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Notalgia paresthetica, possibly an isolated sensory neuropathy involving the posterior primary rami of thoracic nerves T2 through T6, and appearing as pruritus of the back, is apt to be encountered by both dermatologists and neurologists. Two cases illustrate this disorder.
Using the methods of muscle injection of horseradish peroxidase (HRP) and application of HRP to the proximal stump of the cut lateral thoracic nerve (LTN), the motor nucleus of the cutaneous trunci muscle (CTM) has been located predominantly in C8 and T1 spinal cord segments in the ventral and ventrolateral nuclei of Rexed's Lamina IX. Cells of the nucleus are somatotopically arranged rostro-caudally to correspond to the rostro-caudal segmentation. There was a higher average number of HRP-filled cells per section and greater rostro-caudal extent of the nucleus for the cut nerve technique than for the muscle injection technique. Evidence is presented that the CTM is an appendicular muscle in spite of its obvious axial position on the trunk.
BACKGROUND: Transcutaneous electrical nerve stimulation (TENS) has been used extensively to control postoperative pain, but its effects are controversial. This is probably due to the different types of operations performed and, therefore, to the varying intensity of postoperative pain. Here we present an extensive study with TENS in 324 patients who underwent different types of thoracic surgical procedures: posterolateral thoracotomy, muscle-sparing thoracotomy, costotomy, sternotomy, and video-assisted thoracoscopy. METHODS: Each patient cohort was randomly subdivided into three treatment groups: TENS, placebo TENS and control. The effectiveness of TENS was assessed by two factors: the time from the beginning of treatment to the request for further analgesia and the total medication intake during the first 12 hours after operation. RESULTS: Whereas posterolateral thoracotomy produced severe pain, muscle-sparing thoracotomy, costotomy, and sternotomy caused moderate pain, and video-assisted thoracoscopy caused only mild pain. The TENS treatment was not effective in the posterolateral thoracotomy group, but it was useful as an adjunct to other medications in the muscle-sparing thoracotomy, costotomy, and sternotomy groups. In contrast, representing the only pain control treatment with no adjunct drugs, it was very effective in patients having video-assisted thoracoscopy. CONCLUSIONS: These findings show that TENS is useful after thoracic surgical procedures only when postoperative pain is mild to moderate; it is uneffective for severe pain.
We report two unusual cases of postural, post-dural puncture upper thoracic interscapular backache, without headache, that were relieved by epidural blood patching. There is controversy concerning the aetiology of headache associated with the post-dural puncture syndrome. Mechanisms previously proposed have included traction on pain-sensitive intracranial structures such as the dura or blood vessels, or a vascular mechanism which may be adenosine-receptor mediated. These two cases suggest that traction on cervical or upper thoracic nerve roots should be considered as a possible mechanism of pain in the post-dural puncture syndrome.
Four cases of long thoracic mononeuropathy associated with sports participation are presented. Each patient developed shoulder pain or dysfunction after an acute event or vigorous activity, and demonstrated scapular winging consistent with serratus anterior weakness. The diagnosis was confirmed with electromyography in each case. It is suggested that the athletic activity caused a stretch injury to the long thoracic nerve. Conservative management, consisting of range of motion exercises for the shoulder and strengthening of the serratus anterior muscle, resulted in a favorable outcome in all patients.
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Scapula winging is an uncommon condition but one which may be underdiagnosed. Four patients with scapula winging referred to a sports injury clinic are presented. None of the patients was aware of any trauma and a traction injury to the long thoracic nerve is proposed as the aetiology of this condition. These case reports emphasize the importance of excluding winging of the scapula in patients who present to sports injury clinics with shoulder pain.
The three main issues involved in thoracotomy technique for the repair of oesophageal atresia (OA) are: (1) prevention of chest wall deformities; (2) adequate surgical exposure; and (3) the cosmetic appearance of the skin scar. Adequate surgical exposure should be the first priority. The technique described is an endeavour to address all the above concerns, a modification of the technique described by Denis Browne that eliminates the risk of injury to the long thoracic nerve (LTN). A retrospective analysis from case notes of 70 children (1974-1997) with OA from a single surgeon's practice was performed. Data collected included the presence of complications such as wound problems, chest-wall deformities, and evidence of nerve palsies including winged scapula. A uniform technique of a vertical skin incision in the mid-axillary line, preservation of the latissimus dorsi, and division of the serratus anterior muscle anterior to its nerve was followed in all cases. No wound infection, breakdown, or seroma formation was seen in any case. On long-term followup (range 1-22 years, mean 10.5 years) no chest wall deformities or nerve palsies were observed. This modification gives excellent exposure, avoids injury to the LTN, does not lead to chest-wall deformity, and gives a pleasing cosmetic result. The scar is hardly noticeable with the arm by the side of the body.
