The effects of Hypericum perforatum on nerve regeneration after sciatic nerve injury have not yet been evaluated in all its aspects yet. In this experimental study, the effect of Hypericum perforatum on injured nerve tissue was histologically and biochemically investigated. Motor functional healing was surveyed by gait analysis. Rats were divided into 3 groups: Group I (n=8) was intact control group and no intervention and treatment was applied to this group. Group II (n=16) was surgical control group and Group III (n=16) was Hypericum perforatum group. After the operation, while any treatment was performed on Group II, 30 mg/kg dose Hypericum perforatum extract was intraperitoneally administered to the Group III per day for 8 weeks from the 1. st. day of post-op. Gait analysis was made to all rats for functional evaluation at 2. nd. , 3. rd. , 4. th. , 6. th. and 8. th. weeks, and sciatic functional index (SFI) was evaluated. At the end of the eighth week, sciatic nerve tissue samples were taken from the sacrificed rats. Tissues were examined biochemically, histologically and immnohistochemically. Malondialdehyde (MDA) as an indicator of oxidative stress and main antioxidant enzyme [superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (CAT)] levels were biochemically measured. The nerve degeneration and regeneration were histologically viewed, and also cell count was immnohistochemically done by having done anti-S100 staining. It was seen that measurement results of SFI were statistically significantly difference between groups (p<0,001). In the sciatic nerve tissue samples taken from the rats, it was not determined a statistically significant difference between MDA, SOD, GPx and CAT levels detected by ELISA method (p>0,05). In the histological evaluation, it was seen that Hypericum perforatum affected positively the regeneration and immunohistochemically, it was found a statistically significant difference between the anti-S-100 positive cell numbers. The obtained results in this study show that; Hypericum perforatum, which was intraperitoneally administered on rats subjected to nerve injury, has affected positively the nerve regeneration and it can also provide an insight to future studies

Abstract. Objective. Radial to axillary nerve and spinal accessory (XI) to suprascapular nerve (SSN) transfers are standard procedures to restore function after C5 brachial plexus dysfunction. The anterior approach to the SSN may miss concomitant pathology at the suprascapular notch and sacrifices lateral trapezius function, resulting in poor restoration of shoulder external rotation. A posterior approach allows decompression and visualisation of the SSN at the notch and distal coaptation of the medial XI branch. The medial triceps has a double fascicle structure that may be coapted to both the anterior and posterior division of the axillary nerve, whilst preserving the stabilising effect of the long head of triceps at the glenohumeral joint. Reinnervation of two shoulder abductors and two external rotators may confer advantages over previous approaches with improved external rotation range of motion and strength. Methods. Review of the clinical outcomes of 22 patients who underwent a double nerve transfer from XI and radial nerves. Motor strength was evaluated using the MRC scale and grade 4 was defined as the threshold for success. Results. 18/22 patients had adequate follow-up (Mean: 29.5 months). Of these, 72.2% achieved ≥grade 4 power of shoulder abduction and a mean range of motion of 103°. 64.7% achieved ≥grade 4 external rotation with a mean range of motion of 99.6°. Conclusions. The results suggest the use of the combined nerve transfer for restoration of shoulder function via a posterior approach, involving the medial head branch of triceps to the axillary nerve and the XI to SSN

Intro. Sciatic nerve injury (SNI) is a rare and potentially devastating complication after total hip arthroplasty (THA). Neural monitoring has been found in several studies to be useful in preventing SNI, but can be difficult to practically implement during surgery. In this study, we examine the results of using a handheld nerve stimulator for intraoperative sciatic nerve monitoring during complex THA requiring limb lengthening and/or significant manipulation of the sciatic nerve. Methods. We retrospectively reviewed a consecutive series of 11 cases (9 patients, 11 hips) with either severe developmental dysplasia of the hip (Crowe 3–4) or other underlying conditions requiring complex hip reconstruction involving significant leg lengthening and/or nerve manipulation. Sciatic nerve function was monitored intra-operatively with a handheld nerve stimulator by obtaining pre- and post-reduction conduction thresholds during component trialling. The results of nerve stimulation were then used to influence intraoperative decision- making (downsizing components, shortening osteotomy). Results. No permanent postoperative sciatic nerve complication occurred, with an average increase of 28.5mm in limb length, ranging from 6 to 51mm. In 2 out of 11 cases, a change in nerve response was identified after trial reduction, which resulted in an alternate surgical plan (femoral shortening osteotomy and downsizing femoral head). In the remainder cases, the stimulator demonstrated a response consistent with the baseline assessment, assuring that the appropriate lengthening was achieved without SNI. One patient had a transient motor and sensory peroneal nerve palsy, which resolved within two weeks. Conclusions. The intraoperative use of a handheld nerve stimulator facilitates surgical decision-making and can potentially prevent SNI. The real-time assessment of nerve function allows immediate corrective action to be taken before nerve injury occurs

