Superacute onset of Guillain-Barré syndrome after elective spinal surgery: A case report and literature review

RATIONALE

Guillain-Barré syndrome (GBS) epitomizes an acute peripheral neuropathy hallmarked by an autoimmune retort directed at the myelin sheath enwrapping peripheral nerves. While it is widely acknowledged that a majority of GBS patients boast a history of antecedent infections, the documentation of postoperative GBS occurrences is progressively mounting. Drawing upon an exhaustive compendium of recent case reports, the disease's inception spans a gamut from within 1 hour to 1.2 years.

PATIENT CONCERNS

At this juncture, we proffer a singular case: an instance involving a 51-year-old gentleman who underwent lumbar spine surgery, only to encounter immediate debilitation of limb and respiratory musculature.

DIAGNOSES

Post elimination of variables linked to anesthetic agents, encephalon, and spinal cord pathologies, a potent suspicion of superacute GBS onset emerged.

INTERVENTIONS

Subsequent to immunoglobulin therapy, plasmapheresis, and adjunctive support, the patient's ultimate demise became manifest.

OUTCOMES

No progress was found to date.

LESSONS

Given GBS's potential to instigate paralysis, respiratory collapse, and autonomic nervous system aberrations, alongside other pernicious sequelae, coupled with the exceptional rarity of the temporal onset in this particular instance, it undeniably proffers an imposing conundrum for anesthetists in the realm of differential diagnosis and therapeutic conduct. During the postoperative convalescence phase under anesthesia, should the patient evince deviant limb musculature vigor and compromised respiratory sinews, the prospect of GBS must not be consigned to oblivion. Precision in diagnosis conjoined with apt therapeutic measures could well be the harbinger of a divergent denouement for the afflicted patient.

Guillain-Barré syndrome after surgery: a literature review

Guillain-Barré syndrome (GBS) is a rare postoperative complication that is sometimes characterized by serious motor weakness and prolonged weaning from mechanical ventilation. Although the exact nature of the relationship between GBS and the surgical procedure is still unclear, there is a clear increased incidence of GBS in post-surgical patients compared to non-surgical patients. GBS after surgery is unique in several ways. The course of post-surgical GBS unfolds more rapidly than in other situations where GBS develops, the condition is often more severe, and respiratory muscles are more commonly involved. Prompt diagnosis and appropriate treatment are essential, and the condition can worsen if treated inappropriately. Postoperative sedation, intubation, and restraint use make the diagnosis of GBS difficult, as the onset of symptoms of weakness or numbness in those contexts are not obvious. GBS is often misdiagnosed, being attributed to other postoperative complications, and subsequently mishandled. The lack of relevant information further obscures the clinical picture. We sought to better understand post-surgical GBS by performing an analysis of the relevant literature, focusing on clearly documenting the clinical characteristics, diagnosis, and management of GBS that emerges following surgery. We underscore the importance of physicians being aware of the possibility of GBS after major surgery and of performing a variety of laboratory clinical investigations early on in suspected cases.

Post-surgical inflammatory neuropathy after anterior cruciate ligament repair: a case report

BACKGROUND

Unanticipated symptoms of peripheral nerve damage following surgery are distressing to both the patient and their clinical team, including surgeons, anesthesiologists, and neurologists. The causes that are commonly considered for perioperative neuropathy can include surgical trauma, positioning-related injury, or injury related to a regional anesthetic technique. However, these cases often do not have a clear etiology and can occur without any apparent periprocedural anomalies. Postoperative inflammatory neuropathy is a more recently described, and potentially underrecognized cause of perioperative neuropathy which may improve with corticosteroid therapy. Therefore, it is an important etiology to consider early in the evaluation of perioperative neuropathy.

CASE PRESENTATION

An otherwise healthy patient presented for left anterior cruciate ligament reconstruction. He underwent femoral and sciatic ultrasound-guided single-injection peripheral nerve blocks preoperatively, followed by a general anesthetic for the surgical procedure. He developed postoperative neuropathy in the sciatic distribution with both sensory and motor deficits. The patient received multi-disciplinary consultations, including neurology and pain management, and a broad differential diagnosis was considered. Based on neurological evaluation and imaging studies, a final diagnosis of post-surgical inflammatory neuropathy was made. The patient's course improved with conservative management, but immunosuppressive treatment may have been considered for a more severe or worsening clinical course.

CONCLUSIONS

There are limited publications describing postoperative inflammatory neuropathy, and this case serves to illustrate a potentially under-recognized and multifactorial cause of postoperative neuropathy. Perioperative neuropathies are a complication that surgeons and anesthesiologists strive to avoid; however, prevention and treatment of this condition have been elusive. Increased reporting and investigation of postoperative inflammatory neuropathy as one cause for this complication will help to further our understanding of this potentially devastating complication.

Shedding Light on Perioperative Nerve Injury: An Investigation Using the SHED (Symptoms Categorization-History Taking-Examination-Diagnostic Evaluations) Approach

Peripheral nerve blocks (PNBs) provide analgesia and anesthesia in diverse surgical procedures. Despite their recognized benefits, the occurrence of complications, particularly peripheral nerve injuries (PNIs), is a noteworthy concern. Prompt identification and intervention for perioperative nerve injuries are crucial to prevent permanent neurological impairment. A meticulous, systematic evaluation centered on the onset and progression of symptoms becomes imperative. The SHED (symptoms categorization-history taking-examination-diagnostic evaluations) approach serves as a valuable tool for diagnosing causative factors, determining the type of nerve injury, and formulating an effective treatment plan to mitigate further harm. This case report employs the SHED approach to elucidate a perplexing instance of PNIs. The patient, experiencing neurological symptoms post-forearm surgery under a PNB, serves as a focal point. The report underscores the significance of a systematic, stepwise approach in managing patients with suspected PNIs. Vigilant patient monitoring, collaborative teamwork, shared responsibilities, and consideration of potential contributing factors beyond the nerve block are highlighted for an accurate diagnosis and effective treatment of PNIs. The aim is to guide healthcare professionals in navigating similar clinical scenarios, ultimately ensuring patient safety and optimizing outcomes.

Vocal Fold Paralysis After Spinal and Epidural Anesthesia: A Case Report and Scoping Review

OBJECTIVES

Cranial nerve paralysis is a rare complication of spinal and epidural anesthesia, and some cases of vocal fold paralysis (VFP) have been reported. The aim of this article is to report a case, identify evidence supporting the possibility of VFP being a complication of spinal and epidural anesthesia and to investigate the frequency, the characteristics, and the possible mechanisms of such a complication.

DATA SOURCES

CINAHL Complete, Google Scholar, Cochrane Library, Pubmed, and EMBASE.

METHODS

Case report according to CARE guidelines; scoping review according to PRISMA-ScR criteria. All types of studies that reported on patients of any age and sex, all types of spinal/epidural anesthesia regardless of the location and of drugs used were included. A data extraction sheet was completed for each study selected for inclusion based on the full-text screenings. Extracted data included: study characteristics, participant characteristics, intervention characteristics, outcome measures, clinical investigations. The study did not receive external funding.

RESULTS

Eight studies met inclusion criteria and a total of 13 events (in 12 patients, including ours) were reported to date. Although there are some hypotheses in regard to the mechanism underlying the phenomena, including mechanical and inflammatory ones, the exact cause is still unclear.

