No patient showed surgical site infection neither epididymitis. 4 patients (2%) presented seroma and 23 (12.6%) hematoma. Conclusions Laparoendoscopic techniques, especially TEP, has more demanding learning curve than open repairs. Support and tutoring are imperative in the first cases. An adequate selection of cases at the beginning is important. Mastering open preperitoneal hernioplasty surgery leads to better and faster results in TEP approach.

CHOICE OF INGUINAL HERNIA REPAIR PROCEDURE

Introduction. Modern surgical approaches to inguinal hernia repair are laparoscopic (TAPP and TEP) and open (Lichtenstein procedure), which are based on prolene mesh prosthetics. Despite the widespread use of these methods of hernia repair in surgical practice, the frequency of typical postoperative complications: hematoma of the scrotum and inguinal region, false recurrence, paresthesias, neuralgia, etc.
 Aim. To compare TAPP, TEP, and Lichtenstein based on analysis of long-term treatment outcomes.
 Materials and methods. We performed surgical treatment of inguinal hernia in 211 patients. All of them underwent tension-free hernia repair using a prolene prosthesis. Lichtenstein procedure was performed in 65 patients (Lichtenstein group), TAPP (TAPP group) in 81 patients and TEP (TEP group) in 65 patients. In 30 patients of different groups, the blood flow in the vessels of the testis was studied after the procedures performed within 45–60 days.
 Results. Probably (p<0.001) faulty recurrence was observed more often in the Lichtenstein group. Seromas that persisted for more than 30 days (p<0.01) and seromas that required surgical intervention — puncture (p<0.05) were more likely to be noted in the TEP group. Indicators such as hernia recurrence (up to one year) and the intensity and frequency of chronic postoperative neuralgia in the Lichtenstein, TAPP and TEP groups differed improbably. The systolic velocity of blood flow in the vessels of the testis in patients of the Lichtenstein group before the operation was (19.70±3.53). In the postoperative period, an incredible decrease in blood flow was observed (19.28±3.41). In patients of the TAPP group, the preoperative systolic velocity was (19.83±3.27) and improbably decreased to (19.47±3.44) within 45–60 days. A similar improbable decrease was observed in the TEP group — (19.80±3.56) and (19.63±3.51)
 Conclusions. The Lichtenstein procedure and endoscopic methods of inguinal hernia correction (TAPP and TEP) are safe procedures in terms of long-term complications and do not likely affect the systolic blood flow velocity in the testicular arteries.

Estimating the Impact of Postamputation Pain.

Neuromas, neuralgia, and phantom limb pain commonly occur after lower-extremity amputations; however, incidence of these issues is poorly reported and understood. Present literature is limited to small cohort studies of amputees, and the reported incidence of chronic pain after amputation ranges as widely as 0% to 80%. We sought to objectively investigate the incidence of postamputation pain and nerve-related complications after lower-extremity amputation. Patients who underwent lower-extremity amputation between 2007 and 2017 were identified using a national insurance-based claims database. Incidence of reporting of postoperative neuroma, neuralgia, and phantom limb pain were identified. Patient demographics and comorbidities were assessed. Average costs of treatment were determined in the year after lower-extremity amputation. Logistic regression analyses and resulting odds ratios were calculated to determine statistically significant increases in incidence of postamputation nerve-related pain complications in the setting of demographic factors and comorbidities. There were 29,507 lower amputations identified. Postoperative neuralgia occurred in 4.4% of all amputations, neuromas in 0.4%, and phantom limb pain in 10.9%. Nerve-related pain complications were most common in through knee amputations (20.3%) and below knee amputations (16.7%). Male sex, Charlson Comorbidity Index > 3, diabetes mellitus, diabetic neuropathy, diabetic angiopathy, diabetic retinopathy, obesity, peripheral vascular disease, and tobacco abuse were associated with statistically significant increases in incidence of 1-year nerve-related pain or phantom limb pain. Given the incidence of these complications after operative extremity amputations and associated increased treatment costs, future research regarding their pathophysiology, treatment, and prevention would be beneficial to both patients and providers.

