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Biomedical subjects

A Lee Dellon

Publications and source records attributed to A Lee Dellon.

At least 19 recordsLinked to original sources
PubMed2006

From there to here: a personal viewpoint after three decades of neuropathy research.

Currently there is unprecedented interest in research, writing, and clinical experience related to lower extremity peripheral nerve surgery. Its time is here, now. Application of the concepts for diagnosis and treatment of nerve compression, painful neuroma, and neuropathy has been a direct extension from the upper extremity to the lower extremity. By the end of 2005, there were more than a dozen studies demonstrating that the basic neuropathy causes metabolic changes that render the peripheral nerve susceptible to chronic nerve compressions. My hypothesis continues to assert that surgical decompression of known sites of compression can relieve symptoms of neuropathy that are caused by superimposed nerve compressions.

Decompression, Surgical↗
PubMed2006

Prognostic ability of a good outcome to carpal tunnel release for decompression surgery in the lower extremity.

For years, patients who were treated successfully with carpal tunnel release were told there was nothing that could be done about their lower extremity symptoms. Now that lower extremity nerve decompression has been accepted as an option to treat appropriate patients, the authors looked for correlations between a successful outcome with carpal tunnel syndrome and its predictive value of success for lower extremity nerve decompression. Data from a recent study demonstrate that a good result from upper extremity peripheral nerve surgery predicts the outcome for lower extremity peripheral nerve surgery in 88% of patients, and is, therefore, information valuable for prognosis and clinical decision-making.

Animals↗
PubMed2006

Salvage of sensation in a hallux-to-thumb transfer by nerve tube reconstruction.

We report a patient in whom, at 3 years after successful reconstruction of a right avulsed thumb with a microvascular hallux transfer, the insensate transfer had sensibility restored. The radial sensory and both volar digital nerves of the thumb were reconstructed using 2.3-mm-diameter bioabsorbable neural conduits. At 30 months after reconstruction, static 2-point discrimination of the hallux was 4 mm at 14.7 g/mm(2) in this now 42-year-old right-handed man. The cutaneous pressure threshold for 1-point static touch was 0.7 g/mm(2). There were no painful neuromas at the nerve reconstruction sites.

Absorbable Implants↗
PubMed2006

Radial sensory neurotization of the thumb and index finger for prehension after proximal median and ulnar nerve injuries.

Proximal median nerve injuries are functionally disabling, secondary to both motor and sensory deficits. Reestablishment of sensation relies on slow axonal regeneration originating from the site of injury after either primary nerve repair or the use of autogenous nerve grafts. This regeneration can take 2 or more years to restore sensation to the hand, depending on injury location. Distal sensory nerve transfers shorten the recovery time by decreasing the required regeneration distance. The authors present two case reports of patients with proximal median nerve injury, who underwent radial sensory nerve transfers to the ulnar digital nerve of the thumb and the radial digital nerve of the index finger. Protective sensation returned to the index and thumb fingertips at 3 months. By 6 months, both patients attained sufficient sensation to permit active lateral key pinch. At 9 months, each patient had moving sensation; and by 14 months, each patient attained proper localization. Successful digital nerve transfers of the dorsal radial sensory nerves in patients with high proximal median nerve injuries return sensation faster than traditional median nerve repairs. Use of this technique will significantly reduce the insensate time in patients with this unfortunate injury.

Adult↗
PubMed2006

Decompression of the lateral femoral cutaneous nerve in the treatment of meralgia paresthetica.

Meralgia paresthetica (MP) is a painful mononeuropathy of the lateral femoral cutaneous nerve (LFCN). Neurolysis is reserved for patients with MP who respond poorly to medical management. This study retrospectively evaluated the outcomes of 41 patients who underwent either unilateral or bilateral neurolysis of the LFCN for a total of 48 procedures. Twenty-nine procedures involved neurolysis of the LFCN alone and 19 procedures involved neurolysis of the LFCN and resection of one or more additional nerves (ilioinguinal, iliohypogastric, genitofemoral). Overall, surgical outcome was considered by patients to be successful in 77 percent of cases. LFCN neurolysis alone had better results, compared to combined LFCN neurolysis and nerve resection. The conclusion is that neurolysis of the LFCN is an effective treatment for MP in properly selected patients.

