-
Medicina Oral, Patologia Oral Y Cirugia... Jul 2016Coronectomy is an alternative to complete removal of an impacted mandibular third molar. Most authors have recommended coronectomy to prevent damage to the inferior... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Coronectomy is an alternative to complete removal of an impacted mandibular third molar. Most authors have recommended coronectomy to prevent damage to the inferior alveolar nerve during surgical extraction of lower third molars. The present study offers a systematic review and metaanalysis of the coronectomy technique.
MATERIAL AND METHODS
A systematic review and meta-analysis was performed based on a PubMed and Cochrane databases search for articles published from 2014 and involving coronectomy of mandibular third molars located near the inferior alveolar nerve canal, with a minimum of 10 cases and a minimum follow-up period of 6 months. After application of the inclusion and exclusion criteria, a total of 12 articles were included in the study.
RESULTS AND DISCUSSION
Coronectomy results in significantly lesser loss of sensitivity of the inferior alveolar nerve and prevents the occurrence of dry socket. No statistically significant differences were observed in the incidence of pain and infection between coronectomy and complete surgical extraction. After coronectomy, the remaining tooth fragment migrates an average of 2 mm within two years.
CONCLUSIONS
Coronectomy is indicated when the mandibular third molar is in contact with the inferior alveolar nerve and complete removal of the tooth may cause nerve damage.
Topics: Humans; Mandible; Mandibular Nerve; Molar, Third; Tooth Crown; Tooth Extraction; Tooth, Impacted; Trigeminal Nerve Injuries
PubMed: 27031064
DOI: 10.4317/medoral.21074 -
Plastic and Reconstructive Surgery.... Aug 2022Diabetic peripheral neuropathy (DPN) is a leading cause of morbidity. This systematic review and meta-analysis evaluate the efficacy of lower extremity nerve...
BACKGROUND
Diabetic peripheral neuropathy (DPN) is a leading cause of morbidity. This systematic review and meta-analysis evaluate the efficacy of lower extremity nerve decompression in reducing DPN symptoms and complications.
METHODS
A database search was performed using Medline, Embase, Google Scholar, and Cochrane Central Register of Controlled Trials. Articles addressing surgical decompression of lower limb peripheral nerves in patients with diabetes were screened for inclusion. Two independent reviewers undertook the assessment. Methodological quality measures were the Cochrane risk of bias and Newcastle-Ottawa scale.
RESULTS
The pooled sample size from 21 studies was 2169 patients. Meta-analysis of 16 observational studies showed significant improvement in the visual analog scale (VAS) ( < 0.00001) and two-point discrimination ( = 0.003), with strong reliability. Decompression of the tarsal tunnel region had the highest improvement in VAS [MD, 6.50 (95% CI, 3.56-9.44)]. A significant low-risk ratio (RR) of ulcer development and lower limb amputation was detected ( < 0.00001). Lowest RR of ulcer development was detected with tarsal tunnel release [RR, 0.04 (95% CI, 0.00-0.48)]. Improvements in VAS, two-point discrimination, and nerve conduction velocity were nonsignificant in the meta-analysis of five randomized controlled trials (RCTs). The RCT analysis was limited to only two studies for each outcome.
CONCLUSIONS
Meta-analysis of observational studies highlights the efficacy of lower extremity nerve decompression in reducing DPN symptoms, ulcerations, and amputations. Releasing the tibial nerve in the tarsal tunnel region was the most effective observed procedure. Nevertheless, high-quality RCTs are required to support the utility of this intervention in DPN.
PubMed: 35999882
DOI: 10.1097/GOX.0000000000004478 -
Current Pain and Headache Reports May 2023Low back pain (LBP) is a prevalent condition that is associated with diminished physical function, poor mental health outcomes, and reduced quality of life. Peripheral... (Review)
Review
PURPOSE OF REVIEW
Low back pain (LBP) is a prevalent condition that is associated with diminished physical function, poor mental health outcomes, and reduced quality of life. Peripheral nerve stimulation (PNS) is an emerging modality that has been utilized to treat LBP. The primary objective of this systematic review is to appraise the level of evidence on the efficacy of PNS for treatment of LBP.