Risks of therapeutic versus prophylactic neurectomies.

Neuralgia due to a peripheral nerve injury may result in chronic pain, requiring a therapeutic surgical neurectomy. Meanwhile, some neurectomies are performed prophylactically, such as during inguinal mesh removal. Outcomes and risks associated with neurectomies are largely unknown despite consensus panels recommending them. All patients who underwent neurectomy 2013-2020 were analyzed. Data collection included demographics, preoperative symptoms, and postoperative outcomes. Indications for neurectomy were categorized as "therapeutic" if the patient had preoperative neuralgia or "prophylactic" if neurectomy was deemed necessary intra-operatively. 66 patients underwent 80 operations and a total of 122 neurectomies. On average, 1.5 neurectomies were performed per operation. Therapeutic neurectomies were performed in 42 (64%) patients and prophylactic in 34 (52%). The most commonly transected nerve was the ilioinguinal nerve. Average preoperative pain score was 5.8/10. On paired analysis, there was a significant reduction in pain after prophylactic neurectomy (2.5 points, p = 0.002) but not after therapeutic neurectomy. None of the nerves transected prophylactically had postoperative neuralgia, whereas 35% of the nerves transected therapeutically resulted in persistent or recurrent neuralgia (p < 0.001). To treat this, 21% required only nerve blocks and 9% required ablation or reoperative neurectomy. Three patients had complex regional pain syndrome (CRPS), a severe complication; all three were diagnosed with chronic pain syndrome pre-operatively. We demonstrate that prophylactic neurectomy is largely safe. In contrast, a therapeutic neurectomy had a 35% risk of persistent or recurrent neuralgia, 9% required additional ablative or reoperative neurectomy. Three patients advanced from chronic pain syndrome to CRPS. We recommend the decision to perform a neurectomy be judicious and selective, especially in patients with known chronic pain syndrome. Prior to planning surgical neurectomy, other less invasive modalities should be exhausted and patients should be aware of its risks.

СОВРЕМЕННЫЕ ПОДХОДЫ К ВОПРОСАМ ПЛАСТИКИ КОСТНЫХ ДЕФЕКТОВ ОКОЛОНОСОВЫХ ПАЗУХ

In modern clinical otorhinolaryngology, there are different opinions regarding the choice of the surgical approach for interventions on the paranasal sinuses. There are two main options for access to the paranasal sinuses - these are extra- and endonasal approaches, each of which has advantages and disadvantages. In some cases, when using open access, a bone defect of the anterior sinus wall occurs, leading to the development of various pathological conditions. Analyzing the possible outcomes of postoperative changes in the sinuses, many researchers are unanimous in the opinion that the presence of postoperative defects in the walls of the sinuses larger than 1 cm lead to the development of scar changes in the mucous membrane, deformation of the sinus, the development of postoperative neuralgia of the second branch of the trigeminal nerve associated with compression of the nervous ending with a postoperative scar. Variants of using various materials for plastics of postoperative bone defects of the paranasal sinuses are considered, the main advantages and disadvantages of using materials based on autobone, allogeneic bone and cartilage grafts, and various materials of non-biological origin are analyzed. Clinical experience of using allogeneic materials for plastics of facial bone defects is presented.

Role of Neurectomy in Inguinodynia Following Hernioplasty: A Randomized Controlled Trial.

