Management of nerve abscess in leprosy

Leprosy Mailing List, September 8th, 2008

Ref.: Management of nerve abscess in leprosy
From: Salafia A., Mumbai, India

Dear Salvatore,

This has reference to the on-going discussion about nerves and nerve abscess; let me add one more “last” word.
My colleague and I operate in a referral hospital in Mumbai; 95% of the patients referred to us have been treated elsewhere before coming to us and they are referred because the treatment given has not worked.
After few years of trial and error (because nobody in India used to teach about nerve surgery, as the Indian School (unlike the French School) was against surgery of nerves, in 1990 we formulated our protocol which is still valid. Let me add the we have been seen about 650 neuritis cases a year, out of which only about 100-150 have been operated; in the last year and this year too the number of referred cases has come down significantly to about 250-300 a year.
The protocol for all types of neuritis;
a)We operate, as soon as possible, in cases of "visible swelling" (I repeat, already treated for months on elsewhere without benefit), discharging sinus, increasing neural loss, intractable pain and/or paresthesia.
b)All other cases are first given a course of steroids (most clinicians use 'homeopathic dosages of steroids). In our book we suggest 1mg. of Prednisolone (or its equivalent) per kilo body wt. Our routine is: I.M. injection of Dexamethasone in tapering dosages: start with 8-12 mgs (as per body wt.) per day for 3 day, followed by 6-10 mgs. for another 3 days, and then 4-8 mgs for another 3 days. At this point the patient is assessed: 1.)If all symptoms have disappeared or at least reduced significantly, we prescribe oral steroids - starting from 20-30 mgs. of Prednisolone and taper it over a period of 3-6 months or more (assessment once a month or so).
2.)If the symptoms have not subsided or have increased, then we explore surgically without further ado.
About the statement made by Dr. Warren (LML Sept. 2nd, 2008), that any stroke of knife may increase neural damage, we had the same doubt when we started; but once our protocol was set, this problem was solved.
How you may ask? I trained in microsurgery in 1983 under Prof. G. Brunelli (a world authority on the field) and Dr. Chauhan trained too in 1990 under the same teacher, here in India. In 1990 the hospital received an operation microscope (Zeiss), and every since, we have been using (in almost all cases) operation microscope and microsurgical techniques; in this way the damage to the nerves is nil or almost.

Naked-eye surgery (as it is was done in the past and is even done today by some) is not without risks as mentioned in our book, besides we are against all those dubious procedures like stripping the epineurium, ante position of the ulnar etc.. for reasons clearly stated in our book*.
While dealing with nerve abscess, we have been guilty a few times (if guilty is the right word) of being too cautious; let me explain. We have three cases who came to us with large abscesses of the ulnar and total neural loss; we carried out a surgical toilet, the nerve looked totally necrotic yet we refrained ourselves from removing the 'empty shell' which was the epineurium, in the hope that some nerve fibres might be still viable.

Well, one patient, in whom we did a successful claw-hand repair, come exactly after 10 years with a small abscess in the 'empty shell'; and this point the patient insisted that we explore the nerve and remove whatever there was to remove (we explained to him what had happened). We had no other choice but excise the 'empty shell'. The same has happened in another two cases, both coming to us after 8-10 years from the first surgery. Experience and the operation microscope have taught us when to stop and where... To our students (every year we have a training programme for young surgeons) we teach and show (in the O.T.) what to do and what not to do.
I believe this is enough. Thanks for your patience.
Antonio Salafia
Head of dept. or reconstructive surgery
Vimala hospital
Mumbai
India
*Treatment of Neuritis in Leprosy. Medical and Surgical”. A. Salafia, G. Chauhan, 1997.