Phalloplasty With a Free Scapular Flap Improves Postoperative Sensation in Penile Reconstruction

Objective We aimed to evaluate both the long-term surgical outcomes and patient-reported outcomes of free scapular flap (FSF) phalloplasty. MethodThe same surgical team performed phalloplasty in 66 patients using a FSF between March 2000 and September 2018. All patients had at least 24 months of follow-up. The surgical techniques used, complications observed, and surgical and patient-reported outcomes were retrospectively described. ResultA total of 66 patients with indications of penile trauma (n = 19), micropenis (n = 42), and self-amputation (n = 5) underwent FSF phalloplasty. Two patients (3%) had total flap necrosis and 1 (1.5%) had partial flap necrosis. The urethral complication rate was 18.2% (12/66 patients). All patients were able to void while standing after revision procedures or urethroplasty. We found that an FSF is a reliable donor site for penile reconstruction.ConclusionThe FSF phalloplasty creates an esthetically pleasing penis and allows voiding while standing. Most patients can engage in sexual activity. The main drawbacks of using this method are that patients experience different degrees of sensory recovery, and patients undergoing surgery with the “tube-in-tube” technique may find they are be limited by the thickness of the flap. However, by making full use of residual tissue, such as the micropenis glans or scrotal skin, patients can obtain good tactile and erogenous sensation. We believe that using an FSF complements the existing phalloplasty techniques.

Pregnancy following Brown-Séquard syndrome: A rare case report

Brown-Séquard syndrome is an incomplete spinal cord lesion characterized by hemisection injury of the cord. We present a case of pregnancy, delivery and postpartum course following this rare neurological condition. A 42-year-old woman presented with past history of idiopathic hemicord myelitis leading to right sided hemiplegia with decreased contralateral sensation of pain and temperature, consistent with Brown-Séquard syndrome, which was treated with steroids and Therapeutic Plasma Exchange. Thereafter, she had near-complete motor recovery and complete sensory recovery over the next 3months. Three years later, she presented to us at 37+2 weeks of gestation with residual hemiparesis with motor power grade of 4/5 in right upper and lower limbs. She underwent Caesarean section for breech presentation, which was done under general anaesthesia in view of prior spinal cord lesion. She was discharged for follow-up in Neurology outpatient clinic and physical rehabilitation. At follow up after 12 months of delivery, she had complete motor and sensory recovery. Management of spinal cord lesions in pregnancy and delivery requires specialist multidisciplinary care due to risk of medical and obstetric complications. This case demonstrates a rare scenario of a primigravida at term gestation with residual deficits of a past spinal cord lesion.

Spinal Nerve Block and Recovery after Spinal Anesthesia in Frail Patients - a Prospective Cohort Study

BackgroundFrailty in surgical patients is associated with significantly higher incidences of perioperative mortality and complications. Although neuraxial anesthesia is preferable alternative to general anesthesia in frail patients, it remains undetermined whether the pharmacodynamic profiles of local anesthetics used in intrathecal spinal nerve blocks are altered in this population.MethodsThis prospective observational cohort study recruited 62 patients scheduled for operations that were able to be performed under spinal anesthesia between April 22 to June 30, 2020 in our hospitals. Levels of dermatome blockage after spinal anesthesia and the recovery of spinal nerve sensory and motor function were recorded.ResultsThe prevalence of frailty in patients receiving spinal anesthesia in this study was 25.8%. Compared with non-frail patients, frail patients were significantly older, had a higher proportion of females, and tolerated less intense metabolic equivalent activities. The pre-surgical incision sensory blockage levels were not different between frail and non-frail patients following intrathecal administration of similar dose of bupivacaine. Time intervals to pain sensation at surgical sites (sensory recovery) and voluntary knee flexion (motor recovery) were also similar between the frail and non-frail groups. But, frail patients were associated with more episodes of hypotension and required more vasopressors during operations.ConclusionOur study illustrates that bupivacaine sensitivity in spinal nerve blocks is not significantly affected by frailty. However, special attention should be paid to correct intraoperative hypotension after spinal anesthesia in frail patients.

