Ultrasound-guided percutaneous injection of methylene blue to identify nerve pathology and guide surgery

OBJECT The objective of this study was to provide a technique that could be used in the preoperative period to facilitate the surgical exploration of peripheral nerve pathology. METHODS The authors describe a technique in which 1) ultrasonography is used in the immediate preoperative period to identify target peripheral nerves, 2) an ultrasound-guided needle electrode is used to stimulate peripheral nerves to confirm their position, and then 3) a methylene blue (MB) injection is performed to mark the peripheral nerve pathology to facilitate surgical exploration. RESULTS A cohort of 13 patients with varying indications for peripheral nerve surgery is presented in which ultrasound guidance, stimulation, and MB were used to localize and create a road map for surgeries. CONCLUSIONS Preoperative ultrasound-guided MB administration is a promising technique that peripheral nerve surgeons could use to plan and execute surgery.

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Ultrasound-Guided Treatment of Peripheral Nerve Pathology

Seminars in Musculoskeletal Radiology ◽

10.1055/s-0038-1641571 ◽

2018 ◽

Vol 22 (03) ◽

pp. 364-374 ◽

Cited By ~ 2

Author(s):

Nathan Dettori ◽

Hema Choudur ◽

Avneesh Chhabra

Keyword(s):

High Resolution ◽

Peripheral Nerve ◽

Peripheral Nerves ◽

Ultrasound Guided ◽

Future Directions ◽

Dynamic Evaluation ◽

The Individual

AbstractHigh-resolution ultrasound serves as a fast, accessible, reliable, and radiation-free tool for anatomical and dynamic evaluation of various peripheral nerves. It can be used not only to identify and diagnose peripheral nerve and perineural pathology accurately but also to guide various nerve and perineural interventions. We describe the normal and pathologic appearances of peripheral nerves, the pathologies commonly affecting the individual peripheral nerves, and the current ultrasound-guided peripheral nerve interventions and techniques. Future directions are also highlighted.

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Waterjet Dissection of Peripheral Nerves: An Experimental Study of the Sciatic Nerve of Rats

Operative Neurosurgery ◽

10.1227/neu.0b013e3181f9b0c8 ◽

2010 ◽

Vol 67 (suppl_2) ◽

pp. ons368-ons376 ◽

Cited By ~ 3

Author(s):

Christoph A. Tschan ◽

Doerthe Keiner ◽

Harald D. Müller ◽

Kerstin Schwabe ◽

Michael R. Gaab ◽

...

Keyword(s):

Sciatic Nerve ◽

Peripheral Nerve ◽

Nerve Regeneration ◽

Peripheral Nerves ◽

Scar Tissue ◽

Small Water ◽

Peripheral Nerve Surgery ◽

Sciatic Nerves ◽

Nerve Surgery ◽

Waterjet Dissection

ABSTRACT BACKGROUND: Although waterjet dissection has been well evaluated in intracranial pathologies, little is known of its qualities in peripheral nerve surgery. Theoretically, the precise dissection qualities could support the separation of nerves from adjacent tissues and improve the preservation of nerve integrity in peripheral nerve surgery. OBJECTIVE: To evaluate the potential of the new waterjet dissector in peripheral nerve surgery. METHODS: Waterjet dissection with pressures of 20 to 80 bar was applied on the sciatic nerves of 101 rats. The effect of waterjet dissection on the sciatic nerve was evaluated by clinical tests, neurophysiological examinations, and histopathological studies up to 12 weeks after surgery. RESULTS: With waterjet pressures up to 30 bar, the sciatic nerve was preserved in its integrity in all cases. Functional damaging was observed at pressures of 40 bar and higher. However, all but 1 rat in the 80 bar subgroup showed complete functional regeneration at 12 weeks after surgery. Histopathologically, small water bubbles were observed around the nerves. At 40 bar and higher, the sciatic nerves showed signs of direct nerve injury. However, all these animals showed nerve regeneration after 12 weeks, as demonstrated by histological studies. CONCLUSION: Sciatic nerves were preserved functionally and morphologically at pressures up to 30 bar. Between 40 and 80 bar, reliable functional and morphological nerve regeneration occurred. Waterjet pressures up to 30 bar might be applied safely under clinical conditions. This technique might be well suited to separate intact peripheral nerves from adjacent tumor or scar tissue. Further studies will have to show the clinical relevance of these dissection qualities.

