Prevalence of accessory deep peroneal nerve in referred patients to an electrodiagnostic medicine clinic

Background

Variations in the branching of posterior cord are important during surgical approaches to the axilla and upper arm, administration of anesthetic blocks, interpreting effects of nervous compressions and in repair of plexus injuries. The patterns of branching show population differences. Data from the African population is scarce.

Objective

To describe the branching pattern of the posterior cord in a Kenyan population.

Materials and methods

Seventy-five brachial plexuses from 68 formalin fixed cadavers were explored by gross dissection. Origin and order of branching of the posterior cord was recorded. Representative photographs were then taken using a digital camera (Sony Cybershot ^R, W200, 7.2 Megapixels).

Results

Only 8 out of 75 (10.7%) posterior cords showed the classical branching pattern. Forty three (57.3%) lower subscapular, 8(10.3%) thoracodorsal and 8(10.3%) upper subscapular nerves came from the axillary nerve instead of directly from posterior cord. A new finding was that in 4(5.3%) and in 3(4%) the medial cutaneous nerves of the arm and forearm respectively originated from the posterior cord in contrast to their usual origin from the medial cord.

Conclusions

Majority of posterior cords in studied population display a wide range of variations. Anesthesiologists administering local anesthetic blocks, clinicians interpreting effects of nerve injuries of the upper limb and surgeons operating in the axilla should be aware of these patterns to avoid inadvertent injury. A wider study of the branching pattern of infraclavicular brachial plexus is recommended.     

腓深神经对最后区心血管中枢活动的调节作用

目的：观察腓神经（DPN）传入冲动对延髓最后区（AP）兴奋引起的心血管效应的调节作用。方法：观察电刺激AP、AP＋DPN,以及静注受体阻断后DPN的调节作用改变。结果：低频（20、40Hz)电刺激AP引起降压、而高频（60、80Hz)电刺激引起升压效应;电刺激DPN可分别抑制AP兴奋引起的降压、升压效力（P＜0．01）。结论：DPN传入冲动可对AP兴奋的心血管效应进行调节,阿片肽系统可能参与其调节。     

Muscle-sparing approach to the peroneal nerve of the rabbit.

To study nerve degeneration and regeneration the peroneal nerve of the rabbit is a rewarding experimental model. The access to the nerve should be as atraumatic as possible and no muscular tissue should be incised or transected in order to lower postoperative morbidity and enhance the welfare of the animals. Given such conditions it is not possible to expose the undistributed proximal and central parts of the peroneal nerve from the intervertebral notch to its passage through the lateral head of the gastrocnemius muscle by a single approach, but rather a two-level incision is required. Such an approach to the peroneal nerve was carried out on 24 New Zealand White rabbits. The amount of postoperative pain was estimated by the rabbits social and feeding behaviour. The observed overall impairment was impressively low. This approach has been shown to be beneficial for the animals, and is atraumatic and should be strongly recommended.     

Management of iatrogenic injury to the spinal accessory nerve

Spinal accessory nerve injury results in a debilitating shoulder dysfunction. The trapezius is a major suspensory muscle of the shoulder girdle, and paralysis results in chronic pain and debility from disruption of synchronous scapulohumeral rhythm. This injury usually follows a simple posterior triangle lymph node biopsy and is treatable if appropriate measures are taken in a timely fashion. A major pitfall in early management is either failure to recognize or acknowledge the injury or hoping that it will resolve with conservative treatment. Variation of innervation of the trapezius alters clinical presentation and can make diagnosis difficult. We present a series of six patients with iatrogenic spinal accessory nerve injury following a neck node biopsy. Pain was the most common presenting symptom, and a loss of sustained abduction was the most common physical sign. Three patients had a primary nerve repair and the other three patients had nerve grafting. Maximum recovery time ranged from 4 to 10 months. All patients had varying degrees of recovery of motor function, and all six patients were 100 percent painfree. An algorithm for the management of this distressing condition emphasizes the importance of early referral and highlights the pitfalls in making an accurate diagnosis. Whereas conservative therapy is less predictable and needs careful selection, it also runs the risk of delaying a more effective surgical management. Early operative intervention is more definitive and has the best functional results. Prevention is key and is best achieved by avoiding unnecessary biopsies of the posterior triangle lymph node. When operating, knowledge of posterior neck anatomy and judicious use of the bipolar cautery and magnifying loupes are essential in preventing this problem.     