IntroductionTo date, Lichtenstein tension-free mesh hernioplasty is being adopted widely for inguinal hernia repair in adults, although it is accompanied by procedural complications such as recurrences, infection, testicular atrophy, post-operative pain, and nerve injury. As the recurrence rate decreased after Lichtenstein's tension-free hernioplasty, surgeons’ point of focus shifted more toward postoperative groin pain (inguinodynia) after inguinal hernia repair, as it has become a quite significant problem. The nerves of interest in the inguinal region are ilioinguinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves. Out of all the nerves, the ilioinguinal nerve is at the greatest risk of entrapment during meshplasty. Chronic groin pain is quite significant following hernia repair, and irrespective of the severity, it can interfere with normal daily activity. The traditional surgical technique recommends the preservation of the ilioinguinal nerve to avoid the morbidity associated with the cutaneous sensory loss supplied by the nerve. One popular belief is that if we excise the ilioinguinal nerve, then the chance of getting post-operative neuralgia due to entrapment, inflammation, neuroma, or fibrotic reactions will almost become zero. Hence, this study was conducted to evaluate the effect of prophylactic excision of the ilioinguinal nerve in the patients undergoing Lichtenstein hernioplasty for inguinal hernias.MethodsAll consecutive male patients presenting to the Department of Surgery with inguinal hernia and age above 18 years were included in the study. All the patients were operated on under spinal anesthesia. Lichtenstein tension-free hernia repair was taken as the standard procedure for hernia repair. Patients in whom the nerve was preserved were kept in group A, whereas group B comprised patients who had undergone neurectomy. Patients were followed up regarding pain at first, third, and sixth months, at rest, and after exercise. The pain was graded according to the VAS (visual analog scale) scoring.ResultsIn the present study, out of a total of 92 patients, 80 patients were included. In the first month, 15% of the patients in group A had mild pain, while 5% in group B had experienced a moderate degree of pain at rest. After exercise, the result was 30% in group B. Similarly, in the third month of follow-up, it was found that 25% of the patients in group A experienced mild pain, while 12.5% complained about a moderate degree of pain who had to take analgesics for a longer period. After putting them to exercise and then grading the pain, it was found that 32.5% in group A and 15% in group B experienced pain. After follow-up for six months in both groups, it was revealed that there was no significant difference in post-operative pain at rest (10% and 7.5% in groups A and B, respectively). After exercise, 20% of patients in group A complained of pain, while in group B, only 10% experienced pain. There was no significant difference between both the groups while comparing chronic groin pain at rest and after exercise, and after different time intervals in follow-up (p = 0.4513 and 0.548, respectively).ConclusionProphylactic excision of the ilioinguinal nerve in Lichtenstein tension-free meshplasty decreased the incidence of chronic groin pain after surgery but it was statistically insignificant. Furthermore, this procedure did not affect the quality of life after surgery.

Prospective study to evaluate the value of Identification of nerves crossing inguinal canal during inguinal mesh hernioplasty

Abstract Background Long-term morbidity associated with open inguinal hernia repair mainly consists of postoperative chronic pain. The mechanism responsible for the development of this postoperative pain is thought to be the entrapment, inflammation, and fibrotic reactions of the nerve around the mesh. Aim of the Work To analyse and provide comprehensive data on their incidence (identification rates), anatomical characteristics, and possible sources of heterogenecity, to decrease the risk of iatrogenic injury/ entrapment to these nerves during inguinal hernioplasty. Patients and Methods This study identified 40 patients who underwent inguinal hernia repairs with either routine repair or nerve identification and preservation. As several studies point out, a nerve-recognizing procedure is a logical step for minimizing postoperative groin pain. Such an approach can be advocated for two reasons: identification of the nerves for preservation or for performing standard neurectomy in case of interference with the position of the mesh. Results In the present study, there was no difference in pain scorings at one or 3-months after repair between different surgical techniques in patients undergoing open repair of a primary inguinal hernia. In present work, in addition to identifying and preserving all neural structures, specific maneuvers have been adopted for preventing postherniorrhaphy inguinodynia Conclusion The results indicated that routine nerve identification and preservation was associated with a significantly lower incidence of postoperative neuralgia compared with no nerve identification.

Feasibility and efficacy of cryoneurolysis analgesia in robotic-assisted thoracoscopic surgery (CARTS): a pilot study.

