Postoperative Sensory Changes Research Articles

Overview and Prevention of Complications During Fully Endoscopic Lumbar Spine Surgery

Fully endoscopic lumbar surgery has emerged as an alternative technique to classic open microscopic laminectomy or discectomy. It is gaining popularity due to its advantages in terms of minimal invasiveness, while achieving equivalent clinical outcomes. Remarkable technical developments in surgical techniques and instruments have expanded the indications of this surgical method. However, as the utilization of endoscopic surgery increases, related complications inevitably arise and become major clinical issues. Frequent complications include failure to achieve adequate decompression, early recurrence, and the possibility of wrong-level surgery. Intraoperative and perioperative complications can include postoperative sensory changes related to neural injury, dural tears, hematoma, infection, and rarely, water pressure-related problems. This review article presents an overview of the possible intraoperative and perioperative complications associated with uniportal full-endoscopic surgery. We also discuss the pitfalls that can lead to unexpected devastating results. Additionally, we briefly review potential preventive efforts that can help reduce the risks. The objective of this presentation is to reinforce the basic principles and introduce key technical tips for full-endoscopic spine surgery, ultimately leading to clinical success and the prevention of complications.

The Moufarrege Total Submuscular Augmentation or How to Preserve Nipple Erogenous Sensation in Breast Augmentation

Breast augmentation is currently one of the most common plastic surgery procedures performed worldwide. However, patients who underwent this procedure always complain of postoperative sensory changes at the nipple areolar complex. The nipple nervous system includes a tactile sensation system and an erogenous sensation system, the latter being less described and commonly overlooked by plastic surgeons performing breast augmentations. The erogenous sensation is supplied by the IVth, Vth and VIth intercostal nerves who run laterally on the surface along the muscular aponeurosis. Both subpectoral (dual plane) breast augmentations and sub-glandular breast augmentations present a real and constant risk of damage to these nerves, resulting in a permanent loss of nipple erogenous sensation. In the Total Submuscular Breast Augmentation approach, the implant is inserted behind the four muscles: the external oblique, the serratus anterior, the pectoralis minor and the pectoralis major. This approach will preserve the three intercostal nerves responsible for the erogenous sensation of the nipple. In this article we describe the surgical technique and the advantages of the total submuscular breast augmentation.

Quantitative Sensory Changes Following Posterior Spinal Fusion to Treat Adolescent Idiopathic Scoliosis.

Sensory changes surrounding the incision frequently develop after posterior spinal fusion (PSF) to treat adolescent idiopathic scoliosis (AIS). Anecdotally, patients may experience sensory changes on the chest wall. Such postsurgical sensory changes are not well described quantitatively. This study aims to evaluate the presence, intensity, and duration of mechanical sensory changes in AIS patients postoperatively. A prospective cohort of AIS patients, 10 to 21 years old, was followed. Quantitative sensory testing (QST) included touch detection threshold [mechanical detection threshold (MDT)] and pain detection threshold (MPT), using VonFrey monofilaments and pinprick stimulators. QST was performed at 3 sites at T6: the right and left chest at the nipple line and adjacent to the incision below the inferior angle of the scapula. QST at the thenar eminence was the control. QST was collected at baseline, 3 days, 1, and 6 months postoperative. Thirty-four patients (21% males; mean age: 14.9 years old; median preoperative curve: 58 degrees) completed all testing. Mean deformity correction was 64% (SD: 10.4). Adjacent to the incision site, MDT was significantly higher compared with baseline at 3 days and 1 month ( P < 0.001) but not at 6 months ( P = 0.19), whereas MPT was significantly higher at 3 days, ( P < 0.001), 1 month ( P < 0.001), and 6 months ( P = 0.001). For the chest wall in all patients, MPT was higher on the left chest at 3 days ( P = 0.04) and on the right chest at 3 days ( P = 0.022) and 1 month ( P = 0.05). For patients with right-sided curves, MDT ( P = 0.01) and MPT ( P = 0.015) overall were significantly higher on the concave side (left) chest postoperatively. PSF is associated with sensory disturbances that are detectable within days, persist at 1 month, and improve at 6 months postoperatively adjacent to the incision and on the chest wall. We suspect that these sensory changes are transient. Describing postoperative sensory changes will help us better set postoperative expectations for patients undergoing PSF. Level I.