CONCLUSIONS

Only few cases of VFP after spinal or epidural anesthesia have been reported to date; however, it seems possible that VFP might be a potential underreported complication of such procedures. We believe that more research on the topic is warranted, especially considering the wide population potentially at risk.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

Femoral neuropathy: A clinical and electrodiagnostic review

INTRODUCTION/AIMS

Femoral neuropathies can cause severe, prolonged debility, yet there have been few clinical and electrodiagnostic (EDx) studies addressing this condition. The aim of this study was to better understand the etiologies, EDx features, and clinical course of femoral neuropathy.

METHODS

We identified patients evaluated at Mayo Clinic Rochester between January 1, 1999 and July 31, 2019, with possible new femoral neuropathy ascertained via International Classification of Diseases-versions 9 and 10 diagnosis codes presenting within 6 months of symptom onset.

RESULTS

A retrospective review of 1084 records was performed and we ultimately identified 159 patients with isolated femoral neuropathy for inclusion. The most common femoral neuropathy etiologies were compressive (40%), perioperative stretch (35%), and inflammatory (6%). Presenting symptoms included weakness (96%), sensory loss (73%), and pain (53%). Presenting motor physical exam findings demonstrated moderate weakness (34%) or no activation (25%) of knee extension and mild (32%) or moderate (35%) weakness of hip flexion. Seventy-two percent of patients underwent EDx testing, including 22 with femoral motor nerve conduction studies. Treatment often involved physical therapy (89%) and was otherwise etiology-specific. In patients with follow-up data available (n = 154), 83% had subjective clinical improvement at follow-up with a mean time to initial improvement of 3.3 months and mean time to recovery at final follow-up of 14.8 months. Only 48% of patients had nearly complete or complete recovery.

DISCUSSION

In our cohort, the most common etiologies of femoral neuropathy were compression or perioperative stretch with high initial morbidity. Although motor recovery is common, improvement is often prolonged and incomplete.

Parsonage-Turner Syndrome and Hereditary Brachial Plexus Neuropathy

Parsonage-Turner syndrome and hereditary brachial plexus neuropathy (HBPN) present with indistinguishable attacks of rapid-onset severe shoulder and arm pain, disabling weakness, and early muscle atrophy. Their combined incidence ranges from 3 to 100 in 100,000 persons per year. Dominant mutations of SEPT9 are the only known mutations responsible for HBPN. Parsonage and Turner termed the disorder "brachial neuralgic amyotrophy," highlighting neuropathic pain and muscle atrophy. Modern electrodiagnostic and imaging testing assists the diagnosis in distinction from mimicking disorders. Shoulder and upper limb nerves outside the brachial plexus are commonly affected including the phrenic nerve where diaphragm ultrasound improves diagnosis. Magnetic resonance imaging can show multifocal T2 nerve and muscle hyperintensities with nerve hourglass swellings and constrictions identifiable also by ultrasound. An inflammatory immune component is suggested by nerve biopsies and associated infectious, immunization, trauma, surgery, and childbirth triggers. High-dose pulsed steroids assist initial pain control; however, weakness and subsequent pain are not clearly responsive to steroids and instead benefit from time, physical therapy, and non-narcotic pain medications. Recurrent attacks in HBPN are common and prophylactic steroids or intravenous immunoglobulin may reduce surgical- or childbirth-induced attacks. Rehabilitation focusing on restoring functional scapular mechanics, energy conservation, contracture prevention, and pain management are critical. Lifetime residual pain and weakness are rare with most making dramatic functional recovery. Tendon transfers can be used when recovery does not occur after 18 months. Early neurolysis and nerve grafts are controversial. This review provides an update including new diagnostic tools, new associations, and new interventions crossing multiple medical disciplines.

Focal inflammatory neuropathies

This chapter focuses on neuropathies that present with focal involvement of nerve roots, plexus, and/or peripheral nerves associated with autoimmune and inflammatory mechanisms that present with focal involvement of nerve roots, plexus and/or peripheral nerves. The clinical presentation, diagnosis, and treatment of focal autoimmune demyelinating neuropathies, focal nonsystemic vasculitic disorders (diabetic and nondiabetic radiculoplexus neuropathies, postsurgical inflammatory neuropathy, and neuralgic amyotrophy), and focal neuropathies associated with sarcoidosis and bacterial and viral infections are reviewed.

Axillary and musculocutaneous neuropathies

This chapter covers axillary and musculocutaneous neuropathies, with a focus on clinically relevant anatomy, electrodiagnostic approaches, etiologic considerations, and management principles. Disorders of the lateral antebrachial cutaneous nerve, a derivative of the musculocutaneous nerve, are also reviewed. We emphasize the importance of objective findings, including the physical examination and electrodiagnostic evaluation in confirming the isolated involvement of each nerve which, along with the clinical history, informs etiologic considerations. Axillary and musculocutaneous neuropathies are both rare in isolation and most frequently occur in the setting of trauma. Less commonly encountered etiologies include external compression or entrapment, neoplastic involvement, or immune-mediated disorders including neuralgic amyotrophy, postsurgical inflammatory neuropathy, multifocal motor neuropathy, vasculitic neuropathy, and multifocal chronic inflammatory demyelinating polyradiculoneuropathy.

Current status of Guillain-Barré syndrome (GBS) in China: a 10-year comprehensive overview

Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy; a disease involving the peripheral nervous system which is the most common cause of acute flaccid paralysis worldwide. So far, it is still lack of a comprehensive overview and understanding of the national epidemiological, clinical characteristics, and the risk factors of GBS in China, as well as differences between China and other countries and regions in these respects. With the global outbreak of the coronavirus disease 2019 (COVID-19), an epidemiological or phenotypic association between severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and GBS has attracted great attention. In this review, we outlined the current clinical data of GBS in China by retrieving literature, extracting and synthesizing the data of GBS in China from 2010 to 2021. Besides, we compared the characteristics of epidemiology, preceding events and clinical profiles of GBS between China and other countries and regions. Furthermore, in addition to conventional intravenous immunoglobulin (IVIG) and plasma exchange (PE) therapy, the potential therapeutic effects with novel medications in GBS, such as complement inhibitors, etc., have become the research focus in treatments. We found that epidemiological and clinical findings of GBS in China are approximately consistent with those in the International GBS Outcome Study (IGOS) cohort. We provided an overall picture of the present clinical status of GBS in China and summarized the global research progress of GBS, aiming to further understand the characteristics of GBS and improve the future work of GBS worldwide, especially in countries with the middle and low incomes.

Acute polyneuropathies after bariatric surgery: does immunity play a role? Case series and literature review

BackgroundThe incidence of bariatric surgery (BS) is on the rise, and the prevalence of complications associated with this procedure has also increased. The most common neurologic complications of BS are peripheral neuropathy and encephalopathy. In this study, we presented the clinical and electrophysiological courses of five patients with acute-subacute axonal polyneuropathy after BS.MethodWe evaluated neurological examinations, micronutrient deficiencies (B12, folic acid, thiamine, and vitamin D), nerve conduction studies (NCS), and Guillain-Barré syndrome (GBS) disability scores.Cases All patients were female; the average weight loss was 35.2 ± 7.52 kg, and the CSF protein level was 40.98 ± 6.99 mg/d. All patients underwent vitamin supplementation and physical therapies. The presence of more pronounced axonal involvement in NCS and the higher likelihood of normal CSF protein levels in BS-related acute polyneuropathy patients suggest that the underlying pathogenesis may differ from classical GBS. In the presented studies in the literature, inflammation is frequently observed in nerve biopsies of BS patients, suggesting that both micronutrient deficiencies and immune mechanisms play a role in the pathogenesis. Intravenous immunoglobulin (IVIG) treatment may improve neurologic deficits in patients with GBS-like clinical presentations. In the presented study, three patients were treated with IVIG, while two patients were treated with plasma exchange therapy followed by IVIG. Three cases improved significantly and were able to walk without assistance at one year visit.ConclusıonIn patients with bariatric surgery (BS)-associated polyneuropathy, immunotherapy, and intensive pre- and post-operative nutritional management may improve patients' morbidity. Therefore, we suggest close monitoring by a multidisciplinary team for PBS patients.

