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Objective To evaluate the safety and efficacy of a new topical skin ointment with natural ingredients (aloe vera, honey, and peppermint) for dressing skin graft donor sites. Design A double-blind, placebo-controlled, randomized clinical trial. Patients and intervention Researchers enrolled patients who were referred for split-thickness skin graft after burns or surgical wounds on the scalp or face area. For each patient, a thin layer of skin (depth, 0.04 mm; approximate size, less than 15 × 7 cm) was harvested from the thigh by a plastic surgeon with an electric or manual dermatome. The donor sites were divided and randomized to receive either natural ointment or petroleum jelly as a topical agent to dressing. Topical agents were applied on donor site wounds on days 0, 4, 7, and 14. Main outcome measures Wound size, pain, erythema, pruritus, patient discomfort, complications, and physician satisfaction were evaluated at each visit. Main results Among 28 patients, there was no significant difference between the two treatment agents regarding the rate of wound healing (P = .415), pain (P = .081), pruritus (P = .527), and patient discomfort (P = .616). The ointment was superior to petroleum jelly in reducing wound erythema (P = .001) and was associated with significantly better treatment satisfaction (P Conclusions The natural topical ointment investigated in this study may be an acceptable alternative to petroleum jelly in caring for split-thickness donor skin graft donor site wounds to effectively promote wound healing, prevent infection and scarring, reduce pain, and comfort the patient.

To avoid the safety issues related to thoracic paravertebral blocks, we performed midpoint transverse process to pleura blocks in 3 patients before general anesthesia for modified radical mastectomies. The midpoint transverse process to pleura blocks served as the major component of multimodal analgesia. With ultrasound guidance, 7 mL of a mixture of 0.75% ropivacaine and 2% lidocaine with epinephrine were deposited at T2, T4, and T6 levels. We noted decreased sensation to cold and pinprick from T2 to T8 dermatome level with sparing of axilla and infraclavicular areas. The maximum pain numeric rating scale score (0-10) was 4 out on movement and none had mean 24-hour numeric rating scale >3.

Background and importance Acute bilateral brachial plexus injury is rare and usually a result of traction injury. Immediate operative intervention is reserved for rare cases of ongoing compression of the plexus; the role for acute decompression of the brachial plexus secondary to compartment syndrome has not been previously described. In this report, we describe the technique and role for urgent brachial plexus decompression. Clinical presentation A 32-yr-old man presented with acute complete bilateral brachial plexus palsy due to focal rhabdomyolysis and brachial plexus compression after a night of excess alcohol and methadone ingestion. He had complete loss of motor and sensory function from C5 to T1, with the exception of partial sensory sparing of the C5 dermatome. Magnetic resonance imaging demonstrated diffuse muscular edema of the supraclavicular and infraclavicular fossae in addition to the pectoralis muscles and the deltoids bilaterally. He underwent urgent surgical decompression of his supraclavicular and infraclavicular fossae with fasciotomies of the pectoral muscles and the anterior deltoids, allowing direct visualization and decompression of the entire brachial plexus resulting in a near-complete functional recovery. Conclusion Neurosurgeons should include brachial plexus compression due to compartment syndrome in the differential diagnosis of patients with acute upper extremity weakness, particularly when associated with prolonged immobilization and/or substance abuse. Prompt surgical decompression should be performed in these patients if imaging and laboratory data suggest compartment syndrome and resultant neurological deficit.

Introduction Plantar hyperkeratosis, such as corns and calluses, is common in older people and associated with pain, mobility impairment, and functional limitations. It usually develops on the palms, knees, or soles of feet, especially under the heels or balls. There are several treatment methods for plantar hyperkeratosis, such as salicylic acid plaster and scalpel debridement, and conservative modalities, such as using a shoe insert and properly fitting shoes. Methods We present an effective method of reconstructing the wound after corn excision using a split-thickness sole skin graft (STSSG). We harvested the skin graft from the arch of the sole using the dermatome with a skin thickness of 14/1000th inches. Results Because the split-thickness skin graft, harvested from the sole arch near the distal sole, is much thicker than the split-thickness skin graft from the thigh, it is more resistant to weight and friction. The healed wound with STSSG coverage over the distal sole was intact, and the donor site over the sole arch had healed without complication during the outpatient follow-up, 3 months after surgery. Conclusions The recovery time of STSSG for corn excision is shorter than that with traditional treatment. Therefore, STSSG can be a reliable alternative treatment for recurrent palmoplantar hyperkeratosis.

BACKGROUND Holmium laser enucleation of the prostate (HoLEP) has become an important treatment modality for benign prostate hypertrophy. The aim of the present study was to compare regional anesthesia methods for HoLEP operation and to determine the optimal technique. METHODS Sixty patients with American Society of Anesthesiologists scores of I-III were randomly allocated into 3 groups. Patients in group E received an epidural block with 75 mg of bupivacaine plus 50 μg of fentanyl. In group S, 15 mg of bupivacaine and 50 μg fentanyl were used for spinal anesthesia. In group SA, patients received saddle block with 15 mg of bupivacaine and 50 μg of fentanyl. RESULTS Time to T10 dermatome block and to maximal level block were longest in group E (P

Rationale: Herpes zoster frequently causes dermatomal vesicular rash accompanied by severe neuralgia, and reaching a differential diagnosis may be challenging before the appearance of the vesicular rash. Patient concerns: A 40-year-old male patient visited the emergency department with a complaint of sudden onset motor weakness and ipsilateral radiating neuralgia to the Lt. thigh. He had suffered from chickenpox during childhood. Diagnoses: No skin lesion was present at the initial visit. The reverse Straight Leg Raise test was negative. Magnetic resonance imaging showed asymmetrically swollen dorsal root ganglion with Gadolinium enhancement. The vesicular rash that appeared on the sixth day after the symptom onset led to the diagnosis of herpes zoster. Interventions: Antiviral agent of valacyclovir (1000 mg t.i.d.) was administered for 7 days. Outcomes: The patient recovered from motor weaknesses by 2 weeks from the onset of the symptom. Mild degree post-herpetic neuralgia recovered by 2 months. Lessons: A high index of suspicion is necessary to differentiate early herpes zoster radiculitis before the appearance of vesicular rash from compressive radiculopathy. In L2–3 ipsilateral radiating pain along the dermatome or myotome, the absence of reverse Straight Leg Raise sign may be a possible factor in differentiating herpes zoster radiculitis from compressive radiculopathy.

OBJECTIVE Innovative skin substitutes and temporary wound dressings are frequently used in the treatment of superficial and partial-thickness wounds. The aim of this study was to compare 2 commonly used temporary skin dressings with a newly developed collagen matrix to determine changes in microcirculation as measured by blood flow, hemoglobin oxygenation, and relative hemoglobin values during healing of partial-thickness skin defects. METHODS This animal study involved 28 adult male Lewis rats. On the back of each rat, 2 standardized partial-thickness skin defects were generated through a skin dermatome (n = 56). Then, wounds were treated with polylactide-based copolymer skin substitute (Suprathel, PolyMedics, Denkendorf, Germany; n = 14), biosynthetic skin dressing (Biobrane, Smith & Nephew, Hamburg, Germany; n = 14), or Collagen Cell Carrier (CCC; Naturin Viscofan, Weinheim, Germany; n = 14). The remaining control wounds were left untreated (n = 14). MAIN OUTCOME MEASURES Perfusion dynamics were assessed every 10 days for 80 days with the O2C device (LEA Medizintechnik, Gieβen, Germany) to determine blood flow, hemoglobin oxygenation, and relative amount of hemoglobin. MAIN RESULTS Blood flow was increased in all wounds for at least 30 days after wound generation. The relative amounts of hemoglobin were increased in superficial layers (2 mm) for 10 to 20 days. Hemoglobin oxygenation in the superficial layers decreased in the polylactide-based copolymer skin substitute and biosynthetic skin dressing-treated groups and initially increased in the untreated wounds and CCC groups on day 10; these values also decreased. CONCLUSIONS The presented results demonstrate the complex changes in microcirculation in the course of healing partial-thickness wounds with different wound dressings and contribute to a better understanding of these wounds. However, based on the results of the study, a clear recommendation for a specific substitute is not yet possible.

