Dengue hemorrhagic fever is a severe form of dengue presenting commonly with bleeding diathesis, but rarely with peripheral nervous system manifestations. Proximal median neuropathy comprises 1% of upper limb compression syndromes, and this case is the first to report injury to the proximal median nerve due to compression from hematoma formation. This case report presents the rehabilitation process of a 25-year-old Filipino female median nerve entrapment from venipuncture-associated hematoma presenting as burning sensation on the medial elbow, forearm and hand, weak flexion movement of her left thumb, index, and middle fingers. The patient was managed conservatively with pain medications, range of motion, gross and fine motor, and sensory re-education exercises. At 12 months, there was partial but functional recovery of median motor distribution and full recovery of median sensory distribution, as evidenced by improved sensory nerve action potential conduction velocity and amplitude, and compound motor action potential conduction velocity, with persistent decreased amplitude at 50%, and decrease in cross-sectional area of the left median nerve.

This paper highlights the functional outcomes of a conservatively managed median nerve entrapment from venipuncture hematoma from dengue hemorrhagic fever. This case report also emphasizes that in the presence of severe bleeding risk of surgery in the background of severe thrombocytopenia, timely rehabilitation medicine referral with monitoring through clinical evaluation, musculoskeletal ultrasound, and electrodiagnostic study presents a viable alternative in the management of compression neuropathy.

BACKGROUND: Although case reports have suggested that the erector spinae plane block (ESPB) may help analgesia for patients after breast surgery, no study to date has assessed its effectiveness. This retrospective observational study analyzed the analgesic effects of the ESPB after total mastectomy. METHODS: Forty-eight patients were divided into an ESPB group (n = 20) and a control group (n = 28). Twenty patients in the control group were selected by their propensity score matching the twenty patients in the ESPB group. Patients in the ESPB group were injected with 30 mL 0.375% ropivacaine, followed by catheter insertion for further injections of local anesthetics every 12 hours. Primarily, total fentanyl consumption was compared between the two groups during the first 24 hours postoperatively. Secondary outcomes included pain intensity levels (visual analogue scale) and incidence of postoperative nausea and vomiting (PONV). RESULTS: Median cumulative fentanyl consumption during the first 24 hours was significantly lower in the ESPB (33.0 μg; interquartile range [IQR], 27.0–69.5 μg) than in the control group (92.8 μg; IQR, 40.0–155.0 μg) (P = 0.004). Pain level in the early postoperative stage (<3 hr) and incidence of PONV (0% vs. 55%) were also significantly lower in the ESPB group compared to the control (P = 0.001). CONCLUSIONS: Intermittent ESPB after total mastectomy reduces fentanyl consumption and early postoperative pain. ESPB is a good option for multimodal analgesia after breast surgery.
Acute Pain ; Analgesia ; Anesthesia, Conduction ; Anesthetics, Local ; Breast ; Catheters ; Fentanyl ; Humans ; Incidence ; Mastectomy ; Mastectomy, Simple ; Nerve Block ; Observational Study ; Pain, Postoperative ; Postoperative Nausea and Vomiting ; Propensity Score ; Retrospective Studies ; Ultrasonography

BACKGROUND: Breast cancer is complicated by a high incidence of chronic postoperative pain (25%–60%). Regional anesthesia might play an important role in lowering the incidence of chronic pain; however it is not known if the pectoral nerve block (PECS block), which is commonly used for breast surgery, is able to prevent this complication. Our main objective was therefore to detect any association between the PECS block and chronic pain at 3, 6, 9, and 12 months in patients undergoing breast surgery. METHODS: We conducted a prospective, monocentric, observational study. We enrolled 140 consecutive patients undergoing breast surgery and divided them in patients receiving a PECS block and general anesthesia (PECS group) and patients receiving only general anesthesia (GA group). Then we considered both intraoperative variables (intravenous opioids administration), postoperative data (pain suffered by the patients during the first 24 postoperative hours and the need for additional analgesic administration) and development and persistence of chronic pain (at 3, 6, 9, and 12 mo). RESULTS: The PECS group had a lower incidence of chronic pain at 3 months (14.9% vs. 31.8%, P = 0.039), needed less intraoperative opioids (fentanyl 1.61 μg/kg/hr vs. 3.3 μg/kg/hr, P < 0.001) and had less postoperative pain (3 vs. 4, P = 0.017). CONCLUSIONS: The PECS block might play an important role in lowering incidence of chronic pain, but further studies are needed.
Analgesics, Opioid ; Anesthesia, Conduction ; Anesthesia, General ; Anesthesia, Local ; Breast Neoplasms ; Breast ; Chronic Pain ; Clinical Study ; Humans ; Incidence ; Nerve Block ; Observational Study ; Pain, Postoperative ; Prospective Studies ; Thoracic Nerves