Scalp-recorded short and middle latency peroneal somatosensory evoked potentials in normals: comparison with peroneal and median nerve SEPs in patients with unilateral hemispheric lesions

Peroneal somatosensory evoked potentials (SEPs) were performed on 23 normal subjects and 9 selected patients with unilateral hemispheric lesions involving somatosensory pathways.Recording obtained from right and left peroneal nerve (PN) stimulations were compared in all subjects, using open and restricted frequency bandpass filters. Restricted filter (100–3000 Hz) and linked ear reference (A1–A2) enhanced the detection of short latency potentials (P1, P2, N1 with mean peak latency of 17.72, 21.07, 24.09) recorded from scalp electrodes over primary sensory cortex regions. Patients with lesions in the parietal cortex and adjacent subcortical areas demonstrated low amplitude and poorly formed short latency peroneal potentials, and absence of components beyond P3 peak with mean latency of 28.06 msec. In these patients, recordings to right and left median nerve (MN) stimulation showed absence or distorted components subsequent to N1 (N18) potential.These observations suggest that components subsequent to P3 potential in response to PN stimulation, and subsequent to N18 potential in response to MN stimulation, are generated in the parietal cortical regions.     

下丘脑背内侧核在缰核兴奋诱发的心血管反应及腓深神经抑制中的作用

目的 :阐明下丘脑背内侧核 (DMH)在缰核 (Hb)兴奋诱发的心血管反应中的作用及DMH在腓深神经 (DPN)传入冲动调节Hb兴奋诱发的心血管活动中的作用及机制。方法 :脲酯和氯醛糖混合静脉麻醉的家兔 ,电刺激Hb、腓深神经 ,记录股动脉血压及心外膜电图 ,DMH内微量注射受体拮抗剂。结果 :同侧DMH微量注射谷氨酸受体阻断剂Kynurenicacid ,部分取消了电刺激Hb兴奋诱发的升压反应及缺血性心电变化反应。同侧DMH微量注射纳洛酮对腓深神经传入冲动抑制Hb兴奋诱发的上述反应有削弱作用。结论 :DMH及其中的谷氨酸受体参与电刺激缰核兴奋诱发的心血管反应 ,DMH及其中的阿片受体参与了DPN传入冲动对上述心血管反应的抑制作用     

Use of alternative medicine by patients attending a gastroenterology clinic.

We carried out a study to determine the proportion of patients attending a university-based gastroenterology outpatient clinic who sought alternative medical care for the same health problem that had prompted them to see a gastroenterologist. After the patients completed a self-administered questionnaire, the gastroenterologist gave a diagnosis and assigned a functional rating. Of the 395 patients 287 (73%) had not used alternative medicine, and 36 (9%) had sought alternative medical care for the problem that had prompted them to see a gastroenterologist. There were no significant differences between alternative medicine users and nonusers in sociodemographic characteristics, use of health care services or general health status. Patients with a functional disease were more likely to seek alternative medical care than those with organic disease (33% v. 7%) (p less than 0.0001). Fewer alternative medicine users (54%) than nonusers (85%) were satisfied with conventional medicine (p less than 0.001), and more alternative medicine users (49%) than nonusers (13%) were very sceptical of conventional medicine (p less than 0.0001).     

Prevalence of retinopathy in a diabetic clinic.

In a prospective study lasting 14 months an attempt was made to measure the visual acuity and examine the fundi, after mydriasis, of all patients attending the diabetic clinic of a district general hospital. Of 704 patients, 160 (22.7%) had some evidence of retinopathy, and 52 (7.4%) of these were already attending an ophthalmologist. A further 18 (2.6%) were known to have retinopathy and were being followed up in the diabetic clinic. Ninety (12.8%) new patients with diabetic retinopathy were discovered. Most had minimal changes, but 30 (4.3%) were considered to have changes severe enough to be referred to an ophthalmologist. Twenty-two (2.1%) underwent, or were awaiting, photocoagulation, and half of these had had no visual symptoms when first seen. Although some of these patients were already being treated or observed for retinopathy, it is encouraging that relatively few new patients needing treatment for retinopathy were discovered. If retinopathy could be detected early enough physicians might be able to deal with it and so ease pressure on ophthalmological services.     