Case series.This study compared the locations of arm pain, sensory symptoms, and subjective complaints of arm weakness in patients with cervical radiculopathy from MRI confirmed C6 and C7 nerve root compression.Cervical radiculopathy is defined as arm pain, sensory and motor symptoms caused by irritation of a cervical nerve root. The C6 and C7 roots are most commonly involved, and differentiating symptoms associated with each root has proven difficult. Cervical MRI allows accurate identification of nerve root compression and therefore makes it possible to explore symptom patterns that may differentiate C6 from C7 radiculopathy.A total of 122 patients with symptoms suggestive of cervical radiculopathy were recruited. Of these, 30 patients had MRI confirmed C6 and 39 patients C7 nerve root compression. By completing a study questionnaire, patients reported specific arm weakness, and marked the location of arm pain and tingling/numbness on graphic representations of the arm. Marked areas were interpreted by superimposing a grid that divided the arm into 54 distinct areas. The frequencies of reported symptoms with C6 and C7 were totaled and then compared with likelihood rations. Power analysis calculated that 27 patients would be needed in each group based on the assumption that a 30 percentage point difference in frequency of specific symptom would be clinically useful for differentiating C6 from C7 radiculopathy.Arm pain and sensory symptoms were diffuse, and were not distinctly different for C6 or C7 radiculopathy. Some weakness was reported by 41 percent of patients, with specific descriptions of weakness having limited value for differentiating between radiculopathies.The location of pain and sensory symptoms, and specific weakness complaints associated with symptomatic C6 and C7 nerve root compression overlap to the extent that caution should be exercised when predicting root involvement based on symptoms.3.

INTRODUCTION Varicella zoster (VZ) vasculopathy is a rare but well recognized cause of stroke. In the absence of zoster rash and infection in remote past, the disease can pose diagnostic challenge. We report 3 cases of anterior circulation stroke occurring in close temporal relation to VZ. Their clinical, radiologic, and angiographic features are discussed. CASE REPORT Of the 3 patients, 2 had stroke within a span of 4 to 6 weeks of herpes zoster ophthalmicus while the third patient had zoster of cervical dermatome. Magnetic resonance imaging revealed acute subcortical infarcts in 2, while 1 patient showed acute on chronic infarct in left middle cerebral artery territory. The magnetic resonance angiography was abnormal in 2 patients while it was normal in third. All the patients were treated with acyclovir and antiplatelets with good recovery in 2. CONCLUSIONS VZ associated vasculopathy may have diverse clinical profile and neuroimaging features. It should be considered as an important and treatable cause of stroke in appropriate clinical settings.

A 55-year-old immunocompetent woman with a history of shingles presented with 1 week of sharp pain in the right leg, associated with weakness, fevers, and vesicular eruptions. Skin examination showed grouped vesicles distributed predominantly along the right L5 dermatome (figure 1). Neurologic examination revealed right leg weakness (3/5 knee flexion, 4/5 knee extension, 3/5 dorsiflexion, 1/5 toe extension), absent right ankle jerk, and decreased sensation in the anterior shin.1 Postcontrast lumbosacral plexus MRI demonstrated right L5 extraforaminal nerve root thickening and enhancement, consistent with radiculitis (figure 2).2 Skin DNA-PCR testing confirmed herpes zoster. Treatment with IV acyclovir and gabapentin resulted in symptomatic improvement.

Introduction Bleeding may interfere with the visual field and create difficulties in performing the intended treatment, especially in operations involving a small working space such as endoscopic spinal surgery. Therefore, it is important to reduce the risk of bleeding before surgery. Patient concerns A 76-year-old female presented with a history of right anterior thigh pain along the L3 dermatome for 3-years, following a L3 compression fracture. In addition, the patient had developed autoimmune hepatitis at 50 years of age, and the platelet count on laboratory blood collection was 78 × 109/L. Diagnosis Magnetic resonance (MR) images showed a narrowed foramen at the L3-4 level. L3 nerve block was effective. L3 foraminal-stenosis was suspected. Interventions Micro-endoscopic laminectomy (MEL) for foraminal decompression was planned due to possible L3 nerve root compression. Lusutrombopag, a thrombopoietin (TPO) receptor agonist, was orally administered for 7 days starting 7 days preoperatively to address the risks of bleeding. Outcomes The patient successfully underwent MEL without any adverse events or complications. Conclusion The results obtained from the use of lusutrombopag suggested that safety measures could be implemented preoperatively, and that lusutrombopag may be a useful supplemental drug for minimally invasive treatment of patients with cirrhosis and thrombocytopenia.

BACKGROUND Combined spinal-epidural (CSE) analgesia is widely used for delivering labor analgesia. Epidural volume extension (EVE) involves the injection of fluid into the epidural space compressing the dural sac, causing cephalad shift of the cerebral spinal fluid. Our hypothesis was that EVE with 10 mL normal saline during CSE would increase the sensory block height at 15 minutes after intrathecal injection. We expected EVE to decrease pain scores, decrease analgesia onset time, and decrease motor block compared with performing CSE without EVE (NEVE). METHODS We randomly assigned 60 healthy term laboring nulliparous parturients with cervical dilation

Introduction A continuous feeling of hunger is the major cause of dietary treatment failure and the patients abandon the diet. A previous study of our group demonstrated that percutaneous electrical neurostimulation (PENS) of T6 dermatome induces an appetite reduction and significantly greater weight loss compared with only diet as a preoperative measure in morbidly obese patients who are candidates for bariatric surgery. The aim of this study was to evaluate the long-term effect of this therapy. Patients and methods A prospective study was performed, including obese patients with a body mass index between 30 and 40 kg/m undergoing PENS of dermatome T6. Weight loss, dietary compliance, and appetite were assessed before the treatment, after 12 weeks of treatment, and 3 and 9 months after completing the therapy. Results A total of 150 patients were included in the study. A mean weight loss of 11.8±2.6 kg was obtained after 12 weeks of treatment. Three months after completing the therapy, mean weight loss was 14.6±2.7 kg and 9 months after completing the treatment mean weight loss was 14.5±2.8 kg. Median appetite perception quantified by Visual Analogue Scale was 6 before the treatment, 1 after completing the treatment, 1 at 3 months after completing the treatment, and 4 at 9 months after completing the treatment. Dietary compliance after 12 weeks of treatment was 90%, 84% at 3 months after completing the treatment, and 62% at 9 months after completing the treatment. Conclusion PENS of dermatome T6 achieves a significant appetite reduction, which is maintained 3 months after completing the therapy. Later, the patients' appetite is restored, but they do not regain the weight lost.

Ten years after placement of a spinal cord stimulator (SCS) and resolution of pain, this patient presented with progressive paraplegia, worsening thoracic radicular pain at the same dermatome level of the electrodes, and bowel and bladder incontinence. Computed tomographic myelogram confirmed thoracic spinal cord central canal stenosis at the level of electrodes. After removal of the fibrotic tissue and electrodes, the patient had resolution of his thoracic radicular pain and a return of his pre-SCS pain and minimal neurologic and functional return. To the authors' knowledge, no studies have been identified with thoracic SCS lead fibrosis in the United States causing permanent paraplegia. Only one other case has been reported in Madrid, Spain. Patients with SCS presenting with loss of pain relief, new-onset radicular or neuropathic pain in same dermatome(s) as SCS electrodes, worsening neuromuscular examination, or new bladder or bowel incontinence need to be evaluated for complications regarding SCS implantation causing spinal stenosis and subsequent cord compression to avoid permanent neurologic deficits.