Introduction. Tibial nerve anatomy has not been studied profoundly in comparison to Tarsal Tunnel Syndrome (TTS). Assuming symptoms are caused by an anatomical variant or mechanical cause regarding the tibial nerve, it is essential to investigate the anatomy of this structure taking in consideration that surgical and conservative treatments have shown poor results. Methods. 40 lower-leg specimens were obtained. Dissection started 20 centimeters proximal to the Dellon-McKinnon (DM) line towards the medial aspect of the naviculo-cuneiform joint distally. Anteriorly, dissection began at the tibio-talar medial gutter until the medial aspect of the Achilles tendon posteriorly. The plantar aspect extended from medial to lateral within the parameters previously described, ending at the level of the second metatarsal. Results. The flexor retinaculum had a denser consistency in 22.5% of the cases and the average length was 51.9 mm. The flexor retinaculum as an independent structure was found absent and 77.2% of cases as undistinguished extension of the crural fascia. The lateral plantar nerver (LPN) and abductor digiti minimi (ADM) nerve shared same origin in 80% of cases, 34.5% bifurcated proximal to the DM line, 31.2% distally and 34.3% at the same level. The medial calcaneal nerve (MCN) emerged proximal to the DM line in 100% of specimens. The medial plantar nerve (MPN) has its origin proximal to the DM line in 95% of cases. Conclusion. The flexor retinaculum is an extension of the crural fascia and not an independent structure. The LPN and ADM have the same origin in most cases and this presents as an important finding that must be studied in detail for clinical correlations between the motor and sensatory affections of the ADM and LPN respectively. Finally, the branches of the MCN and MPN are the most constant in their distribution and proximal origin in relation to the Dellon-McKinnon line

Background. The use of a knotless TightRope for the stabilisation of a syndesmotic injury is a well-recognised mode of fixation. It has been described that the device can be inserted using a “closed” technique. This presents a risk of saphenous nerve entrapment and post-operative pain. Aim. We aimed to establish the actual risk of injury to the Saphenous Nerve using a “closed” technique for the insertion of a TightRope. Method. 20 TightRopes were inserted into Fresh Frozen Cadavers. This was done using the senior authors preferred technique of divergent tightropes with the distal implant directed slightly anterior to the fibula-tibia axis and the proximal implant slightly posterior in order to simulate the greatest risk to the nerve. This was done under image Intensifier guidance to simulate an intraoperative environment. The medial side of the distal tibia was then dissected to directly record and measure the relationship of the TightRope to the Saphenous Nerve. Measurements were taken using digital calipers from the centre of the button on the medial side of the TightRope to the centre of the nerve at the point of closest proximity. Results. 12 TightRopes were found to exit posterior to the nerve, 7 anterior and 1 penetrated through the centre of the nerve. The mean distance from the centre of the button to the nerve was 6.99mm (range 0.72–14.52mm, standard deviation 4.33mm). In 9 of the 20 TightRopes, the nerve was found to be less than 5mm away. Conclusion. Our findings demonstrated that the risks of damaging or indeed entrapping the Saphenous nerve were high, and therefore we would advocate an open incision on the medial side with judicious exploration to ensure there is no damage to the medial neurological structures

