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Coverpage
January-February 2019
Volume 67 | Issue 7 (Supplement)
Page Nos. 1-161

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NI FEATURE: THE FIRST IMPRESSION - COMMENTARY  

The cover page Highly accessed article p. 1

DOI:10.4103/0028-3886.250722  PMID:30688219
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NI FEATURE: TIMELESS REVERBERATIONS - COMMENTARY Top

My tryst with peripheral nerve surgery p. 2
Bhabani Shankar Das
DOI:10.4103/0028-3886.250705  PMID:30688220
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Evolution of brachial plexus surgery at AIIMS- the last 4 decades p. 4
Veer Singh Mehta, Sumit Sinha
DOI:10.4103/0028-3886.250728  PMID:30688221
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EDITORIAL Top

Peripheral nerve injuries: From surgical reluctance to rewiring - the road less travelled p. 7
B Indira Devi
DOI:10.4103/0028-3886.250720  PMID:30688222
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NI FEATURE: JOURNEY THROUGH THE EONS - EDITORIAL Top

Peripheral nervous system surgery: Travelling through no man's land to new horizons p. 9
Lukas Rasulic, Milan Lepić, Andrija Savić, Toplica Lepić, Miroslav Samardžić
DOI:10.4103/0028-3886.250732  PMID:30688223
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NI FEATURE: THE EDITORIAL DEBATE I-- PROS AND CONS Top

Nerve repair: Bridging the gap from “limp” to “limb” p. 16
Chirag Solanki, Mariano Socolovsky, B Indira Devi, Dhananjaya I Bhat
DOI:10.4103/0028-3886.250712  PMID:30688224
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Peripheral nerve injuries and their surgical treatment: New perspectives on a changing scenario p. 20
Debora Garozzo
DOI:10.4103/0028-3886.250715  PMID:30688225
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NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS Top

Treatment of neuropathic pain after peripheral nerve and brachial plexus traumatic injury p. 23
Daniel Umansky, Rajiv Midha
DOI:10.4103/0028-3886.250718  PMID:30688226
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Neuropathic pain: Searching for the magic bullet p. 25
Lukas Rasulic, Vikram Singh, MS Gopalakrishnan, K V L N Rao
DOI:10.4103/0028-3886.250713  PMID:30688227
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NI FEATURE: THE EDITORIAL DEBATE III-- PROS AND CONS Top

Restoring movements at the shoulder joint in pan-brachial plexus injuries: Focusing on the complex kinesiology p. 27
Manish Singh Sharma
DOI:10.4103/0028-3886.250711  PMID:30688228
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Spinal accessory nerve transfer to the suprascapular nerve to restore shoulder function in brachial plexus injury: Management nuances p. 29
Ankur Bhatnagar
DOI:10.4103/0028-3886.250725  PMID:30688229
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REVIEW ARTICLES Top

Treatment of neuropathic pain after peripheral nerve and brachial plexus traumatic injury p. 32
Ana Carolina Lovaglio, Mariano Socolovsky, Gilda Di Masi, Gonzalo Bonilla
DOI:10.4103/0028-3886.250699  PMID:30688230
Peripheral nerve and brachial plexus injuries typically cause severe impairment in the affected limb. The incidence of neuropathic pain is high, reaching up to 95% of cases, especially if cervical root avulsion has occurred. Neuropathic pain results from damage to the somatosensory system, and its progression towards chronicity depends upon disruptions affecting both the peripheral and central nervous system. Managing these painful conditions is complex and must be accomplished by a multidisciplinary team, starting with first-line pharmacological therapies like tricyclic antidepressants and calcium channel ligands, combined physical and occupational therapy, transcutaneous electrical stimulation and psychological support. For patients refractory to the initial measures, several neurosurgical options are available, including nerve decompression or reconstruction and ablative/modulatory procedures.
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Peripheral nerve tumors in neurofibromatosis 1: An overview on management and indications for surgical treatment in our experience p. 38
Debora Garozzo
DOI:10.4103/0028-3886.250697  PMID:30688231
Neurofibromatosis 1 (NF1) is associated with peripheral nerve tumors (PNTs) in about 30% of cases. In comparison with sporadic forms, NF1 PNTs present some peculiarities: (1) A large prevalence of neurofibromas; (2) the presence of pathognomonic tumoral forms (plexiform neurofibromas); and, (3) a higher incidence (lifetime risk is equal to 8–13%) and an earlier age of onset (2–3 versus 3–6 decades) of malignant peripheral nerve sheath tumors (MPNSTs). For fear of inducing neurological complications, surgical removal of PNTs is generally recommended for symptomatic tumors only. Yet, it can be safely performed by surgeons with expertise in the field. A valid preventive strategy is also essential. Based on the evidence that in NF1, one-third of MPNSTs are consequent to malignant transformation of pre-existing benign tumors, a more aggressive surgical attitude should be advocated.
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COMMENTARY Top