Rationale: Segmental zoster paresis (SZP) is a relatively rare neurologic complication of herpes zoster (HZ), and is characterized by focal asymmetric motor weakness in the myotome that corresponds to skin lesions of the dermatome. The upper extremities are the second most commonly involved regions after the face, and predominantly involve proximal muscles. The pathogenesis of SZP remains unclear; however, most of the reports indicate that it is the inflammation because of the spread of the herpes virus. Patient concerns: A 72-year-old man without trauma history of the left shoulder joint developed weakness of the left proximal upper extremity 10 days after vesicular eruption of HZ. Diagnoses: His left shoulder girdle paresis was diagnosed with the upper truncus of the brachial plexus as a HZ complication according to a series of tests, including cervical magnetic resonance imaging (MRI), cerebral fluid analysis, sonography, and electrophysiological studies. Interventions: Acyclovir and prednisolone were administered during hospitalization to treat SZP. Meanwhile, analgesics and gabapentin were administered to control the patient's neuralgic pain. He also received inpatient (daily) and outpatient (3 times per week) physical therapy along with range of motion and strengthening exercises. Outcomes: Partial improvement of the strength of the left shoulder girdle, and no improvement of the left deltoid muscle was observed 2 months after the interventions. Lessons: This case emphasizes that HZ infections may be complicated by segmental paresis and they should be considered in the differential diagnosis of acute paresis in the upper limb. Awareness of this disorder is important because it avoids unnecessary invasive investigations and interventions, leading to suitable treatments with favorable prognosis.

Case We report 3 patients with classic trigeminal neuropathy (TN) findings, which were due to compressive cervical radiculopathy, and provide a brief anatomic explanation for this association. In each case, left-sided disk herniation between the C5 and C7 levels caused TN and classic (dermatome appropriate) cervical radicular findings, all of which resolved with anterior cervical decompression and fusion (ACDF). Conclusions To our knowledge, this is the first report of TN caused by radicular compression in the caudal subaxial (C5-C7) cervical spine, which resolved after ACDF.

Objectives The aim of this study was to investigate, using quantitative sensory testing (QST) parameters and the painDETECT (PD-Q) screening questionnaire, the presence of neuropathic pain (NeP) in patients with unilateral painful cervical radiculopathy (CxRAD) and in patients with unilateral nonspecific neck-arm pain associated with heightened nerve mechanosensitivity (NSNAP). Methods All patients completed the PD-Q before QST. QST was performed bilaterally in the maximal pain area and the affected dermatome in 23 patients with painful C6 or C7 radiculopathy and in 8 patients with NSNAP following a C6/7 dermatomal pain distribution. Results Patients with CxRAD demonstrated a significant loss of sensory function in mechanical (P≤0.021) and vibration sense (P≤0.003) on the symptomatic side compared with the asymptomatic side in both tested body regions and in the dermatome reduced cold detection (P=0.021) and pressure pain sensitivity (P=0.005), findings consistent with nerve root damage. These sensory alterations in the maximal pain area/symptomatic side are confirmative for the presence of NeP. In contrast to these QST data, only 30% of patients with CxRAD demonstrated a NeP component according to the PD-Q score. In patients with NSNAP, a significant side-to-side difference was demonstrated for warm detection threshold in the dermatome (P=0.030). The PD-Q score indicated that NeP components were unlikely in this group. Discussion QST data suggest that NeP is likely to be observed in patients with painful CxRAD, but not in patients with NSNAP.

BACKGROUND: The epidural test dose, used to identify unintended intrathecal placement, should reliably produce a spinal block without posing a threat to the patient. Most anesthesiologists administer a dose of local anesthetic, commonly lidocaine 45 mg. Pregnant patients are more sensitive to local anesthetics; high and total spinal anesthesia have been reported in the pregnant population with this dose. We hypothesized that lidocaine 30 mg was as effective as lidocaine 45 mg in creating rapid objective evidence of a sensory or motor block. METHODS: In this prospective, randomized, double-blind trial, patients scheduled for cesarean delivery were assigned to 1 of 4 groups: lidocaine 30 mg in the spinal or epidural space, or lidocaine 45 mg by the same routes. A blinded observer assessed the degree of sensory and motor block. The ability to identify intrathecal injection of each dose was compared. Sensory block above T6 dermatome and hypotension were recorded as side effects. RESULTS: Intrathecal administration of lidocaine 30 mg produced rapid subjective and objective signs of neuroblockade within 3 minutes (100%, 95% confidence interval CI, 85%-100% for each). Lidocaine 45 mg produced similar results. All patients in both groups described their legs as warm or heavy after 3 minutes and had a motor block by 5 minutes. On the basis of an intrathecal catheter rate of 1:380, the observed negative predictive value for intrathecal placement if the patient described no sensory changes at 3 minutes was 100% (95% CI, 99.95%-100%) for 30 mg and 100% (95% CI, 99.93%-100%) for 45 mg. We did not identify a decrease in the rate of side effects with the lower dose. CONCLUSIONS: Our results suggest that there is unlikely to be a large difference in the ability of these doses to detect unintentional intrathecal catheter placement. While the negative predictive value for intrathecal injection is very high for both doses, the 95% CI for the sensitivity of either dose is too wide to demonstrate clinical safety to identify all intrathecal catheters. A much larger study is warranted to assess whether there is a lower sensitivity with the 30-mg dose, or a propensity toward high cephalad motor block levels with the 45-mg dose.

The aim of this study was to establish the somatosensory profiles of patients with cervical radiculopathy and patients with nonspecific neck-arm pain associated with heightened nerve mechanosensitivity (NSNAP). Sensory profiles were compared to healthy control (HC) subjects and a positive control group comprising patients with fibromyalgia (FM). Quantitative sensory testing (QST) of thermal and mechanical detection and pain thresholds, pain sensitivity and responsiveness to repetitive noxious mechanical stimulation was performed in the maximal pain area, the corresponding dermatome and foot of 23 patients with painful C6 or C7 cervical radiculopathy, 8 patients with NSNAP in a C6/7 dermatomal pain distribution, 31 HC and 22 patients with FM. For both neck-arm pain groups, all QST parameters were within the 95% confidence interval of HC data. Patients with cervical radiculopathy were characterised by localised loss of function (thermal, mechanical, vibration detection P

Patients suffering from postherpetic neuralgia often complain about hypo- or hypersensation in the affected dermatome. The loss of thermal sensitivity has been demonstrated by quantitative sensory testing as being associated with small-fiber (Aδ- and C-fiber) deafferentation. We aimed to compare laser stimulation (radiant heat) to thermode stimulation (contact heat) with regard to their sensitivity and specificity to detect thermal sensory deficits related to small-fiber dysfunction in postherpetic neuralgia. We contrasted detection rate of laser stimuli with 5 thermal parameters (thresholds of cold/warm detection, cold/heat pain, and sensory limen) of quantitative sensory testing. Sixteen patients diagnosed with unilateral postherpetic neuralgia and 16 age- and gender-matched healthy control subjects were tested. Quantitative sensory testing and laser stimulation of tiny skin areas were performed in the neuralgia-affected skin and in the contralateral homologue of the neuralgia-free body side. Across the 5 thermal parameters of thermode stimulation, only one parameter (warm detection threshold) revealed sensory abnormalities (thermal hypoesthesia to warm stimuli) in the neuralgia-affected skin area of patients but not in the contralateral area, as compared to the control group. In contrast, patients perceived significantly less laser stimuli both in the affected skin and in the contralateral skin compared to controls. Overall, laser stimulation proved more sensitive and specific in detecting thermal sensory abnormalities in the neuralgia-affected skin, as well as in the control skin, than any single thermal parameter of thermode stimulation. Thus, laser stimulation of tiny skin areas might be a useful diagnostic tool for small-fiber dysfunction.

Pain following spinal cord injury has been classified as nociceptive (musculoskeletal, visceral) or neuropathic (above, at, below level). There is no clear relation between the etiology and reported symptoms. Thus, due to different underlying mechanisms, the treatment is often ineffective. We report on a patient with spinal cord injury with neurological level of injury at T8 suffering from bilateral burning and prickling pain in the T9-11 dermatomes bilaterally (at-level pain), as well as diffusely in both legs from below the torso (below-level pain), accompanied by musculoskeletal low back pain. Bilateral comparison of quantitative sensory testing (QST) and skin biopsy revealed completely different findings in the dermatome T9 despite identical at-level pain characteristics. On the right side, QST revealed a normal sensory profile; the intraepidermal nerve fiber density (IENFD) was reduced, but not as severe as the contralateral side. On the left side there was a severe sensory loss with a stronger reduction of the IENDF, similar to the areas below the neurological level. These findings were significantly related to the treatment results. Pregabalin induced unilateral pain relief only in the area with remaining sensory function, whereas the left-sided at-level pain was unchanged. Thus, 2 different underlying mechanisms leading to bilaterally neuropathic pain with identical symptoms and with different treatment success were demonstrated in a single patient. The at-level pain in areas with remaining sensory function despite IENFD reduction could be relieved by pregabalin. Thus, in an individual case, QST may be helpful to better understand pain-generating mechanisms and to initiate successful treatment.