Clinical, Neurophysiologic, and Pathologic Features in Patients With Early-Onset Postradiation Neuropathy

OBJECTIVES

The objective of this study was to study early-onset radiation-induced neuropathy reviewing neurologic course, steroid response, and available nerve biopsies.

METHODS

Patients coded with radiation-induced neuropathy within 6 months of radiation were reviewed from January 1,1999, to August 31, 2022. Patients had to have electrodiagnostically confirmed neuropathy localized within or distal to radiation fields. Neurologic course and nerve biopsies were reviewed.

RESULTS

Twenty-eight patients (16 male and 12 female patients, mean age 63.8 years) were identified. The average radiation dose was 4,659 cGy (range 1,000-7,208). Tumor infiltration was not observed on MRI and PET. Postradiation onsets averaged 2 months (range 0-5). Localizations included brachial (n = 4) plexopathies, lumbosacral (n = 12) plexopathies, radiculopathies (n = 10), and mononeuropathies (n = 2). Neuropathic pain (n = 25) and weakness (n = 25) were typical. The clinical courses were subacute monophasic (n = 14), chronic progressive (n = 8), or static (n = 1), and 5 were without follow-up. Nerve biopsies (n = 8) showed an inflammatory ischemic process with perivascular inflammatory infiltrates (n = 7) or microvasculitis (n = 2). Nine patients, 7 with monophasic courses, received steroid burst therapy with symptom improvement in 8. No patients recovered entirely back to baseline.

DISCUSSION

In contrast to chronic radiation-induced neuropathy, early-onset patients most commonly have painful monophasic courses with residual deficits, possibly steroid responsive. An ischemic inflammatory pathogenesis is suggested.

Autoimmune Axonal Neuropathies

OBJECTIVE

This article reviews autoimmune axonal neuropathies, their characteristic clinical features, disease and antibody associations, appropriate ancillary testing, treatment, and prognosis.

LATEST DEVELOPMENTS

In 2021, the American College of Rheumatology and the Vasculitis Foundation released new summary guidelines for the treatment of antineutrophil cytoplasmic autoantibody-associated vasculitides. In addition, novel autoantibodies have been recently identified; they are often paraneoplastic and associated with axonal neuropathies.

ESSENTIAL POINTS

Recognition of autoimmune axonal neuropathies is important because of the potential for effective treatment to either reverse deficits or slow the progression of disease. It is necessary to properly assess for associations with other systemic disorders (eg, systemic vasculitis, connective tissue disease, neoplasm) so that adequate treatment for both neurologic and non-neurologic aspects of the disease can be initiated.

Neuropathy Score Reporting and Data System (NS-RADS): A Practical Review of MRI-Based Peripheral Neuropathy Assessment

The Neuropathy Score Reporting and Data System (NS-RADS) is a newly developed MR imaging-based classification that standardizes reporting and multidisciplinary communication for MR imaging diagnosis and follow-up of peripheral neuropathies. NS-RADS classification has shown to be accurate and reliable across different centers, readers' experience levels, and degrees of peripheral neuropathies, which include nerve injury, entrapment, neoplasm, diffuse neuropathy, post-interventional status, and temporal changes in muscle denervation. This article brings a practical review of NS-RADS classification, representative MR cases, and a step-by-step tutorial on how to approach this staging system. Readers can gain knowledge and apply it in their practice, aiming to standardize the communications between specialties and improve patient management.

Multimodal Pain Management for Parsonage-Turner Syndrome in the Acute Rehabilitation Setting: A Case Report

Parsonage-Turner syndrome (PTS) is a rare neurological condition characterized by acute shoulder pain and novel neuromuscular weakness in the distribution of the brachial plexus. We present a case report highlighting the difficulties in the diagnosis and management of this condition. A multidisciplinary approach is often required to control this unique type of pain, consisting of neuropathic medications, non-steroidal anti-inflammatory drugs (NSAIDs) to control neuromuscular pain, and modalities provided by experienced physical therapists. Finally, a comprehensive, structured rehabilitation program focusing on the range of motion, neuromuscular re-education, and strengthening is imperative to regain function, reduce symptoms, and improve recovery.

"Knowing It Before Blocking It," the ABCD of the Peripheral Nerves: Part B (Nerve Injury Types, Mechanisms, and Pathogenesis)

Selander emphatically said, "Handle these nerves with care," and those words still echo, conveying a loud and clear message that, however rare, peripheral nerve injury (PNI) remains a perturbing possibility that cannot be ignored. The unprecedented nerve injuries associated with peripheral nerve blocks (PNBs) can be most tormenting for the unfortunate patient and a nightmare for the anesthetist. Possible justifications for the seemingly infrequent occurrences of PNB-related PNIs include a lack of documentation/reporting, improper aftercare, or associated legal implications. Although they make up only a small portion of medicolegal claims, they are sometimes difficult to defend. The most common allegations are attributed to insufficient informed consent; preventable damage to a nerve(s); delay in diagnosis, referral, or treatment; misdiagnosis, and inappropriate treatment and follow-up care. Also, sufficient prospective studies or randomized trials have not been conducted, as exploring such nerve injuries (PNB-related) in living patients or volunteers may be impractical or unethical. Understanding the pathophysiology of various types of nerve injury is vital to dealing with them further. Processes like degeneration, regeneration, remyelination, and reinnervation can influence the findings of electrophysiological studies. Events occurring in such a process and their impact during the assessment determine the prognosis and the need for further interventions. This educational review describes various types of PNB-related nerve injuries and their associated pathophysiology.

The mechanisms and management of persistent postsurgical pain

An estimated 10%-50% of patients undergoing a surgical intervention will develop persistent postsurgical pain (PPP) lasting more than 3 months despite adequate acute pain management and the availability of minimally invasive procedures. The link between early and late pain outcomes for surgical procedures remains unclear-some patients improve while others develop persistent pain. The elective nature of a surgical procedure offers a unique opportunity for prophylactic or early intervention to prevent the development of PPP and improve our understanding of its associated risk factors, such as pre-operative anxiety and the duration of severe acute postoperative pain. Current perioperative pain management strategies often include opioids, but long-term consumption can lead to tolerance, addiction, opioid-induced hyperalgesia, and death. Pre-clinical models provide the opportunity to dissect mechanisms underpinning the transition from acute to chronic, or persistent, postsurgical pain. This review highlights putative mechanisms of PPP, including sensitisation of peripheral sensory neurons, neuroplasticity in the central nervous system and nociceptive signalling along the neuro-immune axis.