Surgical dilemmas in the management of peripheral nerve tumors in neurofibromatosis 1 p. 45
Dhananjaya I Bhat, Mariano Socolovsky, Vikram Singh
DOI:10.4103/0028-3886.250716  PMID:30688232
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REVIEW ARTICLE Top

Radiation-induced brachial plexus neuropathy: A review p. 47
Anshu C Warade, Ashish K Jha, Sanjeev Pattankar, Ketan Desai
DOI:10.4103/0028-3886.250704  PMID:30688233
Radiation-induced brachial plexus neuropathy (RIBPN) is an uncommon problem. It is a delayed nontraumatic brachial plexus neuropathy following radiation treatment for carcinomas in the region of neck, axilla, and chest wall. The incidence is more commonly reported following radiation treatment for carcinoma of breast. The neurological features are characterized by severe neurogenic pain with progressive sensory-motor deficits in the affected upper limb. The incidence has increased following improved survival rate of patients with carcinomas of neck, axilla, and chest wall. The diagnosis of RIBPN is often confused with recurrence of the tumor in the neck and axilla. The management options are limited, and external neurolysis of the involved brachial plexus with excision of the perineural scar tissue is recommended in patients with severe clinical manifestations. We review our experience in the management of RIBPN from 2004 to 2017 and highlight the features of the 11 patients with this disorder whom we encountered during this period. The relevant clinical findings, natural history, pathophysiology, radiological characteristics, and various management options are briefly discussed.
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COMMENTARY Top

Role of surgery in radiation induced brachial plexus neuropathy p. 53
Anil Kumar, MS Gopalakrishnan, Manish Beniwal
DOI:10.4103/0028-3886.250717  PMID:30688234
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REVIEW ARTICLE Top

“Carpal tunnel syndrome:” A bibliometric study of 35 years of research p. 55
Shri Ram
DOI:10.4103/0028-3886.250698  PMID:30688235
Carpal tunnel syndrome (CTS) is a disease caused by compression of the median nerve passing through the wrist. Patients suffer from severe pain and paresthesis in the median nerve. Compression of the median nerve occurs, with prolonged working on keyboards (computer or laptop or music players) being one of the reasons along with others such as diabetes or rheumatoid arthritis. CTS research holds great promise for the patients as well as doctors for better medical treatment. The study has been carried out with an objective to analyze research progress based on the literature published on CTS during the last 35 years. The retrospective study has been carried out from the data indexed in SCOPUS multidisciplinary database from 1983 to 2017 (35 years). The study involves analysis of publication trends in terms of total articles, productive countries, institutions, journals, productive authors, most cited articles along with impact in terms of citation and h-Index. The SCOPUS database yielded 13187 articles during the study period. These articles were analyzed further for interpreting results. In the last 35 years, the number of scientific publications on CTS has been increasing with an annual growth rate of 9.86% per year. USA has been the most productive country. Literature pertaining to females is more than clinical studies involving males.
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ORIGINAL ARTICLES Top