Objective: To evaluate the outcome of Bone-Anchored Hearing Aid surgery without skin thinning, a test group with direct implantation without such thinning was compared with a control group that underwent the traditional procedure. Study Design: This was a single-center, prospective clinical trial designed to evaluate a novel approach to Bone-Anchored Hearing Aid implantation. Eligible patients were enrolled consecutively in the test group or selected to be age-matched controls. Setting: University Hospital. Patients: Eighteen adult patients, suffering from hearing loss, suitable for implantable hearing aid. Methods: Single-step surgery was performed on 18 patients under local anesthesia. In 9 of these, a linear incision was made, a hole was punched through the skin above the bone-anchored implant, and a longer abutment (8.5-12 mm) was introduced, whereas the other 9 were subjected to the standard protocol, using a dermatome and skin thinning. All of the patients were followed for 12 months. Results: The test group exhibited good preservation of the tissue, no increasing skin reactions and no adverse events. The time required for this surgery was reduced, as was their healing time. These patients also experienced less numbness and pain in the surrounding area and had an improved cosmetic outcome. Main Outcome and Conclusion: This clinical trial indicates that introduction of the abutment to the osseointegrated screw directly through the skin, without skin thinning, could be beneficial. This approach had fewer negative effects than the conventional procedure during the 12- month follow-up period.

Background The varying nature of chronic pain (CP) is difficult to correlate to neural activity using typical functional magnetic resonance imaging methods. Arterial spin labeling is a perfusion-based imaging technique allowing the absolute quantification of regional cerebral blood flow, which is a surrogate measure of neuronal activity. Methods Subjects with chronic low back and radicular pain and matched healthy normal subjects, undergoing identical procedures, participated in three sessions: a characterization and training session and two arterial spin labeling sessions. In the first imaging session, CP (if any) was exacerbated using clinical maneuvers; in the second session, noxious heat was applied to the affected leg dermatome, the intensity of which was matched to the pain intensity level of the CP exacerbations for each back pain subject. Results The clinically significant worsening of ongoing CP (≤ 30%, n = 16) was associated with significant regional blood flow increases (6-10 mm/100 g of tissue/min, P less than 0.01) within brain regions known to activate with experimental pain (somatosensory, prefrontal, and insular cortices) and in other structures observed less frequently in experimental pain studies, such as the superior parietal lobule (part of the dorsal attention network). This effect is specific to changes in ongoing CP as it is observed during worsening CP, but it is not observed after thermal pain application, or in matched, pain-free healthy controls. Conclusions Study findings demonstrate the use of arterial spin labeling to investigate the neural processing of CP, and these findings are a step forward in the quest for objective biomarkers of the chronic pain experience.

Plastic Surgeons, by training, are familiar with constriction bands of the fingers and toes. The purpose of this report is to discuss the management of a rare constriction band syndrome that was almost circumferential at the level of the T12 dermatome, and is most appropriately considered a pelvic constriction band as it was below the umbilicus. The patient had constriction bands about the toes at birth, and was also noted to have a band circumferentially below the umbilicus, which did not cause any distress and was not treated. When the patient entered high school and began to lift weights, play football, and have a growth spurt of 2 inches, he began to experience pain below each costal margin and over the iliac crest bilaterally. His physical examination demonstrated pain in the region of the subcostal nerve and the lateral cutaneous branches of L2 as they crossed the iliac crest. By CAT scan, the band appeared to include the rectus fascia. The band was excised to a depth that included the external oblique fascia and preserved the anterior rectus sheath. Small branches of the subcostal nerves and the lateral branches of L2 were killed, and, where appropriate, they were implanted into the external oblique muscle. Closure was obtained by undermining, and a Z-plasty was not included. Healing was without complications and gave an improved appearance to the trunk. At 6 months after surgery, he had resumed college-level rugby and had no further pain related to the constriction band.

Study design Case report. Objective To present the second case of Brown-Sequard syndrome (BSS) produced by type III odontoid fracture managed by conservative treatment. Summary of background data The occurrence of BSS due to odontoid fracture is scarce. So far 6 cases have been reported, and only 1 is produced by type III odontoid fracture. The possible pathophysiology, clinical course and treatment outcome have been rarely discussed. Methods A 39-year-old man presented with weakness of his left arm and leg, mild neck pain, and impaired proprioceptive and light touch sensations below the left C2 dermatome. There were decreased pain and temperature sensations below the right C4 dermatome too. Computerized tomography showed odontoid type III fracture with posterior displacement at that level. Magnetic resonance imaging presented focal hyperintensity around the C2 vertebral level. High dose of prednisolone, close reduction with Gardner-Wells tong skull traction, following external stabilization by Halo-Vest and rehabilitation therapy were applied. Results Complete resolution of neck pain and significant improvement of motor and sensory functions, i.e., light touch and proprioception, were shown 2 months after spinal injury. Impaired temperature discrimination persisted, however. Conclusion BSS is rarely caused by type III odontoid fracture and this is the second report. Conservative intervention is advantageous for both type III odontoid fracture and BSS which is consistent with previous results.

Objective To determine which bone-anchored hearing aid (BAHA) implantation surgical technique is associated with the fewest major postoperative complications and shortest time between surgery and use of the BAHA. The techniques evaluated were 1) a free retroauricular "full-thickness" skin graft, 2) a pedicled parieto-occipital epidermal graft, 3) a dermatome-pedicled parieto-occipital dermal graft, and 4) two broad pedicled local epidermal skin envelopes/skin flaps. Study design Retrospective case study. Setting Tertiary referral center. Patients One hundred forty-three patients who received a BAHA at Maastricht University Medical Center between November 1996 and January 2007. Number and mean age of patients in each group: Technique 1 (n = 30; mean age, 55 yr), Technique 2 (n = 45; mean age, 54 yr), Technique 3 (n = 47; mean age, 55 yr), and Technique 4 (n = 21; mean age, 54 yr). Main outcome measures Cumulative proportion of implants that remained free of major complications versus follow-up interval, time between surgery and use of BAHA. Results Technique 4 (2 broad pedicled local epidermal envelopes/skin flaps) has a significantly higher proportion of implants that remained free of major complications during first year of follow-up (91%; p = 0.021). Pairwise comparisons revealed that Technique 4 also has a significantly shorter time until use (2 mo) than Techniques 1 (2.5 mo), 2, and 3 (both 2.3 mo). Conclusion Two broad pedicled, local epidermal envelopes/flaps are associated with significantly fewer major complications and have one of the shortest times between surgery and use of the BAHA. The use of a dermatome is not associated with fewer major complications. We recommend Technique 4 as the preferred standard in BAHA surgery to minimize complications, postoperative medication, discomfort, and cost.

Intrathecal local anesthetic maldistribution is a well-known cause of spinal anesthesia failure (SAF). This could potentially result in sensory blockade restricted to the sacral dermatomes. We sought to determine the overall incidence of SAF and the role of sacral dermatomes in differentiating between total and partial failures. Of the 3111 spinals prospectively examined, 194 (6.2%) were classified as failures. Of the 72 presumed total failures based on the initial assessment, evaluation of the sacral dermatomes revealed sensory blockade in 32 (44%; 95% confidence interval, 32.7%-56.6%). Sacral dermatome assessment after SAF may be important in safely guiding subsequent anesthetic management.

Percutaneous inoculation of mice with herpes simplex virus type-1 produces marked dynamic allodynia in the zosteriform dermatome. In this study, we examined the electrophysiological excitability of the wide-dynamic range neuron in the spinal dorsal horn and the tibial nerve in response to mechanical (brush, punctum, and pinch) stimuli in mice with herpetic allodynia. The excitatory response of wide-dynamic range neurons to brush, but neither punctum nor pinch, stimulation of the zosteriform dermatome was increased in herpetic mice. The responses of the tibial nerve to all kinds of mechanical stimuli examined were decreased. These results suggest that dynamic allodynia in the affected dermatome is because of the increased excitability of wide-dynamic range neurons, but not primary afferents, to brush stimulation.