Adult↗
PubMed2006

Use of the tourniquet in reconstructive surgery in patients with previous ipsilateral lower extremity revascularization: is it safe? A survey.

Tourniquet use in the previously revascularized ipsilateral lower extremity varies among micro-reconstructive surgeons due to the possible complication of graft failure. Examination of evidence-based literature and a current standard of care is needed to establish guidelines for such tourniquet use. Surveys were sent to vascular surgery program directors of ACGME-accredited residency programs to assess prevailing tourniquet use instruction. The survey addressed issues, including tourniquet use in previous bypass surgery, previous angioplasty, and location relative to graft anatomy. Twenty-eight responses were received out of 87 surveys sent (32 percent response rate). Ninety-three percent considered tourniquet use inappropriate in the ipsilateral lower extremity with previous revascularization. Seventy-one percent indicated tourniquet use inappropriate in previous ipsilateral angioplasty. Sixty-one percent regarded graft conduit type to be important in tourniquet use. There remains a lack of prospective, randomized, controlled studies determining risks of occlusion and other complications to the preexisting bypass graft during tourniquet use. Until such studies are done, this survey recommends avoiding tourniquet use in this patient population.

Angioplasty↗
PubMed2006

Innervated free flaps for foot reconstruction: a review.

Whether to provide a sensate plantar weight-bearing flap to reconstruct the foot remains an unanswered, but frequently asked, question. It has been more than a decade since Graham and Dellon reviewed this subject. Increasing emphasis on outcome analysis of microsurgical reconstruction has prompted this new review. All published peer-reviewed literature related to reconstruction of the plantar surface of the foot was reviewed to identify whether the flaps were 1) local, regional or distant; 2) innervated or non-innervated and, if innervated, then 3) identified as to the donor and the recipient peripheral nerves. Outcome measures included direct measurement of sensibility, development of ulceration, and activities of daily living. It was concluded that it is still not possible to determine that innervated flap reconstruction of the weight-bearing portion of the foot is critical for either durability or ambulation. It is recommended that the original nerves that innervate the flap be blocked prior to harvest to improve flap design, i.e., that the flap actually contains the intended nerve. It is recommended that appropriate donor nerves are selected to innervate the flaps, e.g., the calcaneal nerve should be used to reinnervate heel reconstructions (rather than the sural nerve), and medial/lateral plantar branches be used to reinnervate the arch and the forefoot. Reinnervating a muscle flap with a sensory nerve will permit reinnervation of the muscle and the overlying skin, but whether this provides a superior result in durability and gait remains to be seen.

Foot↗
PubMed2006

Relationship between peripheral nerve decompression and gain of pedal sensibility and balance in patients with peripheral neuropathy.

This was an initial exploratory study to determine if decompression of the 4 medial ankle tunnels (neurolysis of the tibial, medial and lateral plantar, and calcaneal nerves) could lead to improved foot sensibility, increased proprioception and balance, and decreased falls in a population of patients with impaired lower extremity sensation. Fourteen patients with peripheral neuropathy were included in this study. Seventy-one percent of patients were females. Average age was 67 years. All patients were evaluated preoperatively and postoperatively to assess their lower extremity sensibility, as well as their ability to stand still, maintaining their balance with their eyes open and then closed, which is defined as "sway." Lower extremity sensibility was measured with the Pressure-Specified Sensory Device (PSSD), which evaluates 1- and 2-point discrimination for the pulp of the big toe and medial heel. The MatScan Measurement System measured each patient's sway. Neuropathy was the result of diabetes in 72% of patients, a combination of diabetes and hypothyroidism in 7%, chemotherapy in 7%, and idiopathic in 14%. Eight patients underwent peripheral nerve decompression on 1 lower extremity, whereas 6 patients underwent bilateral lower extremity peripheral nerve decompression. Mean toe and heel sensibility improved 9% and 7%, respectively, in the unilateral group, whereas the bilateral group experienced an improvement in mean toe and heel sensibility of 42% (P = 0.02) and 32%, respectively. Preoperative and postoperative sway comparison in the unilateral group revealed a reduction in sway with eyes open and eyes closed by 5% and 31%, respectively. Comparison of preoperative and postoperative sway in the bilateral group showed a reduction with eyes open and eyes closed by 23% and 145% (P = 0.05), respectively. This initial study suggests that there may be benefit from bilateral lower extremity peripheral nerve decompression in helping improve pedal sensibility and balance within the peripheral neuropathy patient population, although further investigation with a larger sample size is warranted to further evaluate these preliminary findings.