Introduction. Management of painful scarring of a nerve after surgery or trauma is challenging. Wrapping with a vein or adhesion barriers such as silicone have been reported with some success. This is a retrospective review of application of a xenograft collagen wrap around a peripheral nerve following neurolysis. There is no report in English literature of use of a collagen wrap for this purpose. Materials/Methods. 12 patients underwent use of the Neuragen™ bovine collagen nerve conduit or NeuraWrap™ (Integra Life Sciences, Plainsboro, NJ) over a 6 year period. The causes were, scarring after carpal tunnel (n=5) or cubital tunnel release (n=3) or partial nerve injury (n=4, radial, median, dorsal ulnar, digital nerves). Follow up ranged from 6–12 months. Outcome was assessed by VAS or functional improvement. Results. No patient developed adverse reaction to the xenograft conduit. All 10 patients with painful scarring reported improvement of pain with reduction in mean VAS from 7 to 2 at final follow-up. The patient with radial palsy with scarring of the nerve had full recovery of radial nerve function by 6 months. The partially injured sensory branch of median nerve and digital nerve regained normal 2PD. The patients with scarring after decompression surgery had improvement in pain and range of motion of adjacent joints but did not show any change in clinical neurological status. Conclusions. A collagen conduit wrapped around a partially injured or scarred nerve is safe and associated with clinical improvement in pain and nerve function

Nerve transfer is an emerging treatment to restore upper limb function in people with tetraplegia. The objective of this study is to examine if a flexible collage sheet (FCS) can act as epineurial-like substitute to promote nerve repair in nerve transfer. A preclinical study using FCS was conducted in a rat model of sciatic nerve transection. A prospective case series study of nerve transfer was conducted in patients with C5-C8 tetraplegia who received nerve transfer to restore upper limb function. Motor function in the upper limb was assessed pre-treatment, and at 6-,12-, and 24-months post-treatment. Macroscopic assessment in preclinical model showed nerve healing by FCS without encapsulation or adhesions. Microscopic examination revealed that a new, vascularised epineurium-like layer was observed at the FCS treatment sites, with no evidence of inflammatory reaction or nerve compression. Treatment with FCS resulted in well-organised nerve fibres with dense neurofilaments distal to the coaptation site. Axon counts performed proximal and distal to the coaptation site showed that 97% of proximal axon count of myelinated axons regenerated across the coaptation site after treatment with CND. In the proof of concept clinical study 17 nerve transfers were performed in five patients. Nerve transfers included procedures to restore triceps function (N=4), wrist/finger/thumb extension (N=6) and finger flexion (N=7). Functional motor recovery (MRC ≥3) was achieved in 76% and 88% of transfers at 12 and 24 months, respectively. The preclinical study showed that FCS mimics epineurium and enable to repair nerve resembled to normal nerve tissue. Clinical study showed that patients received nerve transfer with FCS experienced consistent and early return of motor function in target muscles. These results provide proof of concept evidence that CND functions as an epineurial substitute and is promising for use in nerve transfer surgery

Our unit has pursued a policy of using donor nerves from the same limb for grafting. Nerves which have already been affected by the primary injury are selected where possible, thus avoiding any new sensory deficit. 36 of the 41 brachial plexus repairs were available for outcome data collected prospectively over 2 years. Over a nine year period, donor nerves used for the 41 brachial plexus repairs included the lateral cutaneous nerve of the forearm, superficial radial, medial cutaneous of the forearm, ulnar and sural nerves. Patients were grouped into having injured nerve grafts only (A), injured and uninjured nerve grafts (B) and uninjured nerve grafts. The repaired brachial plexus nerves were assessed by measuring the MRC grading of the power of movement of the muscle innervated by that nerve (i.e. elbow flexion for musculocutaneous nerve). These were graded as good (MRC grading 3 or better), fair (MRC grade 1 or 2), or poor (MRC 0). The greatest success for nerve grafting was elbow flexion with good results in 22 out of 27 assessments. Using Mann-Whitney test, Group A had significantly better results (p=0.025) than group C. However, ignoring the poorer results of shoulder abduction there was no significant difference between all 3 groups of patients. We conclude that using injured nerve grafts taken distal to the lesion in the brachial plexus is as effective as using nerve material from an uninjured limb