MP67-18 SURGICAL TREATMENT OF PEYRONIE'S DISEASE IN THE OLDER MAN: CHARACTERISTICS AND OUTCOMES

You have accessJournal of UrologySexual Function/Dysfunction: Peyronie's Disease I1 Apr 2018MP67-18 SURGICAL TREATMENT OF PEYRONIE'S DISEASE IN THE OLDER MAN: CHARACTERISTICS AND OUTCOMES George Abdelsayed, Shaan Setia, and Laurence Levine George AbdelsayedGeorge Abdelsayed More articles by this author , Shaan SetiaShaan Setia More articles by this author , and Laurence LevineLaurence Levine More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2202AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES As the general population ages, so does the typical male patient in a urologic practice. Moreover, the prevalence of Peyronie′s Disease (PD) increases with age. Considering surgery remains the gold standard for definitive treatment of PD, there is a paucity of data on surgical treatment in older men. We describe our experience with the surgical treatment of PD in men older than 65 years. METHODS We performed a retrospective review of all patients 65 years or older with PD who underwent surgical treatment at our tertiary care institution from January 2010 to September 2017. Baseline characteristics were obtained by history and physical examination as well as penile duplex ultrasound with vasoactive injection. We compared pre- and post-operative characteristics of patients who underwent penile implantation with straightening maneuvers (PP+SM), tunica albuginea plication (TAP) and plaque excision with grafting (PEG). RESULTS A total of 86 men had surgery for PD with a mean age of 68 years (range: 65-79 years). Of our population, 20% had Diabetes Mellitus, 52% had hypertension, and 48% had a smoking history. Surgical management included either PP+SM (n=39, 45%), TAP (n=25, 29%) or PEG (n=22, 26%). The mean curvature for all men was 60° (range: 0-100°). Men who underwent a PEG had a mean curvature of 79°, significantly higher than men who underwent PP+SM (49°, p<0.01) or TAP (61°, p<0.01). Men who underwent PEG were also significantly more likely to have penile narrowing/indentation and/or hinge compared to men who underwent TAP (96% vs 64%, 72% vs 8% respectively, p<0.01). Patient reported baseline erectile function (1-10/10) was significantly lower in men who underwent PP+SM compared to TAP or PEG (5/10 vs 8/10 vs 9/10 respectively; p<0.01). Overall, 97% of all men reported to be straight following surgery (95% in PP+SM, 96% in TAP, 96% PEG; p>0.05) with 93% of men engaging in penetrative intercourse (95% in PP+SM, 92% in TAP, 95% in PEG; p>0.05). Post-operative sensory changes were reported in 23% of all men (23% in PP+SM, 24% in TAP, 18% in PEG; p>0.05) with no incidence of cold glans. Overall patient reported post-operative satisfaction was 85% (85% in PP+SM, 88% in TAP, 82% in PEG; p>0.05). There were 3 reported complications (1 infection, 1 seroma and 1 urinary retention). Mean follow up was 44 months (range: 1-91 months). CONCLUSIONS With the increasing adoption of non-surgical treatment modalities in PD, surgical correction in older men is safe, effective and associated with high patient satisfaction. Our outcomes suggest that surgery is a viable option for the properly selected older man with PD. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e914 Advertisement Copyright & Permissions© 2018MetricsAuthor Information George Abdelsayed More articles by this author Shaan Setia More articles by this author Laurence Levine More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intraoperative Electrophysiological Monitoring Navigation Results during Sagittal Anterior Reduction Maneuver of High Grade Spondylolisthesis L5-S1 using an ALIF Surgical Technique

