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IntroductionThe peripheral nerves of patients with diabetes are often pathologically swollen, which results in entrapment at places of anatomical narrowing. This results in nerve dysfunction. Surgical treatment of compression neuropathies in the lower extremities (lower extremity nerve decompression (LEND)) results in relief of symptoms and gain in peripheral nerve function, which may lead to less sensory loss (short term) and less associated detrimental effects including foot ulceration and amputations, and lower costs (long term). The aim of the DeCompression trial is to evaluate the effectiveness and (cost-)effectiveness of surgical decompression of compressed lower extremity nerves (LEND surgery) compared with patients treated with conventional (non-surgical) care.Methods and analysisA stratified randomised (1 to 1) controlled trial comparing LEND surgery (intervention) with conventional non-surgical care (control strategy) in subjects with diabetes with problems of neuropathy due to compression neuropathies in the lower extremity. Randomisation is stratified for participating hospital (n=11) and gender. Patients and controls have the same follow-up at 1.5, 3, 6, 9, 12, 18, 24 and 48 months. Participants (n=344) will be recruited in 12 months and enrolled in all affiliated hospitals in which they receive both the intervention or conventional non-surgical care and follow-up. Outcome assessors are blinded to group assignment. Primary outcome: disease-specific quality of life (Norfolk Quality of Life Questionnaire—Diabetic Neuropathy). Secondary outcomes: health-related quality of life (EuroQoL 5-dimension 5-level (EQ-5D5L), 36-item Short Form (SF-36)), plantar sensation (Rotterdam Diabetic Foot Test Battery), incidence of ulcerations/amputations, resource use and productivity loss (Medical Cost Questionnaire, Productivity Cost Questionnaire) during follow-up. The incremental cost-effectiveness ratio will be estimated on the basis of the collected empirical data and a cost-utility model.Ethics and disseminationEthics approval has been granted by the Medical Research Ethics Committee of Utrecht University Medical Center (reference: NL68312.041.19v5, protocol number: 19-335/M). Dissemination of results will be via journal articles and presentations at national and international conferences.Trial registration numberNetherlandsTrial Registry NL7664.

•Prospective study on surgical treatment options for meralgia paresthetica.•Confirms results from previous retrospective studies.•Chance on pain relief higher after the neurectomy than after the neurolysis procedure.•RCT needed to further investigate potential differences in effectiveness.•Protocol for such a RCT is presented. Various surgical procedures can be applied in the treatment of meralgia paresthetica. The two main ones are neurolysis and neurectomy of the lateral femoral cutaneous nerve. To date, no prospective or randomized controlled trial has compared the effectiveness of these procedures with standardized outcome measures. In this study we present our results for two prospectively followed cohorts and we present the protocol for a double blind randomized controlled trial (RCT). All patients that had an indication for surgical treatment of idiopathic meralgia paresthetica between August 2012 and April 2014 were included in the study. The patient decided on the type of treatment (neurolysis or neurectomy) after informed consent had been given. Primary outcome was measured using the Likert scale obtained 6 weeks after the surgery. Successful pain reduction was defined as Likert 1 or 2. Secondary outcome measures were the Numeric Rating Scale (NRS) and Bothersomeness Index (BSI). In case of neurectomy the BSI for numbness was also obtained. A total of 22 consecutive patients were included: neurolysis was performed in 8 patients and neurectomy in 14 patients (one bilateral case). Successful pain reduction was observed more frequently after neurectomy (93.3%) than after neurolysis (37.5%, P<0.05). Secondary outcome scores (NRS and BSI pain) were also better after neurectomy, although not significantly (respectively P=0.07 and 0.05). Paired analysis of the scores before and after the surgery showed an improvement in both the NRS and BSI after the neurectomy procedure (both P<0.001), while scores were not significantly different before and after the neurolysis procedure. Patient's scores for the BSI numbness after the neurectomy procedure were low (mean 1.4, SD±1.0, range 0–3). The results of our prospective study confirm results previous studies reported in the literature in that the percentage pain relief was better after neurectomy than after neurolysis. A RCT is needed to further investigate potential differences in effectiveness. The protocol for such a trial is presented in this article.

Background Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and neurectomy in patients with ACNES. Methods Adult ACNES patients having short-lived success following injections are randomized to PRF or neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure. Discussion Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery. Trial registration Nederlands Trial Register (Dutch Trial Register), NTR5131 ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131 ). Registered on 15 April 2015.