Our unit has pursued a policy of using donor nerves from the same limb for grafting. Nerves which have already been affected by the primary injury are selected where possible, thus avoiding any new sensory deficit. Methods. 36 of the 41 brachial plexus repairs were available for outcome data collected prospectively over 2 years. Over a nine year period, donor nerves used for the 41 brachial plexus repairs included the lateral cutaneous nerve of the forearm, superficial radial, medial cutaneous of the forearm, ulnar and sural nerves. Patients were grouped into having injured nerve grafts only (A), injured and uninjured nerve grafts (B) and uninjured nerve grafts. The repaired brachial plexus nerves were assessed by measuring the MRC grading of the power of movement of the muscle innervated by that nerve (i.e. elbow flexion for musculocutaneous nerve). These were graded as good (MRC grading 3 or better), fair (MRC grade 1 or 2), or poor (MRC 0). Results. The greatest success for nerve grafting was elbow flexion with good results in 22 out of 27 assessments. Using Mann-Whitney test, Group A had significantly better results (p=0.025) than group C. However, ignoring the poorer results of shoulder abduction there was no significant difference between all 3 groups of patients. Conclusion. Using injured nerve grafts taken distal to the lesion in the brachial plexus is as effective as using nerve material from an uninjured limb

Introduction. Pain after trauma has received relatively little research attention compared with surgical techniques and functional outcomes, but is important to patients. We aimed to describe nerve dysfunction and pain characteristics using tibial fractures as a model. We hypothesized that early nerve dysfunction was associated with neuropathic and chronic pain. Materials and Methods. Adult patients with isolated open or closed tibial diaphyseal fractures were prospectively observed for 1-year in 5 Major Trauma Centres. Nerve dysfunction was assessed using Semmes-Weinstein monofilaments, acute pain with the visual numerical rating scale (VNRS), neuropathic pain with the doleur neuropathique-4 score and quality of life (QOL) using the EQ-5D score. Results. Of 77 included patients, twenty-six (33.8%) had Gustilo-Anderson grade II or worse injuries. Forty-six (63.0%) had operative repair; 0 operation notes reported nerve injury. Mean VNRS pain scores one week post-injury were 4.6/10 (SD 2.4). Seventeen patients (23.3%) presented with impaired sensation, persisting in 11 (15.1%) at 3-months. Neuropathic pain affected 16 (20.8%) patients one week post-injury; a further 20 (26.0%) had >2 symptoms of nerve pain. Only four (11.1%) received anti-neuropathic drugs. At 6-months, twenty-three (31.5%) reported mobility problems, 21 (28.8%) difficulty completing normal activities, 25 (34.2%) pain and 15 (20.5%) anxiety and depression. Conclusions. Nerve dysfunction and neuropathic pain are common early features in patients with tibial fractures, but are poorly recognised and inadequately treated. Pain has long-term effects on patients’ QOL. Future work should aim to improve identification and management of neuropathic pain

Peripheral nerve injuries (PNI) occur in 10% of combat casualties. In the immediate field-hospital setting, an insensate limb can affect the surgeon's assessment of limb viability and in the long-term PNI remain a source of considerable morbidity. Therefore the aims of this study are to document the recovery of combat PNI, as well as report on the effect of current medical management in improving functional outcome. In this study, we present the largest series of combat related PNI in Coalition troops since World War II. From May 2007 – May 2010, 100 consecutive patients (261 nerve injuries) were prospectively reviewed in a specialist PNI clinic. The functional recovery of each PNI was determined using the MRC grading classification (good, fair and poor). In addition, the incidence of neuropathic pain, the results of nerve grafting procedures, the return of plantar sensation, and the patients' current military occupational grading was recorded. At mean follow up 26.7 months, 175(65%) of nerve injuries had a good recovery, 57(21%) had a fair recovery and 39(14%) had a poor functional recovery. Neuropathic pain was noted in 33 patients, with Causalgia present in 5 cases. In 27(83%) patients, pain was resolved by medication, neurolysis or nerve grafting. In 35 cases, nerve repair was attempted at median 6 days from injury. Of these 62%(22) gained a good or fair recovery with 37%(13) having a poor functional result. Forty-two patients (47 limbs) initially presented with an insensate foot. At final follow up (mean 25.4 months), 89%(42 limbs) had a return of protective plantar sensation. Overall, 9 patients were able to return to full military duty (P2), with 45 deemed unfit for military service (P0 or P8). This study demonstrates that the majority of combat PNI will show some functional recovery. Adherence to the principles of war surgery to ensure that the wound is clear of infection and associated vascular and skeletal injuries are promptly treated will provide the optimal environment for nerve recovery. Although neuropathic pain affects a significant proportion of casualties, pharmacological and surgical intervention can alleviate the majority of symptoms. Finally, the presence of an insensate limb at initial surgery, should not be used as a marker of limb viability. The key to recovery of the PNI patient lies in a multi-disciplinary approach. Essential to this is regular surgical review to assess progress and to initiate prompt surgical intervention when needed. This approach allows early determination of prognosis, which is of huge value to the rehabilitating patient psychologically, and to the whole rehabilitation team