Introduction Unstable isthmic spondylolisthesis is a common disease. Treatment of high-grade dysplastic spondylolisthesis remains challenging. According to the literature, decompressive laminectomy and posterolateral screws fusion is preferred by most surgeons. Surgical treatment of spondylolisthesis has been recommended in patients with pain refractory to conservative treatment, slippage progression, or severe slippage on presentation. Controversy exists as to the optimal surgical approach for high-grade spondylolisthesis. Moreover, some authors reported the incidence of L5 root palsy during the reduction procedure. We believe that satisfactory nerve root decompression may be achieved by complete anterior discectomy and restoration of disc height (Indirect Decompression), followed by ALIF graft and posterior pedicle screws Material and Methods We performed a prospective study of 23 cases of surgical treatment using intraoperative electrophysiological monitoring for patients with high-grade spondylolisthesis. Each patient received treatment consisting of anterior retroperitoneal approach and indirect nerve decompression with anterior sagittal progressive realignment maneuver, and circumferential fusion with ALIF cage and L5-S1 minimally invasive pedicle fixation with intraoperative neurological monitoring with transcranial electric motor evoked potentials and continuous spontaneous electromyography recording. Results Intraoperative monitoring did show different transitory patterns with no any final abnormal changes. The patients got well after surgery, and they showed no postoperative sensory changes and motor paralysis of the extremities. A postoperative X-rays films showed suitable reduction of the slippage. Conclusion This report describes 23 cases of surgical treatment using intraoperative electrophysiological monitoring with transcranial electric motor evoked potentials and continuous spontaneous electromyography for patients with high-grade dysplastic spondylolisthesis. We successfully perform anterior sagittal reduction maneuvers without any neurological deficit using intraoperative electrophysiological monitoring.

XLIF-Related Postoperative Events versus Psoas Muscle Dimension and Ratio: A Possible Preoperative Evaluation Factor

Introduction Advanced intraoperative neuromonitoring (IONM) is used to attenuate postoperative complications and side effects of extreme lateral interbody fusion (XLIF). Specific factors relate to the presence of postoperative injury are not well understood. This study aims to identify intraoperative variables with correlations to new postoperative anterior thigh/groin sensory changes. Patients and Methods A total of 29 patients with various degenerative lumbar conditions were treated with XLIF at a single institution. Mean age was 59 years, 69% were females, and 21% had undergone previous lumbar surgery. A total of 47 levels (mean 1.6, range 1–3) were treated with XLIF. Supplemental pedicle screw and rod fixation was used in 24 patients (83%). Dynamically evoked electromyography was used in all cases. Analysis of baseline demographic and treatment variables were performed at a per patient basis ( n = 29), whereas analysis of intraoperative variables were performed at a per levels treated basis ( n = 47). Results Within 24 hours postoperative, 10 (34%) patients experienced anterior thigh/groin sensory changes (4 reported pain only, 5 reported pain plus other sensory changes, and 1 paresthesia without pain). Symptom resolution occurred at 1 month postoperative for four patients, at 3 months postoperative for two patients. At 3 months postoperative, six patients had complete symptom resolution, three patients had symptom improvements, and one patient had no change in perioperative symptoms. Psoas dimension in the lateral–latero direction were significantly smaller for patients with postoperative sensory changes ( p = 0.025), and similarly, patients with postoperative sensory changes had a significantly higher ratio of psoas muscle in the anterior–posterior to lateral–latero directions ( p = 0.026). Conclusion In addition to IONM, MRI evaluation of psoas shape, position, and dimension may be of help in preoperative planning of a safe XLIF access and eventually, predict those cases with higher risk of approach-related postoperative events.

Relationship between psoas muscle dimensions and post operative thigh pain. A possible preoperative evaluation factor.