Opioid therapy has been the mainstay therapy of post-operative pain management in thoracic surgery patients. With the high incidence of chronic pain in thoracic surgery patients and adverse effects of opioids, we examined the safety and efficacy of cryoneurolysis as an adjunct for narcotic-free pain management in robotic-assisted thoracoscopic lobectomies. Ten consecutive patients undergoing robotic-assisted (DaVinci) pulmonary resection and cryoneurolysis were compared to ten patients managed without intraoperative cryoneurolysis. All patients received multimodal pain regimen including paravertebral blocks as per our institutional enhanced recovery pathway. Patients with chronic pain and chronic opioid use were excluded. We compared inpatient and outpatient opioid consumption measured in morphine equivalents (mme), incidence of opioid-free outpatient recovery, and adverse events. The two groups did not differ significantly in terms of baseline demographics. Both inpatient (88.13 vs 26.92mme) and outpatient (118.5 vs 34.5mme) use of narcotics were significantly lower in the cryoneurolysis group (p < 0.05) with seven of ten patients receiving cryoneurolysis able to recover without the use of opioids in the outpatient setting, compared to two in the control group. One patient reported post-operative neuralgia in each cryoneurolysis and control group. There were no readmissions in either group and mean length of stay was identicalat 1.7days in control group and 1.1days in experimental group (p = 0.33). The use of intraoperative intercostal cryoneurolysis may safely reduce the utilization of outpatient opioids in patients undergoing robotic-assisted thoracoscopic surgery. A randomized controlled trial is warranted to validate these findings in a larger cohort of patients.

Long-Term Efficacy of T3 Versus T3+T4 Thoracoscopic Sympathectomy for Concurrent Palmar and Plantar Hyperhidrosis

BackgroundMore than 50% of patients with palmar hyperhidrosis (PAH) also have plantar hyperhidrosis (PLH). We compared the long-term results of T3 sympathectomy with those of combined T3+T4 sympathectomy among patients with concurrent PAH and PLH. Materials and methodsWe retrospectively analyzed the records of patients with concurrent PAH and PLH who underwent T3 alone or T3+T4 sympathectomy from January 1, 2012, to December 31, 2017. Preoperative and postoperative sweating (hyperhidrosis index) was evaluated through questionnaires, physical examination, and outpatient follow-up. The relief rates and hyperhidrosis index were used as outcome measures to compare the efficacy of the two approaches. Patients’ satisfaction and side effects were also evaluated. ResultsOf the 220 eligible patients, 60 underwent T3 sympathectomy (T3 group), and 160 underwent T3+T4 sympathectomy (T3+T4 group). Compared with the T3 group, the T3+T4 group showed higher symptom relief rates both for PAH (98.75% versus 93.33%, P = 0.048) and PLH (65.63% versus 46.67%, P = 0.01), and a greater postoperative decrease in both hyperhidrosis indices. The rate of severe compensatory hyperhidrosis also increased (10% versus 5%, P = 0.197), although the rates of overall satisfaction were comparable between the groups. The incidence of postoperative pneumothorax requiring chest tube placement and postoperative neuralgia was also similar. There were no cases of perioperative death, secondary operation, wound infection, or Horner syndrome in either group. ConclusionsCompared with T3 alone, T3+T4 sympathectomy achieved a higher symptom relief rate and a lower hyperhidrosis index. T3+T4 sympathectomy may be a choice for the treatment of concurrent PAH and PLH; however, patients need to be informed that this kind of surgery may increase the risk of compensatory sweating.