RECENT FINDINGS
Twenty-nine articles were included in this systematic review, consisting of 828 total participants utilizing PNS as the primary modality for LBP and 173 participants using PNS as salvage or adjunctive therapy for LBP after SCS placement. Different modalities of PNS therapy were reported across studies, including conventional PNS systems stimulating the lumbar medial branch nerves, peripheral nerve field stimulation (PNFS), and restorative neuromuscular stimulation of the multifidus muscles. All studies consistently reported positive modest to moderate improvement in pain intensity with PNS therapy when comparing baseline pain intensity to each study's respective primary follow-up period. There was a very low GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) quality of evidence supporting this finding. Inconsistency was present in some comparative studies that demonstrated no difference between PNS therapy versus control cohorts (sham or SCS therapy alone), which therefore highlighted the potential for placebo effect. This systematic review highlights that PNS, PNFS, and neuromuscular stimulation may provide modest to moderate pain relief in patients with LBP, although evidence is currently limited due to risk of bias, clinical and methodological heterogeneity, and inconsistency in data.
Topics: Humans; Low Back Pain; Quality of Life; Transcutaneous Electric Nerve Stimulation; Pain Management; Peripheral Nerves
PubMed: 37060395
DOI: 10.1007/s11916-023-01109-2 -
PM & R : the Journal of Injury,... Nov 2023Nerve pain frequently develops following amputations and peripheral nerve injuries. Two innovative surgical techniques, targeted muscle reinnervation (TMR) and... (Review)
Review
OBJECTIVE
Nerve pain frequently develops following amputations and peripheral nerve injuries. Two innovative surgical techniques, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI), are rapidly gaining popularity as alternatives to traditional nerve management, but their effectiveness is unclear.
LITERATURE SURVEY
A review of literature pertaining to TMR and RPNI pain results was conducted. PubMed and MEDLINE electronic databases were queried.
METHODOLOGY
Studies were included if pain outcomes were assessed after TMR or RPNI in the upper or lower extremity, both for prophylaxis performed at the time of amputation and for treatment of postamputation pain. Data were extracted for evaluation.
SYNTHESIS
Seventeen studies were included, with 14 evaluating TMR (366 patients) and three evaluating RPNI (75 patients). Of these, one study was a randomized controlled trial. Nine studies had a mean follow-up time of at least 1 year (range 4-27.6 months). For pain treatment, TMR and RPNI improved neuroma pain in 75%-100% of patients and phantom limb pain in 45%-80% of patients, averaging a 2.4-6.2-point reduction in pain scores on the numeric rating scale postoperatively. When TMR or RPNI was performed prophylactically, many patients reported no neuroma pain (48%-100%) or phantom limb pain (45%-87%) at time of follow-up. Six TMR studies reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores assessing pain intensity, behavior, and interference, which consistently showed a benefit for all measures. Complication rates ranged from 13% to 31%, most frequently delayed wound healing.
CONCLUSIONS
Both TMR and RPNI may be beneficial for preventing and treating pain originating from peripheral nerve dysfunction compared to traditional techniques. Randomized trials with longer term follow-up are needed to directly compare the effectiveness of TMR and RPNI with traditional nerve management techniques.
Topics: Humans; Phantom Limb; Amputation, Surgical; Neurosurgical Procedures; Neuroma; Peripheral Nerves; Muscles; Muscle, Skeletal; Randomized Controlled Trials as Topic
PubMed: 36965013
DOI: 10.1002/pmrj.12972 -
Skeletal Radiology Jan 2021To evaluate the frequency, clinico-pathologic and imaging features of malignant tumors in peripheral nerves which are of non-neurogenic origin (non-neurogenic peripheral...
OBJECTIVE
To evaluate the frequency, clinico-pathologic and imaging features of malignant tumors in peripheral nerves which are of non-neurogenic origin (non-neurogenic peripheral nerve malignancy-PNM).
MATERIALS AND METHODS
We retrospectively reviewed our pathology database for malignant peripheral nerve tumors from 07/2014-07/2019 and performed a systematic review. Exclusion criteria were malignant peripheral nerve sheath tumor (MPNST). Clinico-pathologic and imaging features, apparent diffusion coefficient (ADC), and standard uptake values (SUV) are reported.