Spinal accessory nerve (SAN) injury mostly occurs during surgical procedures. SAN injury caused by manipulation therapy has been rarely reported. We present a rare case of SAN injury associated with manipulation therapy showing scapular winging and droopy shoulder. A 42-year-old woman visited our outpatient clinic complaining of pain and limited active range of motion (ROM) in right shoulder and scapular winging after manipulation therapy. Needle electromyography and nerve conduction study suggested SAN injury. Physical therapy (PT) three times a week for 2 weeks were prescribed. After a total of 6 sessions of PT and modality, the patient reported that the pain was gradually relieved during shoulder flexion and abduction with improved active ROM of shoulder. Over the course of 2 months follow-up, the patient reported almost recovered shoulder ROM and strength as before. She did not complain of shoulder pain any more.
Accessory Nerve Injuries* ; Accessory Nerve* ; Adult ; Ambulatory Care Facilities ; Electromyography ; Female ; Follow-Up Studies ; Humans ; Musculoskeletal Manipulations* ; Needles ; Neural Conduction ; Range of Motion, Articular ; Shoulder ; Shoulder Pain

BACKGROUND: Clinical manifestations of diabetic peripheral neuropathy (DPN) vary along the course of nerve damage. Nerve conduction studies (NCS) have been suggested as a way to confirm diagnoses of DPN, but the results have limited utility for evaluating clinical phenotypes. The current perception threshold (CPT) is a complementary method for diagnosing DPN and assessing DPN symptoms. We compared NCS variables according to clinical phenotypes determined by CPT measurements. METHODS: We retrospectively enrolled patients with type 2 diabetes mellitus who underwent both NCS and CPT tests using a neurometer. CPT grades were used to determine the clinical phenotypes of DPN: normoesthesia (0 to 1.66), hyperesthesia (1.67 to 6.62), and hypoesthesia/anesthesia (6.63 to 12.0). The Michigan Neuropathy Screening Instrument (MNSI) was used to determine a subjective symptom score. DPN was diagnosed based on both patient symptoms (MNSI score ≥3) and abnormal NCS results. RESULTS: A total of 202 patients (117 men and 85 women) were included in the final analysis. The average age was 62.6 years, and 71 patients (35.1%) were diagnosed with DPN. The CPT variables correlated with MNSI scores and NCS variables in patients with diabetes. Linear regression analyses indicated that hypoesthesia was associated with significantly lower summed velocities and sural amplitudes and velocities, and higher summed latencies, than normoesthesia. Sural amplitude was significantly lower in patients with hyperesthesia than in patients with normoesthesia. CONCLUSION: NCS variables differed among patients with diabetes according to clinical phenotypes based on CPT and decreased sural nerve velocities was associated with hyperesthesia.
Diabetes Mellitus, Type 2* ; Diabetic Neuropathies ; Diagnosis ; Humans ; Hyperesthesia ; Hypesthesia ; Linear Models ; Male ; Mass Screening ; Methods ; Michigan ; Neural Conduction* ; Peripheral Nervous System Diseases ; Phenotype* ; Retrospective Studies ; Sensory Thresholds ; Sural Nerve