Clinical, electrophysiological and laboratory parameters, and outcome in patients with biopsy proven systemic and nonsystemic vasculitic neuropathy p. 62
Kiran Kumar Ramineni, Sadanandavalli Retnaswami Chandra, Anita Mahadevan, Girish Baburao Kulkarni, C Nitin Ramanujam
DOI:10.4103/0028-3886.250709  PMID:30688236
Aim: To describe the clinical and laboratory findings of patients with biopsy proven vasculitic neuropathy. Introduction: Peripheral neuropathies form one of the most common disorders of the nervous system. However, more than 50% of them are labelled as 'idiopathic' and, therefore, treatment options become less. In this study, we tried to evaluate the phenotypic as well as laboratory characteristics and outcome of patients with biopsy proven vasculitic neuropathy. Patients and Methods: Review of biopsy proven definite or probable vasculitic neuropathy was done. Results: The cohort consisted of 67 subjects. There were 21 patients of systemic vasculitis (SVS) and 46 of non-systemic vasculitic neuropathy (NSVN). The nerve biopsy revealed definite vasculitis in 37 and probable vasculitis in 30 patients. The symptoms at onset were paraesthesia (68.7%), and paraesthesia and weakness (28.4%). Diffuse polyneuropathy occurred in 70.1% patients. The course was chronic in the majority (80.59%) of patients. Electrophysiology revealed mononeuritis multiplex in 32.84%, and polyneuropathy in 67.16% of patients. Pure sensory neuropathy was present in 16.42%. Among the patients who had undergone bilateral nerve conduction studies, the majority (71.05%) of patients had an asymmetric neuropathy. An elevated erythrocyte sedimentation rate (ESR) was observed in 80.59% (mean 71.57 ± 30.81 mm/1hr [in SVS] and 35.24 ± 21.62mm/1 hr in NSVN) of patients. The treatment included steroids, other immunomodulators, and symptomatic medications. The mean follow up was 10.98 ± 9.58 months. The outcome was good in 73.46% (43.8% with SVS and 87.88% with NSVN) patients, with those having a NSVN having a significantly better outcome. Conclusion: Vasculitis is a potentially treatable cause of peripheral neuropathy. The clinical features, electrophysiology, laboratory results and nerve biopsy may help in the diagnosis and categorization of patients into non-systemic and systemic vasculitic neuropathies. The long-term outcome is better in patients with NSVN compared to those with systemic vasculitis.
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High resolution ultrasonography of peripheral nerves in diabetic peripheral neuropathy p. 71
Youdhwir Singh, Rashmi Dixit, Sapna Singh, Sandeep Garg, Neera Chowdhury
DOI:10.4103/0028-3886.250719  PMID:30688237
Purpose: The purpose of the study was to assess the usefulness of high-resolution ultrasonography (HRU) in the evaluation of diabetic peripheral neuropathy (DPN). Methods: Thirty-seven adult diabetic patients with clinically diagnosed DPN and 45 healthy adult volunteers were included in the study. HRU of the right medial, ulnar, common peroneal, and posterior tibial nerves was done. The mean cross-sectional area (CSA) of the involved nerves was measured in the two groups at identical positions. The CSA was compared between the two groups, and Student t-test was applied to assess statistical significance. Results: There was a significant increase in the CSA of the median, ulnar, common peroneal, and posterior tibial nerve in DPN patients as compared to healthy volunteers. Sonographic findings were compared with nerve conduction study (NCS) for all the nerves studied except common peroneal nerve (CPN), as the NCS of CPN is not routinely done. DPN was classified as mild or moderate to severe on the basis of latency and velocity assessed by NCS. The mean CSA in all the examined nerves was higher in moderate to severe DPN than the mild DPN, but this was not statistically significant except for ulnar nerve with a P value of < 0.0001. Conclusion: HRU demonstrates a morphological change in patients with DPN in the form of an increase in CSAs, which was statistically significant. HRU can objectively complement other diagnostic investigations such as NCS. High resolution ultrasonography of peripheral nerves has the potential to become the investigation of first choice for the evaluation of DPN.