Objective To compare the efficacy of percutaneous vertebroplasty (PVP) with and without interventional tumor removal (ITR) on malignant vertebral compression fractures and symptoms of neurological compression. Materials and methods A total of 52 patients with malignant vertebral compression fractures and symptoms of neurological compression were selected for PVP and ITR ( n  = 24, group A) or PVP alone ( n  = 28, group B). A 14-G needle and a guidewire were inserted into the vertebral body, followed by sequential dilatation of the tract with the working cannula until the last working cannula reached the distal pedicle of the vertebral arch. ITR was performed with marrow nucleus rongeurs. Then, 5–10 mL cement was injected into the extirpated vertebral body. Results PVP procedures with and without ITR were successful in all patients, except for one patient in group A. The clinical assessment obtained at the initial and final follow-up indicated that the rates of full recovery and improved neurological compression symptoms were significantly higher in group A than in group B ( P  < 0.05). Conclusion Treatment of malignant vertebral compression fractures with symptoms of neurological compression with PVP and ITR resulted in better intermediate-term clinical results in terms of improved neurological compression symptoms than the currently recommended approach of PVP. Key Points • Percutaneous vertebroplasty (PVP) is now widely used for vertebral collapse due to malignancy • PVP can be coupled with interventional tumour removal (ITR) • PVP coupled with ITR provided better clinical results for neurological compression • PVP coupled with ITR provided better pain relief • PVP and ITR can remove tumour and helps prevent polymethyl methacrylate leakage

Objective: To investigate the effect of decompression of nerves in the lower extremity in patients with painful diabetic polyneuropathy on static balance using a sensitive pressure mat system. Design: Non-blinded randomized controlled trial. Setting: Single center study performed at the University Medical Center Utrecht between 2010-2013. Subjects: Patients with painful diabetic polyneuropathy assessed with the Diabetic Neuropathy Symptom score and Diabetic Neuropathy Examination between 18-90 years. Exclusion criteria were: physical problems leading to instability, BMI>35 kg/m2, ankle fractures in history, amputations proximal to the tarsometatarsal joints, active foot ulcer(s), severe occlusive peripheral vascular diseases. Intervention: Unilateral surgical nerve decompression at four sites in the lower extremity, the contralateral limb was used as control (within-patient comparison), with one year follow-up. Main measures: Preoperatively and 6 and 12 months postoperatively, weight bearing and five variables of sway of the center of pressure were measured with a pressure mat with eyes open and eyes closed. T-test was used for evaluation of postoperative results. Results: Thirty-nine Patients met inclusion criteria and were enrolled for stability testing. Postoperatively no significant differences for sway variables and weight bearing were seen compared to preoperatively measurements. Conclusions: There is no evidence that surgical decompression of nerves of the lower extremity influences stability within one year after surgery in patients with painful diabetic polyneuropathy.

The radial nerve is the biggest branch of the posterior cord of the brachial plexus and one of its five terminal branches. Entrapment of the radial nerve at the elbow is the third most common compressive neuropathy of the upper limb after carpal tunnel and cubital tunnel syndromes. Because the incidence is relatively low and many agents can compress it along its whole course, entrapment of the radial nerve or its branches can pose a considerable clinical challenge. Several of these agents are related to normal or variant anatomy. The most common of the compressive neuropathies related to the radial nerve is the posterior interosseus nerve syndrome. Appropriate treatment requires familiarity with the anatomical traits influencing the presenting symptoms and the related prognoses. The aim of this study is to describe the compressive neuropathies of the radial nerve, emphasizing the anatomical perspective and highlighting the traps awaiting physicians evaluating these entrapments.