RESULTS
After exclusion of all neurogenic tumors (benign = 196, MPNST = 57), our search yielded 19 non-neurogenic PNMs (7%, n = 19/272), due to primary intraneural malignancy (16%, n = 3/19) and secondary perineural invasion from an adjacent malignancy (16%, n = 3/19) or metastatic disease (63%, n = 12/19). Non-neurogenic PNMs were located in the lumbosacral plexus/sciatic nerves (47%, n = 9/19), brachial plexus (32%, n = 6/19), femoral nerve (5%, n = 1/19), tibial nerve (5%, n = 1/19), ulnar nerve (5%, n = 1/19), and radial nerve (5%, n = 1/19). On MRI (n = 14/19), non-neurogenic PNM tended to be small (< 5 cm, n = 10/14), isointense to muscle on T1-W (n = 14/14), hyperintense on T2-WI (n = 12/14), with enhancement (n = 12/12), low ADC (0.5-0.7 × 10-3 mm/s), and variable metabolic activity (SUV range 2.1-13.1). A target sign was absent (n = 14/14) and fascicular sign was rarely present (n = 3/14). Systematic review revealed 89 cases of non-neurogenic PNM.
CONCLUSION
Non-neurogenic PNMs account for 7% of PNT in our series and occur due to metastases and primary intraneural malignancy. Although non-neurogenic PNMs exhibit a non-specific MRI appearance, they lack typical signs of neurogenic tumors such as the target sign. Quantitative imaging features identified by DWI (low ADC) and F-FDG PET/CT (high SUV) may be helpful clues to the diagnosis.
Topics: Fluorodeoxyglucose F18; Humans; Magnetic Resonance Imaging; Neoplasms; Nerve Sheath Neoplasms; Peripheral Nerves; Peripheral Nervous System Neoplasms; Positron Emission Tomography Computed Tomography; Positron-Emission Tomography; Retrospective Studies
PubMed: 32699955
DOI: 10.1007/s00256-020-03556-z -
Intensive Care Medicine Aug 2018Although invasive intracranial devices (IIDs) are the gold standard for intracranial pressure (ICP) measurement, ultrasonography of the optic nerve sheath diameter... (Meta-Analysis)
Meta-Analysis
PURPOSE
Although invasive intracranial devices (IIDs) are the gold standard for intracranial pressure (ICP) measurement, ultrasonography of the optic nerve sheath diameter (ONSD) has been suggested as a potential non-invasive ICP estimator. We performed a meta-analysis to evaluate the diagnostic accuracy of sonographic ONSD measurement for assessment of intracranial hypertension (IH) in adult patients.
METHODS
We searched on electronic databases (MEDLINE/PubMed, Scopus, Web of Science, ScienceDirect, Cochrane Library) until 31 May 2018 for comparative studies that evaluated the efficacy of sonographic ONSD vs. ICP measurement with IID. Data were extracted independently by two authors. We used the QUADAS-2 tool for assessing the risk of bias (RB) of each study. A diagnostic meta-analysis following the bivariate approach and random-effects model was performed.
RESULTS
Seven prospective studies (320 patients) were evaluated for IH detection (assumed with ICP > 20 mmHg or > 25 cmHO). The accuracy of included studies ranged from 0.811 (95% CI 0.678‒0.847) to 0.954 (95% CI 0.853‒0.983). Three studies were at high RB. No significant heterogeneity was found for the diagnostic odds ratio (DOR), positive likelihood ratio (PLR) and negative likelihood ratio (NLR), with I < 50% for each parameter. The pooled DOR, PLR and NLR were 67.5 (95% CI 29‒135), 5.35 (95% CI 3.76‒7.53) and 0.088 (95% CI 0.046‒0.152), respectively. The area under the hierarchical summary receiver-operating characteristic curve (AUHSROC) was 0.938. In the subset of five studies (275 patients) with IH defined for ICP > 20 mmHg, the pooled DOR, PLR and NLR were 68.10 (95% CI 26.8‒144), 5.18 (95% CI 3.59‒7.37) and 0.087 (95% CI 0.041‒0.158), respectively, while the AUHSROC was 0.932.