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Functional outcome of spinal accessory nerve transfer to the suprascapular nerve to restore shoulder function: Results in upper and complete traumatic brachial plexus palsy in adults p. 77
Mario G Siqueira, Roberto S Martins, Davi Solla, Wilson Faglioni, Luciano Foroni, Carlos O Heise
DOI:10.4103/0028-3886.250708  PMID:30688238
Background: Shoulder stability, abduction and external rotation are vital for the performance of usual daily tasks. Aims: To compare the functional outcomes in the shoulder following spinal accessory to suprascapular nerve transfer (SASNT). Patients and Methods: Comparison of the outcome of adult patients with upper traumatic brachial plexus palsy undergoing SASNT with patients with complete palsy submitted to the same procedure. Statistical Analysis: Ranges of motion were compared via the Mann-Whitney U test. The percentages of patients with a favorable outcome were compared by the chi-square test. All tests were two-tailed and P values <0.05 were considered statistically significant. Results: SASNT was performed in 76 patients: 23 cases (30.2%) of upper-plexus injuries and 53 cases (69.7%) of complete brachial plexus palsy. Good shoulder abduction was achieved in 15 patients (65.2%) with upper plexus palsy and a good external rotation in 5 (21.7%). In those patients with a good recovery, the average range of motion (ROM) was 53° for shoulder abduction and 71.2° for external rotation. Thirty-six patients (67.9%) with complete palsy had a good shoulder abduction recovery with 30.7° of average ROM, but only 3 patients (5.6%) recovered a good shoulder external rotation with 68.3° of average ROM. There was no statistical difference for the abduction outcome, but the external rotation outcome was superior in the upper plexus palsy group. Conclusion: SASNT is a consistent procedure to achieve functional recovery of shoulder abduction after a partial or complete plexus injury, but the outcomes of external rotation were quite disappointing in both the groups.
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Injection-related iatrogenic peripheral nerve injuries: Surgical experience of 354 operated cases p. 82
Ketan Desai, Anshu C Warade, Ashish K Jha, Sanjeev Pattankar
DOI:10.4103/0028-3886.250703  PMID:30688239
Objective: A retrospective analysis of surgically treated 354 cases of injection-related iatrogenic peripheral nerve injuries was performed. The purpose of this clinical study was to present our experience in the management of various types of injection-related peripheral nerve injuries and discuss various issues that are associated with this subset of peripheral nerve injuries. Methods: Over a 17-year period, 354 cases of injection-related iatrogenic peripheral nerve injuries were managed surgically at the Department of Neurosurgery at P.D. Hinduja Hospital and Seth G S Medical College, Mumbai. In our series, the injection-related iatrogenic nerve injuries were following intramuscular injections, brachial nerves block procedures, subclavian and jugular venous cannulation procedures for central line placements, and routine intravenous injections in the peripheral veins of the limbs. The age of the patients ranged from 5 years to 65 years. Pain, paresthesia, and sensory-motor deficits were the common presenting features in our series. The operative procedures performed in our series were external neurolysis and excision of neuroma/contused portion of the nerve and sural nerve cable grafting. The follow-up ranged from 6 months to 84 months. There were no major intraoperative complications in our series. Results: In our series, functional improvement (power grade 3 or above) was noted in 190 (53.7%) patients following surgical intervention. In 164 (46.3%) patients, there was either a non-functional status or no recovery. Neurological deterioration in the form of motor weakness was noted in 9 (2.5%) patients in our series after the surgery. The best results (90.1%) were noted with radial nerve repair following surgical intervention. Conclusion: Injection-related iatrogenic nerve injuries are not an uncommon problem. Surgery should be the preferred treatment option when the injured nerve fails to recover following the insult. The results are rewarding in a significant percentage of patients following timely intervention. The problem of litigation attached with this type of injury is also highlighted.
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COMMENTARY Top