A major cause of morbidity in lower limb amputees is phantom limb pain (PLP) and residual limb pain (RLP). This study aimed to determine if surgical interposition of nerve endings into adjacent muscle bellies at the time of major lower limb amputation can decrease the incidence and severity of PLP and RLP. Data was retrospectively collected from January 2015 to January 2021, including eight patients that underwent nerve interposition (NI) and 36 that received standard treatment. Primary outcomes included the 11-point Numerical Rating Scale (NRS) for pain severity, and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, behaviour, and interference. Secondary outcome included Neuro-QoL Lower Extremity Function assessing mobility. Cumulative scores were transformed to standardised t scores. Across all primary and secondary outcomes, NI patients had lower PLP and RLP. Mean ‘worst pain’ score was 3.5 out of 10 for PLP in the NI cohort, compared to 4.89 in the control cohort (p=0.298), and 2.6 out of 10 for RLP in the NI cohort, compared to 4.44 in the control cohort (p=0.035). Mean ‘best pain’ and ‘current pain’ scores were also superior in the NI cohort for PLP (p=0.003, p=0.022), and RLP (p=0.018, p=0.134). Mean PROMIS t scores were lower for the NI cohort for RLP (40.1 vs 49.4 for pain intensity; p=0.014, 44.4 vs 48.2 for pain interference; p=0.085, 42.5 vs 49.9 for pain behaviour; p=0.025). Mean PROMIS t scores were also lower for the NI cohort for PLP (42.5 vs 52.7 for pain intensity; p=0.018); 45.0 vs 51.5 for pain interference; p=0.015, 46.3 vs 51.1 for pain behaviour; p=0.569). Mean Neuro-QoL t score was lower in NI cohort (45.4 vs 41.9;p=0.03). Surgical interposition of nerve endings during lower limb amputation is a simple yet effective way of minimising PLP and RLP, improving patients’ subsequent quality of life. Additional comparisons with targeted muscle reinnervation should be performed to determine the optimal treatment option

We undertook this study to investigate the outcomes of surgical treatment for acute carpal tunnel syndrome following our protocol for concurrent nerve decompression and skeletal stabilization for bony wrist trauma to be undertaken within 48-hours. We identified all patients treated at our trauma centre following this protocol between 1 January 2014 and 31 December 2019. All patients were clinically reviewed at least 12 months following surgery and assessed using the Brief Michigan Hand Outcomes Questionnaire (bMHQ), the Boston Carpal Tunnel Questionnaire (BCTQ) and sensory assessment with Semmes-Weinstein monofilament testing. The study group was made up of 35 patients. Thirty-three patients were treated within 36-hours. Patients treated with our unit protocol for early surgery comprising nerve decompression and bony stabilization within 36-hours, report excellent outcomes at medium term follow up. We propose that nerve decompression and bony surgical stabilization should be undertaken as soon as practically possible once the diagnosis is made. This is emergent treatment to protect and preserve nerve function. In our experience, the vast majority of patients were treated within 24-hours

