Management of Chronic Facial Pain

Pain persisting for at least 6 months is defined as chronic. Chronic facial pain conditions often take on lives of their own deleteriously changing the lives of the sufferer. Although much is known about facial pain, it is clear that those physicians who treat these conditions should continue elucidating the mechanisms and defining successful treatment strategies for these life-changing conditions. This article will review many of the classic causes of chronic facial pain due to the trigeminal nerve and its branches that are amenable to surgical therapies. Testing of facial sensibility is described and its utility introduced. We will also introduce some of the current hypotheses of atypical facial pain and headaches secondary to chronic nerve compressions and will suggest possible treatment strategies

3D CT ANGIOGRAPHY OF ABDOMINAL WALL VASCULAR PERFORATORS TO PLAN DIEAP FLAPS

Purpose : Since the first report of TRAM flap reconstruction, there have been numerous studies to reduce complications of elective breast reconstruction. Current methods of preoperative perforator localization can be time-consuming, inaccurate, and imprecise. Thus, we sought to evaluate ultra-high resolution 3D CT angiography for the preoperative mapping of DIEAP flap perforating vessels. Methods: We reviewed all perforator-based breast reconstructions performed over a 5-month period. Candidates for DIEAP flap reconstruction were sent for a focused CT scan of the abdominal wall, using the 64 slice multi-detector CT scanner. Results: This article presents our first 23 flaps in 17 patients with preoperative ultra-high resolution 3D CT angiography. The reconstruction plan changed in three patients (18%). There was one take-back for venous congestion, but no partial or total flap loss. Conclusions: Preoperative perforator flap planning for breast reconstruction utilizing 3D CT angiogram is safe, easy to read, and can change the operative plan. Since the first report of the transverse rectus abdominis myocutaneous (TRAM) flap used for reconstruction of the breast after oncologic resection, 1 there have been numerous modifications to reduce the morbidity of breast reconstruction using abdominal autologous tissues. 2-6 Our institution has seen a dramatic increase in perforator flap breast reconstruction over the past 6 years. During the evolution of surgical techniques from the pedicled TRAM flap, to the free TRAM, to the muscle-sparing free TRAM, to the deep inferior epigastric artery perforator (DIEAP) flap and superficial inferior epigastric artery (SIEA) flap, there has been a constant battle between attempts to minimize morbidity to the patient by reducing the dissection of the anterior abdominal wall, while maximizing flap blood flow and viability. It had been shown that partial flap necrosis and fat necrosis rates in DIEAP flaps are higher than those in Free TRAM flaps for breast reconstruction. 7 However, other reports have found little difference. METHODS AND MATERIALS We conducted an IRB-approved review of all perforator-based autologous tissue breast reconstruction patients at The Johns Hopkins Hospital Avon Foundation Breast Center between October 19, 2005 and March 19, 2006. Each patient has had a minimum of 6-months follow-up. Patient Selection All female patients who presented to The Johns Hopkins Hospital Avon Foundation Breast Center for breast reconstruction following mastectomy for treatment or prevention of breast cancer were evaluated for suitability of immediate or delayed breast reconstruction with free autologous tissue transfer versus implant-based reconstruction. Those women who were candidates for DIEAP flap reconstruction were then sent for a preoperative C

Positive effect of neurolysis on diabetic patients with compressed nerves of the lower extremities: a systematic review and meta-analysis

PMCID: PMC4173835BACKGROUND: Despite proven benefits of upper extremity nerve decompression in diabetics, neurolysis for diabetic patients with lower extremity (LE) nerve compression remains controversial. METHODS: A search of ClinicalTrials.gov and Cochrane clinical trials registries, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, CINAHL, SCOPUS, and Google Scholar from 1962 to 2012, yielded 1956 citations. Any potential randomized or quasi-randomized controlled trials and observational cohort studies of diabetics with neurolysis of the common peroneal nerve, deep peroneal nerve, or tibial nerve were assessed. We included articles in any language that 1) provided information about diabetic patients who had neurolysis for symptomatic nerve compression diagnosed by (+) Tinel sign or electrodiagnostic study, and 2) quantified outcomes for pain, sensibility, or ulcerations/amputations. Case reports, review articles, animal or cadaver studies, and studies with 3 months. A meta-analysis of descriptive statistics was performed. RESULTS: Ten clinical series with a mean clinical relevance score of 70% and a mean methodologic quality score of 50% met inclusion criteria. We included 875 diabetic patients and 1053 LEs. Pain relief >3 points on visual analog scale occurred in 91% of patients; sensibility improved in 69%. Postoperative ulceration/amputation incidence was significantly reduced compared to preoperative incidence (odds ratio = 0.066, 95% confidence interval = 0.026-0.164, P < 0.0001). CONCLUSIONS: Observational data suggest that neurolysis significantly improves outcomes for diabetic patients with compressed nerves of the LE. No randomized controlled trials have been published.JH Libraries Open Access Fun

The Positive Effect of Neurolysis on Diabetic Patients with Compressed Nerves of the Lower Extremities: A Systematic Review and Meta-analysis

Background: Despite proven benefits of upper extremity nerve decompression in diabetics, neurolysis for diabetic patients with lower extremity (LE) nerve compression remains controversial. Methods: A search of ClinicalTrials.gov and Cochrane clinical trials registries, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, CINAHL, SCOPUS, and Google Scholar from 1962 to 2012, yielded 1956 citations. Any potential randomized or quasi-randomized controlled trials and observational cohort studies of diabetics with neurolysis of the common peroneal nerve, deep peroneal nerve, or tibial nerve were assessed. We included articles in any language that 1) provided information about diabetic patients who had neurolysis for symptomatic nerve compression diagnosed by (+) Tinel sign or electrodiagnostic study, and 2) quantified outcomes for pain, sensibility, or ulcerations/amputations. Case reports, review articles, animal or cadaver studies, and studies with <10 patients were excluded. We assessed pain relief, recovery of sensibility, and postoperative incidence of ulcerations/amputations at follow-up >3 months. A meta-analysis of descriptive statistics was performed. Results: Ten clinical series with a mean clinical relevance score of 70% and a mean methodologic quality score of 50% met inclusion criteria. We included 875 diabetic patients and 1053 LEs. Pain relief >3 points on visual analog scale occurred in 91% of patients; sensibility improved in 69%. Postoperative ulceration/amputation incidence was significantly reduced compared to preoperative incidence (odds ratio = 0.066, 95% confidence interval = 0.026–0.164, P < 0.0001). Conclusions: Observational data suggest that neurolysis significantly improves outcomes for diabetic patients with compressed nerves of the LE. No randomized controlled trials have been published