Restoring Sensorimotor Function Through Neuromodulation After Spinal Cord Injury: Progress and Remaining Challenges

Spinal cord injury (SCI) is a major disability that results in motor and sensory impairment and extensive complications for the affected individuals which not only affect the quality of life of the patients but also result in a heavy burden for their families and the health care system. Although there are few clinically effective treatments for SCI, research over the past few decades has resulted in several novel treatment strategies which are related to neuromodulation. Neuromodulation—the use of neuromodulators, electrical stimulation or optogenetics to modulate neuronal activity—can substantially promote the recovery of sensorimotor function after SCI. Recent studies have shown that neuromodulation, in combination with other technologies, can allow paralyzed patients to carry out intentional, controlled movement, and promote sensory recovery. Although such treatments hold promise for completely overcoming SCI, the mechanisms by which neuromodulation has this effect have been difficult to determine. Here we review recent progress relative to electrical neuromodulation and optogenetics neuromodulation. We also examine potential mechanisms by which these methods may restore sensorimotor function. We then highlight the strengths of these approaches and remaining challenges with respect to its application.

Artery-Only Fingertip Replantation Distal to the Lunula: A Retrospective Analysis of Clinical Results

Background: Both arterial and venous repair are crucial for optimal results in digital replantation. However, anastomosis of veins becomes challenging in very distal fingertip amputation. This study aimed to report the clinical results of an artery-only replantation without vein repair for a distal fingertip amputation and to analyze the survival rate and clinical outcomes based on the amputation level. Methods: We performed a retrospective review of 47 digits in 38 patients who had undergone fingertip replantation with a mean follow-up period of 12 months. All patients had complete fingertip amputation distal to the lunula. Only one central artery repair distal to the arch was performed. All patients received the postoperative protocol including external bleeding and anticoagulation therapy. Results: By Ishilawa’s classification, 12 digits in subzone I, and 35 digits in subzone II. 31 of the 47 fingertip replantations (66%) were successful, and a significantly higher survival rate was observed in subzone I than in subzone II. The mean total active motion of surviving digits was 86% of normal side. The mean grip strength was 82% of normal side. The sensory recovery according to modified Highet and Saunders’ classification was S4, S3+, S3, and S2 in fingers 19, 2, 5 and 3, respectively. Conclusions: 66% of survival rate was achieved in fingertip replantation distal to lunula which including large number of crushing/avulsion injury. The result of comparison for the survival rate based on amputation level, a significantly higher survival rate was observed in subzone I compared to subzone II. Therefore, the artery-only fingertip replantation had a better indication for distal amputation, and an aggressive attempt for venous anastomosis or drainage, including a secondary surgery for proximal amputation could be attributed to a higher success rate.

Comparative assessment of fingertip replantation in paediatric and adult patients within a single institution

The purpose of this retrospective study was to compare the outcomes of paediatric and adult fingertip replantation within a single institution. Our retrospective study found no significant difference in the survival rate between the paediatric (10/12) and adult (22/26) groups. At 6 months follow-up, there was no significant difference in sensory recovery between both groups, as measured with Semmes–Weinstein testing, but a significant difference in mean static two-point discrimination testing values between the paediatric (4.0 mm) and adult (6.2 mm) groups. Moreover, the mean time for regaining sensation was faster in paediatric patients (1.3 months) as compared with adult patients (4.1 months). Five children and four adults received erythrocyte transfusion. Paediatric fingertip replantation has similar survival rates, faster and better sensory nerve recovery as compared with adults despite a higher erythrocyte transfusion rate. Although technically demanding, paediatric fingertip replantation is recommended, whenever possible, because of the good outcomes achievable. Level of evidence: IV

Injuries of the Peripheral Mandibular Nerve, Evaluation of Interventions and Outcomes: A Systematic Review

Trigeminal nerve injuries are common and there is currently no consensus on both timing and type of intervention to achieve the best outcomes. A systematic review was performed to compare the outcomes of the many different types of therapeutic interventions for nerve injury. PubMed, EBSCO, and Cochrane Review databases were used to search for studies published from January 1, 2000 to December 31, 2019. Included studies detailed treatment of an injury to peripheral branches of the trigeminal nerve, either known transection or injury causing persistent alteration in sensation. The primary outcome was functional sensory recovery via the Medical Research Council scale. Twenty studies were included, detailing outcomes of 608 subjects undergoing intervention for 622 nerve injuries. Surgical interventions were able to achieve functional sensory recovery in approximately >80% or more of the subjects. There was heterogeneity among how procedures were performed, timing to intervention, and methods of measuring recovery. The data of this study supports the ability of surgical intervention to achieve functional sensory recovery in a significant number of subjects, and found evidence for better outcomes with intervention closer to the time of injury.