Video assisted thoracoscopic management of primary spontaneous pneumothorax

Abstract&#x0D; Objective: To analyze the outcome of Video assisted Thoracoscopy (Vats) in Primary Spontaneous Pneumothorax (PSP).&#x0D; Methods: This case series was carried out from Jan 2010 to Jan 2017 in Dept of Thoracic Surgery CMH Rawalpindi and Lahore. A total of 98 patients underwent Video-assisted thoracoscopic for PSP. Inclusion criteria were physiologically fit patients with PSP for recurrent attacks, occupational hazards and prolonged air leak. Exclusion criteria included secondary spontaneous pneumothorax, previous pleurodesis and physiologically unfit patient for general anesthesia. Vanderschueren's thoracoscopic classification was used for macroscopic staging. A 3-port technique was used for apical stapling with partial pleurectomy up to 6th rib. Parietal pleura and diaphragm was also abraded.&#x0D; Results: Occupational hazard was the commonest indication for surgery, n= 39 (39.7%). This was followed by recurrent pneumothorax n=37 (37.7%), persistent air leak n= 19 (19.38%), and contra lateral pneumothorax n=4 (4.08). Mean age was 22.8 years ± 6.5. Majority of the cases were in stage 3 of Vanderschueren’s classification, n=69 (70.4%). Stage 4 were n= 18 and stage 2 were n=7. Mean operative time was 51minutes ±14.4. Postoperative prolonged air leak occurred in 3 patients and post-operative neuralgia occurred in 8 patients. Mean follow-up was 22 months ± 5.5, range 5-24 months for all patients. One had generalized recurrence and 2 patients have subpulmonic trapping of air.&#x0D; Conclusions: Video-assisted thoracoscopic stapling and pleurectomy is an effective definitive treatment for primary spontaneous pneumothorax when indicated with minimal recurrence.&#x0D; Keywords: Video-assisted thoracoscopy, blebs, pneumothorax. Continuous...

Video assisted thoracoscopic management of primary spontaneous pneumothorax.

To analyze the outcome of Video assisted Thoracoscopy (Vats) in Primary Spontaneous Pneumothorax (PSP). This case series was carried out from Jan 2010 to Jan 2017 in Department of Thoracic Surgery CMH Rawalpindi and Lahore. A total of 98 patients underwent Video-assisted thoracoscopic for PSP. Inclusion criteria were physiologically fit patients with PSP for recurrent attacks, occupational hazards and prolonged air leak. Exclusion criteria included secondary spontaneous pneumothorax, previous pleurodesis and physiologically unfit patient for general anaesthesia. Vanderschueren's thoracoscopic classification was used for macroscopic staging. A 3-port technique was used for apical stapling with partial pleurectomy up to 6th rib. Parietal pleura and diaphragm was also abraded. Occupational hazard was the commonest indication for surgery, n= 39 (39.7%). This was followed by recurrent pneumothorax 37 (37.7%), persistent air leak 19 (19.38%) and contra lateral pneumothorax n=4 (4.08%). Mean age was 22.8 ± 6.5 years. Majority of the cases , 69(70.4%) were in stage 3 of Vanderschueren's classification. Stage 4 were (18.5%) and stage 2 were 7 (7.14%). Mean operative time was 51 ± 14. 4 minutes. Postoperative prolonged air leak occurred in 3 patients and post-operative neuralgia occurred in 8 patients. Mean follow-up was 22 ±5.5 months, range 5-24 months for all patients. One had generalized recurrence and 2 patients had subpulmonic trapping of air. Video-assisted thoracoscopic stapling and pleurectomy is an effective definitive treatment for primary spontaneous pneumothorax when indicated with minimal recurrence.

Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases

Purpose The authors illustrate their results in the surgical treatment of symptomatic thoracic disc herniations (TDHs) by comparing the traditional open to the less invasive retropleural lateral approaches. Methods Retrospective review of 94 consecutive cases treated at a single Institution between 1988 and 2014. Fifty-two patients were males, 42 females, mean age was 53.9 years. Mean follow-up was 46.9 months (12–79 months). 33 patients were diagnosed with a giant thoracic disc herniation (GTDH). Upon admission, the most common symptoms were: motor impairment (91.4%, n = 86), neuropathic radicular pain with VAS > 4 (50%), bladder and bowel dysfunction (57.4% and 41.4% respectively) and sensory disturbances (29.7%). The surgical approach was based upon level, laterality and presence or absence of calcified lesions. Results Decompression was performed in 7 cases via a thoraco-laparo-phrenotomy and in 87 cases via an antero-lateral thoracotomy. Out of the latter cases, 49 (56%) were trans-thoracic trans-pleural approaches (TTA) and 38 (44%) were less invasive retropleural approaches (MIRA). At follow-up, there were 59.5% neurologically intact patients according to the McCormick Scale, while 64.8% and 67% had no bladder or bowel dysfunction respectively. Complications occurred in 24 patients (25.5%). Pulmonary complications were the commonest (12.7%) with pleural effusion being significantly more common in patients treated with TTA compared to MIRA (20% vs 5.2%: X2 4.13 P:0.042). Severe post-operative neuralgia (VAS 7–10) was also significantly more frequent in the TTA group (22.4% vs 2.6% X2 7.07 p 0.0078). Conclusions MIRA is a safe and effective technique to obtain adequate TDH decompression and is associated with lower morbidity compared to TTA.