OBJECTIVE: To assess the predictive variables after sonographically guided corticosteroid injection in carpal tunnel syndrome. METHODS: A prospective, observational study was carried out on 25 wrists of 20 consecutive patients with carpal tunnel syndrome, confirmed by the American Association of Neuromuscular and Electrodiagnostic Medicine criteria, which includes clinical history, symptoms, and evidence of slowing of distal median nerve conduction. Visual analogue scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were asked to the patients before and 4 weeks after the procedure. On a basis of VAS difference before and after the procedure, we divided the patients into two groups: more than 50% of VAS improving (good response group) and less than 50% of VAS improving (poor response group). Also, nerve conduction studies and ultrasound evaluations were performed prior to sonographically guided corticosteroid injection and at 4 weeks after the procedure. The cross-sectional area (CSA) of median nerve at maximal swelling point around wrist was measured by manual tracing using ultrasonography. With assessments mentioned above, we tried to assess predictive variables for prognosis after sonographically guided corticosteroid injection in carpal tunnel syndrome. RESULTS: The CSA of median nerve at wrist measured before the procedure was significantly larger in good response group than in poor response group. Furthermore, the CSA of median nerve at wrist, symptom severity scale of BCTQ, motor/sensory latency and sensory amplitude were correlated with VAS improving. CONCLUSION: The CSA of median nerve at wrist is the strongest predictive value for sonographically guided corticosteroid injection in mild-to-moderate carpal tunnel syndrome.
Adrenal Cortex Hormones ; Carpal Tunnel Syndrome* ; Humans ; Median Nerve ; Neural Conduction ; Observational Study ; Prognosis ; Prospective Studies ; Treatment Outcome ; Ultrasonography ; Wrist

BACKGROUND: Anesthesiologists who have finished formal training and want to learn ultrasound-guided regional anesthesia (UGRA) commonly attend 1 day workshops. However, it is unclear whether participation actually changes clinical practice. We assessed change implementation after completion of a 1 day simulation-based UGRA workshop. METHODS: Practicing anesthesiologists who participated in a 1 day UGRA course from January 2012 through May 2014 were surveyed. The course consisted of clinical observation of UGRA procedures, didactic lectures, ultrasound scanning, hands-on perineural catheter placement, and mannequin simulation. The primary outcome was the average number of UGRA blocks per month reported at follow-up versus baseline. Secondary outcomes included preference for ultrasound as the nerve localization technique, ratings of UGRA teaching methods, and obstacles to performing UGRA. RESULTS: Survey data from 46 course participants (60% response rate) were included for analysis. Participants were (median [10th–90th percentile]) 50 (37–63) years old, had been in practice for 17 (5–30) years, and were surveyed 27 (10–34) months after their UGRA training. Participants reported performing 24 (4–90) blocks per month at follow-up compared to 10 (2–24) blocks at baseline (P < 0.001). Compared to baseline, more participants at follow-up preferred ultrasound for nerve localization. The major obstacle to implementing UGRA in clinical practice was time pressure. CONCLUSIONS: Participation in a 1 day simulation-based UGRA course may increase UGRA procedural volume by practicing anesthesiologists.
Anesthesia, Conduction* ; Catheters ; Education ; Follow-Up Studies ; Lectures ; Manikins ; Nerve Block ; Teaching ; Ultrasonography