Background Clinical benefits of thoracic epidural anesthesia (TEA) are partly ascribed to thoracic sympathetic block. However, data regarding sympathetic activity during TEA are scarce and contradictory. This prospective, randomized, double-blind study evaluated the segmental propagation of sympathetic block after low-concentration, high-volume TEA using digital thermography. Methods Twenty-four patients were included in the study. Thoracic epidural catheters were placed at a median insertion level of T8-T9. Patients were accommodated for 20 min to the room temperature of 23 degrees +/- 0.3 degrees C. Skin temperature was recorded by digital thermography. After baseline measurement of heart rate, arterial pressure, and core body and skin temperature, 10 ml saline (control group) or 10 ml bupivacaine, 0.25% (TEA group), respectively, was administered epidurally. Five minutes (t5) and 20 min (t20) after baseline measurements, hemodynamic parameters and core body temperature were again measured, and sensory block was identified by loss of cold-warm discrimination. In the thumb, the toe, and each thoracic dermatome, difference from baseline temperature was calculated at t5 and t20. Data were analyzed by Mann-Whitney U test. Results Baseline characteristics did not differ among groups. Median spread of sensory block at t20 was T5-L5. At both t5 and t20, skin temperature decreased more in the control group than in the TEA group in all thoracic dermatomes (P < 0.05). Toe temperature increased in the TEA group compared with the control group (P < 0.05), whereas thumb temperature remained unchanged. Conclusion TEA with 10 ml bupivacaine, 0.25%, induced thoracic and lumbar sympathetic block that precedes and exceeds sensory block. Caudal limit of sympathetic block could not be demonstrated in this study.

Temporal summation of "second pain" (TSSP) is considered to be the result of C-fiber-evoked responses of dorsal horn neurons, termed 'windup'. TSSP is dependent on stimulus frequency (or=0.33Hz) and is relevant for central sensitization and chronic pain. We have previously shown that compared to normal controls (NC), fibromyalgia (FM) subjects show abnormal TSSP, requiring lower stimulus intensities/frequencies to achieve similar TSSP. However, it is unknown whether abnormal TSSP in FM is influenced by peripheral sensitization of C-fiber nociceptors and/or bias in pain ratings. Thus, we evaluated 14 FM subjects and 19 NC with pain threshold tests to selective C-fiber stimulation, 30s heat stimuli, and repetitive brief (1.5s) heat pulses at 0.33Hz using a contact heat stimulator (CHEPS). The intensity of heat pulses was varied to achieve maximal TSSP ratings of 45+/-10 (numerical pain scale 0-100) in both FM and NC groups. We found that NC and FM subjects had similar pain thresholds to C-fiber stimulation and yet FM subjects required lower heat pulse temperatures to generate the same magnitudes of TSSP (p.05). This combination of findings does not support peripheral sensitization and suggests central TSSP abnormalities in FM subjects. In a second experiment, all aspects of individually adjusted TSSP heat pulses were kept the same except that the baseline temperature (BT) between heat pulses was surreptitiously alternated between 35 degrees C and 40 degrees C. These changes of BT resulted in significantly greater TSSP ratings of FM subjects compared to NC subjects, both at 35 degrees C and at 40 degrees C, but did not change their response to the first heat pulse of a stimulus train. These findings provide strong support for alterations of central pain sensitivity and not peripheral sensitization or rating bias as responsible for TSSP differences between NC and FM subjects.

BACKGROUND: The presence of a transitional vertebra can create difficulty in identifying the lumbar level corresponding to an exiting nerve root at the time of a spinal nerve block. We investigated the possibility that the muscle innervation pattern and sensory dermatomes of the lumbar nerve roots are altered when a lumbosacral transitional vertebra is present using electrical stimulation. METHODS: We determined the existence of transitional vertebrae using Castellvi's criteria. Patients having transitional vertebrae with lumbosacral radiculopathy were recruited for the study. Selective nerve root blocks using electrical stimulation were performed. Neurologic symptoms caused by S1 or L5 nerve root compression in the patients with a lumbarized S1 or sacralized L5, respectively, were compared with those caused by either L5 or S1 nerve root compression in patients with a normal configuration. RESULTS: Thirty-two patients had transitional vertebrae, of whom 12 had a lumbarized S1 and 20 had a sacralized L5. The distribution of motor and sensory symptoms caused by the lumbarized S1 (L6) nerve root stimulation was similar to that of the S1 nerve root stimulation in the normal configuration. In 17 patients, the distribution of motor and sensory symptoms caused by the sacralized L4 nerve root stimulation was similar to that of L5 nerve root stimulation in the normal configuration. CONCLUSIONS: Our findings suggest that the function of the lumbosacral nerve roots is altered in patients with a sacralized L5, and that the L4 nerve root serves the usual function of the L5 nerve root.

SummaryBackground and objective: Motor function recovers rapidly but the extended duration of sensory block after spinal anaesthesia with hyperbaric ropivacaine may delay patients' ambulation after surgery. We tested whether compensating a reduction of the ropivacaine dose with a small dose of lidocaine would be adequate for surgery and shorten recovery from spinal anaesthesia. Methods: Fifty-six consecutive outpatients, who were scheduled for lower extremity surgery under spinal anaesthesia, were randomized into two groups to receive either a hyperbaric solution of lidocaine 20 mg and ropivacaine 5 mg (Group LR) or hyperbaric ropivacaine 10 mg (Group R). Sensory block was tested with pinprick and motor block on the Bromage scale at 5-min intervals until 30 min, then at 15-min intervals until 90 min, and thereafter at 30-min intervals until full bilateral recovery. Blinded interviews were performed on the first and seventh postoperative day. Results: The groups did not differ significantly regarding success of sensory block reaching T10 dermatome on the operative side, 24 (86%) in Group LR and 23 (82%) in Group R, median (range) onset time 5 (5–20) vs. 10 (5–25) min or median duration of T10 sensory block 68 (5–115) vs. 50 (20–115) min, respectively. Two patients in each group required general anaesthesia. Recovery did not differ between the groups, median time of full motor recovery was 75 min in both groups, sensory recovery of S2 2.5 h vs. 2.8 h, first voluntary micturition 4.2 (2.2–6.1) vs. 4.5 (2.4–6.6) h in the LR vs. R Group, respectively. Transient neurological symptoms did not appear. Conclusion: It is concluded that spinal anaesthesia with hyperbaric lidocaine 20 mg + ropivacaine 5 mg and hyperbaric ropivacaine 10 mg was quite similar regarding frequency, onset, duration of T10 dermatome sensory block and recovery. The patients would have been ready for discharge after voluntary micturition, 4.2–4.5 h from the subarachnoid injection of local anaesthetics.

We prospectively evaluated, in randomized order, 2 indirect methods of confirming the localization of an epidural catheter for postoperative analgesia in 218 surgical patients: epidural stimulation test (EST) and epidural pressure waveform analysis (EPWA). The epidural space was localized by using a loss of resistance technique. All catheters were inserted 5 cm into the epidural space and primed with 5 mL of 0.9% normal saline. There were no differences between the methods: the positive predictive value and specificity were high (100% in both groups), but the sensitivity was moderate (80% for EST and 81% for EPWA) and the negative predictive value was low (16% for EST and 17% for EPWA). Combining both methods yielded better sensitivity (97%) and negative predictive value (57%) (P < 0.001). The sensitivity of EST was increased to 87% (P < 0.05) if sensory response was included as well as motor response for stimulation less than 10 mA. We suggest the inclusion of sensory response in the appropriate dermatome at a current

A safe and reliable method for monitoring intravesical pressure on a long-term basis is needed for conditional electrical stimulation to be feasible as a treatment option for neurogenic detrusor overactivity in patients with a spinal cord injury. Therefore, we investigated the possibility of recording afferent nerve activity related to mechanical activity of the bladder and other pelvic organs from the extradural sacral nerve root in human.Nerve cuff electrodes were temporary placed on the extradural S3 sacral root in 6 spinal cord injured patients who underwent implantation of an extradural FineTech-Brindley Bladder System (Finetech Medical Lt., Welwyn Garden City, United Kingdom). The dorsal penile/clitoral nerve was electrically stimulated to evoke compound action potentials. Electroneurographic signals were recorded together with bladder and rectal pressure during mechanical stimulation of the dermatome rapid bladder filling and rectal distention, and during bladder contraction evoked by electrical stimulation of the contralateral sacral root.Compound action potentials and electroneurographic responses during stimulation of the dermatome and rectum were present in all 6 patients and during bladder filling in 5 of 6. However, recorded responses from the bladder and rectum were small and mainly phasic in nature. Nerve responses following bladder contractions were present in 4 of 5 stimulated patients.Afferent nerve activity from the dermatome, bladder and rectum can be recorded using cuff electrodes placed on the extradural S3 sacral root in humans but improvements in recording quality and sophisticated signal processing methods are needed for chronic application.

