ANALYSIS OF THE RESULTS OF LASER DESTRUCTION OF THE ARTICULAR BRANCH OF THE OBTURATOR NERVE IN ELDERLY AND SENILE PATIENTS WITH DEGENERATIVE COXARTHROSIS

Цель исследования - анализ результатов использования лазерной деструкции суставной ветви запирательного нерва у пациентов пожилого и старческого возраста с дегенеративным коксартрозом. Проспективно изучены результаты лечения 34 пациентов старше 65 лет c симптоматичным дегенеративным заболеванием тазобедренного сустава (ТБС), имеющим соматические противопоказания к выполнению его тотального эндопротезирования. В обследуемой группе в период с 2017 по 2019 г. проведена лазерная деструкция суставной ветви запирательного нерва (970 нм, частотой 9 Гц и мощностью 3 Вт в суммарной дозе 100 Дж). Средний катамнез наблюдения составил 12 мес. Для оценки эффективности хирургического лечения анализировали динамику уровня болевого синдрома в ТБС по визуально-аналоговой шкале, качества жизни - по анкете SF-36, функционального состояния ТБС - по шкале W.H. Harris и наличие операционных осложнений. В результате установлено, что применение лазерной деструкции суставной ветви запирательного нерва при дегенеративном коксартрозе у пациентов пожилого и старческого возраста (при невозможности проведения тотального эндопротезирования ТБС) позволило значительно снизить уровень дооперационного болевого синдрома, восстановить качество жизни и улучшить функциональное состояние пациентов при низком риске развития неблагоприятных последствий. The aim of the study was to analyze the results of the use of laser destruction of the articular branch of the obturator nerve in elderly and senile patients with degenerative coxarthrosis. The results of treatment of 34 patients over 65 years of age with symptomatic degenerative diseases of the hip joint (HJD) and somatic contraindications for total hip arthroplasty have been prospectively studied. In the study group, in the period from 2017 to 2019, laser destruction of the articular branch of the obturator nerve (970 nm, frequency 9 Hz and power 3 W in a total dose of 100 J) was carried out. The average follow-up was 12 months. To assess the effectiveness of surgical treatment, the dynamics of the pain syndrome in the hip joint was analyzed according to the visual analogue scale, the quality of life according to the SF-36 questionnaire, the functional state of the hip joint according to the W.H. Harris scale and the presence perioperative surgical complications. As a result, it was found that the use of laser destruction of the articular branch of the obturator nerve in degenerative coxarthrosis in elderly and senile patients (if total hip arthroplasty was not possible) made it possible to significantly reduce the level of preoperative pain syndrome, restore the quality of life and improve the functional state of patients with low risks of surgical complications.

High-resolution MRI of a peroneal intraneural ganglion cyst arising from the knee joint: illustrative case

BACKGROUND The advancement of high-resolution imaging and increased clinical experience have led to an increased understanding of the formation and treatment of intraneural ganglion cysts. Nearly all intraneural ganglion cysts in the common peroneal nerve have been reported to arise from a joint connection to the superior tibiofibular joint. The authors have identified four cases of intraneural ganglion cysts arising from the knee joint itself; however, none of these reported cases were well described, documented, or illustrated with high-resolution imaging. OBSERVATIONS Here the authors present the case of an intraneural ganglion cyst arising from the knee joint and causing intermittent weakness and pain. The articular branch to the knee joint was clearly demonstrated on high-resolution magnetic resonance imaging and confirmed at surgical exploration. The patient was treated with articular branch ligation and has had complete resolution of his symptoms without recurrence of the cyst on follow-up imaging. LESSONS This case adds to the mounting evidence that intraneural cyst pathology is dependent on a connection to a synovial joint as stated in the unifying theory of intraneural cyst development.

Cadaveric evaluation of the feasibility of glenohumeral joint denervation

Purpose To assess the feasibility of total shoulder denervation through two proposed incisions. Methods Total shoulder denervation was performed through an extended delta-pectoral approach and a transverse dorsal approach at the spine of the scapula. The study involved six cadavers. Course and number of articular branches from the lateral pectoral, axillary and supra-scapular nerve were documented. Results All shoulder joint articular branches were accessible through the proposed anterior and posterior approaches. The articular branch of the lateral pectoral nerve and supra scapular nerve were present in all the specimen. Axillary nerve articular branches were variable in number but when present anteriorly were proximal to the deltoid muscular branches and posteriorly proximal to the muscular branches to the teres minor. Conclusion Total glenohumeral denervation was feasible through our proposed anterior and posterior approaches. Enhanced knowledge of articular nerve branches could provide interventional targets for joint and ligament pain, with low risk of muscle weakness.

An intraneural ganglion cyst of the ulnar nerve at the wrist: a case report and literature review

Background Intraneural ganglion cysts of the ulnar nerve at the wrist are rare and poorly understood. We report a case of an intraneural ganglion cyst at the level of the wrist. Case presentation: A 48-year-old man presented with the complaints of weakness for 6 months and serious aggravation for 1 month in his right hand. After examinations, including ultrasound, the patient was diagnosed with an intraneural ganglion cyst. Intraoperatively, with exposure of the ulnar nerve, we found that the intraneural ganglion cyst was at the level of Guyon’s canal and extended approximately 6 cm proximally. Postoperatively, sensation of the fingers was normal, but atrophy of his muscles and limited straightening of his ring and little fingers were similar to those preoperatively. Conclusions Diagnosis of an intraneural cyst before surgery is mostly based on ultrasound and magnetic resonance imaging. Transection of the articular branch is an important measure to prevent recurrence of this cyst. If the ulnar nerve is compressed and causes symptoms, nerve decompression, including removal/aspiration of the cyst, and sometimes external neurolysis of the nerve, are necessary to relieve the symptoms and allow regeneration of the nerve. However, these should be performed without damaging the nerve fascicles.