CONCLUSIONS
Although the wide 95% CI in our pooled DOR suggests caution, ultrasonographic ONSD may be a potentially useful approach for assessing IH when IIDs are not indicated or available (CRD42018089137, PROSPERO).
Topics: Adult; Humans; Intracranial Hypertension; Intracranial Pressure; Optic Nerve; Prospective Studies; Sensitivity and Specificity; Ultrasonography
PubMed: 30019201
DOI: 10.1007/s00134-018-5305-7 -
The Cochrane Database of Systematic... Dec 2022Traumatic peripheral nerve injury is common and incurs significant cost to individuals and society. Healing following direct nerve repair or repair with autograft is... (Review)
Review
BACKGROUND
Traumatic peripheral nerve injury is common and incurs significant cost to individuals and society. Healing following direct nerve repair or repair with autograft is slow and can be incomplete. Several bioengineered nerve wraps or devices have become available as an alternative to direct repair or autologous nerve graft. Nerve wraps attempt to reduce axonal escape across a direct repair site and nerve devices negate the need for a donor site defect, required by an autologous nerve graft. Comparative evidence to guide clinicians in their potential use is lacking. We collated existing evidence to guide the clinical application of currently available nerve wraps and conduits.
OBJECTIVES
To assess and compare the effects and complication rates of licensed bioengineered nerve conduits or wraps for surgical repair of traumatic peripheral nerve injuries of the upper limb. To compare effects and complications against the current gold surgical standard (direct repair or nerve autograft).
SEARCH METHODS
We used standard, extensive Cochrane search methods. The latest search was 26 January 2022. We searched online and, where not accessible, contacted societies' secretariats to review abstracts from the British Surgical Society of the Hand, International Federation of Surgical Societies of the Hand, Federation of European Surgical Societies of the Hand, and the American Society for Peripheral Nerve from October 2007 to October 2018.
SELECTION CRITERIA
We included parallel group randomised controlled trials (RCTs) and quasi-RCTs of nerve repair in the upper limb using a bioengineered wrap or conduit, with at least 12 months of follow-up.
DATA COLLECTION AND ANALYSIS
We used standard Cochrane procedures. Our primary outcomes were 1. muscle strength and 2. sensory recovery at 24 months or more. Our secondary outcomes were 3. British Medical Research Council (BMRC) grading, 4. integrated functional outcome (Rosén Model Instrument (RMI)), 5. touch threshold, 6. two-point discrimination, 7. cold intolerance, 8. impact on daily living measured using the Disability of Arm Shoulder and Hand Patient-Reported Outcome Measure (DASH-PROM), 9. sensory nerve action potential, 10. cost of the device, and 11. adverse events (any and specific serious adverse events (further surgery)). We used GRADE to assess the certainty of the evidence.
MAIN RESULTS
Five studies involving 213 participants and 257 nerve injuries reconstructed with wraps or conduits (129 participants) or standard repair (128 participants) met the inclusion criteria. Of those in the standard repair group, 119 nerve injuries were managed with direct epineurial repair, and nine autologous nerve grafts were performed. One study excluded the outcome data for the repair using an autologous nerve graft from their analysis, as it was the only autologous nerve graft in the study, so data were available for 127 standard repairs. There was variation in the functional outcome measures reported and the time postoperatively at which they were recorded. Mean sensory recovery, assessed with BMRC sensory grading (range S0 to S4, higher score considered better) was 0.03 points higher in the device group (range 0.43 lower to 0.49 higher; 1 RCT, 28 participants; very low-certainty evidence) than in the standard repair group (mean 2.75 points), which suggested little or no difference between the groups, but the evidence is very uncertain. There may be little or no difference at 24 months in mean touch thresholds between standard repair (0.81) and repair using devices, which was 0.01 higher but this evidence is also very uncertain (95% confidence interval (CI) 0.06 lower to 0.08 higher; 1 trial, 32 participants; very low-certainty evidence). Data were not available to assess BMRC motor grading at 24 months or more. Repair using bioengineered devices may not improve integrated functional outcome scores at 24 months more than standard techniques, as assessed by the Rosén Model Instrument (RMI; range 0 to 3, higher