Cutaneous response to capsaicin has been used to assess central sensitization in pain research. This study compared the response to intradermal capsaicin in the forearm and foot of vulvar vestibulitis (vestibulodynia)-afflicted cases and controls. We hypothesized that cases will experience greater spontaneous pain, larger cutaneous areas of punctate hyperalgesia and dynamic allodynia, and greater vascular flow than controls. We also hypothesized enhanced post-injection pain in the foot compared to the forearm based on dermatome proximity of the foot and vulva. Methods. Ten vulvar vestibulitis syndrome (VVS) cases and 10 age and ethnically matched controls underwent two randomized, cross-over trials with intra-dermal injections of capsaicin or a saline placebo in the forearm and foot. Outcome measures included spontaneous pain level, surface area of punctate hyperalgesia, surface area of dynamic allodynia, cutaneous blood flow, regional skin temperature and vital signs. Results. VVS cases experienced greater spontaneous pain, punctate hyperalgesia and dynamic allodynia than pain-free controls. Within the VVS group, post-capsaicin spontaneous pain, punctate hyperalgesia and dynamic allodynia were similar in the forearm and foot. Post-capsaicin blood flow did not differ between cases and controls by anatomic site. Measures of depression and anxiety correlated with spontaneous pain intensity but did not correlate with measures of hyperalgesia, allodynia, or blood flow. VVS cases had higher resting pulse rates and lower resting systolic blood pressures than in controls. Conclusion. VVS patients show enhancement of post-capsaicin pain response extending far beyond the anatomic location of the primary complaint.

STUDY DESIGN Case report. OBJECTIVE To present a case of primary hydatid cyst in the lumbar subcutaneous tissue affecting posterior paravertebral muscle and mimicking disc herniation. SUMMARY OF BACKGROUND DATA Cystic hydatid disease is a rare but significant parasitic disease in endemic areas. Musculoskeletal or soft tissue hydatidosis accounts for about 0.5% to 5% of all echinococcal infections in endemic areas and is almost secondary to the hepatic or pulmonary disease. Primary lumbar subcutaneous hydatid cyst affecting paravertebral muscle and extending to neural foramina is a very rare condition even in endemic areas. METHODS A 25-year-old-female patient was admitted with swelling and pain in the right lumbar region for 3 months. The pain was reflecting in the right gluteal region and the right leg. Lumbar extension and right lateral flexion was painful and straight leg raising test was positive at right side. There was a mild hypoesthesia at L5 dermatome. According to the magnetic resonance image that the clinician obtained for initial diagnosis of lumbar disc herniation, we found multi-cystic masses located at the right paravertebral muscle at the level of L3-L5 which extended to L4-L5 neural foramina and at subcutaneous tissue at the right gluteal region. RESULTS The patient was operated for the purpose of removal of cysts. Postoperatively, diagnosis of hydatid cyst was confirmed by histopathology. CONCLUSION By this case, we emphasize that cystic hydatid disease should be taken into consideration in the differential diagnosis of low back pain and could mimic disc herniation. LEVEL OF EVIDENCE N/A.

The mechanisms of spatial summation of pain (SSP) include pain coding dependent on impulse frequency and the number of recruited central neurons. However, SSP may also be influenced by pain inhibitory mechanisms, such as diffuse noxious inhibitory controls. Abnormal interactions between pain inhibitory mechanisms and SSP may be relevant for chronic pain conditions such as fibromyalgia (FM) and may help explain why widespread pain is characteristic for this chronic pain syndrome. The present study was designed to determine the difference of thermal SSP in the upper extremities between FM and normal control (NC) subjects, particularly within and across dermatomes of the hand. Fourteen NC and 19 FM subjects were enrolled in this study. SSP testing sessions involved immersion of each individual fingertip as well as stepwise immersion of the fingers, hands, and forearms in a hot water bath (46 degrees Celsius) for 5s and 20s. In addition, immersion of several fingertips across dermatome C(7)-C(8) was compared to progressive immersion of the index finger (dermatome C(7)). These experiments demonstrated significant spatial summation of heat-induced pain in both FM and NC subjects. SSP was most extensive within the fingers, and became negligible as the stimulus area increased above the hand. Furthermore, SSP was more pronounced within one dermatome such as that of the index finger than across several dermatomes of the hand. These results were similar for both FM and NC subjects. Thus, mechanisms of SSP, including possible inhibitory factors that limit this relevant pain mechanism, appear to be similar for both FM and NC subjects.

Background The authors have previously observed an apparent association between rostral spread of spinal anesthesia and choice of intravenous vasopressor given to maintain maternal systolic arterial pressure during cesarean delivery. This study tested the hypothesis that an intravenous infusion of phenylephrine can reduce rostral spread of spinal anesthesia in pregnancy, compared with ephedrine. Methods The study was randomized and double blind. It compared phenylephrine 100 microg/ml (phenylephrine group, n = 30), and ephedrine 3 mg/ml (ephedrine group, n = 30), given by infusion, to prevent maternal hypotension during combined spinal-epidural anesthesia for cesarean delivery. Two ml intrathecal plain levobupivacaine, 0.5%, combined with 0.4 ml intrathecal fentanyl, 50 microg/ml, and 10 ml epidural saline was given with the patient in the sitting position. The upper level of neural blockade to cold and light touch sensation was recorded at 10 and 20 min postspinal. Epidural space pressure was recorded at 5, 10, 15, and 20 min. Results At 20 min, the upper dermatome blocked to cold sensation was median T3 (interquartile range, T2-T4) for the phenylephrine group, compared with T1 (T1-T2) for the ephedrine group (P = 0.001). At 20 min, the upper dermatome blocked to light touch sensation was median T5 (T4-T8) for the phenylephrine group, compared with T3 (T2-T6) for the ephedrine group (P = 0.009). The mean epidural space pressure in the phenylephrine group was 16 (13-19) mmHg, compared with 16 (13-18) mmHg in the ephedrine group (P = 0.63). Conclusions This study provides evidence that intravenous phenylephrine can decrease rostral spread of spinal anesthesia in pregnancy, compared with intravenous ephedrine. Further work is required to investigate possible mechanisms and to assess its clinical significance.

UNLABELLED Epidural volume extension (EVE) via a combined spinal-epidural (CSE) technique is the enhancement of a small-dose intrathecal block by epidural saline boluses. In this prospective, randomized, double-blind study, we compared the EVE technique with single-shot spinal anesthesia with respect to its sensory and motor block profile and hemodynamic stability. Sixty-two parturients (n = 31 in each group) undergoing elective cesarean deliveries were administered either spinal anesthesia with hyperbaric 0.5% bupivacaine 9 mg and fentanyl 10 microg or CSE comprising intrathecal hyperbaric 0.5% bupivacaine 5 mg with fentanyl 10 microg, followed by 0.9% saline 6.0 mL through the epidural catheter 5 min thereafter. In each group, the lowest systolic blood pressure (SBP), sensory block level to loss of pain from pinprick, and modified Bromage scores were recorded at 2.5-min intervals. The visual analog pain score (VAS), peak sensory block height, highest modified Bromage motor score, time for sensory regression to the tenth thoracic dermatome (T10), and motor block recovery were compared between groups. Both groups were comparable in demographic data, VAS scores, peak sensory block height, time for sensory regression to T10, and lowest SBP recorded. Patients in the EVE group demonstrated significantly faster motor recovery to modified Bromage 0 (73 +/- 33 min versus 136 +/- 32 min, P < 0.05). IMPLICATIONS When compared with conventional, single-shot spinal anesthesia, epidural volume extension of a small-dose spinal block provides satisfactory anesthesia for cesarean delivery with only 55% of the bupivacaine dose required and is associated with faster motor recovery of the lower limbs.