Identifying risk factors for chronic postsurgical pain and preventive measures: a comprehensive update

INTRODUCTION

Chronic postsurgical pain (CPSP) is a prevalent condition that can diminish health-related quality of life, cause functional deficits, and lead to patient distress. Rates of CPSP are higher for certain types of surgeries than others (thoracic, breast, or lower extremity amputations) but can occur after even uncomplicated minimally invasive procedures. CPSP has multiple mechanisms, but always starts as acute postsurgical pain, which involves inflammatory processes and may encompass direct or indirect neural injury. Risk factors for CPSP are largely known but many, such as female sex, younger age, or type of surgery, are not modifiable. The best strategy against CPSP is to quickly and effectively treat acute postoperative pain using a multimodal analgesic regimen that is safe, effective, and spares opioids.

AREAS COVERED

This is a narrative review of the literature.

EXPERT OPINION

Every surgical patient is at some risk for CPSP. Control of acute postoperative pain appears to be the most effective approach, but principles of good opioid stewardship should apply. The role of regional anesthetics as analgesics is gaining interest and may be appropriate for certain patients. Finally, patients should be better informed about their relative risk for CPSP.

"Knowing It Before Blocking It," the ABCD of the Peripheral Nerves: Part D (Approach to the Patient With Nerve Injuries)

"Prevention is always better than cure." However, despite all precautions or preventive measures, sometimes patients develop neurodeficits due to suspected nerve injury in the perioperative period. Assessment and evaluation of the patient's symptoms can provide clues to the causative factors. Such causative factors can be corrected immediately to avoid further deterioration, or some may require further workup. The management plan for such a diagnosed nerve injury depends on the symptoms, the finding of the medical history, and the diagnostic imaging and tests. Simultaneous symptomatic relief in the form of pain medications, steroids, anti-inflammatory drugs, psychological counseling, and reassurance is essential to expedite treatment goals. Diagnosing and treating nerve injuries cannot be laid down as a straightforward part. It is a zigzag puzzle in its own right, playing with time and injury progression. Careful assessment to diagnose the extent of nerve damage plays an important role in treatment plans. It helps decide when to proceed and when to postpone, whether conservative strategies would suffice, or surgical repair would be required. Although most nerve injuries are self-limiting, some cases require surgical intervention that needs to be diagnosed early. The revolution was started by Sunderland in 1945 when he described neurosurgical techniques that drastically changed the entire scenario of nerve repairs. The ultimate effective treatment and full recovery may not be guaranteed, but attempts must be made to achieve the best results. With the patient's interests in mind, it is important to formulate a plan ensuring a good quality of life with minimal impact on their daily activities. Multifactorial nerve injury requires a multidisciplinary approach that primarily includes reassuring, psychological counseling, multimodal analgesia, and neurological and occupational consultations. This article describes the step-by-step approach known as the symptoms categorization-history taking-examination-diagnostic evaluations (SHED) approach to managing patients with peripheral nerve injuries. It also details the various modalities for diagnosing nerve injuries, sequential electrodiagnostic studies, and treatment plans depending on the type and extent of nerve injuries. It will help readers to design a treatment plan based on the patient's symptoms and evaluation results.

Postoperative ulnar neuropathy: a systematic review of evidence with narrative synthesis

BACKGROUND

Postoperative ulnar neuropathy (PUN) is an injury manifesting in the sensory or motor distribution of the ulnar nerve after anaesthesia or surgery. The condition frequently features in cases of alleged clinical negligence by anaesthetists. We performed a systematic review and applied narrative synthesis with the aim of summarising current understanding of the condition and deriving implications for practice and research.

METHODS

Electronic databases were searched up to October 2022 for primary research, secondary research, or opinion pieces defining PUN and describing its incidence, predisposing factors, mechanism of injury, clinical presentation, diagnosis, management, and prevention.

RESULTS

We included 83 articles in the thematic analysis. PUN occurs after approximately 1 in 14 733 anaesthetics. Men aged 50-75 yr with pre-existing ulnar neuropathy are at highest risk. Preventative measures, based on consensus and expert opinion, are summarised, and an algorithm of suspected PUN management is proposed, based upon the identified literature.

CONCLUSIONS

Postoperative ulnar neuropathy is rare and the incidence is probably decreasing over time with general improvements in perioperative care. Recommendations to reduce the risk of postoperative ulnar neuropathy are based on low-quality evidence but include anatomically neutral arm positioning and padding intraoperatively. In selected high-risk patients, further documentation of repositioning, intermittent checks, and neurological examination in the recovery room can be helpful.

The Peripheral Nerve Surgeon's Role in the Management of Neuropathic Pain

Neuropathic pain (NP) underlies significant morbidity and disability worldwide. Although pharmacologic and functional therapies attempt to address this issue, they remain incompletely effective for many patients. Peripheral nerve surgeons have a range of techniques for intervening on NP. The aim of this review is to enable practitioners to identify patients with NP who might benefit from surgical intervention. The workup for NP includes patient history and specific physical examination maneuvers, as well as imaging and diagnostic nerve blocks. Once diagnosed, there is a range of options surgeons can utilize based on specific causes of NP. These techniques include nerve decompression, nerve reconstruction, nerve ablative techniques, and implantable nerve-modulating devices. In addition, there is an emerging role for preoperative involvement of peripheral nerve surgeons for cases known to carry a high risk of inducing postoperative NP. Lastly, we describe the ongoing work that will enable surgeons to expand their armamentarium to better serve patients with NP.

Neuraxial and Regional Anesthesia in a Patient With Amyotrophic Lateral Sclerosis: A Case Report

Patients with amyotrophic lateral sclerosis (ALS) who undergo lower extremity joint arthroplasty are rarely encountered. Patients with ALS are at an increased risk for perioperative anesthetic complications. Anesthetic techniques, regional or general, present different risks to patients with ALS. The historical concern of worsening pre-existing neurologic symptoms with regional anesthesia is being re-examined in light of emerging evidence supporting its use in patients with ALS. Here, we present the successful perioperative management of a patient with severe bulbar ALS undergoing total knee arthroplasty. Despite his advanced bulbar symptoms, he was independently ambulatory with severe knee pain related to osteoarthritis. During multidisciplinary planning with the patient and his wife, it became clear that his primary perioperative concern was avoiding intubation, prolonged ventilation, and tracheostomy placement. With this in mind, we planned for a neuraxial anesthetic without intraoperative sedation, a postoperative adductor canal peripheral nerve block, and multimodal non-opioid analgesia. There were no perioperative complications. At the six-week follow-up, he experienced improved ambulation and showed no signs of worsened ALS symptoms.

[Peripheral neuropathies during systemic diseases: Part II (vasculitis)]

Primary systemic vasculitides, mainly of the small and medium-sized vessels, are frequently associated with peripheral neuropathies. When the disease is already known, the appearance of a neuropathy should suggest a specific injury, especially when associated with other systemic manifestations. Conversely, when neuropathy is inaugural, close collaboration between neurologists and internists is necessary to reach a diagnosis. A standardized electro-clinical investigation specifying the topography, the evolution and the mechanism of the nerve damage enables the positive diagnosis of the neuropathy. Several elements orient the etiological diagnosis and allow to eliminate the main differential diagnosis: non systemic vasculitic neuropathy. The existence of associated systemic manifestations (glomerular or vascular nephropathy, interstitial lung disease, intra-alveolar hemorrhage, ENT involvement…), biological markers (ANCA, cryoglobulinemia, rheumatoid factor), and invasive examinations allowing histological analysis (neuromuscular biopsy) are all useful tools for.