Carpal tunnel syndrome is the most frequent form of median nerve entrapment, accounting for 90% of all entrapment neuropathies. Routinely nerve conduction study (NCS) tests are ordered to confirm the diagnosis however; there are issues of long waiting periods and costs with it. We aimed to compare carpal tunnel questionnaire score (CTQS) by Kamath and Stothard (2003) to nerve conduction study result in the diagnosis of carpal tunnel syndrome. This prospective study involved analysis of data from all the patients referred to NHS Tayside (Dundee) hand clinic with signs and symptoms of Carpal tunnel syndrome (CTS) from September 2016 to February 2017. Statistical analysis was done using SPSS and sensitivity and specificity was calculated. The questionnaires were filled in by a team of specialist physiotherapists. Nerve conduction study tests were done by a team of consultant neurophysiologists. Both the groups were blinded to each other's assessment. We analysed 88 patients who filled in CTQS and also underwent NCS. We noted that CTQS of less than 3 correlated 100% to negative nerve conduction result. When the carpal tunnel questionnaire score was more than or equal to 5, 54 patients had positive NCS result and 6 patients had negative NCS result, giving a 90% predictability of a positive NCS result. Mean waiting period of carpal tunnel patients for NCS was 141 days. We noted from this prospective study that CTQS was sensitive enough to exclude carpal tunnel syndrome when the questionnaire score was less than 3. In addition, the questionnaire revealed a 90% probability of having carpal tunnel syndrome when CTQS was more than or equal to 5. Based on the present study, we would recommend that patients in grey zone of 3 to 4 on questionnaire should undergo NCS, resulting in only 20% of patients (based on the figures from the current study) being referred for NCS. The questionnaire can be used in primary health care or specialist physiotherapy screening clinic as a tool for diagnosing CTS with implications of cost saving and avoiding long waiting periods

The suprascapular nerve is an ideal target for nerve blockade to alleviate shoulder pain given its widespread innervation to the shoulder girdle. Many techniques have been described. To widen the availability of this treatment we investigate whether an anatomical landmark technique can be easily learned by novice injectors to provide efficacious blockade. Five injectors were recruited with varying experience; from the novice medical student to an orthopaedic consultant. Five torsos (10 shoulders) were used. A single page of written instruction and illustration of the Dangoisse landmark technique was provided prior to injection of a Thiel embalmed cadaver bilaterally. A pre-mixed injectate with blue dye was used. Cadavers were dissected and the presence or absence of dye staining reported by 3 observers and a consensus agreement reached. Dissection demonstrated diffuse staining in the suprascapular fossa. 90% of shoulders were found to have adequate staining of the suprascapular nerve directly, or its distal branches, in a manner which would provide adequate anaesthesia. The inter-observer agreement was good (k = 0.73) for staining at the supraspinous fossa and excellent (k=0.87) for staining distally. The technique was easily performed by novice injectors with a 100% success rate. We demonstrate that this technique is reproducible by a range of clinicians to effectively provide anaesthesia of the SScN. The main risks are ineffective block (10% in this series) and of intravascular injection. Within a resource strained healthcare environment greater uptake of this technique is likely to be of benefit to a wider array of patients

Introduction: Reports on nerve injury after arthroscopic ACL reconstruction using hamstring tendon autograft had mainly focused on injury to the infrapatellar branch of the saphenous nerve (IPBSN), with few reports on injury of the sartorial branch of the saphenous nerve (SBSN). Aim of the work: was to define the level of anatomical termination of the saphenous nerve in relation to knee joint level and the relation of its sartorial branch to the surrounding tendons so that it could be avoided during hamstring tendon harvesting. Materials and Methods: This anatomical study included cadaveric dissection of the medial aspect of the knee joint of 25 preserved knees. The saphenous nerve was dissected proximal to the knee joint and followed distally till it was divided into its two terminal branches. Results: In 68 %, the saphenous nerve gave its two terminal branches at a mean distance of 8 cm above the knee joint line. In 32 %, the level of termination of the saphenous nerve was below the knee joint line by a mean distance of 3 cm. In 92 % the saphenous nerve or the SBSN was passing posterior to the sartorius tendon by a mean distance of 19.8 mm. In 68 % the saphenous nerve or the SBSN continued distally anterior to the gracilis tendon, while in 16 % the SBSN continued distally posterior to the gracilis tendon. In 20 % the distance between the saphenous nerve or the SBSN and gracilis tendon was 5 mm or less. In 12 % the saphenous nerve or the SBSN was lying directly anterior to the gracilis and in 4 %, the SBSN was lying directly behind the gracilis tendon at the knee joint line. In all the knees the saphenous nerve or the SBSN was passing distally anterior to the semitendinosus tendon at a mean distance of 23.1 mm. Conclusion: The saphenous nerve or its terminal branch the SBSN, is at a close anatomical relation with the gracilis tendon. This might predispose the nerve to be damaged during passage of the tendon stripper over the tendon. Clinical correlation: The saphenous nerve or its terminal branch the SBSN, are at a risk of injury during arthroscopic ACL reconstruction using hamstring tendon autograft. The nerve Injury of the saphenous nerve or its terminal branch (SBSN) might be an intrinsic problem associated with the technique itself