Drop Foot Secondary to a Peroneal Intraneural Ganglion Connected to the Superior Tibiofibular Joint: A Case Report

Peroneal neuropathy is the most frequent mononeuropathy of the lower extremity. Intraneural ganglion cysts (INGCs) are among rare causes of peroneal nerve palsy. According to the articular (synovial) theory, the articular branch plays the key role in the pathogenesis. Patients present with pain around the fibular head and neck, motor weakness resulting in foot drop and paresthesia in the anterolateral calf and foot. Ultrasonography (US) and MRI are both useful in the diagnosis, but MRI is the best imaging modality in the demonstration of the articular connection and the relation of the cyst with adjacent structures, even without special neurography sequences. We present a 32-year-old male patient referred to our neurosurgery clinic with suspicion of lumbar radiculopathy. He presented with right foot drop which began 3 weeks prior. On examination, there was 90% loss in the ankle dorsiflexion and finger extension. Ankle eversion was also weakened. There was no low back or posterolateral thigh pain to suggest L5 radiculopathy and sciatic neuropathy. Following negative lumbar spine MRI, peripheral neuropathy was concerned. Electrodiagnostic evaluations findings were consistent with acute/subacute common peroneal nerve (CPN) axonal neuropathy. Subsequent MRI of knee showed a homogeneous, thin-walled tubular cystic lesion, extending along the course of the CPN and its articular branch. Full recovery of the neuropathy was achieved with early diagnosis and decompression via microsurgical epineurotomy. The diagnosis of INGC was confirmed by histopathologic examination. INGCs, although rare, should also be considered in the differential diagnosis of peripheral mononeuropathies.

Anatomical variations and distributions of obturator nerve on Ethiopian cadavers

Variations in anatomy of the obturator nerve are important to surgeons and anesthesiologists performing surgical procedures in the pelvic cavity, medial thigh and groin regions. They are also helpful for radiologists who interpret computerized imaging and anesthesiologists who perform local anesthesia. This study aimed to describe the anatomical variations and distribution of obturator nerve. The cadavers were examined bilaterally for origin to its final distribution and the variations and normal features of obturator nerve. Sixty-seven limbs sides (34 right and 33 left sides) were studied for variation in origin and distribution of obturator nerve. From which 88.1% arises from L2, L3 and L4 and; 11.9% from L3 and L4 spinal nerves. In 23.9%, 44.8% and 31.3% of specimens the bifurcation levels of obturator nerve were determined to be intrapelvic, within the obturator canal and extrapelvic, respectively. The anterior branch subdivided into two, three and four subdivisions in 9%, 65.7% and 25.4% of the specimens, respectively, while the posterior branch provided two subdivisions in 65.7% and three subdivisions in 34.3% of the specimens. Hip articular branch arose from common obturator nerve in 67.2% to provide sensory innervation to the hip joint. Accessory obturator nerve was not observed at all in this study. Key words: Variations, obturator nerve

Intraneural Synovial Cyst of the Common Peroneal Nerve: An Unusual Cause of Foot Drop with Four-Year Follow-Up

In our case report, we describe a 55-year-old male patient with isolated foot drop due to an intraneural synovial ganglion. We successfully treated the lesion with decompression via epineurotomy combined with primary division of the recurrent articular branch of the common peroneal nerve (CPN). Compression neuropathies of the common peroneal nerve arise from a variety of causes. Intrinsic compression due to intraneural ganglion cysts of the CPN is rare. Previous reports of simple decompression of the cystic fluid have resulted in recurrence. The unified articular theory describes a pathway for fluid to fill from the proximal tibiofibular joint into the CPN via a recurrent articular branch. In our case, we divide this articular branch which we feel prevents recurrence.

Ulnar Neuropathy due to Intraneural Ganglion Cyst of the Ulnar Nerve at the Elbow

Intraneural ganglion cysts are rare mucinous cyst originating within the epineurium of peripheral nerves. They occur most commonly in the peroneal nerve. However, they have also been described in many nerves in the vicinity of synovial joints. Intraneural ganglion cysts in the upper extremity are rare. Those at the elbow joint comprise only 9% of intraneural ganglion ever reported.A 66-year-old and right-handed male patient presented with a sudden onset of right-hand weakness. He initially noticed paresthesia with decreased sensation in the lateral two digits and radial palm in his right hand. Physical examination showed thenar muscle atrophy and muscle weakness of the abductor pollicis brevis in the right hand. Preoperative diagnosis of intraneural ganglion cyst was made on the basis of characteristic magnetic resonance imaging (MRI) findings. On exploration, the ulnar nerve was identified proximal to the elbow joint. Its articular branch was addressed and divided from the elbow joint.To the best of our knowledge, addressing the articular branch connecting the glenohumeral joint for the treatment of intraneural ganglion at the elbow has only been reported twice. We experienced a rare occurrence of intraneural ganglion cyst at the elbow manifesting an ulnar neuropathy. Here, we report intraoperative findings for the articular branch-connected to intraneural ganglion of the ulnar nerve at the elbow. Early diagnosis of intraneural ganglion with precise identification of the pathology and addressing the articular branch with atraumatic dissection of ganglion cyst are essential to achieve successful treatment for this rare lesion.