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Harvest of Supraspinal Nerve Grafts

Anatomy of the Sural Nerve
The sural nerve consists of two parts: a medial sural cuteus nerve and lateral sural cuteus nerve.

This nerve arises from the tibial nerve just below the knee joint and runs downward between the gastronemius heads.

Located on the posterolateral side of the calf, the lateral sural cutaneous nerve arises from the common peroneal nerve.

A sensory cutaneus nerve (also known as short saphenous nerve), except for some unmyelinated autonomic fibers, emerges from the root of the S1 or S2 nerve.With a relatively easy technique, up to 25 cm of nerve graft can be harvested. The sural nerve innervates the lateral third of the leg, the side of the foot, the heel, and the side of the ankle. Sural nerve grafts are frequently used as cable grafts.

Indications

The graft is accessible to the distal and proximal segments of an intact motor or sensory nerve.

Contraindications

Peripheral neuropathy with compromised sensation to the lower extremity may also create a contraindication if the patient requires intact foot and lower leg sensation (for employment or sports reasons).

Graft Harvesting Technique

It is best to identify the sural nerve approximately 2 cm posterior to the lateral malleolus and approximately 2 to 3 cm proximal. In this area, it has not undergone significant branching.It is necessary to make a longitudinal incision in the region above, and if the saphenous vein is visible, the nerve or a branch of it is close by. The nerve can be traced proximally through this incision or through a series of “stairstep” transverse incisions.

After exposing the nerve proximally and distally, the nerve is cut proximally and distally and placed on moist gauze. The proximal incisions are determined by gently pulling the nerve at the distal incision.Sutures of 4-0 Vicryl are used to close the donor site, and staples or nylons are used to close the skin.

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Tic douloureux

Trigeminal neuralgia, also known as tic douloureux, is a chronic pain condition that causes burning or shock-like pain in the face. Nicolaus Andre, a French physician, coined the term “tic douloureux” in 1756 in reference to the facial spasms that can occur during severe pain attacks.

The pain that occurs in short, unpredictable episodes rarely lasts more than a few seconds or a minute or two in a trigeminal neuralgia attack. The pain can feel like an electric shock or can be described as a sharp shooting pain.

Generally, trigeminal neuralgia affects just one side of the face. The pain is felt on the lower part of the face. Trigeminal neuralgia can progress to cause longer, more frequent attacks of searing pain.

The pain can sometimes affect both sides of the face, though not always at the same time.

The intensity of pain can be physically and psychologically incapacitating. People with tic douloureux may have regular attacks for days, weeks or months at a time. In severe cases attacks may happen hundreds of times a day.

Even though it can be debilitating, this disorder does not pose a life-threatening threat. A spontaneous remission is possible, although most people experience episodes over a long period of time.

The anatomy of the trigeminal nerve

This nerve supplies the face with sensory information and provides motor and sensory input to the masticatory muscles. It is a fifth cranial nerve (CN V).

Three trigeminal nerves split off from the trigeminal nerve (trigeminal = threefold):

  1. Ophthalmic (V1): Supplies the eye, upper eyelid, and the forehead
  2. Maxillary (V2): Supplies lower eyelid, cheek, nostril, upper lip, and upper gum
  3. Mandibular (V3): Supplies the lower lip, lower gum, jaw and the muscles of mastication

The mandibular division of the trigeminal nerve provides somatic motor innervation for the chewing muscles. The trigeminal nerve is a mixed nerve and it supplies the general somatic sensory function for touch, temperature, and pain in the face.

This figure shows the fifth cranial nerve, the trigeminal nerve.

Tic douloureux causes

Trigeminal neuralgia, also known as tic douloureux, occurs when the trigeminal nerve’s function is disrupted. Most cases result from compression of the trigeminal nerve root near its entry point into the pons.The problem is usually caused by a contact between a blood vessel – in this case, an artery or a vein – and the trigeminal nerve at the base of your brain. This pressure puts pressure on the nerve, causing it to malfunction.

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There is a wide variety of possible causes of neuralgia, and it can affect different parts of the body.

Trigeminal Neuralgia: Angioneuropathy involves pain from the trigeminal nerve, which travels from the brain to the face. It’s believed that a blood vessel presses against the trigeminal nerve at the point where it meets the brainstem.Trigeminal neuralgia causes pain in the face, usually on one side, and is most common in the elderly.

Postherpetic Neuralgia: This type of neuralgia occurs as a complication of shingles and may occur anywhere on the body. Shingles is caused by a virus that causes a blistering rash.There is an increased risk of neuropathy occurring in the area where the shingles outbreak occurred, and it may be mild, moderate, or severe, persistent, or intermittent, and may last for months or years.

Glossopharyngeal Neuralgia: Glossopharyngeal neuralgia produces neck and throat pain. It is not quite as common as cranial neuralgia.

Causes of Neuralgia

Any type of neuralgia is caused by damage to a nerve. Your body’s nerves are covered by a protective sheath called the myelin sheath. When this is damaged or worn away, you experience the stabbing, severe, shock-like pain that is characteristic of neuralgia.

There are numerous factors, including old age, that can cause myelin damage. Unfortunately, the cause of neuralgia is often never determined.

A variety of infections can cause postherpetic neuralgia, including chicken pox, shingles, Lyme disease, and HIV. Syphilis can also trigger the condition.

Multiple Sclerosis: There are many symptoms associated with multiple sclerosis (MS), including facial nerve pain. MS is caused by degradation of myelin.