BACKGROUND AND PURPOSE: The objective of this study was to find a sensitive method for the early detection of diabetic polyneuropathy (DPN) and determine the relationship between the functions of somatic and autonomic small nerve fibers in DPN. METHODS: Patients with type 2 diabetes mellitus and DPN based on clinical symptoms, signs, intraepidermal nerve fiber density (IENFD), and findings in the quantitative sudomotor axon reflex test (QSART) were enrolled retrospectively. Neurological examinations and nerve conduction studies were performed on all patients. Heart-rate variability during deep breathing (DB ratio) and the Valsalva maneuver (Valsalva ratio) were used to quantify the cardiovagal function. Patients were divided into two groups: 1) normal nerve conduction, defined as small-fiber neuropathy (SFN) and 2) abnormal nerve conduction, defined as mixed-fiber neuropathy. RESULTS: In total, 82 patients were enrolled (age: 60.7±10.7 years, mean±SD). A decreased IENFD was the most frequent abnormality across all of the patients, followed by abnormalities of the QSART and cardiovagal function. A decreased IENFD was more sensitive than the QSART, DB ratio, and Valsalva ratio for detecting diabetic SFN. The DB ratio was significantly correlated with the duration of diabetes mellitus and clinical symptoms and signs. There was no correlation between the IENFD and the findings of the QSART for the distal leg. CONCLUSIONS: Measuring the IENFD was a more sensitive method than the QSART for the early detection of DPN. The degree of involvement of the somatic small nerve fibers and sudomotor nerve fibers was independent in DPN.
Axons ; Diabetes Mellitus ; Diabetes Mellitus, Type 2* ; Diabetic Neuropathies ; Humans ; Leg ; Methods ; Nerve Fibers* ; Neural Conduction ; Neurologic Examination ; Reflex ; Respiration ; Retrospective Studies ; Valsalva Maneuver

BACKGROUND AND PURPOSE: Diabetes mellitus (DM) has been proposed as a risk factor for carpal tunnel syndrome (CTS), but this remains controversial. We investigated the association between DM and CTS using both ultrasonography (US) and nerve conduction study (NCS) data. METHODS: We analyzed a prospectively recruited database of neuromuscular US and medical records of subjects who had undergone NCSs and electromyography for symptoms suggestive of CTS. Subjects were assigned to the follow groups: Group I, CTS with DM; Group II, CTS without DM; Group III, no CTS with DM; and Group IV, no CTS without DM. US cross-sectional area (CSA) and NCS measurements at the median nerve (MN) were compared among groups. We used a general linear mixed model to adjust for statistically significant covariates. RESULTS: The 230 participants comprised 22, 83, 19, and 106 in Groups I–IV, respectively. In multivariate analyses, the MN action potential amplitude in females was the only variable that was significantly associated with DM (p<0.001). Groups with DM tended to have a longer latency, smaller amplitude, and lower conduction velocity in the NCSs compared to groups without DM. The measured US CSA values did not differ significantly among the groups. CONCLUSIONS: NCS measurements of the MN tended to differ between DM and non-DM patients regardless of the presence or absence of CTS. However, US did not reveal any statistically significant relationship between CTS and DM.
Action Potentials ; Carpal Tunnel Syndrome* ; Diabetes Mellitus* ; Electromyography ; Female ; Humans ; Median Nerve ; Medical Records ; Multivariate Analysis ; Neural Conduction ; Prospective Studies ; Risk Factors ; Ultrasonography

OBJECTIVE: To establish the cutoff value of cross-sectional area (CSA) of the median nerve at the wrist, for determination of electrophysiologically moderate and severe carpal tunnel syndrome (CTS). METHODS: The prospective study was conducted among patients suspected of having CTS. A total of 106 patients (185 symptomatic wrists) received nerve conduction study (NCS) and ultrasonography. To establish a cutoff value, various diagnostic properties were calculated across a range of the CSA. RESULTS: A mean±standard deviation of CSA of the median nerve of normal and mild, moderate and severe CTS was 9.4±2.1, 12.0±2.7, 13.8±4.7, and 15.4±4.1 mm², respectively. The positive relationship between CTS severities and CSA was observed (rs=0.56). A 14 mm² CSA had sufficient power to rule in moderate and severe CTS, with a specificity of 91.4% and sensitivity of 42.3%. In addition, it showed a post-test probability (positive predictive value) of 86.3% as against a pre-test probability of 56.2%. CONCLUSION: Patients who had ≥14 mm² of median nerve CSA had very high probability of moderate to severe CTS.
Carpal Tunnel Syndrome* ; Electrophysiology ; Humans ; Median Nerve* ; Neural Conduction ; Prospective Studies ; Sensitivity and Specificity ; Ultrasonography ; Wrist*