Indiscriminate use of intramuscular injections: An unforeseen public health hazard p. 92
Anil Kumar, Debora Garozzo, Dhaval P Shukla
DOI:10.4103/0028-3886.250707  PMID:30688240
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NI FEATURE: PATHOLOGY PANORAMA - ORIGINAL ARTICLE Top

Patterns of peripheral neuropathy in Sjogren's syndrome in a tertiary care hospital from South India p. 94
Yareeda Sireesha, Meena Angamuthu Kanikannan, Anjan Pyal, Gampa Sandeep, Megha S Uppin, Rukmini Mridula Kandadai, Shaik Afshan Jabeen, Rajendra Varaprasad, Liza Rajasekhar, Mathukumalli L Neeharika, Rupam Borgohain
DOI:10.4103/0028-3886.250714  PMID:30688241
Introduction: Sjogren's syndrome (SS) is a systemic autoimmune disease that apart from involving the exocrine glands can affect any organ. Involvement of the peripheral nervous system results in a wide spectrum of neuropathic manifestations. Objective: To evaluate the clinico-electrophysiological patterns as well as pathological characteristics of neuropathy in SS patients presenting to a neuromuscular clinic in a tertiary hospital from South India. Materials and Methods: This is a retrospective study from the Departments of Neurology, Rheumatology, and Pathology from Nizam's Institute of Medical Sciences. Twenty-one patients with the diagnosis of SS and peripheral neuropathy, seen between 2010 and 2016 were analyzed. Clinical records, conventional nerve conduction studies, and lip and nerve biopsy reports were collected. Results: Twenty one patients with SS had associated neuropathy. Female-to-male ratio was 2:1. In 14 (66.7%) patients, neuropathy was the initial manifestation, while in 4 (20%), exocrinopathy preceded neuropathy. The patterns of neuropathy included mononeuropathy multiplex (MNM) in 7 patients (30%), ganglionopathy in 4 (20%), length-dependant trigeminal autonomic neuropathy, and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) in 2 (10%), and cranial neuropathy in 1 (10%). Eighteen (86%) were seropositive with either anti Ro/SS-A or anti La/SS-B antibodies. Schirmer's test was positive in 13 (61.9%) patients. Nerve biopsy showed vasculitis in 5 patients and demyelinating and axonopathy in 2 patients each. Conclusions: We conclude that neuropathy is frequently the initial presentation of SS. MNM is the most common pattern followed by ganglionopathy. The pattern of neuropathy helps in arriving at the diagnosis of SS. Serology is a useful initial laboratory test. However,confirmation of SS is not by mere serology. Schirmer's test and lip biopsy are equally essential for the diagnosis, especially in seronegative patients when the clinical index of suspicion is high.
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NI FEATURE: THE QUEST - COMMENTARY Top

Use of animal models in peripheral nerve surgery and research p. 100
Chandan B Mohanty, Dhananjaya I Bhat, B Indira Devi
DOI:10.4103/0028-3886.250706  PMID:30688242
Animal models are widely used in research of peripheral nerve injury and regeneration, since there are only minor differences in the anatomy of peripheral nerves and the physiology of nerve regeneration between the humans and animals. Animal models, especially rodents, are widely used for this purpose. This narrative review provides a brief overview of the role of animal models in peripheral nerve surgery and research.
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Recent advances in nerve repair p. 106
Sudheesh Ramachandran, Rajiv Midha
DOI:10.4103/0028-3886.250702  PMID:30688243
Peripheral nerve injuries are extremely devastating, and their management is exceedingly complex. Microsurgical repair is the mainstay of treatment and this includes direct nerve repair, nerve grafts, nerve tubes and nerve transfers. Today, nerve transfers are being widely performed due to an increased understanding of cortical plasticity, motor re-education and perioperative rehabilitation, and they are now known to produce excellent functional outcomes. This manuscript reviews the current strategies for nerve repair, including comments on outcomes, with special emphasis on existing nerve transfer techniques.
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COMMENTARY Top

Nerve conduits as replacements of autografts in peripheral nerve surgery: Still a work in progress p. 115
Kuntal Kanti Das, Arun Kumar Srivastava
DOI:10.4103/0028-3886.250729  PMID:30688244
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NI FEATURE: CENTS (CONCEPTS, ERGONOMICS, NUANCES, THERBLIGS, SHORTCOMINGS) - COMMENTARY Top