Aged↗
PubMed2006

The clinical importance of variations in the surgical anatomy of the superficial peroneal nerve in the mid-third of the lateral leg.

The superficial peroneal nerve (SPN) provides fundamental motor and sensory innervation to the leg and foot. A variety of surgical procedures is performed in the vicinity of this nerve, requiring that the surgeon be familiar with its specific anatomy. We dissected 111 legs to define the anatomic position of the SPN and found that the nerve had 4 distinct variations in location. In 77 (69.4%) specimens, the nerve coursed within the lateral compartment of the leg, while in 18 (16.2%) of the legs, the nerve split and contained branches in both the lateral and anterior compartments. The nerve in 7 (6.3%) legs was found within the intermuscular septum, and in 9 (8.1%) of the specimens, the SPN traveled only within the anterior compartment. These results confirm 4 anatomic variants of the SPN, which will aid surgeons in locating the nerve in the lateral aspect of the leg.

Decompression, Surgical↗
PubMed2006

Wound healing in denervated tissue.

Sacral and trochanteric pressure sores in patients with plegias, and foot ulceration in patients with diabetic neuropathy, are similar because these wounds occur in tissues that do not have normal innervation. While it is recognized that insensitive tissue increases the likelihood of ulceration and recurrence of ulceration, this review attempts to answer the question, Is wound healing impaired in denervated tissue? A review of the scientific literature of the past 35 years demonstrates that all phases of wound healing are impaired in denervated tissue, and these mechanisms are different from those related to one of the underlying diseases, diabetes. Understanding the value of innervation, a goal of wound healing should be to seek strategies that provide reinnervation to these at-risk tissues.

Animals↗
PubMed2005

Painful foot neuromas after toe-to-thumb transfer.

Reconstruction of the thumb by transfer of a toe has evolved technically to the point that this complex procedure can result in a mobile, sensate, and aesthetically pleasing digit that contributes to an almost-normally functioning hand. Donor site deformity is well recognized, primarily as it relates to the appearance of the foot after transfer of the hallux to the thumb position and stiffness of the remaining portions of the big toe. The present report describes donor site disability related to painful neuromas of the superficial and deep peroneal nerves and the common plantar digital nerve to the first webspace. Salvage of the disabled donor foot is possible by applying techniques used to treat painful neuromas of the upper extremity, neuroma resection, and muscle implantation. The specific techniques used in treating this painful foot donor site after toe-to-thumb transfer are described.

Adult↗
PubMed2005

Anatomy of pudendal nerve at urogenital diaphragm--new critical site for nerve entrapment.

OBJECTIVES: To investigate the relations of the pudendal nerve in this complex anatomic region and determine possible entrapment sites that are accessible for surgical decompression. Entrapment neuropathies of the pudendal nerve are an uncommon and, therefore, often overlooked or misdiagnosed clinical entity. The detailed relations of this nerve as it exits the pelvis through the urogenital diaphragm and enters the mobile part of the penis have not yet been studied. METHODS: Detailed anatomic dissections were performed in 10 formalin preserved hemipelves under 3.5x loupe magnification. The pudendal nerve was dissected from the entrance into the Alcock canal to the dorsum of the penis. The branching pattern of the nerve and its topographic relationship were recorded and photographs taken. RESULTS: The anatomic dissections revealed that the pudendal nerve passes through a tight osteofibrotic canal just distal to the urogenital diaphragm at the entrance to the base of the penis. This canal is, in part, formed by the inferior ramus of the pubic bone, the suspensory ligament of the penis, and the ischiocavernous body. In two specimens, a fusiform pseudoneuromatous thickening was found. CONCLUSIONS: The pudendal nerve is susceptible to compression at the passage from the Alcock canal to the dorsum of the penis. Individuals exposed to repetitive mechanical irritation in this region are especially endangered. Diabetic patients with peripheral neuropathy can have additional compression neuropathy with decreased penile sensibility and will benefit from decompression of the pudendal nerve.