Inherited myopathy plus: Double-trouble from rare neuromuscular disorders

A rare disorder in the USA is one that affects <200,000 people, making inherited myopathies rare diseases. Increasing access to genetic testing has been instrumental for the diagnosis of inherited myopathies. Genetic findings, however, require clinical correlation due to variable phenotype, polygenic etiology of certain inherited disorders, and possible co-existing independent neuromuscular disorders. We searched the Mayo Clinic Rochester medical record (2004-2020) to identify adult patients carrying pathogenic variants or likely pathogenic variants in genes causative of myopathies and having a coexisting independent neuromuscular disorder classified as rare at https://rarediseases.info.nih.gov/. One additional patient was identified at Nationwide Children's hospital. Clinical and laboratory findings were reviewed. We identified 14 patients from 13 families fulfilling search criteria. Seven patients had a "double-trouble" inherited myopathy; two had an inherited myopathy with coexistent idiopathic myositis; three had an inherited myopathy with coexisting rare neuromuscular disorder of neurogenic type; a female DMD carrier had co-existing distal spinal muscular atrophy, which was featuring the clinical phenotype; and a patient with a MYH7 pathogenic variant had Sandhoff disease causing motor neuron disease. These cases highlight the relevance of correlating genetic findings, even when diagnostic, with clinical features, to allow precise diagnosis, optimal care, and accurate prognosis.

Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians

Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.

Lumbosacral Radiculoplexus Neuropathy After COVID-19

INTRODUCTION

Lumbosacral Radiculoplexus Neuropathy (LRPN) is a subacute, painful, paralytic, asymmetric immune-mediated lower-limb neuropathy associated with weight loss and diabetes mellitus (called DLRPN). Approximately one-third of LRPN cases have a trigger. Our purpose is to show that COVID-19 can trigger LRPN.

CASE REPORT

We describe the clinical, neurophysiological, radiologic, and pathologic findings of a 55-year-old man who developed DLRPN after severe acute respiratory syndrome coronavirus-2 infection. Shortly after mild coronavirus disease 2019 (COVID-19), the patient developed severe neuropathic pain (allodynia), postural orthostasis, fatigue, weight loss, and weakness of bilateral lower extremities requiring wheelchair assistance. One month after COVID-19, he was diagnosed with type 2 diabetes mellitus. Neurological examination showed bilateral severe proximal and distal lower extremity weakness, absent tendon reflexes, and pan-modality sensation loss. Electrophysiology demonstrated an asymmetric axonal lumbosacral and thoracic radiculoplexus neuropathies. Magnetic resonance imaging showed enlargement and T2 hyperintensity of the lumbosacral plexus. Cerebral spinal fluid (CSF) showed an elevated protein (138 mg/dL). Right sural nerve biopsy was diagnostic of nerve microvasculitis. He was diagnosed with DLRPN and treated with intravenous methylprednisolone 1 g weekly for 12 weeks. The patient had marked improvement in pain, weakness, and lightheadedness and at the 3-month follow-up was walking unassisted.

CONCLUSION

COVID-19 can trigger postinfectious inflammatory neuropathies including LRPN.

NSAID chronotherapy after impacted third molar extraction: a randomized controlled trial

OBJECTIVES

Postoperative pain management impacts patients' quality of life and morbidity. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are widely used for this following a 3-doses-per-day regime. However, pain and inflammation follow a circadian rhythm, and animal models assessing the scheduling of NSAID administration (e.g., chronotherapy) have shown that while their use during the active phase of the day enhances postoperative recovery, their administration during the resting phase could have detrimental effects. This observation has led us to hypothesize that night administration of NSAID might be unnecessary in post-surgical scenarios. Therefore, a randomized clinical trial was conducted to test this hypothesis in surgical third molar extractions.

MATERIALS AND METHODS

Seventy (18-35 years) healthy participants requiring surgical removal of impacted lower third molars were recruited and randomized into a double-blind placebo-controlled study. For three days postoperatively, the treatment group (n = 33) received ibuprofen (400 mg) at 8 AM, 1 PM, and a placebo at 8 PM, while the control group (n = 37) received ibuprofen (400 mg) at 8 AM, 1 PM, and 8 PM. Pain severity was assessed by visual analog scale (VAS) and healing indicators including facial swelling, mouth opening, and C-reactive protein blood levels were also measured.

RESULTS

Pain VAS measures showed a circadian variation peaking at night. Also, no significant differences were observed between the two groups of the study in terms of postoperative pain scores (estimate: 0.50, 95% CI = [- 0.38, 1.39]) or any other healing indicator.

CONCLUSIONS

Postoperative pain follows a circadian rhythm. Moreover, night administration of ibuprofen might not provide any significant benefits in terms of pain management and control of inflammation, and two doses during the day only could be sufficient for pain management after surgical interventions.

KNOWLEDGE TRANSFER STATEMENT

Even though this study cannot rule out the possibility that a reduced regime is different than a standard regime, nocturnal doses of ibuprofen seem to have no clinical significance in the short term, and the results of this study provide evidence in favor of reducing ibuprofen administration from three doses to two doses only after third molar surgery.

Current perspectives on the diagnosis, assessment, and management of vasculitic neuropathy

INTRODUCTION

Vasculitic neuropathy can present associated with both primary and secondary systemic vasculitis as a result from underlying diseases such as rheumatic diseases and infections, Moreover, confined vasculitis in the peripheral nervous system may be present. Thus, the diagnosis and management of vasculitic neuropathy require multidisciplinary approaches.

AREAS COVERED

Current views as well as relevant clinical research on the diagnosis, assessment, and management of vasculitic neuropathy are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for reports published between July 2017 and July 2022.

EXPERT OPINION

For the treatment of vasculitic neuropathy, determining the causative primary disease is important and often requires diagnosis by tissue biopsy. Due to the scarce research on the treatment of vasculitic neuropathy, treatment is empirically based on findings from studies of systemic vasculitides involving other organs, particularly antineutrophil cytoplasmic antibody-associated vasculitis. In addition to conventional glucocorticoids and immunosuppressive agents, complement-targeted therapy, anti-B-cell therapy, and disease-specific molecular targeted therapies have recently gained relevance. Future research is needed to develop new patient-specific therapeutic options.

Postoperative peripheral neuropathy considered to be induced by surgical stress

BACKGROUND

Most surgeons are unaware that idiopathic neuropathy, which occurs independently of mechanical injury, can present as postoperative peripheral neuropathy. The aim of this study was to reveal the presence of postoperative neuropathy considered to be induced by surgical stress and to make surgeons aware that idiopathic neuropathy can occur postoperatively.

METHODS

We conducted a survey among orthopedic surgeons regarding patients with postoperative neuropathies of unknown cause. For each case, the type of neuropathy, preceding surgery and anesthesia, patient background, clinical findings, and clinical course were investigated.

RESULTS

Seven patients were identified. The mean time from surgery to the onset of neuropathy was 9.3 days (range 1-15 days). Five of the patients fully recovered spontaneously within 1 year, while the remaining two underwent neurolysis. One patient presented with hourglass-like constrictions in the radial nerve. No inflammatory cells were found in the epineurium of the affected nerve.

CONCLUSIONS

Although it is rare, postoperative idiopathic neuropathy occurs in clinical practice, and it is crucial that surgeons recognize the existence of this neuropathy to elucidate its pathogenesis as well as to reduce the risk of litigation.