scores better); the CIs allow for both no important difference and a better outcome with standard repair (mean RMI 1.875), compared to the device group (0.17 lower, 95% CI 0.38 lower to 0.05 higher; P = 0.13; 2 trials, 60 participants; low-certainty evidence). Data from one study suggested that the five-year postoperative outcome of RMI may be slightly improved after repair using a device (mean difference (MD) 0.23, 95% CI 0.07 to 0.38; 1 trial, 28 participants; low-certainty evidence). No studies measured impact on daily living using DASH-PROM. The proportion of people with adverse events may be greater with nerve wraps or conduits than with standard techniques, but the evidence is very uncertain (risk ratio (RR) 7.15, 95% CI 1.74 to 29.42; 5 RCTs, 213 participants; very low-certainty evidence). This corresponds to 10 adverse events per 1000 people in the standard repair group and 68 per 1000 (95% CI 17 to 280) in the device group. The use of nerve repair devices may be associated with a greater need for revision surgery but this evidence is also very uncertain (12/129 device repairs required revision surgery (removal) versus 0/127 standard repairs; RR 7.61, 95% CI 1.48 to 39.02; 5 RCTs, 256 nerve repairs; very low-certainty evidence).
AUTHORS' CONCLUSIONS
Based on the available evidence, this review does not support use of currently available nerve repair devices over standard repair. There is significant heterogeneity in participants, injury pattern, repair timing, and outcome measures and their timing across studies of nerve repair using bioengineered devices, which make comparisons unreliable. Studies were generally small and at high or unclear risk of bias. These factors render the overall certainty of evidence for any outcome low or very low. The data reviewed here provide some evidence that more people may experience adverse events with use of currently available bioengineered devices than with standard repair techniques, and the need for revision surgery may also be greater. The evidence for sensory recovery is very uncertain and there are no data for muscle strength at 24 months (our primary outcome measures). We need further trials, adhering to a minimum standard of outcome reporting (with at least 12 months' follow-up, including integrated sensorimotor evaluation and patient-reported outcomes) to provide high-certainty evidence and facilitate more detailed analysis of effectiveness of emerging, increasingly sophisticated, bioengineered repair devices.
Topics: Humans; Upper Extremity; Peripheral Nerves
PubMed: 36477774
DOI: 10.1002/14651858.CD012574.pub2 -
Revista Brasileira de Ortopedia Apr 2022Peripheral nerve damage is an important cause of seeking medical attention. It occurs when the continuity of structures is interrupted and the propagation of nervous...
Peripheral nerve damage is an important cause of seeking medical attention. It occurs when the continuity of structures is interrupted and the propagation of nervous impulses is blocked, affecting the functional capacity of individuals. To assess the effects of the immunosuppressants tacrolimus and cyclosporine on the regeneration of peripheral nerves, a systematic review of the literature was carried out. The articles included were published until September 2018 and proposed to evaluate the effects of the immunosuppressants tacrolimus and cyclosporine on nerve regeneration and neuroprotection, available in the MEDLINE, EMBASE, Cochrane Library, Web of Science, Oxford Pain Relief Database, and LILACS databases. The research analysed a total of 56 articles, of which 22 were included in the meta-analysis. Statistical analysis suggests the protective effect of tacrolimus in the regeneration of the number of myelinated axons (95% confidence interval [CI]: 0.93-2.39; < 0.01); however, such effect was not observed in relation to cyclosporine (95%CI: - 0.38-1.18; = 0.08) It also suggests that there is a significant relationship between the use of tacrolimus and myelin thickness (95%CI= 2.00-5.71; < 0. 01). The use of immunosuppressants in the regeneration of peripheral nerve damage promotes an increase in the number of myelinated axons in general, regardless of the administered dose. In addition, it ensures greater myelin thickness, muscle weight and recovery of the sciatic functional index. However, heterogeneity was high in most analyses performed.
PubMed: 35652029
DOI: 10.1055/s-0041-1736467 -
Journal of Reconstructive Microsurgery Jul 2021Robotic-assisted techniques are a tremendous revolution in modern surgery, and the advantages and indications were well discussed in different specialties. However,...