Comparative study of preservation versus elective division of ilioinguinal nerve on chronic groin pain after lichtenstein tension free inguinal hernia repair

Background: Post-hernioplasty chronic groin pain is one of the most important complications encountered after inguinal hernia repair. Routine ilioinguinal nerve excision has been proposed to avoid chronic post-hernioplasty neuralgia. The study aimed to evaluate the effect of routine ilioinguinal nerve excision compared to nerve preservation on chronic groin pain and other sensory symptoms in lichtenstein inguinal hernia repair.Methods: The study was conducted in the department of general surgery, at S.P. Medical College and PBM Hospital, Bikaner for duration of 15 months from august 2018 to November 2019. A total of 60 patients of uncomplicated inguinal hernia, who met the inclusion criteria, planned for lichtenstein hernioplasty were randomly divided into 2 groups with 30 cases with ilioinguinal nerve preservation (group A) and 30 cases with elective division of the nerve (group B). Follow up was done upto1 year and patients were inquired regarding pain, hypoesthesia and numbness and data was compared and analysed.Results: The incidence of post-operative neuralgia was 23.33% vs 6.67% (p=0.05) at 1 year in group A and group B respectively. The difference in pain was significant in both groups. The incidence of post-operative hypoesthesia was 10% vs 16.67% (p&gt;0.05) at 1 year follow up in group A and group B respectively. The incidence of numbness was 11.11% vs 16.67% (p&gt;0.05) at 1 year in group A and group B respectively. No statistically significant difference was found in both groups.Conclusions: The prophylactic exicision of ilioinguinal nerve during lichtenstein mesh repair decreases the incidence of chronic groin pain after surgery.

The microendoscopic approach for far lateral lumbar disc herniation: a preliminary series of 33 patients

BackgroundFar lateral lumbar disc herniation (FLLDH) compresses the nerve root at the same level. The laterally herniated disc fragment typically could not be exposed by the standard posterior hemi-laminectomy technique, and a total facetectomy including wide bone removal is usually mandatory for good exposure and removal of the herniation but simultaneously increasing the risk of instability.ObjectiveIn the present study, the author presents his initial 4-year experience and surgical outcome in treatment of far lateral lumbar disc herniation with a posterior endoscopic approach.MethodsThis study was carried out in the period between February 2011 and January 2015, where 33 consecutive patients with symptomatic FLLDHs underwent a posterior endoscopic lateral approach for resection of the herniation. The mean age was 39.3 years, range 26–59 years. Patients were followed up for 4 years (mean follow-up was 19.9 months, range 3–47 months). Patients had their clinical outcomes reviewed and evaluated in terms of pain by visual analog scale (VAS) and in terms of functional outcome by modified Macnab criteria (MMC).ResultsMean operative time was 91 min (range 55–166 min). At initial follow-up, according to MMC (3 months postoperative), 86% of patients were pain-free (28/33) and considered their postoperative status as excellent and 14% as good (5/33), and no patients reported a fair or poor outcome. There were no new postoperative neurological deficits or major complications. There were three cases of accidental medial facetectomy due to excess bony work, a single case of dural tear, and a single case that had a transient postoperative neuralgia that persisted for 2 weeks.ConclusionsFLLDH can be treated adequately with the reported microendoscopic approach. The technique is associated with marked improvement in back pain and lower limb symptoms, as well as a short length of hospitalization and other benefits of minimal invasiveness. Although a transitory learning curve is necessary, the endoscope in general was safe in handling bimanually and allowed adequate mobility and visualization.