BACKGROUND: Shoulder complaints in scaffolders are very common and may result in permanent disability. METHODS: We present two case reports of patients who developed acute shoulder complaints. After lifting weights up to 50 kg both patients suffered an isolated lesion of the long thoracic nerve resulting in serratus anterior paralysis. RESULTS: Physical signs are unilateral winging of the scapula and loss of strength in the arm. A combined effect of pressure and stretching of the nerve resulted in an occupational injury with a different prognosis of reversibility in both patients. CONCLUSION: Shoulder pads in the overall and limiting the weight to carry may prevent future injuries.
The case of long thoracic mononeuropathy associated with sport participation a presented. The diagnosis was confirmed with electromyography. It is suggested that the athletic activity caused a stretch injury to the long thoracic nerve. Degenerative changes and infections were excluded. Conservative management, consisting of range of motion exercises for the shoulder and strengthening of the serratus anterior muscle, resulted in a forable outcome. The 12 month follow-up showed only slight changes in EMG and clinical examination.
The purpose of this study was to assess the effectiveness of functional magnetic stimulation (FMS) for producing expiratory function in normal human subjects. Twelve able-bodied normal subjects were recruited for this study. FMS of the expiratory muscles was performed by using a magnetic stimulator and placing the magnetic coil along the lower thoracic spine. Results showed that peak expired pressure, volume, and flow rate generated by FMS at the end of normal inspiration (102.5 +/- 13.62 cmH2O, 1.6 +/- 0.16 liters, and 4.8 +/- 0.35 l/s, respectively) were comparable to their voluntary maximal levels (P > 0.1). The optimal coil placement was between T7 and T11, and the optimal stimulation parameters were a frequency of 25 Hz and 70-80% of maximal intensity. We conclude that 1) FMS of the lower thoracic nerves in normal subjects resulted in a significant expiratory function comparable to their voluntary maximum; 2) FMS was noninvasive and was well tolerated by all subjects; and 3) FMS may be useful to produce cough in patients in critical care or perioperative settings, or in patients with neurological disorders.
The purposes of this study were to determine the occurrence of serratus anterior muscle weakness after axillary node dissection, to monitor the recovery of serratus anterior muscle strength, and to compare shoulder range of motion in palsied and nonpalsied groups. Thirty-six patients were studied who had 40 axillary node dissections for breast carcinoma or malignant melanoma. Range of motion and manual muscle tests were done preoperatively and at specific postoperative intervals by two observers. To regain range of motion, all subjects were treated daily while hospitalized and as needed when outpatients. Twelve of the 40 dissections (30%) resulted in serratus anterior muscle palsy after surgery. Strength was normal in all the palsied shoulders by the sixth month after surgery. Both the palsied and nonpalsied groups had comparable range of motion at each assessment. The mechanism of long thoracic nerve injury and the clinical significance of serratus anterior muscle palsy are discussed as well as the rationale for early detection and proper physical therapy management. This study suggests that serratus anterior muscle palsy is a frequent but reversible event after axillary node dissection.
Octapamine and its synthetic enzyme, tyramine beta-hydroxylase (TBH), are found in high concentrations at two points along second thoracic nerve roots in lobsters. The first is in the proximal section of the second root between the ventral nerve cord and the bifurcation of the root into medial (to flexor muscles) and lateral (to extensors) branches. The second region of high concentration is within a well known crustacean neurosecretory system, the pericardial organ, located close to the ends of the lateral branches of the roots. 2. With several different staining procedures, small clusters of nerve cell bodies are found within the connective tissue sheath in the proximal regions of the second roots. No cell bodies are seen in the pericardial organ regions. Cell bodies are variable in number and position between corresponding roots in the same animal and homologous roots among different animals. The average numbers of cell bodies, however, correlate well with TBH and octopamine content, and with the synthesis of octopamine in these same regions of roots. 3. Small clusters of root cell bodies dissected from preparations have greater than 500-fold higher activities of TBH than isolated efferent excitatory and inhibitory or afferent sensory axons. 4. Along with octopamine, the preferential synthesis of acetylcholine and serotonin is also seen in proximal segments of roots. Acetylcholine synthesis in these regions may represent transmitter synthesized in the nerve terminals innervating the root cells. The role of serotonin in these regions is not understood at this time but the amounts of endogenous serotonin found are only a tenth of the amounts of octopamine present. 5. Dopamine is not synthesized from tyrosine in second thoracic roots. However, if DOPA or dopamine are used as precursor compounds, then noradrenaline, which is usually not found in lobsters, can be accumulated in proximal segments of roots. 6. Phenolamines are converted to two further metabolites by lobster tissues. The compounds are unidentified and are named fast and slow product on the basis of their migration on electrophoresis at acid pH. Some partial characterization of slow product reveals that it is a mixture of compounds that can be converted on mild acid hydrolysis to fast product and the parent phenolamine. 7. The several lines of evidence presented suggest that nerve cells found in the proximal segments of the second thoracic roots contain and can synthesize octopamine. Since not all the cells in any single root have been analysed for octopamine or TBH, however, the possibility that one or more of the cells contain physiologically interesting substances other than octopamine is not eliminated.