Current status of magnetic resonance neurography in evaluating patients with brachial plexopathy p. 118
Vaishali Upadhyaya, Divya N Upadhyaya
DOI:10.4103/0028-3886.250730  PMID:30688245
Magnetic resonance neurography (MRN) is recognized as the imaging modality of choice in the evaluation of patients with brachial plexopathy. It adds vital information to the results of the clinical evaluation and electrodiagnostic tests and facilitates patient management. Its indications include both trauma and non-traumatic forms of plexopathy such as inflammatory, neoplastic and compressive. This article will familiarize readers with the routine MRN protocol in clinical practice and discuss the utility of the different sequences. The timing of the scan is important, especially with reference to trauma and this has been discussed. Both the advantages and limitations of MRN have been elaborated upon.
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Magnetic resonance neurography and ultrasonogram findings in upper limb peripheral neuropathies p. 125
Ankita Aggarwal, Manisha Jana, Deep N Srivastava, Raju Sharma, Shivanand Gamanagatti, Atin Kumar, Vijay Kumar, Rajesh Malhotra, Kanwaljeet Garg
DOI:10.4103/0028-3886.250701  PMID:30688246
Peripheral neuropathy is defined as any disease or damage to the peripheral nerves. Imaging modalities are emerging as a complementary tool of choice for diagnosis of peripheral neuropathies. This has been made possible by the advent of high-resolution ultrasound, higher field strength magnets, better surface array coils, and superior software. In addition, imaging plays a pivotal role in deciding the management. They help in determining the continuity and course of the nerve, thereby helping in the pre-surgical mapping of nerve. Imaging studies also help in prognosticating the recovery by determining the event to be acute or chronic. This article describes the imaging findings of various neuropathies affecting upper limb peripheral nerves, broadly categorized as traumatic and non-traumatic. The non-traumatic group is further divided as entrapment, infective, inflammatory and tumors.
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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - COMMENTARY Top

Iatrogenic peripheral nerve injuries p. 135
Anil Kumar, Dhaval Shukla, Dhanajaya I Bhat, B Indira Devi
DOI:10.4103/0028-3886.250700  PMID:30688247
Iatrogenic peripheral nerve injury is a considerable social and economic concern and the majority of cases are preventable. Complications should be referred to, and dealt with promptly by experienced surgeons, to ensure the best chances for an optimal functional recovery. Their prevention should be emphasized. Their management should include ensuring an early diagnosis, administering an appropriate treatment with rehabilitation, rendering psychological support and providing control of pain. We will address the aetiology, predisposing factors, diagnostic approaches, and management strategies to reduce the incidence of iatrogenic peripheral nerve injuries.
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Management protocol in the case of iatrogenic peripheral nerve injuries p. 140
Sumit Sinha
DOI:10.4103/0028-3886.250696  PMID:30688248
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NI FEATURE: THE FOURTH DIMENSION - COMMENTARY Top

A summary of some of the recently published, seminal papers on nerve pathology p. 142
K Raghavendra, Madhav V Kulkarni, Divesh Thaploo, Nagesh C Shanbhag, Dhananjaya I Bhat, Kuntal K Das
DOI:10.4103/0028-3886.250723  PMID:30688249
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LETTERS TO EDITOR Top

Unusual association of leprosy with Lucio phenomenon with secondary antiphospholipid antibody syndrome and ischemic stroke p. 150
Surendra Kumar, Jayantee Kalita, RN Rao, Usha K Misra
DOI:10.4103/0028-3886.250724  PMID:30688250
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Sciatic nerve schwannoma: A rare case p. 151
Harish Naik, Vernon Velho
DOI:10.4103/0028-3886.250727  PMID:30688251
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Enigma in management of plexiform neurofibromas of bilateral brachial and lumbosacral plexuses: Shall we let nature take its course? p. 154
Anil Kumar, B Indira Devi
DOI:10.4103/0028-3886.250731  PMID:30688252
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NEUROIMAGE Top

Post-injection sciatic nerve injury: MRI p. 157
Ankita Agarwal, Arif Mirza, Aishwarya Gulati, Parveen Gulati
DOI:10.4103/0028-3886.250726  PMID:30688253
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BOOK REVIEWS Top

Manual of peripheral nerve surgery: From the basics to complex procedures p. 159
Anil Kumar
DOI:10.4103/0028-3886.250721  
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Nerves and nerve injuries p. 160
Gopalakrishnan M Sasidharan
DOI:10.4103/0028-3886.250710  
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Online since 20th March '04
Published by Wolters Kluwer - Medknow