ROLE OF ROUTINE ILIOINGUINAL NEURECTOMY IN PREVENTION OF CHRONIC POST OPERATIVE PAIN FOLLOWING LICHTENSTEIN HERNIOPLASTY

BACKGROUND : Lichtenstein hernioplasty is a widely performed surgery for the repair of groin hernia. Postoperative pain is a frequent and disabling complication of this surgery. The ilioinguinal nerve, due to it’s close proximity immediately beneath the divided external oblique fascia, is most frequently involved. Theoretically, ilioinguinal nerve excision looks lucrative in prevention of postoperative neuralgia due to nerve entrapment in sutures, inflammation, fibrosis or neuroma. Methods: 120 patients with confirmed diagnosis of inguinal hernia reporting to surgery OPD and undergoing surgery were randomized in two groups: Group A (60 patients ) in which prophylactic ilioinguinal neurectomy was performed and Group B (60 patients ) in which the ilioinguinal nerve was preserved. Results: At POD 1, 2nd week, one month post operatively, the pain in the neurectomy group was lesser though it was statistically significant only at rest. However, the post operative pain was significantly lesser in neurectomy group at 3 months post operatively (p=0.024 at rest, p=0.049 during coughing, p=0.036 during walking). Numbness at post operative day 1 and until one month after surgery, was significantly higher in the neurectomy group. But the degree of numbness was insignificant in the two groups thereafter. Conclusion: Ilioinguinal neurectomy results in significantly lower incidence of chronic postoperative pain. Even in early postoperative period, the pain severity in neurectomy patients is much less than that in control group. But there is a side effect of increased incidence of numbness in area of sensory innervations of the nerve in patients undergoing elective neurectomy in the initial post operative days. This numbness should not condemn the procedure as this improved with time and the incidence was almost similar in the two groups in the long run.

Memantine for the treatment of general neuropathic pain: a narrative review.

Neuropathic pain (NP) is difficult to treat and is associated with a decline in quality of life. NP aetiologies are numerous and a number of pathologies display neuropathic characteristics. Of the various N-methyl-d-aspartate antagonists that are alternatives to be recommended in first-line NP treatment, memantine has the safest side-effect profile and has long been approved in Alzheimer's disease. The review covers memantine studies in postherpetic neuralgia, diabetic pain, postoperative pain, complex regional pain syndrome, chronic phantom limb pain, opioid-refractory pain and fibromyalgia. Results were inconclusive because of studies with poor levels of evidence, paucity of trials and small samples. Two recent randomized trials, however, showed significant efficacy of memantine: one demonstrated prophylactic effects against postoperative neuralgia and pain-associated psychological impairment; in the other, memantine improved pain and cognition in fibromyalgia. Both studies found no side effects or adverse events. Given the high rate of therapeutic failure in chronic states, often because of adverse events, the excellent benefit/risk ratio of memantine in these pilot studies encourages further exploration of this drug in NP prevention and in fibromyalgia in larger-scale studies.

“All-in-one mesh” hernioplasty: A new procedure for primary inguinal hernia open repair

We propose a new open mesh hernia repair procedure for the treatment of inguinal hernias in adults aiming to improve patients' comfort and to reduce the incidence of chronic neuralgia. From September 2012 to August 2015, 250 consecutive patients were treated with "all in-one" mesh hernioplasty procedure in our Institution. According to the devised technique, a new smaller prosthesis was placed on the floor of the inguinal canal in order to strengthen all areas of weakness from which hernias may originate. The mesh was enveloped by a fibro-cremasteric sheath avoiding contact with neural structures. Follow-up was carriedout at 3, 6, 12, 18 and 24 months for evaluation of postoperative pain using VisualAnalogue Scale score, need of medication, patients' comfort and short or long-term complications. All patients were discharged within 24h from surgery. Slight pain was reported by the majority of patients and 47.6% of them did not require pain medication at home. After the 1st postoperative week 96.8% reported no pain and no other symptoms. No relevant limitation of normal activities was reported. There has been no postoperative neuralgia. One recurrence was observed. This new hernioplasty technique respects the anatomy of the inguinal canal, uses a smaller mesh, and seems to avoid neuralgia with maximum comfort for the patients.