We have used a modified technique in five patients to correct winging of the scapula caused by injury to the brachial plexus or the long thoracic nerve during transaxillary resection of the first rib. The procedure stabilises the scapulothoracic articulation by using strips of autogenous fascia lata wrapped around the 4th, 6th and 7th ribs at least two, and preferably three, times. The mean age of the patients at the time of operation was 38 years (26 to 47) and the mean follow-up six years and four months (three years and three months to 11 years). Satisfactory stability was achieved in all patients with considerable improvement in shoulder function. There were no complications.
A 37-yr-old woman presented with a 7-mo history of unilateral shoulder girdle stiffness, pain, and weakness and had already been diagnosed with frozen shoulder. Physical examination revealed scapular winging and suspicious focal paralysis of shoulder girdle muscles. Subsequently, electrodiagnostic studies reported denervation of deltoid, infraspinatus, serratus anterior, and lower cervical paraspinal muscles, in addition to a prolonged long thoracic nerve latency. The history, physical examination, and cervical magnetic resonance imaging scan seemed most consistent with neuralgic amyotrophy, although the electrodiagnostic examination could be interpreted as cervical radiculopathy. Some of the difficulties in identifying neuralgic amyotrophy and distinguishing it from cervical radiculopathy are discussed herein. Historically, frozen shoulder has seemed to develop as a complication of the neuropathic process. Both neuralgic amyotrophy and frozen shoulder have a poorly understood pathogenesis, and their combined presence is presumed to be rare. Because of difficulties inherent in the physical examination of frozen shoulder, a coexistent neuropathic process may go undetected.
Lateral thoracic nerve reflex latencies values were measured in ponies using a simple, non-invasive technique. The reflex was elicited using an external triggering hammer attached to an electrodiagnostic unit. The resulting evoked, compound muscle action potentials were recorded with electrodes, which were placed over the 6th ribs or 11th rib level with the axilla. Two superimposed repeats of 4 signal-averaged sweeps of 50 or 100 milliseconds were recorded and the estimated reflex pathway was measured for each subject in order to calculate the reflex latencies and latency velocities. Mean left and right 6th rib peak latencies were not significantly different from each other (P = .609), but left 6th rib latencies were shorter than those recorded from the 11th rib (P < .0001), substantiating the existence of an indirect (central) pathway to the reflex. The calculated left and right 6th rib latency velocities were not significantly different from each other (P = .58) but left 6th rib latency velocities were different from left 11th rib (P = .009). The calculated latency velocities were within the broad range for corticospinal tract motor conduction velocities and comparable to magnetic motor evoked latency velocities. The use of lateral thoracic reflex latency measurements to objectively identify the site of spinal cord lesions is discussed.
HISTORY AND CLINICAL FINDINGS: A previously healthy 26-year-old man complained of gradually increasing headache after an attack of flu. After 4 days an erythema with papules but no blisters was noted in the area of distribution of the left 10th thoracic nerve. As a child he had varicella (chickenpox) without complications. INVESTIGATIONS: Lymphocytic pleocytosis and evidence of an abnormal blood-brain barrier were noted in cerebrospinal fluid (CSF). Serology for varicella zoster virus revealed an IgG titre of > 7400 IU/l in serum and 21 IU/l in CSF. The corresponding IgM titres were negative. TREATMENT AND COURSE: The headaches and cutaneous changes regressed under i.v. treatment with acyclovir, 10 mg/kg body weight, 3 x daily for 10 days. Repeat CSF examination after 10 days showed merely minimal residual changes of inflammation. CONCLUSION: This case illustrates the risk of severe neurological complications of herpes zoster infection. A seemingly minor rash with headache must be correctly diagnosed and immediate high-dosage acyclovir treatment instituted to prevent life-threatening and severe complications of herpes zoster meningitis or encephalitis.
Serotonin activates a cardiogenic hypertensive chemoreflex. During this reflex, sympathetic efferent neural discharges were examined in 10 anesthetized dogs. Thoracic nerves were identified, severed distally, and placed across electrodes. The efferent neurogram was recorded along with an electrocardiogram and blood pressure and stored on tape. Neurograms were later analyzed by a Lab 8/e computer with a Schmitt trigger. The resting tone and the elicited discharges of the multifiber preparations were plotted as poststimulus histograms. The integrals of the histograms were normalized. During the reflex, sympathetic efferent discharges averaged 4.9 (+/- 0.8) s in duration and the total discharge frequency was 199 (+/- 16)% of control tone. The evoked peak blood pressure response averaged 221/171 mmHg. Following autonomic blockade, the attenuated blood pressure response averaged 125/96 mmHg. The sympathetic efferent discharges then lasted 5.2 (+/- 0.7) s (NS). However, total discharge frequency (268 +/- 37% of control tone) was significantly greater (P less than 0.01) that before autonomic blockade. These data suggest that baroreceptors influence the rate of discharge and the total amount of neural traffic, but not the duration of the sympathetic response evoked by the cardiogenic hypertensive chemoreflex.