Purpose and Background: We have previously reported our investigations of nerve ingrowth into intervertebral discs (IVD) from patients with mechanical low back pain. We have shown that in discs that are painful on discography (pain level discs) nerves actively grow into the deep annulus fibrosus and nucleus pulposus. Nerve ingrowth accompanies blood vessel ingrowth and advances into the nucleus pulposus from the end plate. The morphology and neurochemistry of these nerves indicate them to be nociceptive. The growth of non-myelinated pain fibres in other settings is regulated by the cytokine Nerve Growth Factor (NGF). In this study, we have investigated the production and distribution of NGF, or more particularly its active isoform – NGF-β, and its receptors, in diseased intervertebral discs in order to establish whether this cytokine might be responsible for the observed nerve ingrowth in this situation. Methods: Tissue sections of 21 pain level, 15 non-pain level diseased and 12 normal intervertebral discs, taken at the time of spinal surgery, and from cadavers, were probed by radioactive in situ hybridisation (ISH) for expression of NGF-β, and by immunohistochemistry (IHC) for its high and low affinity receptors (trk-A and p75 respectively). In addition, either serial sections were stained with cell specific markers (CD31 – endothelial cell, PGP9.5 – neurones, GAP43 – actively growing nerves) or sections were doubled stained (two antibodies or both ISH and IHC). Results: We have demonstrated that NGF-β is synthesised by the endothelial cells of blood vessels growing into the IVD from the end plate. The high affinity receptor is expressed by those small nerve fibres that accompany the vessels and in their offshoots in pain level discs that are growing from perivascular nerves into the disc. In addition to their expressing the nerve specific molecule PGP9.5, the trk-A positive cells also express the nerve growth associated protein GAP43. Conclusion: The data indicate that nerve ingrowth into IVD is regulated by NGF-β. We have localised this production to the endothelial cells of ingrowing blood vessels. NGF-β is a potential therapeutic target for the management of back pain

Purpose: The aim of this study was to investigate the results of end-to-side neurorraphy of the common peroneal nerve (CPN) to the tibial nerve (TN) in rats, after administration of bFGF or NGF. Materials: Five (5) groups of adult male Wistar rats, each comprising 25 animals, were studied:. End-to-side neurorraphy (4 groups) Group A bFGF (20ng) Group B NGF (25ng) Group C (normal saline) Group X [bFGF (20ng) + NGF (25ng)]. Negative control group (G) Animal keeping was conform to standard conditions set by the NIH (appropriate cages for housing; standard rat chow and water ad libitum; 12h – light/darkness exposure). All experimental procedures were performed under the supervision of a veterinarian and were prospectively approved by the Animal Experimental Ethics Committee. Methods: In groups A, B and X, the CPN was sharply divided at a distance of 7mm distal to its origin from the rat sciatic nerve; the proximal CPN stump was then sutured into the thigh muscles, whereas the distal CPN stump was sutured terminolaterally to the ipsilateral TN. Sub sequently, a total volume of fifty microliters (50μl) of the corresponding solution of growth factor(s) was administered in each case beneath the epineurium, proximal to the CPN/TN coaptation site, with the aid of a microsyringe. The same surgical procedure was carried out in group C (positive control group), as well, but an equal volume (i.e. 50μl) of normal saline was administered instead. Finally, in each of the animals of the remaining group G, both the proximal and the distal stump of the CPN were carefully sutured into the neighbouring muscles; hence, the latter would constitute a negative control group, thanks to the resulting atrophy of the CPN – innervated musculature. All surgical procedures took place with the animals under dissociative anaesthesia and were performed under sterile conditions, using the operating microscope and applying microsurgical techniques. In each case, the right CPN was operated upon; the contralateral (left) CPN remained intact, thus serving as control. Euthanasia was achieved by means of intracardiac administration of high – dose sodium pentobarbital. Results: The evaluation of the outcome four (4) months postoperatively was based on clinical examination, walking-track analysis, electromyographic and histomorphometric studies. Our data indicate that the administration of the growth factors under investigation has a favorable effect on the outcome of CPN repair; the administration of bFGF, in particular, seems to improve the results of terminolateral neurorraphy in the time span studied. Conclusions: In rats, CPN repair via end-to-side neurorraphy to the TN can be enhanced by the administration of bFGF or NGF