Background Double crush syndrome refers to a nerve in the proximal region being compressed, affecting its proximal segment. Instances of this syndrome involving ulnar and cubital canals during ulnar neuropathy are rare. Diagnosis solely through clinical examination is challenging. Although electromyography (EMG) and nerve conduction studies (NCS) can confirm neuropathy, they do not incorporate inching tests at the wrist, hindering diagnosis confirmation. We recently encountered eight cases of suspected double compression of ulnar nerve, reporting these cases along with a literature review. Methods The study included 5 males and 2 females, averaging 45.6 years old. Among them, 4 had trauma history, and preoperative McGowan stages varied. Ulnar neuropathy was confirmed in 7 cases at both cubital and ulnar canal locations. Surgery was performed for 4 cases, while conservative treatment continued for 3 cases. Results In 4 cases with wrist involvement, 2 showed ulnar nerve compression by a fibrous band, and 1 had nodular hyperplasia. Another case displayed ulnar nerve swelling with muscle covering. Among the 4 surgery cases, 2 improved from preoperative McGowan stage IIB to postoperative stage 0, with significant improvement in subjective satisfaction. The remaining 2 cases improved from stage IIB to IIA, respectively, with moderate improvement in subjective satisfaction. In the 3 cases receiving conservative treatment, satisfaction was significant in 1 case and moderate in 2 cases. Overall, there was improvement in hand function across all 7 cases. Conclusion Typical outpatient examinations make it difficult to clearly differentiate the two sites, and EMG tests may not confirm diagnosis. Therefore, if a surgeon lacks suspicion of this condition, diagnosis becomes even more challenging. In cases with less than expected postoperative improvement in clinical symptoms of cubital tunnel syndrome, consideration of double crush syndrome is warranted. Additional tests and detailed EMG tests, including inching tests at the wrist, may be necessary. We aim to raise awareness double crush syndrome with ulnar nerve, reporting a total of 7 cases to support this concept.

Abstract BACKGROUND While high-resolution imaging is increasingly used in guiding decisions about surgical interventions for the treatment of trigeminal neuralgia, direct assessment of the extent of vascular contact of the trigeminal nerve is still considered the gold standard for the determination of whether nerve decompression is warranted. OBJECTIVE To compare intraoperative and magnetic resonance imaging (MRI) findings of the prevalence and severity of vascular compression of the trigeminal nerve in patients without classical trigeminal neuralgia. METHODS We prospectively recruited 27 patients without facial pain who were undergoing microvascular decompression for hemifacial spasm and had undergone high-resolution preoperative MRI. Neurovascular contact/compression (NVC/C) by artery or vein was assessed both intraoperatively and by MRI, and was stratified into 3 types: simple contact, compression (indentation of the surface of the nerve), and deformity (deviation or distortion of the nerve). RESULTS Intraoperative evidence of NVC/C was detected in 23 patients. MRI evidence of NVC/C was detected in 18 patients, all of whom had intraoperative evidence of NVC/C. Thus, there were 5, or 28% more patients in whom NVC/C was detected intraoperatively than with MRI (Kappa = 0.52); contact was observed in 4 of these patients and compression in 1 patient. In patients where NVC/C was observed by both methods, there was agreement regarding the severity of contact/compression in 83% (15/18) of patients (Kappa = 0.47). No patients exhibited deformity of the nerve by imaging or intraoperatively. CONCLUSION There was moderate agreement between imaging and operative findings with respect to both the presence and severity of NVC/C.

Background Double crush syndrome (DCS) is a relatively rare nerve compression syndrome among peripheral nerve compression diseases. However, ulnar nerve double entrapment caused by peri-cubital tunnel ganglion cysts has been rarely reported. Case presentation Here, we present a case of a 54-year-old woman who experienced occasional pain, numbness and paralysis in her right half hand for 1 year. A B-ultrasound of the right elbow initially revealed cubital tunnel syndrome only. Further Magnetic Resonance Imaging (MRI) showed a ganglion cyst near the cubital tunnel. After evaluation, we performed open surgery to excise the cyst and incise the cubital tunnel, completely decompressing the ulnar nerve entrapment. Ulnar nerve anterior transposition was also performed simultaneously. Conclusions The patient was followed up for 1 month, and she experienced a complete recovery with no functional limitations. Clinical trial number Not applicable.

Epithelioid sarcomas are rare soft tissue tumors and have possibility to involve the peripheral nerve and present as sensory and motor disorders. The symptoms are similar to those of nerve compression diseases. This situation is extremely rare in clinic and was only reported as several case reports in literature. It can be easily ignored and misdiagnosed in clinic and may bring out severe outcomes. From January 2003 to December 2017, a retrospective analysis of ten patients with epithelioid sarcomas which involved the peripheral nerves was made. The medical data, detailed clinical courses and the follow-up results were stated. In these cases, the tumors invaded the median nerve, ulnar nerve, radial nerve, brachial plexus, sciatic nerve and presented as relative symptoms. Early diagnosis and treatment are the keys to better prognosis. We recommended high-resolution ultrasound as a standard diagnostic tool for nerve compression syndromes not only reveal the morphological structure of the peripheral nerve, but also discover the tumor involving the nerve. Adequate surgical methods including wide resection and lymph node dissection if necessary. The manners of functional reconstruction need to be applied flexibly by the doctors. Postoperative rehabilitation is important for functional recovery. We want to share our experiences in the diagnosis and treatment to overcome this particular condition.