Common sites for Morton's neuromas

Morton's Neuroma is a painful condition of the forefoot that is caused by the entrapment of the common intermetatarsal nerve as it passes through the forefoot to the toes. Morton's Neuroma was first described by Dr. Morton, a Viennese physician, in 1876.
Where are most Morton's neuromas found?

A) In the tarsal tunnel
B) At the first metatarsal phalangeal joint
C) The second and third interdigital space
D) At the attachment of the plantar fascia
E) At the head of the fifth metatarsal

Answer and Discussion

The answer is C.

The interdigital spaces of the foot are common sites for painful neuromas, a condition termed Morton's neuroma. The second and third common digital branches of the medial plantar nerve are the most frequent sites for development of interdigital neuromas. Morton's neuromas develop as a result of chronic trauma and repetitive stress, as occurs in persons wearing tight-fitting or high-heeled shoes. Pain and paresthesias are usually mild at onset and are located in the interdigital space of the affected nerve. In some cases, the interdigital space between the affected toes may be widened as a result of an associated ganglion or synovial cyst. Pain is noted in the affected interdigital space when the metatarsal heads of the foot are squeezed together. Injection with 1% lidocaine (Xylocaine) can assist in confirming the diagnosis.

The symptoms of Morton's neuroma include the following;

• A dull achy sensation in the forefoot, usually between the 3rd and 4th toes.
• Pain that increased with the time a person spends on their feet, particularly in high heels and narrow fitting shoes.
• Pain that is not relieved by rest. Neuroma pain takes several minutes to hours to subside.
• Numbness of the 3rd and 4th toes.
• A sensation of walking on something, such as a bunched up sock
• .Occasionally, a snapping sensation or electrical shock sensation (Muldier's Sign).

The digital nerve(1) running in the narrow space between the metatarsal bones where it splits into two(2) and where a Mortons Neuroma is usually found.

Craniotomy for resection of 4th Ventricle Tumor

Dr. Pakzaban demonstrates the technique of suboccipital craniotomy for access to the posterior cranial fossa using an Aesculap bone scalpel. This approach is used in many different operations including decompression of Chiari malformation. In this case, it is being used for resection of a 4th ventricle tumor known as subependymoma.

Placement of Surgical Clip

Intraoperative placement of a surgical clip for a paraclinoid aneurysm.

Causalgia

DEFINITION: A syndrome of sustained burning pain after a traumatic nerve injury combined with vasomotor and sudomotor dysfunction and later trophic changes.


Causalgias are divided into two forms:
1. Causalgia major involves peripheral nerve injury with electrical "crosstalk" (ephapse) that causes severe hyperactivity of sympathetic system (hyperpathia, vasoconstriction, and movement disorder). The major form is severe, usually caused by injury with high velocity sharp objects (e.g., butcher's knife), vibratory component major trauma (e.g., bullet), or high-voltage nerve lesions (electrocution).

2. Causalgia minor involves the same principle as causalgia major, but milder injury, e.g., injury to the dorsum of hand or foot, nerve root contusion, patient falling from a height on gluteal region resulting in "guillotine" effect, bruising of nerve root caught at the narrowed intervertebral foramen.

SO,The difference between the two categories is a matter of degree and severity. To classify causalgia as an independent illness is artificial, and causalgia is nothing but a sever form of RSD(Reflex Sympathetic Dystrophy ).

In this severe form of RSD, the course of the disease is quite accelerated from stage 1 through 4 in a matter of weeks or months. S. Weir Mitchell in 1872 first reported rapid development of atrophic changes in the skin, nails, and soft tissues of the extremity in a matter of days to weeks.
Whereas in RSD of disuse the extremity is cold, in ephaptic dystrophy the thermography reveals in the distal portion of the extremely cold extremity that there is an isolated hot spot that points to the area of scar formation and ephaptic peripheral nerve dysfunction . In this area the vasoconstrictive capability of the sympathetic nerve is paralyzed, and there is a topical hot spot. This hot spot can be appreciated only by thermograph.

CAUSALGIC PAIN:
- Usually pain occurs after the injury to a nerve trunk.
- The pain is spontaneous, severe, and quite persistent.
- There is a markedly lowered threshold for aggravation of pain. This is the case in all RSD patients, but it is more exaggerated in causalgics. So even a breeze over the skin or the touch of a bed sheet or a change of the environment or a family argument and aggravation can markedly aggravate the pain. This feature of emotional aggravation is common to all RSD patients, and it is nothing but the role of the frontal lobe and the limbic system in aggravation of hyperpathic pain.
- The pain is felt distal to the proximal nerve injury, i.e., in the hand or foot. This is typical but not invariable. The pain does not necessarily have to be a burning type of pain, and can be described in many other hyperpathic forms.

Tubular Diskectomy

A video showing the procedure of Tubular Diskectomy of a herniated disk.

Endoscopic Anterior Skull Base Resection by RRC

An endoscopic anterior skull base resection may be necessary in select neoplasms. Obviating the need for any external incisions, this approach has become increasingly valuable to address a number of sinonasal neoplasms affecting the anterior skull base, through a minimally invasive technique. This video reviews the endoscopic anterior skull base approach for a typical esthesioneuroblastoma. It also touches on the reconstructive technique using a free alloderm graft, which has been in use by us for over 10 years, and has yielded consistent results, with no CSF leaks.

Carpal Tunnel Choices

This 3D medical animation depicts carpal tunnel syndrome and carpal tunnel release. Carpal tunnel syndrome is a nerve disorder of the hand caused by compression of the median nerve.2 different types of carpal tunnel release are animated, an open carpal tunnel procedure and the endoscopic approach.