Introduction. Nerve conduction studies are considered to be the investigation of choice for the diagnosis of Carpal Tunnel Syndrome. However they are expensive and can be painful. We scored patients based on a ten point scoring system; four symptoms (Katz Hand Diagram – Classic and Probable pattern for tingling and numbness, nocturnal paresthesia, bilateral symptoms), four signs (weak thumb abduction test, Tinel sign, Phalen sign, Hypoalgesia in median nerve territory) and two risk factors (age more than 40 years and female sex). This was done in an effort to predict the severity of carpal tunnel syndrome and to correlate it with nerve conduction studies. Method. A prospective study of 59 patients was performed between May 2009 and March 2010. For every patient in the study we completed a scoring system based on ten points and correlated it with the severity (normal, mild, moderate and severe) result from the nerve conduction studies. Results. There were 61 completed data sets (59 patients, two patients had bilateral carpal tunnel release). The mean age of patients was 60 years (range: 37–91 years). The mean duration of symptoms was 17 months. The female to male ratio was 2.3:1. All scores greater than seven matched with nerve conduction study of moderate to severe intensity apart from three scores which were greater than seven that matched with a normal result. Conclusion. Based on this study, we believe that patients who score less than eight may require nerve conduction studies to confirm the diagnosis of carpal tunnel syndrome. However patients who score more than seven have a 93% chance of having moderate to severe carpal tunnel syndrome on nerve conduction studies

Paediatric supracondylar fractures are the most common elbow fracture in children, and is associated with an 11% incidence of neurologic injury. The goal of this study is to investigate the natural history and outcome of motor nerve recovery following closed reduction and percutaneous pinning of this injury. A total of 246 children who underwent closed reduction and percutaneous pinning following supracondylar humerus fractures were prospectively enrolled over a two year period. Patient demographics (age, weight), Gartland fracture classification, and associated traumatic neurologic injury were collected and analyzed with descriptive statistics. Patients with neurologic palsies were separated based on nerve injury distribution, and followed long term to monitor for neurologic recovery at set time points for follow up. Of the 246 patient cohort, 46 patients (18.6%) sustained a motor nerve palsy (Group 1) and 200 patients (82.4%) did not (Group 2) following elbow injury. Forty three cases involved one nerve palsy, and three cases involved two nerve palsies. No differences were found between patient age (Group 1 – 6.6 years old, Group 2 – 6.2 years old, p = 0.11) or weight (Group 1 – 24.3kg, Group 2 – 24.5kg, p = 0.44). A significantly higher proportion of Gartland type III and IV injuries were found in those with nerve palsies (Group 1 – 93.5%, Group 2 – 59%, p < 0 .001). Thirty four Anterior Interosseous Nerve (AIN) palsies were observed, of which 22 (64.7%) made a full recovery by three month. Refractory AIN injuries requiring longer than three month recovered on average 6.8 months post injury. Ten Posterior Interosseous Nerve (PIN) palsies occurred, of which four (40%) made full recovery at three month. Refractory PIN injuries requiring longer than three month recovered on average 8.4 months post injury. Six ulnar nerve motor palsies occurred, of which zero (0%) made full recovery at three month. Ulnar nerve injuries recovered on average 5.8 months post injury. Neurologic injury occurs significantly higher in Gartland type III and IV paediatric supracondylar fractures. AIN palsies remain the most common, with an expected 65% chance of full recovery by three month. 40% of all PIN palsies are expected to fully recover by three month. Ulnar motor nerve palsies were slowest to recover at 0% by the three month mark, and had an average recovery time of approximately 5.8 months. Our study findings provide further evidence for setting clinical and parental expectations following neurologic injury in paediatric supracondylar elbow fractures