Pressure on Nerves: Several different pressure sources can wear away the myelin on nerves, including bones, ligaments, blood vessels, and tumors. The pressure of swollen blood vessels is a common cause of trigeminal neuralgia.

Diabetes (Diabetic Neuropathy):There is a high probability that people with diabetes will experience some form of neuralgia because excess glucose in the bloodstream can damage the myelin.

Less Common Causes: In cases where neuralgia cannot be attributed to infections, multiple sclerosis, diabetes, or pressure on the nerves, it may be due to one of many less common factors. These include:

  • chronic kidney disease
  • porphyria (a rare blood disease)
  • medications like cisplatin, paclitaxel, or vincristine (prescribed to cancer patients)
  • trauma, such as that caused by surgery
  • chemical irritation
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A systematic review of the literature and an illustrated case report on Scalp Cirsoid Aneurysm

Scalp cirsoid aneurysms are arteriovenous fistulas in the scalp without vascular access to the brain.

Draining veins dilatation can cause headache, tinnitus, and hemorrhage, as well as cosmetic concerns, masses, and local pain.

The etiopathogenesis of this condition is poorly understood. Treatment consists of surgery (fistula repair by simple surgical ligation until gross total resection), embolization (either endovascular or percutaneous), or a combination of both.

The last 10 years’ publications were reviewed in an updated systematic review.

A young boy with a posttraumatic cirsoid aneurysm with compelling documentation of head vascular examinations and multiple treatment options is described as well.The use of coils and cyanoacrylate for percutaneous embolization or endovascular embolization, respectively)This is accompanied by a reduction of pulsatile mass.

The final esthetic result was extremely pleasing due to a cosmetic surgery team that performed gross total resection.

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How to deal with Scalp Lacerations with this “HAT” trick!

How many of you have heard of the Hair Apposition Technique, or perhaps even used it on a patient? I figured it existed since 2002, but have only learned about it recently!

Hair Apposition Technique, or HAT trick, is a creative method of approximating the scalp lacing by using the patient’s own hair as sutures.

Let me explain the steps:

  1. Irrigate your wound as usual, inspect for foreign bodies
  2. Pull together 3-7 strands of hair on one side of the wound.
  3. Do the same on the other side of the wound.
  4. Twist these two hair bundles in 360-degree revolutions. Do not tie a knot
  5. Secure the intertwined hair bundles by applying a few drops of Dermabond.
  6. Repeat as needed to close the length of the laceration.

If your patients have short hair, don’t worry, you can still use the HAT trick; all you need is two pairs of clamps.

Traditional staples/sutures have 3 advantages over them : 1) Zero pain (especially useful in kids; just tell them you’re braiding their hair!) 2) No need to anesthetize the wound (forget waiting for your nurses to first apply LET, then waiting more for it to kick in) 3) No need to return to ED for removal! The hair will unravel on its own after a week.

A quick tip for preventing loose hairs from entering your field of repair! When you try to staple Goldberg’s latest scalp lac and his hair keeps falling in, try using petroleum-based ointment instead. Apply ultrasound jelly (or grease) around the area to smooth down the strands, and spread them out to the sides as follows:

Using this method, you will not only be able to visualize the lac more clearly, but you will also be able to avoid trapping hair within the lac, which could cause wound dehiscence, a foreign body reaction, or local cellulitis.

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Foot drop can be treated through peroneal or tibial nerve transfer operations

Patients with foot drop have difficulty lifting the front part of their foot and toes. Despite its debilitating nature, current treatment options are limited. 

The term “foot drop” may seem simple, but it describes an often-complicated condition in which the foot is unable to elevate at the ankle, resulting in difficulty walking and a floppy appearance. Foot drop is caused by a number of factors, but one important factor is damage to the nerves controlling the leg muscles that bend and lift the front part of the foot and toes.As a result, people either drag their feet and toes or walk with high steps referred to as the ‘steppage’ gait.Foot drop often leads to pain or discomfort neurological symptoms, such as tingling or burning. This way of walking requires more effort and in time may lead to other problems, such as back or hip pain.

The peroneal nerve is a group of muscles that runs from the back of the knee around to the front of the shin and provides movement (motor control) and sensation to the lower leg, foot, and toes.Moreover, as this nerve supplies the tibialis anterior muscle (TAM), which lifts the foot, any damage disrupting the motor control pathway between the peroneal nerve and TAM can result in foot drop.Consequently, the peroneal nerve can be damaged by injuries such as sports injuries, gunshot wounds, hip replacements, childbirth, or diabetic complications as it lies close to the surface of the skin.Foot drop can also be caused by multiple sclerosis, a stroke, spinal cord damage, or cerebral palsy.

Handling foot drop ups and downs

Figure 1: The incision at the popliteal fossa.

The extent and cause of foot drop determine the types of treatment available. An orthosis (ankle-foot orthosis) can be fitted to help support the foot and improve walking ability, but many users find them uncomfortable and unhygienic.

Nerve stimulators, which apply small electrical charges to the leg, can help some patients gain more mobility. If the nerve does not recover, surgical treatment may be considered. Peroneal nerve decompression is an option for compressed nerves, or tendons may be transferred from one leg to another.In general, however, foot drop is difficult to treat successfully due to the small size of the nerve that is involved (less than 6cm). Nerve grafting is therefore a limited treatment option.

Exposition of the peroneal nerve at the popliteal fossa. (B) A cross-section showing the direction of the fibers to the tibialis anterior at the popliteal fossa.

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