Neuroanatomy of CSF Flow

Simplified Aqueductal Stenting for Isolated Fourth Ventricle

In this video, the authors demonstrate a new method for treating isolated fourth ventricle syndrome using a fiber optic endoscope. They illustrate the technique in a 39-year-old woman with coccidiomycosis. This case demonstrates that the technique is feasible and may offer several advantages over currently applied methodologies.

Endoscopic endonasal transsphenoidal adenomectomy

This video demonstrates the endoscopic endonasal transsphenoidal approach and removal of a pituitary adenoma (EETA). This is a benign hormonally inactive tumor of the pituitary gland.
The surgery is performed by E.J. van Lindert, MD PhD, in the neurosurgical department of Radboud University Nijmegen Medical Centre, The Netherlands.

Corrective Surgery: Microvascular Decompression

Microvascular decompression actually treats the vessel causing the cranial nerve disorder, it potentially provides a long-term solution to the problem.

Transsphenoidal Surgery

Transsphenoidal surgery is a procedure used to remove pituitary tumors from the brain. The surgeon works through a small opening (ostium) at the back of the nose (septum) that leads to an air pocket called the sphenoid sinus. To access the pituitary tumor, the surgeon goes through the sphenoid sinus and cuts through the tissue covering the pituitary gland. The tumor is removed with small instruments called curets. A small scope inserted through the sphenoid sinus helps the surgeon to visualize the tumor. A large tumor may need to be cut into smaller pieces before it's removed.

Scoliosis Test and Surgical Techniques

Adam's Forward Bend Test


Scoliosis - Advanced Surgical Techniques



FOR photos and other information CLICK HERE

Treatment Of Acromegaly

Medical Care:

Because elevated GH/IGF-I concentration is associated with increased mortality rates, try to decrease/normalize their concentration. Most experts define cure, or adequate control, as a glucose-suppressed GH concentration of less than 2 ng/mL by radioimmunoassay (RIA) (1 mcg/L by IRMA) and normalization of the serum IGF-I concentration.

No single modality of treatment consistently achieves the above levels. A multimodality approach usually requires surgery as the first line of treatment, followed by medical therapy for residual disease. Radiation treatment is generally reserved for refractory cases.

1* Somatostatin and dopamine analogues and GH receptor antagonists are the mainstays of medical treatment and are generally used after failure of primary surgery to induce complete remission.
2* Bromocriptine is a dopamine agonist with limited effectiveness in the treatment of acromegaly. It can reduce the circulating GH level to less than 5 ng/mL in only 20% of patients and can normalize the IGF-I concentration in 10% of patients. Shrinkage in tumor size is also observed in fewer than 20% of patients. Cabergoline, another dopamine agonist, fares somewhat better with response rates of 46%.
3* Tumors that cosecrete prolactin have a better response rate to dopamine agonists. The response to these agents is often detected by a trial of the drug in suitable patients.
4* Somatostatin is a natural inhibitor of GH secretion. Because of its very short half-life, long-acting analogues have been developed. The long-acting analogue can be administered once per month but is extremely expensive (>$12,000/y in 1999).
o Octreotide is the most extensively studied and used somatostatin
analogue.
o It primarily binds to the somatostatin receptor subtypes II and V and
inhibits GH secretion.
o Treatment with octreotide reduces GH concentration to less than 5 ng/mL
in 65% of patients and to less than 2 ng/mL in 40% of patients; it
normalizes concentration IGF-I in 60% of patients.
o Tumor shrinkage is observed in 20-50% of patients.
5* Pegvisomant, a GH receptor antagonist normalizes IGF-I levels in 90-100% of patients. As expected from its mechanism of action, GH levels increase during treatment and no decrease in tumor size is seen. A minority of patients may experience an increase in tumor size; whether this is due to natural history of the disease or an effect of treatment is unclear. Periodic imaging studies are advised in patients on this medication.
6* Radiation treatment takes to reduce/normalize GH/IGF-I levels. About 60% of patients have a GH concentration of less than 5 ng/mL 10 years after radiotherapy. A similar percentage of patients develop panhypopituitarism as a result of treatment. Because of the disappointing results and adverse effects, radiotherapy is used as an adjuvant for large invasive tumors and when surgery is contraindicated. Some studies suggest that radiation is associated with the development of secondary tumors.

Surgical Care:

Even though surgery might not cure a significant number of patients, it is employed as first-line therapy. Patients with residual disease can then be offered adjuvant treatment.

* Transsphenoidal hypophysectomy has the dual advantage of rapidly improving
symptoms caused by mass effect of the tumor and significantly reducing or
normalizing GH/IGF-I concentrations CLICK HERE
* Remission depends on the initial size of the tumor, the GH level, and the
skill of the neurosurgeon.
* A remission rate of 80-85% can be expected for microadenomas and 50-65% for
macroadenomas.
* The postoperative GH concentration may predict remission rates. According to
the results of one study, a postoperative GH concentration of less than 3
ng/dL was associated with a 90% remission rate, which declined to 5% in
patients with postoperative GH concentration greater than 5 ng/dL.

Prognosis:

-Remission depends on the initial size of the tumor, the GH level, and the skill of the neurosurgeon.

* Remission rates of 80-85% and 50-65% can be expected for microadenomas and
macroadenomas, respectively.
* The postoperative GH concentration may predict remission rates. According to
the results of one study, a postoperative GH concentration of less than 3
ng/dL was associated with a 90% remission rate, which declined to 5% in
patients with a postoperative GH concentration greater than 5 ng/dL.