STUDY DESIGN: Spinal somatosensory-evoked potentials (SSEPs), elicited by mixed nerve and dermatomal stimulation, and compound evoked muscle potentials (CMAPs), elicited by lower thoracic interspinous space stimulation, were recorded in rats that underwent single nerve root transection. OBJECTIVES: To investigate and compare the effects of single nerve root transection using various electrophysiological models and to define a monitoring strategy that can easily and accurately predict compromise caused by a single lumbosacral nerve root injury. SUMMARY OF BACKGROUND DATA: Neuromonitoring is an important and effective preventive measure against neurologic complications during spinal surgery, but monitoring the lumbosacral nerve roots is not well established. METHODS: Rats received (Group I) a sham operation or had the (Group II) left L4, (Group III) L5, or (Group IV) L6 nerve root transected. SSEP were recorded at the thoracolumbar junction following stimulation of the sciatic nerve (M-SSEP) and the L5 dermatome (D-SSEP). CMAP was recorded at the intrinsic muscles of the foot by electrical stimulation in the lower thoracic spinal cord. Potentials recorded before and after a single nerve root transection were compared and correlated with clinical status by walking-track analysis 1 week later. RESULTS: Relative amplitudes in Group II were 54.1% (M-SSEP), 84.6% (D-SSEP), and 85.5% (CMAP); 25.2% (M-SSEP), 66.5% (D-SSEP), and 85.8% (CMAP) in Group III; and 66.5% (M-SSEP), 95.5% (D-SSEP), and 23.2% (CMAP) in Group IV. M-SSEP is sensitive but not specific to single nerve root injury. D-SSEP and CMAP are less sensitive but more specific. CONCLUSIONS: Injury to a single lumbosacral nerve root is diagnosed more easily with M-SSEP. With D-SSEP and CMAP, it was possible to differentiate the lesioned nerve root by stimulating the primary dermatome or recording from the innervated muscle. M-SSEP is an easy-sampling and appropriate tool for screening nerve root injury; its poor specificity may be overcome by using D-SSEP and CMAP in addition. Optimal monitoring of the lumbosacral nerve roots during lumbar spinal surgery requires the administration of M-SSEP, D-SSEP, and CMAP to provide independent verification of lumbosacral nerve root integrity and to allow detection of the occasional injuries that selectively affect either the sensory or motor system.

A man was evaluated at age 35 years for burning/shooting pain in his left chest and drenching sweats affecting the lower trunk and legs since bilateral T2-T6 sympathectomy at age 22 for palmar and axillary hyperhidrosis. Thermoregulatory sweat test showed anhidrosis above T5/6 (sparing the left T2 dermatome) with rapid and profuse sweating elsewhere (figure). Severe compensatory hyperhidrosis is a known complication of extensive sympathectomy. Limited sympathotomy (disruption of fibers between stellate and T2 ganglia) or sympathectomy (e.g., T4 ganglionectomy) might be preferred for medically refractory palmar hyperhidrosis, maximizing palmar dryness, minimizing compensatory hyperhidrosis, and rarely causing intercostal neuralgia or Horner syndrome.1,2 Medical therapy for hyperhidrosis, whether primary or compensatory, may include topical agents, oral medications with anticholinergic properties, or botulinum toxin injections; all were unsuccessful or not tolerated in this patient.

Objective and importance Paragangliomas of the thoracic spine are rare. Previously described cases involved nonfunctioning tumors. This report documents the diagnosis and surgical treatment for a patient who presented with a functioning thoracic paraganglioma. Clinical presentation A 53-year-old woman presented with a 10-month history of headaches, facial flushing, and palpitations associated with hypertension. Urinary catecholamine levels were markedly elevated. Magnetic resonance imaging and m-[(123)I]iodobenzylguanidine scans demonstrated an extradural tumor located within the T12 vertebra, with a significant paraspinal component. The neurological examination revealed mild hypesthesia in the right T12 dermatome. Intervention The patient underwent resection of the tumor after alpha-adrenergic receptor blockade. Grossly complete excision was achieved without neurological complications. Postoperatively, the patient was normotensive and exhibited catecholamine levels within the normal range. Conclusion Functioning paragangliomas of the thoracic spine are rare lesions that are difficult to treat. Successful treatment requires careful surgical planning and expert pharmacological manipulation.

Split-thickness skin grafts remain central to the strategy of burn wound treatment. The dressing used to cover the donor wound site has a significant effect on healing parameters. The purpose of this study was to compare split-thickness skin graft donor site reepithelialization under Xeroform and Jelonet dressings. A dermatome was used to cut two consecutive strips of skin from 25 paired donor sites on the thigh, calf, or back of 19 participants. Standardization of the harvest method was achieved by using the same surgeon to harvest the compared skin graft strips, with attention to consistency of dermatome skin-thickness setting, downward pressure, and angle of dermatome approach. A strip of Xeroform or Jelonet was applied to one of each pair of wounds. Epidermal and dermal thickness was measured from biopsy specimens cut at the midpoint of each split-thickness graft strip. The day of final dressing separation was declared the day of complete donor reepithelialization (healing). The mean healing time for Xeroform and Jelonet was 10.4 +/- 2.6 days (n = 25) and 10.6 +/- 2.8 days (n = 25) (p = 0.76) at sites cut to a mean depth of 0.23 +/- 0.08 mm and 0.23 +/- 0.09 mm (p = 0.89), respectively. There was no correlation between graft thickness and healing time for sites dressed with Xeroform (r = 0.17) or Jelonet (r = 0.02). Donors sites reharvested 10 to 21 days after a prior harvest healed an average of 3.1 days earlier than virgin sites (8.4 +/- 1.6 versus 11.5 +/- 2.6 days, p < 0.001), although reharvested grafts were on average 0.05 mm thicker (p = 0.10). The mean thickness of reepithelialized donor-site epidermis (0.13 +/- 0.04 mm, n = 30) was found to be twice the thickness of virgin epidermis from the same sites (0.06 +/- 0.02 mm, n = 38, p < 0.001). Thirty-six grafts harvested with dermatomes set to cut 8/1000 inch (0.20 mm) deep ranged from 0.12 to 0.42 mm thick, with only eight of these grafts measuring within +/-10 percent of the desired thickness setting. Before donor dressing separation, Xeroform and Jelonet dressings were judged to be more comfortable by nine patients and one patient, respectively, whereas no difference was detected by six patients. The authors now use Xeroform as the preferred donor dressing.

Objective and importance Intradural-extradural dumbbell C2 schwannomas are rare. This report concerns two such cases with the intradural compartment located ventral to the spinal cord and involving both sensory and motor rootlets. Clinical presentation One patient was a 57-year-old woman with sensory disturbances in the right extremities and hyperreflexia in the left extremities. The other patient was a 73-year-old man who presented with tetraparesis, walking disability, atrophy of the nuchal and bilateral shoulder muscles, and pain in the right C2 dermatome. Intervention The extradural component of the tumor was removed first; next, the intradural component was removed successfully via the posterior approach combined with a C1-C2 laminectomy. The patients experienced symptomatic improvement without further deficits except for sensory impairment of the C2 dermatome in one of the patients. Conclusion Intradural-extradural dumbbell C2 schwannomas can be satisfactorily managed with a posterior approach. Removal of the extradural component and opening of the dural ring of the C2 nerve root are necessary for safe extraction of the intradural ventrally located component after debulking. These tumors may arise extradurally within the nerve sheath, extend intradurally and ventrally toward the spinal cord, and involve both sensory and motor rootlets.