Cadaver↗
PubMed2005

Reconstruction of the spinal accessory nerve with autograft or neurotube? Two case reports.

Injury to the spinal accessory nerve is most commonly iatrogenic, but can be related to cervical trauma or resection of tumor. Of the two most recent publications related to injury of the spinal accessory nerve, one describes transfer of the levator scapulae muscle to restore shoulder function, while the other reports on the results of six surgical repairs, three of which used a sural nerve graft to reconstruct a short neural defect. The present report describes the results obtained in two patients when an iatrogenic injury to the XIth nerve was reconstructed at 3 months after the loss of shoulder function. Denervation of the XIth nerve was confirmed by a first EMG at 6 weeks, and a second one at 12 weeks. At surgery, each XIth nerve was found to have an in-continuity neuroma, most probably related to electrocoagulation. Intraoperative electrical stimulation did not pass the region of nerve injury. In the first patient, the XIth nerve was reconstructed with an autograft from the greater auricular nerve. In the second patient, the XIth nerve was reconstructed with a bioabsorbable conduit, the Neurotube. The patient with the Neurotube reconstruction reached M5 trapezius function by 3 months after surgery, and had no nerve graft donor-site morbidity, while the patient with the autograft reached M4 function by 6 months after reconstruction, and has persistent numbness of the ear lobe. This is the first reported case of a cranial motor nerve being reconstructed with a bioabsorbable conduit.

Accessory Nerve↗
PubMed2005

Superficial peroneal nerve anatomic variability changes surgical technique.

UNLABELLED: Entrapment of the superficial peroneal nerve is an uncommon entrapment that occurs in sports trauma or fracture and dislocation as the nerve comes under pressure between the underlying muscles and the overlying fascia. Although the superficial peroneal nerve traditionally is depicted as being in the lateral compartment, we have found it in the anterior compartment in some patients. We hypothesized that patients with entrapment of the superficial peroneal nerve were more likely to have this anatomic variant than the normal population and that surgical decompression of both compartments would improve clinical outcome versus the historic surgical approach of decompressing just the lateral compartment. We retrospectively reviewed the location of the superficial peroneal nerve in a consecutive series of 35 limbs in 31 patients with entrapment of the superficial peroneal nerve. The results showed that the location of the superficial peroneal nerve was not different from the reported normal variation. However, the location of the superficial peroneal nerve in the anterior compartment in 47% of the patients in this series suggests that surgeons must explore the anterior and the lateral compartments in each patient with entrapment or neuroma of the superficial peroneal nerve. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series-no, or historical, control group). See the Guidelines for Authors for a complete description of levels of evidence.

Evidence-Based Medicine↗
PubMed2005

Abdominal wall neuroma pain after breast reconstruction with a transverse abdominal musculocutaneous flap: cause and treatment.

Breast reconstruction with either a pedicled or microvascular transfer of the transverse rectus abdominus musculocutaneous flap, whether with or without the muscle, is now the standard of care when patients choose an autologous form of reconstruction. Complications related to flap loss and abdominal wall weakness have been well described. Complications related to painful neuromas of the intercostal nerves, ilioinguinal and iliohypogastric nerves have not been described previously. The diagnosis and treatment of pain related to neuromas of the abdominal wall is discussed in this paper.

Abdominal Neoplasms↗
PubMed2005

Postarthroplasty "palsy" and systemic neuropathy: a peripheral-nerve management algorithm.

Postarthroplasty palsy, occurrence of dysfunction of the sciatic or peroneal nerve after total joint replacement of the hip or knee, is a complication that remains poorly understood. Characteristics of a series of 24 patients with postarthroplasty palsy are reviewed, with the finding that, overall, 58.4% of the patients had an underlying peripheral neuropathy. The role of this neuropathy predisposing the arthroplasty patient to stretch/traction injury is discussed and should be emphasized as a risk factor prior to surgery and should influence the surgeon's intraoperative use of force during the arthroplasty procedure. This clinical problem is addressed from the perspective of peripheral nerve surgery, with an algorithm suggested for its management. The algorithm suggests that if a peroneal palsy is still present at 3 months after an arthroplasty and neurosensory testing fails to demonstrate a sensory reinnervation pattern in the territories of the deep or superficial peroneal nerve, then surgical neurolysis of the common peroneal nerve is indicated.

Algorithms↗