Advanced intraoperative neuromonitoring (IONM) is used to attenuate postoperative complications and side effects of extreme lateral interbody fusion (XLIF). Specific factors relate to the presence of postoperative injury are not well understood. This study aims to identify intraoperative variables with correlations to new postoperative anterior thigh/groin sensory changes. Twenty-nine patients with various degenerative lumbar conditions were treated with XLIF at a single institution. Mean age was 59 years, 69% were female, and 21% had undergone previous lumbar surgery. A total of 47 levels (mean 1.6, range 1-3) were treated with XLIF. Supplemental pedicle screw and rod fixation was used in 24 patients (83%). Dynamically-evoked electromyography was used in all cases. Analysis of baseline demographic and treatment variables were performed at a per patient basis (n = 29), whereas analysis of intraoperative variables were performed at a per levels treated basis (n = 47). Within 24 hours postoperative, 10 (34%) patients experienced anterior thigh/groin sensory changes (4 reported pain only, 5 reported pain plus other sensory changes, and 1 paresthesia without pain). Symptom resolution occurred at 1 month postoperative for 4 patients, at 3 months postoperative for 2 patients. At 3 months postoperative, 6 patients had complete symptom resolution, 3 patients had symptom improvements, and 1 patient had no change in perioperative symptoms. Psoas dimension in the lateral-latero direction were significantly smaller for patients with postoperative sensory changes (p = 0.025), and similarly, patients with postoperative sensory changes had a significantly higher ratio of psoas muscle in the anterior-posterior to lateral-latero directions (p = 0.026). In addition to IONM, MRI evaluation of psoas shape, position, and dimension may be of help in preoperative planning of a safe XLIF access and eventually, predict those cases with higher risk of approach-related post-operative events.

Anterior Transposition of the Superficial Peroneal Nerve Branch During the Internal Fixation of the Lateral Malleolus

Because of the anatomic variations of the superficial peroneal nerve (SPN), it has long been stressed that caution should be exercised at the time of open reduction and internal fixation (ORIF) of the lateral malleolus. Blair and Botte described type B intermediate dorsal cutaneous nerve (IDCN) in which the SPN penetrates crural fascia posterior to the fibula about 5 cm proximal to the joint and crosses the lateral border of the fibulae. We hypothesized that the type B IDCN is especially vulnerable to direct surgical injury if present and the anterior transposition of this nerve may decrease the incidence of symptoms related to the SPN injury. Fifty-three ankle fractures in 53 adult patients treated by the ORIF of lateral malleolus using the lateral approach between the periods from May 2001 to December 2006 were included. Intraoperative documentation about the presence of the type B IDCN variant at the surgical field was performed, and preoperative and postoperative sensory changes were carefully evaluated. We encountered Blair type B variant in 7 cases (12%). The IDCN was carefully dissected and transposed anteriorly before the plating. One of these seven patients had sensory deficit preoperatively, and it was recovered spontaneously 5 months after operation. There was one patient whose IDCN was inadvertently severed, and it was repaired. At the time of last follow-up, only partial recovery of the sensory deficit was noted. Five of seven patients did not show any neurologic deficit with anterior transposition. Recognition and anterior transposition of the type B IDCN could reduce the incidence of the SPN nerve injuries during the ORIF of the lateral malleolar fractures.

Objective Assessment of Nerve Injury after Greater Saphenous Vein Stripping

The complication of nerve injury after greater saphenous vein stripping for varicosity is subjective, and a method for objective evaluation has never been established. The aim of this study was to evaluate postoperative sensory changes by quantitative assessment of current perception threshold (CPT), and to clarify the relation between CPT and symptoms. Between January 2003 and August 2005, 27 limbs in 18 patients were enrolled. Quantitative sensory function was determined through CPT using a Neurometer (Neurotron, Inc., USA), with which saphenous nerve neural fiber selective minimum sensing values against three electrical stimuli (2000, 250, 5 Hz) were measured. CPT measurements were scheduled on the day before the operation, and 2-7 days, 1, 3, and 6 months after the operation. An increase in CPT value of more than 20% or decrease to below 50% compared to the preoperative value with at least two stimuli was defined as CPT abnormality. Subjective symptoms were observed in 13 limbs in the early postoperative period, and 10 limbs showed CPT abnormality. In 6 limbs with a CPT increase over 20% with all three stimuli, neurological symptoms continued for 6 months. CPT evaluation provides an objective indication of neurological symptoms in the lower limb following varicose vein surgery.

Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs.