STUDY DESIGN Spinal somatosensory-evoked potential (interspinous-space-recorded evoked potentials after peripheral nerve or dermatomal stimulation) and conductive spinal cord evoked potential (interspinous-space-recorded evoked potentials after spinal cord stimulation) were analyzed in rats under different concentrations of the anesthetic desflurane. OBJECTIVES To investigate and compare the effects of a new volatile anesthetic, desflurane, on the common intraoperative neuromonitoring models. SUMMARY OF BACKGROUND DATA Intraoperative evoked potentials are sensitive to most anesthetics. Interpretation of the data becomes complicated because of a suppression effect caused by the anesthesia. Desflurane has become a valuable anesthetic in neurosurgery because of its pharmacokinetic advantages. METHODS Fifteen rats were placed under general anesthesia, and vital signs were closely monitored. Needle recording electrodes were placed stereotactically into the thoracolumbar interspinous ligament; dermatomal somatosensory-evoked potential by L5 dermatome, mixed-nerve somatosensory-evoked potential by sciatic nerve stimulation, and spinal cord evoked potential of the same recording electrodes elicited by C2-C3 interspinous stimulation were obtained. The effects of desflurane were examined at end-tidal concentrations of 6% (1.05 minimal alveolar concentration), 9% (1.57 minimal alveolar concentration), and 12% (2.10 minimal alveolar concentration). RESULTS Amplitude decreased and latency was delayed in all three kinds of potentials, and the more so with higher concentrations. Comparing 9% with 6% desflurane, the amplitude in dermatomal somatosensory-evoked potential, mixed-nerve somatosensory-evoked potential, and spinal cord evoked potential decreased to 84.3%, 88.9%, and 70.8%, respectively, values with no statistically significant difference. However, at 12%, again compared with 6%, the amplitude decreased further to 64.4%, 70.3%, 41.8%, respectively; mixed-nerve somatosensory-evoked potential and dermatomal somatosensory-evoked potential were significantly more preserved than spinal cord evoked potential (P = 0.04). CONCLUSIONS The concentration of desflurane alters the amplitude of somatosensory-evoked potential and spinal cord evoked potential, and, to a lesser degree, delays the latency; spinal cord evoked potential is more liable to be suppressed than somatosensory-evoked potential. The dose-dependent suppression effect on amplitude should be considered when interpreting changes during surgery. Furthermore, the potential benefit of somatosensory-evoked potential elicited by direct major nerve stimulation should be considered because of its large amplitude and higher resistance, even with a greater concentration of volatile anesthetics.

Study Design. Neurotracer was applied to various sites in the rat lumbar spine and related tissues. The segmental distribution of labeled neurons in dorsal root ganglia (DRG) was investigated. Objectives. To clarify the stereoscopic structure of afferent fibers innervating the lumbar spine and related tissues. Summary of Background Data. Afferent fibers in the rat L5–L6 lumbar intervertebral disc are reported to originate from neurons in L1 and L2 DRG. However, anatomic studies determined that each dorsal ramus of the spinal nerve sends nerves to dorsal elements of the corresponding lumbar vertebra. Methods. Fluorescent neurotracer DiI (1,1′-dioctadecyl-3,3,3′,3′-tetramethylindocarbocyanine perchlorate) was applied to various sites of the lumbar spine and related tissues in the L2, L5, and L6 levels in rats. DRG were sectioned 3 weeks after DiI application. Rostrocaudal distribution of DiI-labeled neurons was investigated. Results. At L5, DiI-labeled neurons were prominent in DRG L3 for the lamina, L2 for the spinous process, L2 for the back muscle fascia, and L1 for the skin. Dorsal elements are therefore innervated by neurons in more rostral DRG. In the transverse plane, the more distant from the DRG a site was, the more rostral the DRG innervating the site. This structure suggested a concentric innervation pattern in the transverse plane. Conclusion. Stereoscopically, the peripheral innervation territory of a lumbar DRG is conical, with the apex at the ganglion and the base circumference located on the dermatome. The lumbar spine itself is involved in the conical innervation territories of DRG.

BACKGROUND. The treatment of chronic lesions in hidradenitis suppurativa (HS) remains a challenge for dermatologists. In most cases, wide surgical excision of the affected skin reduces the recurrence rate to a minimum. Split-thickness skin grafts have usually been applied to resurface large postoperative defects. OBJECTIVE. The aim of this study is to introduce an alternative method of skin grafting, called ‘‘reused’’ or ‘‘recycled’’ skin graft, for the reconstruction of the large skin defect with chronic gluteal HS. METHODS. The study consisted of six patients (two females and four males) with gluteal HS. After a wide en bloc excision, the wound was immediately recovered with meshed-skin graft, made from the resected skin itself. Thus, the sacrifice of the skin donor is spared. The drum dermatome (Padgett-Hood) is suitable to take the split-skin graft from the resected skin of the affected buttock. The thickness of grafts was set between 12/1,000 and 20/1,000 inches, and all grafts were meshed with 1.5 times the expansion. The skin grafts were secured in place on the wound and a tie-over dressing was applied. RESULTS. Postoperative complications were usually minor ones, such as hematoma, discharge, and small areas of graft skin necrosis (less than 1 cm 2 ), although one patient developed a3 4c m 2 graft necrosis and wound infection. The follow-up period after surgery ranged from 8 to 36 months. No patient experienced any functional disabilities or recurrence during follow-up years. CONCLUSION. When the epidermal involvement remains mild to moderate, this reused skin graft technique is an alternative choice to resurface the surgical defect of gluteal HS. It is superior to the conventional procedure, which requires fresh skin donor site. H. -W. KUO, MD, AND K. OHARA, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.

UNLABELLED We examined the success of inserting epidural catheters via the caudal route in infants by using electrocardiographic guidance. A case series of 20 patients with thoracic epidural analgesia was studied. After the induction of general anesthesia, an 18-gauge IV catheter was inserted into the caudal space to allow threading of a 20-gauge epidural catheter. The electrocardiogram (ECG) tracings via the epidural catheter, as well as the surface ECG at the target spine level, were recorded simultaneously with a modified two-channel five-lead ECG system. The epidural catheter was advanced from the caudal space until the tip reached the target level as demonstrated by a match in the configuration of the epidural ECG tracing to that of the surface ECG tracing at the target level. The catheter tip location was verified by postoperative radiographs. All catheter tips were located within two vertebrae of the target level, and satisfactory intraoperative epidural anesthesia was achieved in all subjects. IMPLICATIONS Epidural electrocardiography may be used to guide the positioning of the thoracic epidural catheter tip via the caudal approach to the appropriate dermatome for optimum analgesia.

Study Design. Peripheral sensory functions in patients with radiculopathy resulting from lumbar disc herniation and in control individuals were analyzed using current perception threshold testing. Objective. To evaluate the severity of sensory disturbance quantitatively in patients with lumbar radiculopathy. Summary of Background Data. Subjective evaluation of the severity of sensory disturbance associated with spinal disorders using conventional methods often is difficult. Current perception threshold evaluation is a recently proposed method for studying peripheral nerve dysfunction. This is a quantitative sensory test for analyzing functions of A-beta, A-delta, and C fibers. Methods. In this study, 48 patients with lumbar radiculopathy resulting from lumbar disc herniation were examined. The mean age of the patients was 37.9 years. All the patients had pain distribution from the compression of one lumbar nerve root (L5 or S1), and unequivocal unilateral disc herniation of the corresponding level was shown by magnetic resonance imaging. Eleven healthy volunteers were used as control subjects. Their mean age was 38.2 years. Current perception threshold evaluation using a Neurometer device was performed at three frequencies: 2000, 250, and 5 Hz. The stimulus sites were located on the dorsal side of the first metatarsus (the L5 dermatome) and the dorsal side of the fifth metatarsus (the S1 dermatome). These sites were investigated on both legs in all the patients and control subjects. The intensity of pain was scored using a visual analog scale. Results. In the control group, there were no significant differences in current perception threshold values at any frequency between the left and right legs. In the patient group, the current perception threshold values in the affected legs were significantly higher than those in the contralateral legs at all frequencies. The current perception threshold values in the affected legs in the patient group were significantly higher than those in the control subjects at 2000 and 250 Hz, whereas there were no significant differences at 5 Hz. The current perception threshold values in the affected legs were significantly higher in patients with hypesthesia than in those without hypesthesia at 2000 and 250 Hz, and in patients with severe pain than in those with less pain at 5 Hz. Conclusions. Current perception threshold testing showed that the functions of A-beta, A-delta, and C fibers deteriorated in patients with lumbar radiculopathy. This technique may be useful for quantifying sensory nerve dysfunction in patients with radiculopathy.