Isolated Nerve Palsy of the Flexor Pollicis Longus After a Radial Shaft Fracture: A Case Report

We present the case of a patient who developed an isolated palsy of the flexor pollicis longus (FPL) branch of the anterior interosseous nerve (AIN) following a fracture of the right radial shaft. The diagnosis of AIN palsy in this setting is rare, especially involving partial neuropathies of only the FPL branch. Clinical presentation in this scenario can be mistaken for other musculoskeletal pathology, and electrodiagnostic studies can be helpful in confirming the diagnosis.

Guillain-Barré Syndrome with Respiratory Failure following Spine Surgery for Incomplete Cervical Cord Injury: A Case Report and Literature Review

Guillain-Barré syndrome (GBS) often develops after a respiratory or gastrointestinal infection. A few cases have been reported on GBS following elective spinal surgery not preceded by an infectious disease. In patients with underlying upper motor neuron disease such as a spinal cord injury, concurrent development of lower motor neuron diseases, such as GBS, could be overlooked. Here, we present an uncommon case of an 87-year-old man with GBS that had developed after an operation for a traumatic cervical spinal cord injury. After surgery, he showed weakness over all four limbs with paresthesia, but he was able to hold a standing position with minimal assistance. Unfortunately, his muscle strength over his four limbs gradually weakened from two to four weeks later, and he became almost completely paralyzed. Cerebrospinal fluid (CSF) studies revealed albuminocytologic dissociation. A nerve conduction study (NCS) indicated an acute axonal polyneuropathy superimposed on chronic sensorimotor polyneuropathy. Thus, the patient was diagnosed with GBS. However, the patient’s family declined immune-modulatory therapy due to personal reasons. The patient progressed into respiratory failure and remained ventilator-dependent before his death three years later. This case highlights the importance of taking GBS into account when postoperative weakness occurs in patients with spinal cord injury, and a worse prognosis if GBS is left untreated.

A case series of new radicular pain following the insertion of spinal cord stimulator

Purpose

Although spinal cord stimulation (SCS) is a safe procedure, equipment-related, biological and neurological complications have been observed in previous research, particularly case reports. No reports of new neuropathic pain in the absence of neurological deficit or positive MRI findings have been described. We detail three cases of new-onset radicular pain in the L5/S1 dermatome following insertion of SCS.

Methods

This was a retrospective case series of three patients. Details of clinical background, indications for SCS and events occurring during insertion and further management were recorded.

Results

All three cases were technically difficult and required multiple epidural entry levels, with repeated passage of the electrode into and within the epidural space. All cases involved accessing epidural space T12/L1 and L1/L2. A possible explanation for the new-onset radicular pain could concern oedema to the conus medullaris, resulting from repeated passage of the electrode at the T12/L1 level. Alternative explanations could be direct trauma to transiting nerve roots, neuroplastic changes resulting in peripheral and central sensitisation and immune-mediated nerve injury.

Conclusion

MRI imaging should be analysed prior to the SCS procedure to identify the level of the conus medullaris, with the aim of avoiding repeated passage of electrodes at that level. Unintended neurological adverse events should be discussed with patients during the consent process. Careful patient selection and psychological screening may also help identify patients who may be unlikely to respond to SCS therapy. Further reporting of new radiculopathic pain following SCS insertion is required to strengthen understanding of its potential causes.

Guillain-Barre syndrome after coronary artery bypass graft surgery: a case report and literature review

Background

Guillain-Barre syndrome (GBS) is an acute polyradiculoneuropathy, often preceded by an infection. Rarely, it is preceded by a surgical procedure. Most of the postsurgical GBS cases are reported with the neurosurgical, gastrointestinal, orthopedic, and cardiac procedures. GBS is rarely reported after a coronary artery bypass grafting (CABG). To date, only 12 cases have been reported in the literature. Our case is 13th in number and the first case from Pakistan.

Case presentation

We report a case of a 54-year-old man presented with acute flaccid quadriparesis and areflexia after a CABG procedure. He was subsequently diagnosed with an acute inflammatory demyelinating polyneuropathy (AIDP) variant of GBS and underwent five sessions of plasmapheresis. His weakness improved and could ambulate unassisted on follow-up visits.

Conclusion

GBS is a potentially treatable condition if timely diagnosed and managed. It should be considered in every patient presenting with an acute-onset weakness after surgery.

Idiopathic brachial plexopathy after pacemaker implant

A middle-aged woman presented with symptomatic complete heart block and underwent an uneventful dual chamber pacemaker implantation. Three weeks post procedure, she developed left arm pain and weakness, with neurological localization to the lower trunk of left brachial plexus. Possibilities of traumatic compression by the device/leads or postoperative idiopathic brachial plexopathy were considered. After ruling out traumatic causes, she was started on oral steroids, to which she responded remarkably. This case highlights the importance of recognizing this rare cause of brachial plexopathy following pacemaker implantation, because not only does an expedited diagnosis and medical treatment lead to prompt recovery with minimal neurological deficits, but it also circumvents an unnecessary surgical re-exploration.

Iatrogenic peripheral nerve injuries - Common causes and treatment: A retrospective single-center cohort study

BACKGROUND

Iatrogenic nerve injuries can result from surgical damage. Thus, physicians should be aware of the risk factors and procedures that need to be followed in such patients. The purpose of this study was to examine data pertaining to patients with known iatrogenic nerve injuries and to elucidate the detailed causes of these injuries, the affected nerves, and the type of surgical procedures for treatment.

METHODS

This retrospective study included 232 consecutive patients who underwent surgical treatment for peripheral nerve palsy or nerve injury between 2006 and 2017 at our hospital. Among the 232 patients investigated, we identified 51 cases with iatrogenic nerve injuries (23 women and 28 men; mean age, 51.3 years). Among the 51 patients, 45 were referred from other hospitals, and the remaining were from our hospital. Data were summarized using descriptive statistics.

RESULTS

Direct surgical damage occurred in 94% (48/51) of patients with iatrogenic nerve injuries. Such injuries mostly developed after surgery for bone fractures (33%), resection of soft tissue tumors (22%), and carpal tunnel release procedures (20%). The nerves most commonly affected in such procedures are the radial nerve (26%), median nerve (24%), and ulnar nerve (17%). The median interval of referral to our hospital after nerve injury was 5.1 months. The median interval of surgery to correct the injury was 7 months. Surgeries to correct iatrogenic nerve injuries performed at our hospital included neurolysis (55%), nerve grafts (29%), direct suture procedures (10%), and tendon transfers (6%).

CONCLUSIONS

We believe that wide dissemination of the results obtained in this study will reduce the incidence of iatrogenic peripheral nerve injuries and increase the speed of referrals to specialized centers.

Electrodiagnostic Assessment of Plexopathies

Disorders of the brachial and lumbosacral plexus are complex and may occur as a consequence of trauma, compression, inflammatory disorders, malignant infiltration, or delayed effects of radiation therapy. An understanding of plexus anatomy and surrounding structures will allow the electromyographer to facilitate an efficient and comprehensive assessment of the plexus. A careful and thorough electrodiagnostic assessment allows for localization within the plexus and may provide important information about underlying pathology and prognosis.

A prospective evaluation of phrenic nerve injury after lung transplantation: Incidence, risk factors, and analysis of the surgical procedure

BACKGROUND

Phrenic nerve injury (PNI) is a complication of lung transplantation related to the surgical procedure and associated with increased morbidity. However, the incidence and risk factors, specifically regarding surgical techniques, have not been adequately studied.