The influence of continuous exposure to 50 Hz electric field on nerve regeneration in a rat peroneal nerve crush injury model

The effect of power frequency electric field (EF) on nerve regeneration was investigated on a rat peroneal nerve crush injury model. The animals were assigned to three groups: 50 Hz EF and Static EF groups were exposed at 10 kV/m. The sham group was kept in the same setting without any EF applications. EF was uninterruptedly applied for 21 days postoperatively. Repeated measures analysis of daily walking tracks during EF exposure demonstrated lower toe spread recovery (TSR) in the 50 Hz EF group. Significant difference across the groups was found only at days 7, 8, 12, 16, 17, 20, and 21 when TSR was analyzed for each measurement time. Print length recovery and peroneal function index did not differ across the groups. Walking track parameters were found to recover to their baseline values by day 28 in all groups. Day 14 but not day 21 measurements revealed smaller nerve cross-sectional area, lower total regenerating axon area, and higher mean myelin debris area in 50 Hz EF group. Both day 14 and 21 measurements revealed higher total myelin debris area, lower EDL muscle weight, and lack of significant enlargement in nerve cross-section distal to the injury, compared to the normal counterpart in 50 Hz EF group. All differences were in keeping with lower rates of Wallerian degeneration and nerve regeneration in 50 Hz EF group. When walking track, histomorphometry and muscle weight are considered individually, their differences across the groups may appear to be subtle to derive a conclusion for a 50 Hz EF effect. However, their concordance with each other in direction of effect suggests that continuous 50 Hz EF exposure has a weak effect that is detrimental mostly to the rate of early nerve regeneration in this axonotmetic injury model. Recovery of walking tracks was not different between Static EF and Sham groups. This suggests that the surface charges that may indirectly affect walking behaviors of the rats, do not account for the lower recovery of TSR in 50 Hz EF group. Differences in nerve regeneration between 50 Hz EF and Static EF groups suggests that electric induction may be required for pure EF effects even though the estimated density of induced fields is not above the endogenous background level for the 50 Hz EF exposure in this study.     

Follow up of patients presenting with fatigue to an infectious diseases clinic.

OBJECTIVES--To determine the symptomatic and functional status during follow up of patients referred to hospital with unexplained fatigue and to identify patient variables associated with persistent functional impairment. DESIGN--Follow up by postal questionnaire six weeks to four years (median 1 year) after initial clinical assessment of patients referred to hospital during 1984-8. SETTING--Infectious diseases outpatient clinic in a teaching hospital. PATIENTS--200 consecutive patients with fatigue of uncertain cause for at least six weeks; 177 fulfilled the inclusion criteria. MAIN OUTCOME MEASURES--Findings at initial assessment; current symptoms, beliefs about the cause of illness, coping behaviours emotional disorder, social variables including membership of self help organizations, and degrees of recovery and functional impairment from questionnaire responses. RESULTS--144 (81%) patients returned completed questionnaires. Initial assessment did not indicate the cause of fatigue, other than preceding infection. The proportion of patients with functional impairment was significantly smaller with longer follow up (33% (11/33) at two to four years, 73% (29/40) at six weeks to six months; chi 2 for trend = 12.5, df = 1; p less than 0.05). Functional impairment was significantly associated with belief in a viral cause of the illness (odds ratio = 3.9; 95% confidence interval 1.5 to 9.9), limiting exercise (3.2; 1.5 to 6.6), avoiding alcohol (4.5; 1.8 to 11.3), changing or leaving employment (3.1; 1.4 to 6.9), belonging to a self help organization (7.8; 2.5 to 23.9), and current emotional disorder (4.4; 2.0 to 9.3). CONCLUSIONS--Short term prognosis for recovery of function was poor but improved with time. Most patients had made a functional recovery by two years after initial clinic attendance. Impaired functioning was more likely with certain patient characteristics. Prospective studies are required to clarify whether these associations are the consequences of a more disabling illness or indicate factors contributing to impaired function.