Effects of Microselective Neurotomy on Focal Spasticity and Description of the Surgical Technique

We studied the microselective neurotomy (MSN) and its advantages to alleviate disabling spasticity. The best indication for MSN is focal spasticity. We performed 298 MSN, 87 nerves on the upper limb, 211 nerves on the lower limb) in 68 patients. The initial causes were: stroke, cranial trauma, postoperative complications and multiple sclerosis. MSN procedures were performed on the median nerve (n = 40) for wrist and finger flexion;musculo-cutaneus nerve (n = 38) for elbow flexion;ulnaris nerve (n = 9) for cubital deviation of the hand;gastrocnemius nerve (n = 98) and soleus nerve (n = 49) for equinus foot, tibial posterior nerve (n = 45) for varus foot, and fascicles (or bundles) of the flexor digitorum for “claw” toes (n = 19). The main preoperative test to identify the responsible nerve was a neuromuscular block with local anesthesia (lidocaine or bupivacaine) injected into the site of the nerve connecting the spastic muscle. During surgery, the identified nerve was exposed and its epineurium opened. Nerve bundles were teased apart into individual rootlets and a number of rootlets cut were previously planned, according to the spasticity. Follow-up was performed for up to 10 years, with a mean period of 29 months. Results demonstrated a reduction of limb spasticity of 2 to 3 points: modified Ashworth scale (MAS). Pain and clonus were also diminished in the affected limb. In some cases, voluntary movement was once again possible. MSN is a useful alternative in those cases of focal spasticity where physiotherapy and nerve block with botulinum toxin or phenol no longer produce satisfactory results.

Radial optic neurotomy in treating central retinal vein occlusion: a Meta-analysis

AIM： To assess the feasibility of radial optic neurotomy （RON） in central retinal vein occlusion （CRVO） treatment with a Meta-analysis.METHODS： Electronic databases were searched for comprehensive articles that compared efficacy of RON with that of other treatments in CRVO. Study quality was assessed and risk ratio （RR） and 95% confidence interval （Cl） with fix or random-effects model were calculated according to the heterogeneity. RESULTS： A total of 200 eyes from 5 studies were included. The results indicated that no significant differences were found between groups with and without RON in improvement of visual acuity （VA） at 6mo follow- up （pooled RR 0.51, 95%CI 0.22 to 1.18, P=0.117） while improvement of VA showed significantly favourable in patients receiving RON treatment at 12mo follow-up （pooled RR 2.27, 95% CI 1.31 to 3.95, P=0.004）. For complications, RON treatment was more effective in reducing neovascular glaucoma （pooled RR 0.45, 95%CI 0.21 to 0.97, P=0.042） but was comparable in retinal detachment （pooled RR 2.41, 95%CI 0.51 to 11.39, P=0.267） and vitreous hemorrhage （pooled RR 0.91, 95%CI 0.33 to 2.46, P=0.847）. CONCLUSION： Compared with some certain treatment modalities, RON might offer better VA at 12mo and decrease the rate of neovascular glaucoma without changing the rate of retinal detachment and vitreous hemorrhage. Further studies are required considering the limitation of the research.

The application of intraoperative neurophysiological monitoring in selective dorsal neurotomy for primary premature ejaculation:a prospective single-center study

Selective dorsal neurotomy(SDN)is a surgical treatment for primary premature ejaculation(PE),but there is still no standard surgical procedure for selecting the branches of the dorsal penile nerves to be removed.We performed this study to explore the value of intraoperative neurophysiological monitoring(IONM)of the penile sensory-evoked potential(PSEP)for standard surgical procedures in SDN.One hundred and twenty primary PE patients undergoing SDN were selected as the PE group and 120 non-PE patients were selected as the normal group.The PSEP was monitored and compared between the two groups under both natural and general anesthesia(GA)states.In addition,patients in the PE group were randomly divided into the IONM group and the non-IONM group.During SDN surgery,PSEP parameters of the IONM group were recorded and analyzed.The differences in PE-related outcome measurements between the perioperative period and 3 months'postoperation were compared for the PE patients,and the differences in effectiveness and complications between the IONM group and the non-IONM group were compared.The results showed that the average latency of the PSEP in the PE group was shorter than that in the normal group under both natural and GA states(P<0.001).Three months after surgery,the significant effective rates in the IONM and non-IONM groups were 63.6%and 34.0%,respectively(P<0.01),and the difference in complications between the two groups was significant(P<0.05).IONM might be useful in improving the short-term therapeutic effectiveness and reducing the complications of SDN.

Selective peripheral neurotomy (SPN) as a treatment strategy for spasticity

Spasticity can be caused by central nervous system dysfunction,such as cerebral palsy and stroke.The accepted pathogenesis of spasticity is that the muscles are in the state of uninhibited stretch reflex without enough control of central nervous system.So far,there is no ideal way about how to repair central nervous system.However,the uninhibited stretch reflex can be reduced,targeting the posterior root of the spinal cord and peripheral nerves innervating the limbs,which are called selective posterior rhizotomy(SPR)and selective peripheral neurotomy(SPN),respectively.SPN is indicated for focal or multifocal spasticity,which is well accepted due to its low invasiveness and ease of use.How does the operation work?What do we do before and during this operation?Is there any risk to the patients?Our review summarizes the mechanism,indications,preoperative assessments,techniques,and complications of SPN.We hope that the spastic patients,such as pediatric cerebral palsy patients and older stroke patients,will benefit from this surgery.