The aim of this study was to identify the anatomical variations in the inguinal course of the ilioinguinal nerve (IIN) and the iliohypogastric nerve (IHN) during operative repair of inguinal hernias. A consecutive series of 110 primary inguinal hernias were repaired by the mesh technique. Particular attention was paid to early identification and recording of the course of both the IIN and IHN and preserving them throughout the operative procedure. The course of both nerves was found to be consistent with that described in anatomical texts in only 46 of 110 explorations (41.8%). The course of one or both nerves was found to be a variant in the other 64 of 110 (58.2%) explorations and often rendered them susceptible to injury. These variations included: (1) acute infero-lateral angulation of the IIN at its exit behind the superficial inguinal ring (SIR) fibers in 20 of 64 cases; (2) similar direction of the IIN but in a plane superficial to the external oblique aponeurosis (EOA) and proximal to the SIR in 18 of 64 cases; (3) a single stem for both nerves over the spermatic cord in 24 of 64 cases, with variation in the subsequent course; (4) absence of one or both nerves in 8 of 64 cases; (5) accessory IIN or IHN in 3 of 64 cases; and (6) aberrant origin of the IIN from the genitofemoral nerve (GFN) in 2 of 64 cases. None of 68 of 105 patients seen at 3 months postoperatively (compliance rate 65%) complained of sensory disturbances or pain in a dermatome distribution of the IIN or IHN. It is concluded that anatomical variations in the inguinal course of the IIN and the IHN are extremely common but readily identifiable. Their early identification and preservation is likely to abolish, or considerably decrease, the incidence of postoperative sensory changes and/or neuralgia pain.

Sensory changes after traditional and ultrasound-assisted liposuction using computer-assisted analysis.

Postoperative sensory changes (i.e., hypesthesias) that occur after suction-assisted lipoplasty (SAL) are expected clinical sequelae. These disturbances usually return to normal within several weeks to months postoperatively. The presumed mechanism of injury is direct trauma to the peripheral nerves from the suction cannula. In addition, the potential for demyelination of peripheral nerves secondary to cavitation during ultrasound-assisted liposuction (UAL) is well known. Quantitative data describing hypesthesia after both procedures are limited. The purpose of this study was to objectively evaluate the severity and duration of postoperative hypesthesia after liposuction to better educate patients preoperatively. Furthermore, the authors use the three-stage UAL technique and wanted to determine whether a clinical difference in sensory return existed between suction- and ultrasound-treated areas. A total of 21 patients underwent liposuction performed by the senior author (RJ.R.). The abdomen, flanks, thighs, and medial knees were tested for objective sensation with the Pressure Specified Sensory Device preoperatively and at 2, 6, and 10 weeks postoperatively. A total of 102 sites were tested. On average, the SAL-treated areas improved to normal sensation by 6 weeks, whereas the UAL-treated areas took, on average, 10 weeks to recover. The severity of the hypesthesia was not correlated with larger aspiration volumes or longer UAL exposure time per site. At 10 weeks, 90 percent of UAL-treated patients and 89 percent of liposuction patients overall had recovered normal sensation. This study provides the body-contouring surgeon with good, objective data with which to educate patients regarding sensory return after liposuction.

Sensory changes after treatment of operable breast cancer.

A study has been conducted to compare the nature and severity of post-operative sensory changes (sensory loss, paraesthesiae, and pain) among patients with breast cancer treated by either modified radical mastectomy or a conservative procedure (tumourectomy, axillary clearance, iridium implant, and external radiotherapy). There was a similar incidence of post-operative sensory loss in the two groups, reported by 82% of the mastectomy group and 77% of the iridium group, and an equivalent rate of improvement (76 and 80% respectively). Post-operative paraesthesiae occurred in 61% of the mastectomy group and 63% of the iridium group; maximum severity of paraesthesiae was similar as was the percentage improving. Among the mastectomy group 55% reported phantom breast sensation and 61% of the iridium group had post-operative breast pain. Improvement occurred in 58% of those with breast pain. These findings may have implications for the counseling of patients with breast cancer who are going to be treated by certain conservative procedures.