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AN ECLECTIC REVIEW OF THE HISTORY OF PERIPHERAL NERVE SURGERY

Neurosurgery ◽

10.1227/01.neu.0000346252.53722.d3 ◽

2009 ◽

Vol 65 (suppl_4) ◽

pp. A3-A8 ◽

Cited By ~ 11

Author(s):

Allan H. Friedman

Keyword(s):

Peripheral Nerve ◽

Peripheral Nerves ◽

Nerve Repair ◽

Lessons Learned ◽

Injured Nerve ◽

Peripheral Nerve Surgery ◽

Distinguished Career ◽

History Of ◽

Nerve Surgery

Abstract WE TAKE OUR present concepts of nerve repair for granted. In fact, the pioneers who established these principles traveled a road filled with erroneous dogma, bad advice, and misleading data. The lessons learned from a review of the history of peripheral nerve surgery are applicable to all neurosurgical disciplines. In honor of Dr. David Kline's distinguished career, we will review 3 aspects of the history of peripheral nerve surgery: Can an injured nerve regain function? How do peripheral nerves regenerate? When should a neuroma in continuity be resected?

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Cadaveric Model Simulations for Training in Ultrasound-Guided Percutaneous Placement of a Novel Peripheral Nerve Stimulation Electrode

Surgical Technology Online ◽

10.52198/21.sti.38.ns1401 ◽

2021 ◽

Author(s):

Roberto Gazzeri ◽

Alessandro Cesaroni ◽

Ezio Amorizzo ◽

Emanuele Piraccini ◽

Fabrizio Micheli ◽

...

Keyword(s):

Peripheral Nerve ◽

Nerve Stimulation ◽

Peripheral Nerves ◽

Peripheral Nerve Stimulation ◽

Electrode Placement ◽

Surgical Approaches ◽

Ultrasound Guided ◽

Model Simulations ◽

Cadaveric Model ◽

Stimulation Electrode

Peripheral nerve stimulation (PNS) electrodes are used to treat intractable painful conditions involving peripheral nerves. Methods for performing PNS continue to evolve, from open surgical to minimally invasive placement of electrodes. A PNS system consisting of subcutaneously implanted leads with an integrated anchor and electrodes, and an external pulse generator to produce peripheral neuromodulation, is now available for use in the clinical setting. This novel system allows either surgical or percutaneous lead positioning, and avoids the use of long leads or extensions crossing the joints, which are exposed to mechanical stress and damage. To identify methods for successfully inserting these electrodes, we investigated if a cadaver model could be an effective educational tool for teaching PNS electrode placement using ultrasound guidance. Six cadavers were studied in an attempt to find an ideal approach for ultrasound-guided electrode placement into the upper and lower extremities and cervical spine, and to describe the unique anatomy of the peripheral nerves relative to percutaneous stimulation-electrode placement. The use of cadaveric model simulations offers opportunities to practice percutaneous placement of PNS electrodes under stress-free conditions without patient discomfort, to acquire skill and confidence in performing these surgical approaches. Ultrasound-guided percutaneous placement of PNS electrodes should be learned in a simulation laboratory before such placement is performed in actual patients.

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Introduction: Peripheral Nerve Surgery—Biology, Entrapment, and Injuries

Neurosurgical FOCUS ◽

10.3171/foc.2009.26.2.e1 ◽

2009 ◽

Vol 26 (2) ◽

pp. E1 ◽

Cited By ~ 9

Author(s):

Allan H. Friedman ◽

W. Jeffrey Elias ◽

Rajiv Midha

Keyword(s):

Peripheral Nerve ◽

Peripheral Nerves ◽

Nerve Repair ◽

Peripheral Nerve Injuries ◽

Significant Progress ◽

Vital Function ◽

Harvey Cushing ◽

Nerve Transfers ◽

Electrophysiological Technique ◽

Nerve Surgery

Surgery aimed at repairing damaged peripheral nerves has a long history. Refuting the timehonored nihilism of Hippocrates and Galen that an injured nerve cannot regain function, a few adventurous medieval surgeons attempted to repair severed nerves.6,8 However, the ability of a peripheral nerve repair to restore function was not generally accepted until 1800.1,4 Neurosurgeons, beginning with Harvey Cushing, have had an interest in repairing damaged peripheral nerves.2 Significant progress in the treatment of peripheral nerve injuries resulted from experience with the numerous injuries that occurred during World Wars I and II.3,7,12 Surgeons steadily defined the anatomy of peripheral nerves and developed techniques for decompressing and repairing peripheral nerves.9,11 Kline and Dejonge5 developed an intraoperative electrophysiological technique for detecting axons regenerating across a damaged segment of nerve. In the second 2 decades of the 20th century, distal nerve transfers were rediscovered whereby the proximal end of a less essential nerve is used to reinnervate the distal end of a nerve, providing a more vital function.10

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Preoperative ultrasound-guided mapping of peripheral nerves