METHODS

We conducted a prospective single-center study over 4-years, in recipients of lung transplantation with a normal pretransplant phrenic nerve conduction study (PNCS). Diaphragm ultrasound and PNCS were performed in the first 21 postoperative days and PNI was defined when both tests were abnormal. Patients were followed up until hospital discharge. The association between transplant characteristics and PNI was analyzed by using logistic regression models.

RESULTS

Two hundred eleven lung grafts implanted in 127 patients were included in the study. After lung transplantation, PNI was diagnosed in 43.3% of the subjects and 29% of the operated hemithorax. Regression logistic model showed that the variables related to PNI were female gender (p = 0.02), bilateral lung transplantation (BLT) (p = 0.001), right lung graft (p = 0.003), clamshell incision (p = 0.01), mediastinal adhesions (p = 0.002), longer operative time (p = 0.003), intraoperative extracorporeal support (p = 0.02), and blood transfusion (p = 0.003). Conversely, age >61 years (p = 0.008) and higher thoracic diameter (p = 0.04) were protective factors. The use of electrocautery, cardiac mechanical retractors, and diaphragmatic traction was not associated with PNI. Morbidity was increased without any difference in mortality.

CONCLUSIONS

PNI is a frequent complication after lung transplantation, associated with higher morbidity. Mainly risk factors were age, BLT, female gender, and variables related to surgical difficulties. Lung graft in the right hemithorax and mediastinal adhesiolysis were the most relevant technical variables.

Postoperative neurological complications after brachial plexus block: a retrospective study conducted at a teaching hospital

PURPOSE

Serious complications after ultrasound-guided regional anaesthesia can be devastating for the patient. The pathogenesis of postoperative neurological complications (PONC) is multifactorial and includes mechanical, vascular and chemical factors besides the nerve puncture itself. The primary aim of this study was to assess the incidence of PONC after brachial plexus block (BPB).

METHODS

This is an observational retrospective single-centre study conducted at the regional anaesthesia unit of a teaching hospital. All BPBs performed from January 2011 to November 2019 were included. The outcomes analysed were the incidence, aetiology and diagnosis of PONCs and the incidence of other postoperative complications such as local anaesthetic systemic toxicity (LAST), pneumothorax, wrong-side block, etc. The performance of trainees and experienced anaesthesiologists was compared across all the outcomes.

RESULTS

From a total of 5340 BPBs included, 15 cases developed PONC, yielding a rate of 2.81:1000 (95% CI 1.70-4.63). Thirteen patients underwent neurophysiological exams which confirmed nine neuropathies. The rate of PONCs for supervised trainees was 1.80:1000 (95% CI 0.701-4.62), not statistically different from that of experienced anaesthesiologists (p = 0.241). Three cases were considered to present with a PONC probably related to BPB [0.562:1,00 (95% CI 0.191-1.65)]. The incidence of long-term PONCs was 1.12:1000 (95% CI 0.515-2.45). Such complications proved irreversible in 2 cases. The incidences of LAST, pneumothorax and other complications observed were 0.749:1000 (95% CI 0.291-1.92), 0.187:1000 (95% CI 0.0331-1.06) and 4.31:1000 (95% CI 2.87-6.46), respectively.

CONCLUSIONS

This survey suggests that complications after ultrasound-guided BPB, including blocks performed by trainees, are uncommon.

TRIAL REGISTRATION

Clinicaltrials.gov ID: NCT04451642.

Development of Acute Inflammatory Demyelinating Polyneuropathy 11 Days after Spinal Surgery: A Case Report and Literature Review

Guillain–Barré syndrome (GBS) usually has a good prognosis; however, patients may develop sequelae without prompt treatment. We herein describe an 81-year-old woman who developed acute-onset excruciating thigh pain and weakness in her lower extremities after spinal surgery. We diagnosed acute inflammatory demyelinating polyradiculoneuropathy by a nerve conduction study, which showed findings of demyelination without cerebrospinal fluid analysis because of a spinal prosthesis. Although anti-GM1 and anti-GalNAc-GD1a antibodies were positive, the patient was clinically diagnosed with acute inflammatory demyelinating polyradiculoneuropathy (a subtype of GBS), not acute motor axonal neuropathy. She recovered well with immunoglobulin therapy. A literature review of 18 cases revealed that unexplained weakness, areflexia, and numbness of the extremities after spinal surgery, a shorter time from spinal surgery to symptom onset to general GBS, abnormal nerve conduction study results, normal spinal imaging findings, and the development of atypical symptoms such as cranial and autonomic nerve syndrome and respiratory failure are useful for diagnosing GBS when cerebrospinal fluid examination cannot be performed after spinal surgery.

Perioperative Ulnar Neuropathy: A Contemporary Estimate of Incidence and Risk Factors

BACKGROUND

Retrospective and prospective studies 2 decades ago from the authors' institution reported the incidence of perioperative ulnar neuropathy persisting for at least several months in a noncardiac adult surgical population to be between 30 and 40 per 100,000 cases. The aim of this project was to assess the incidence and explore risk factors for perioperative ulnar neuropathy in a recent cohort of patients from the same institution using a similar definition for ulnar neuropathy.

METHODS

We performed a retrospective incidence and case-control study of all adults (≥18 years) undergoing noncardiac procedures with anesthesia services between 2011 and 2015. Each incident case of persistent ulnar neuropathy within 6 months of surgery was matched by age, sex, procedure date, and procedure type to 5 surgical patient controls. For the case-control study, separate conditional logistic regression analyses were performed to assess specific risk factors including the patient's body position and arm position, as well as body mass index (BMI), surgical duration, and selected patient comorbidities.

RESULTS

Persistent ulnar neuropathy of at least 2 months duration was found in 22 of 324,124 anesthetics for patients who underwent these procedures during the study period for an incidence rate of 6.8 (95% confidence interval [CI], 4.3-10.3) per 100,000 anesthetics. The incidence of ulnar neuropathy was higher in men compared to women (10.7 vs 3.0 per 100,000; P = .016). From the matched case-control study, the odds of ulnar neuropathy increased with higher BMI (odds ratio [OR] = 1.67 [1.16-2.42] per 5 kg/m2 increase in BMI; P = .006), history of cancer (OR = 6.46 [1.64-25.49]; P = .008), longer procedures (OR = 1.53 [1.18-1.99] per hour; P = .001), and when 1 or both arms were tucked during surgery (OR = 6.16 [1.85-20.59]; P = .003).

CONCLUSIONS

The incidence of persistent perioperative ulnar neuropathy observed in this study was lower than the incidence reported 2 decades ago from the same institution and using a similar definition for ulnar neuropathy. Several of the previously reported risk factors continue to be associated with the development of persistent perioperative ulnar neuropathy, providing ongoing targets for practice changes that might further decrease the incidence of this problem.

Polyneuropathy and Korsakoff syndrome complicating sleeve gastrectomy

We report a case of a 36 year old gentleman presenting with polyneuropathy and Korsakkoff Syndrome complicating Sleeve Gastrectomy.