BACKGROUND
Robotic-assisted techniques are a tremendous revolution in modern surgery, and the advantages and indications were well discussed in different specialties. However, the use of robotic technique in plastic and reconstructive surgery is still very limited, especially in the field of peripheral nerve reconstruction. This study aims to identify current clinical applications for peripheral nerve reconstruction, and to evaluate the advantages and disadvantages to establish potential uses in the future.
METHODS
A review was conducted in the literatures from PubMed focusing on currently published robotic peripheral nerve intervention techniques. Eligible studies included related animal model, cadaveric and human studies. Reviews on robotic microsurgical technique unrelated to peripheral nerve intervention and non-English articles were excluded. The differences of wound assessment and nerve management between robotic-assisted and conventional approach were compared.
RESULTS
Total 19 studies including preclinical experimental researches and clinical reports were listed and classified into brachial plexus reconstruction, peripheral nerve tumors management, peripheral nerve decompression or repair, peripheral nerve harvesting, and sympathetic trunk reconstruction. There were three animal studies, four cadaveric studies, eight clinical series, and four studies demonstrating clinical, animal, or cadaveric studies simultaneously. In total 53 clinical cases, only 20 (37.7%) cases were successfully approached with minimal invasive and intervened robotically; 17 (32.1%) cases underwent conventional approach and the nerves were intervened robotically; 12 (22.6%) cases converted to open approach but still intervened the nerve by robot; and 4 (7.5%) cases failed to approach robotically and converted to open surgery entirely.
CONCLUSION
Robotic-assisted surgery is still in the early stage in peripheral nerve surgery. We believe the use of the robotic system in this field will develop to become popular in the future, especially in the fields that need cooperation with other specialties to provide the solutions for challenging circumstances.
Topics: Animals; Humans; Neurosurgical Procedures; Peripheral Nerves; Plastic Surgery Procedures; Robotic Surgical Procedures; Robotics
PubMed: 33401326
DOI: 10.1055/s-0040-1722183 -
Journal of Plastic, Reconstructive &... Mar 2022Within the field of peripheral nerve surgery, the use of fibrin glue as an alternative to conventional microsurgical suture repair is becoming increasingly popular.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Within the field of peripheral nerve surgery, the use of fibrin glue as an alternative to conventional microsurgical suture repair is becoming increasingly popular. Advantages of fibrin glue for nerve reconstruction include technical ease of use, less tissue manipulation, and shorter operation times. Although fibrin glue seems a promising alternative to conventional microsurgical repair, further insight into the outcomes of nerve recovery is essential.
OBJECTIVE
To summarize the current literature on the use of fibrin glue for peripheral nerve repair and compare these results with outcomes following conventional suture repair.
METHODS
A systematic search in Embase, MEDLINE, Web of Science, Cochrane, and Google Scholar databases was performed. The search included animal, cadaveric, and human studies assessing outcomes following peripheral nerve repair using fibrin glue. Data on outcomes were subdivided into functional outcomes, electrophysiology, histopathology, biomechanical outcomes, and operation times. We calculated standardized mean differences and combined these in a random effects model to estimate the overall effect.
RESULTS
From a total of 2057 references, 37 animal, two cadaveric, and four human studies were included. Fibrin glue repairs resulted in similar functional and electrophysiology outcomes and shorter operation times than suture repairs. However, fibrin glue alone resulted in lower strength and more dehiscence. No dehiscence was reported when fibrin glue was combined with one or two sutures. Yet, we also found that methodological details were poorly reported in animal studies, resulting in an unclear risk of bias. This should be taken into consideration when interpreting the results.
CONCLUSION
The results indicate that nerve regeneration may be similar in fibrin glue repairs and suture repairs. Combining fibrin glue with one or two positional sutures allows for a precise realignment of the nerve fibers and seems to provide sufficient strength to prevent dehiscence.
Topics: Animals; Fibrin Tissue Adhesive; Humans; Nerve Regeneration; Peripheral Nerves; Suture Techniques; Sutures; Tissue Adhesives
PubMed: 35125308
DOI: 10.1016/j.bjps.2022.01.007