Journal of Neurosurgery ◽

10.3171/2013.5.jns122243 ◽

2013 ◽

Vol 119 (3) ◽

pp. 709-713 ◽

Cited By ~ 21

Author(s):

Michael Gofeld ◽

Sandee J. Bristow ◽

Sheila Chiu ◽

Michel Kliot

Keyword(s):

Methylene Blue ◽

Peripheral Nerves ◽

Operating Time ◽

Skin Incision ◽

Blue Dye ◽

Ultrasound Guided ◽

Mapping Procedure ◽

Portable Ultrasound ◽

Surgical Access ◽

Preoperative Ultrasound

Object Surgical exposure of a peripheral nerve can be technically challenging, making the operation more extensive and time consuming, particularly in the treatment of small nerves with an anatomically variable position. This study describes the application of ultrasound to facilitate surgical access and localization of targeted peripheral nerves. Methods A preclinical feasibility study was performed at the University of Washington's Willed Body Program laboratory. Unembalmed cadavers were placed on the dissection table in positions mimicking those typically required for surgical access to specific nerves that can be challenging to localize. A high-frequency portable ultrasound system was used to identify the nerves. An extraneural injection of methylene blue immediately adjacent to the target nerve was performed under ultrasound guidance as the experimental nerve mapping procedure. Surgical dissections through a small skin incision parallel to skin tension lines were guided by the transducer position and angle. Success was determined by the accuracy and rapidity of surgical identification and exposure of the nerve. Results Using ultrasound-guided mapping, all anticipated peripheral nerves were correctly identified via a direct approach from the skin incision. This was confirmed by performing an anatomical dissection to expose and identify the intended nerve and its relation to the injected methylene blue dye. In no case was intraneural injection of the dye observed. Conclusions Preoperative ultrasound-guided nerve mapping may be useful in facilitating surgical access to a targeted nerve and thereby minimizing tissue dissection and operating time.

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Adipose Tissue Uses in Peripheral Nerve Surgery

International Journal of Molecular Sciences ◽

10.3390/ijms23020644 ◽

2022 ◽

Vol 23 (2) ◽

pp. 644

Author(s):

Allison Podsednik ◽

Raysa Cabrejo ◽

Joseph Rosen

Keyword(s):

Peripheral Nerve ◽

Peripheral Nerves ◽

Animal Studies ◽

Surgical Repair ◽

Fat Grafting ◽

Adipose Derived Stem Cells ◽

Injury Site ◽

Peripheral Nerve Surgery ◽

Improved Outcomes ◽

Nerve Surgery

Currently, many different techniques exist for the surgical repair of peripheral nerves. The degree of injury dictates the repair and, depending on the defect or injury of the peripheral nerve, plastic surgeons can perform nerve repairs, grafts, and transfers. All the previously listed techniques are routinely performed in human patients, but a novel addition to these peripheral nerve surgeries involves concomitant fat grafting to the repair site at the time of surgery. Fat grafting provides adipose-derived stem cells to the injury site. Though fat grafting is performed as an adjunct to some peripheral nerve surgeries, there is no clear evidence as to which procedures have improved outcomes resultant from concomitant fat grafting. This review explores the evidence presented in various animal studies regarding outcomes of fat grafting at the time of various types of peripheral nerve surgery.

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Intraoperative ultrasound-assisted peripheral nerve surgery

Neurosurgical FOCUS ◽

10.3171/2015.6.focus15232 ◽

2015 ◽

Vol 39 (3) ◽

pp. E4 ◽

Cited By ~ 5

Author(s):

Clayton L. Haldeman ◽

Christopher D. Baggott ◽

Amgad S. Hanna

Keyword(s):

Peripheral Nerve ◽

Peripheral Nerves ◽

Imaging Modality ◽

Intraoperative Ultrasound ◽

Pathological Anatomy ◽

Peripheral Nerve Surgery ◽

Surgical Adjunct ◽

High Resolution Ultrasonography ◽

Nerve Surgery ◽

Deep Location

Historically, peripheral nerve surgery has relied on landmarks and fairly extensive dissection for localization of both normal and pathological anatomy. High-resolution ultrasonography is a radiation-free imaging modality that can be used to directly visualize peripheral nerves and their associated pathologies prior to making an incision. It therefore helps in localization of normal and pathological anatomy, which can minimize the need for extensive exposures. The authors found intraoperative ultrasound (US) to be most useful in the management of peripheral nerve tumors and neuromas of nerve branches that are particularly small or have a deep location. This study presents the use of intraoperative US in 5 cases in an effort to illustrate some of the applications of this useful surgical adjunct.

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