Impact of Completion Lymphadenectomy on Quality of Life for Head and Neck Cutaneous Melanoma

OBJECTIVE

Recent randomized data suggest that completion lymph node dissection after a positive sentinel lymph node biopsy (SLNB) improves locoregional control but does not improve survival for melanoma patients. Locoregional recurrences of head and neck cutaneous melanoma (HNCM) may result in significant morbidity. A better understanding of morbidity is thus important to inform decisions about whether to pursue completion neck dissection (ND).

STUDY DESIGN

Cross-sectional study.

SETTING

Academic tertiary care hospital.

METHODS

Clinical data were collected for patients with HNCM seen between 2016 and 2019 who were at least 1-year disease free. Each patient completed the Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (SLANSS), Neck Dissection Impairment Index, and SF-36 (Short Form-36). Scores were compared by surgical treatment: wide local excision (WLE) only, SLNB, and ND. Univariate and multivariable regression was performed.

RESULTS

Of 474 patients, 140 returned questionnaires (29.5% response rate; WLE, n = 49; SLNB, n = 76; ND, n = 15). No significant differences in SLANSS or Neck Dissection Impairment Index scores were found between the WLE and SLNB groups. SLANSS scores differed by 2 SD (P = .001) in the ND cohort, which had a 36% rate of neuropathy. Neck impairment was worse by 1 SD (P = .01) in the ND cohort. No differences were found in SF-36 domains.

CONCLUSION

Neuropathy and neck impairment are components of morbidity after ND. These risks must be balanced with potential morbidity of locoregional recurrence in HNCM.

Cauda equina syndrome due to herpes simplex virus type 2-associated meningoradiculitis (Elsberg syndrome) after posterior lumbar spinal fusion surgery: Case report and review of literature

Elsberg syndrome is a rare but well-defined clinical condition, including acute or subacute lumbosacral meningoradiculitis, which might be accompanied by myelitis and is often associated with herpes simplex virus type 2 (HSV-2) infection. We report the case of an immunocompetent 24-year-old man who presented with perineal pain, saddle hypoesthesia, and urinary retention associated with Elsberg syndrome due to HSV-2 infection 20-day after the posterior lumbar spinal fusion surgery. Lumbar magnetic resonance imaging (MRI) with gadolinium enhancement showed mildly enhanced and swollen right sacral nerve roots. One week after the admission, electromyography and nerve conduction studies (EMG-NCS) demonstrated severe axonal damage and radiculopathy at right S3 and S4 roots. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis, elevated protein, positive HSV-2 IgG index, and positive HSV-2 polymerase chain reaction (PCR). The patient was treated with intravenous acyclovir for 14 days and showed a gradual improvement in anal sphincter control and urination. Therefore, according to our findings, surgery might have an immunosuppressing role, and in cases with symptoms of cauda equina syndrome (CES) and systemic infection, in the postoperative setting, viral meningoradiculitis should be considered.

Plantar incision with severe muscle injury can be a cause of long-lasting postsurgical pain in the skin

AIMS

Although chronic local inflammation in deeper tissues after skin wound healing might produce chronification of acute postsurgical pain, its mechanisms have not been fully elucidated. We hypothesized that muscle injury and severe inflammation would prolong acute postsurgical pain by its central nervous system mechanisms.

MAIN METHODS

After approval of the Animal Care Committee, experiments were performed in Male Sprague-Dawley rats weighing 250-300 g. Plantar incision and plantar incision combined with cryoinjury of the plantar flexor digitorum brevis muscle were made in the plantar incision group and muscle injury group, respectively. Pain-related behaviors were assessed, and inflammatory cells were isolated from injured muscle and analyzed by flow cytometry. Spinal microglial activation was assessed with Iba-1 staining.

KEY FINDINGS

Mechanical hyperalgesia from day 5 to day 8 and spontaneous pain-related behavior from day 3 to day 7 were significantly greater in the muscle injury group than in the plantar incision group (P < 0.05), whereas there was no significant difference between the two groups in thermal hyperalgesia. In the muscle injury group, the number of inflammatory cells on day 4 was significantly larger and spinal Iba-1 expression levels on days 4 and 7 were significantly higher than those in the plantar incision group (P < 0.05).

SIGNIFICANCE

Surgical injury in deep tissues accompanying severe muscle inflammation induced prolonged postsurgical pain in the healing wound of the skin not by the persistence of muscle inflammation but by a central mechanism involving microglial activation at the level of the spinal cord.

Effects of anesthetic agents on inflammation in Caco-2, HK-2 and HepG2 cells

Anesthetic agents are often used in surgical procedures to relieve pain in patients with traumatic injuries. Several anesthetic agents can cause immunosuppression by suppressing the secretion of immune factors such as cytokines. However, the effects of different anesthetic agents on inflammation are not completely understood. In the present study, three cell lines, Caco-2, HK-2 and HepG2, were treated with five anesthetic agents, including sodium barbiturate, midazolam, etomidate, ketamine and propofol, to investigate the effects of different anesthetic agents on inflammation in in vitro models. The expression levels of inflammatory genes, including NF-κB and its downstream cytokines, were detected via reverse transcription-quantitative PCR. The results indicated that anesthetic agents, including sodium barbiturate, ketamine and propofol, but not midazolam and etomidate, exerted significant inhibitory effects on NF-κB expression in the three different cell lines. Sodium barbiturate, ketamine and propofol also decreased the expression levels of the NF-κB downstream cytokines, including IL-1β and IL-18. Moreover, sodium barbiturate, ketamine and propofol reduced the effect of TNF-α on inflammatory activity in the three cell lines. The results of the present study may provide novel insight into the effects of anesthetic agents on inflammation and may aid with selecting the most appropriate anesthetic agent in surgical procedures.

Lumbosacral Radiculoplexus Neuropathy: Neurologic Outcomes and Survival in a Population-Based Study

OBJECTIVE

To determine whether patients in the community with lumbosacral radiculoplexus neuropathy (LRPN) have milder neuropathy than referral patients, we characterized the outcomes and survival of population-based compared to referral-based LRPN cohorts.

BACKGROUND

Previously, we found that the incidence of LRPN is 4.16/100,000/y, a frequency greater than other inflammatory neuropathies. The survival of patients with LRPN is uncharacterized.

METHODS

Sixty-two episodes in 59 patients with LRPN were identified over 16 years (2000-2015). Clinical findings were compared to previous referral-based LRPN cohorts. Survival data were compared to those of age- and sex-matched controls.

RESULTS

At LRPN diagnosis, median age was 70 years, median Neuropathy Impairment Score (NIS) 22 points, 92% had pain, 95% had weakness, 23% were wheelchair-bound, and median modified Rankin Scale score (mRS) was 3 (range 1-4). At last follow-up, median NIS improved to 17 points (p < 0.001) with 56% having ≥4 points improvement, 16% were wheelchair-bound, and median mRS was 2. Compared to referral-based LRPN cohorts, community patients with LRPN had less impairment, less bilateral disease (37% vs 92%), and less wheelchair usage (23% vs 49%). LRPN survival was 86% at 5 years and 55% at 10 years. Compared to age- and sex-matched controls, patients with LRPN had 76% increased risk of death (p = 0.016). In multivariate analysis, diabetes, age, stroke, chronic kidney disease, peripheral artery disease, and coronary artery disease were significant mortality risk factors but LRPN was not.

CONCLUSION

LRPN is a painful, paralytic, asymmetric, monophasic, sometimes bilateral pan-plexopathy that improves over time but leaves patients with impairment. Although having LRPN increases mortality, this increase is probably due to comorbidities (diabetes) rather than LRPN itself.