The Anatomy of Dorsal Ramus Nerves and Its Implications in Lower Back Pain

This article reviews the relationship between the spinal dorsal ramus system and low back pain, including the anatomy, clinical findings, pathogenesis and treatment of low back pain mediated by spinal dorsal ramus and zygapophysial (facet) joint syndrome. Each spinal dorsal ramus arises from the spinal nerve and then divides into a medial and lateral branch. The medial branch supplies the tissues from the midline to the zygapophysial joint line and innervates two to three adjacent zygapophysial joints and their related soft tissues. The lateral branch innervates the tissues lateral to the zygapophysial joint line. The clinical pain presentations follow these anatomic distributions, which can be used for localizing the involved dorsal ramus. The diagnosis can be confirmed by performing a single dorsal ramus block that results in relief of pain and muscle spasm. Etiologically, any factor that stimulates the spinal dorsal ramus can cause low back pain, which is distinct from zygapophysial joint syndrome. Clinically, L1 and L2 are the most common sites of dorsal rami involvement. Treatment includes spinal dorsal ramus injection therapy and percutaneous neurotomy. Summarily, irritation of the spinal dorsal ramus system is a potential source of low back pain. Based on the anatomy and clinical presentation, the involved spinal dorsal ramus can be localized and treated.

Zygapophysial joint pain in selected patients

The zygapophysial joints(z-joints), together with the intervertebral disc, form a functional spine unit. The joints are typical synovial joints with an innervation from two medial branches of the dorsal rami. The joint capsule and the surrounding structures have an extensive nerve supply. The stretching of the capsule and loads being transmitted through the joint can causepain. The importance of the z-joints as a pain generator is often underestimated because the prevalence of z-joint pain(10%-80%) is difficult to specify. Z-joint pain is a somatic referred pain. Morning stiffness and pain when moving from a sitting to a standing position are typical. No historic or physical examination variables exist to identify z-joint pain. Also, radiologic findings do not have a diagnostic value for pain from z-joints. The method with the best acceptance for diagnosing z-joint pain is controlled medial branch blocks(MBBs). They are the most validated of all spinal interventions, although false-positive and false-negative results exist and the degree of pain relief after MBBs remains contentious. The prevalence of z-joint pain increases with age, and it often comes along with other pain sources. Degenerative changes are commonly found. Z-joints are often affected by osteoarthritis and inflammatory processes. Often additional factors including synovial cysts, spondylolisthesis, spinal canal stenosis, and injuries are present. The only truly validated treatment is medial branch neurotomy. The available technique vindicates the use of radiofrequency neurotomy provided that the correct technique is used and patients are selected rigorously using controlled blocks.

Interventional pain therapy in cervical post-surgery syndrome

Fifteen percent to forty percent of patients present with persistent disabling neck pain or radicular pain after cervical spine surgery. Persistent pain after cervical surgery is called cervical post-surgery syndrome(CPSS). This review investigates the literature about interventional pain therapy for these patients. Because different interventions with different anatomical targets exist, it is important to find the possible pain source. There has to be a distinction between radicular symptoms(radicular pain or radiculopathy) or axial pain(neck pain) and between persistent pain and a new onset of pain after surgery. In the case of radicular symptoms, inadequate decompression or nerve root adherence because of perineural scarring are possible pain causes. Multiple structures in the cervical spine are able to cause neck pain. Hereby, the type of surgery and also the number of segments treated is relevant. After fusion surgery, the so-called adjacent level syndrome is a possible pain source. After arthroplasty, the load of the facet joints in the index segment increases and can cause pain. Further, degenerative alterations progress. In general, two fundamentally different therapeutic approaches for interventional pain therapy for the cervical spine exist: Treatment of facet joint pain with radiofrequency denervation or facet nerve blocks, and epidural injections either via a transforaminal or via an interlaminar approach. The literature about interventions in CPSS is limited to single studies with a small number of patients. However, some evidence exists for these procedures. Interventional pain therapies are eligible as a target-specific therapy option. However, the risk of theses procedures(especially transforaminal epidural injections) must be weighed against the benefit.

Progresses in pharmaceutical and surgical management of premature ejaculation

Objective:Premature ejaculation(PE)is regarded as one of the most common male sexual dysfunctions.This review introduced several pharmaceutical and surgical methods for the management of PE.The definition,etiology,behavioral,and psychological therapy of PE were also discussed.Data sources:"Premature,""ejaculation,"or"sexual dysfuction"were used as the medical subject headings(MeSH)to obtain relevant articles before June 2019 on Pubmed,Google Scholar and CNKI.Most articles used were written in English and several Chinese articles were also cited.Study selection:Full-text articles of retrospective/prospective/randomized controlled trials were analyzed.Animal experiments and letters were excluded.Results:There are four PE sub-types:lifelong PE,acquired PE,natural variable PE,and subjective PE.Behavioral therapy,psychotherapy,medication,topical anesthetics,and surgery are currently used for the treatment of PE.However,all the above treatments have limitations.Therefore,novel ways should be investigated to more efficiently control PE.Conclusions:The pharmaceutical therapy that is currently being used in clinical practice for the management of PE is still the main choice globally due to its good efficacy.Surgery may be a choice for patients who are resistant to medication.However,it should be performed cautiously.