Impact of nerve surgery on opioid and medication use in patients with chronic nerve injuries

Introduction: Limited information is available regarding the ability of nerve surgery to affect medication use patterns in patients with chronic pain or neuropathy due to nerve injury. Methods: A retrospective survey was distributed to all operative patients (N = 767) from a single nerve surgeon\u27s practice between 2014 and 2020. Data collected included demographics, specifics of the injury and symptoms, medication and opioid use before surgery, and medication/opioid use following surgery. Results: Out of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years; 68.9% female and 31.1% male. More than 50% of the patients took at least three medications. More than 50% of the patients after surgery did not need medication or had significant reduction; 54.1% of the patients took opioid medication daily, and 97.3% of patients reported that narcotic medications did not resolve their problem. Patients rated the effectiveness (Likert scale 0-10) of opioid medications in general at an average 3.25 ± 2.03. Of patients who took opioids regularly, 61.6% reported a negative effect of these medications on daily or professional activities. After surgery, more than 50% of the patients did not need opioids or had a significant reduction in opioid usage. Conclusions: Untreated nerve injuries lead to ongoing chronic pain, explaining why medications are mostly ineffective in eliminating symptoms. In this study, nerve surgery targeting the anatomical source of symptoms effectively reduced both opioid and nonopioid medication use

The SIEA SHRIMP flap: An ultrathin axial pattern free flap useable in obese patients

The reconstruction of distal extremity wounds poses a unique surgical challenge. In free tissue transfer, a thin, pliable skin flap is the ideal. Obese patients have a paucity of thin skin donor sites. Herein we report the discovery of a free SHRIMP flap (Superthin Harvest of a Reliable Islanded Medial Pannus flap) based on the SIEA vessels, harvested from a thick abdominal pannus at the time of cosmetic abdominoplasty. A 61-year-old woman with a chronic wound of the right Achilles tendon was evaluated for reconstruction after failing conservative measures. At the time of consultation, the patient expressed interest in abdominoplasty. Therefore, a skin flap from the abdomen or rectus abdominis muscle flap in the context of an abdominoplasty was offered. Despite obesity affecting the pannus, the superficial inferior epigastric vessels were found to course superficially beneath the dermis at time of abdominoplasty. This allowed straightforward harvest of a superthin flap of skin and minimal subcutaneous fat, which contoured to the ankle with an aesthetically pleasing outcome. The patient was satisfied with the results of her abdominoplasty and coverage of her chronic wound. The SHRIMP flap provides a straightforward, axial pattern, superthin free skin flap based on the superficial inferior epigastric vessels, and represents a useful option in obese patients. The flap can be combined with abdominoplasty for an aesthetic donor site

Failed targeted muscle reinnervation: Findings at revision surgery and concepts for success

Although it was initially described for improved myoelectric control, targeted muscle reinnervation (TMR) has quickly gained popularity as a technique for neuroma control. With this rapid increase in utilization has come broadening indications and variability in the described technique. As a result, it becomes difficult to interpret published outcomes. Furthermore, there is no literature discussing the management of failed cases which are undoubtedly occurring. Methods: This is a retrospective case series of two patients who underwent revision surgery for failed TMR. The authors also review the current literature on TMR and outline technical and conceptual pitfalls and pearls based on our local experience. Results: Excessive donor nerve redundancy, kinking, donor-recipient nerve size mismatch, superficial placement of the nerve coaptation, inappropriate target selection, and incomplete target muscle denervation were identified as technical pitfalls of TMR surgery. Techniques to avoid these pitfalls were described. Conclusions: Although TMR has been a major development in amputee care for both pain management and improved myoelectric control, it is important to acknowledge that it is not a foolproof surgery and does not provide a guaranteed result. Failed cases of TMR represent opportunities to learn about factors contributing to unfavorable outcomes and refine our techniques empirically

Growth of Inflaton Perturbations and the Post-Inflation Era in Supersymmetric Hybrid Inflation Models

It has been shown that hybrid inflation may end with the formation of non-topological solitons of inflaton field. As a first step towards a fully realistic picture of the post-inflation era and reheating in supersymmetric hybrid inflation models, we study the classical scalar field equations of a supersymmetric hybrid inflation model using a semi-analytical ansatz for the spatial dependence of the fields. Using the minimal D-term inflation model as an example, the inflaton field is evolved using the full 1-loop effective potential from the slow-rolling era to the U(1)_{FI} symmetry-breaking phase transition. Spatial perturbations of the inflaton corresponding to quantum fluctuations are introduced for the case where there is spatially coherent U(1)_{FI} symmetry breaking. The maximal growth of the dominant perturbation is found to depend only on the ratio of superpotential coupling \lambda to the gauge coupling g. The inflaton condensate fragments to non-topological solitons for \lambda/g > 0.09. Possible consequences of non-topological soliton formation in fully realistic SUSY hybrid inflation models are discussed.Comment: 27 pages LaTeX, 8 figures. Additional references and discussio

Vanishing Cosmological Constant in Modified Gauss-Bonnet Gravity with Conformal Anomaly

We consider dark energy cosmology in a de Sitter universe filled with quantum conformal matter. Our model represents a Gauss-Bonnet model of gravity with contributions from quantum effects. To the General Relativity action an arbitrary function of the GB invariant, f(G), is added, and taking into account quantum effects from matter the cosmological constant is studied. For the considered model the conditions for a vanishing cosmological constant are considered. Creation of a de Sitter universe by quantum effects in a GB modified gravity is discussed.Comment: 8 pages latex, 1 figure. To appear in Int. J. Mod. Phys.