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Skin biopsy: Watch out for the digital nerves.
- Bo Povlsen (7 June 2007)
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Skin biopsy: Watch out for the digital nerves.
- Giuseppe Lauria (11 June 2007)
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Evidence-based demyelination
- GEORGE Y CALDWELL, SINGAPORE 259858 (19 June 2007)
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Bo Povlsen, Consultant Orthopaedic Surgeon Guy's Hospital, London, SE1, England
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I much enjoyed the content of the article as I mostly see patients with neurological problems of the hands in my clinical practice. However, as a hand surgeon I was concerned about the fig. 3 bottom right photo which seem to indicate that a skin bipsy had been taken from the radio-volar skin of the left index finger. My concern was accentuated by the fact that in the summary points box it was suggested that a skin biopsy was easy and almost painless. Furthermore, nowhere was there any indication that potential injuries could be caused by the use of this technique. I am of the opinion that a skin biopsy as indicated above carries a high risk of causing a digital nerve injury leading to a neuroma causing chronic pain which may require reconstructive surgery. My recommendation is therefore that if volar digital skin biopsies are required then it is much safer to harvest these in the midline of the finger but patients should be warned of the potential nerve injury and neuroma risk as important nerves are only a few millimeters under the skin surface on fingers. Competing interests: None declared |
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Giuseppe Lauria, Senior consultant Neuromuscular Diseases Unit, National Neurological Institute “Carlo Besta”, Milan
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We thank Dr. Povlsen for his comment on our paper, which gives us the opportunity to emphasize the safety of skin biopsy. The inclination of the figure may have been confounding. We are aware that a biopsy taken on the radial aspect of the finger would likely injury the digital nerve branch. In fact, biopsy of the finger must be performed on the palmar skin. The picture shows the small scar of a 3-mm punch taken close to the midline of the first phalange. We and other researchers have performed such biopsy in several healthy subjects and patients with no side effect. In this region, biopsy is safe, much easier and well tolerated than in the exact midline of the finger or in the fingertip. The two main differences between biopsy of the hairy skin and that of the finger performed as we have described are that in the latter topical anaesthesia may be more painful and bleeding may last longer. Competing interests: None declared |
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GEORGE Y CALDWELL, GENERAL PRACTITIONER 31 BALMORAL PARK, #18-33, SINGAPORE 259858
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Here we have a method of being certain of Demyelination in some strange Neuropathies. Many of the early symptoms are so often passed over by the Primary Doctor until diagnosis is made far too late by the senior Pundits for any worthwhile treatment to be effective. There is far too much of "Let's see how it goes, eh?" and "Maybe it's a trapped nerve?" and in periodic surges the symptoms come and go. There would be no harm done there and then in getting up and giving the necessary Vitamin B.12 or B.1 injection. Demyelination may be the result of malabsorption of Vitamins or an attack by a Virus. Whichever, early treatment is advised and indeed mandatory. Malabsorption today may occur because of the multiplicity of strong drugs which patients are prescribed (iatrogenic disease). Anti- convulsants we know prevent the absorption of Vitamin B.12, as does alcohol. Myelin is produced by Oligodendroglia in the brain and are not these cells just those which become scarred with Amyloid in Alzheimer's Disease? Perpipheral Neuropathy occurs significantly in Beri-beri and is easily rectified by immediate injections of Vitamin B.1 whatever the symptomatology is. Malbsorption is the main cause here. In Herpes Zoster the latent virus of Varicella causes the Demyelination that results in the pain. If the myelin is not restored then the pain remains as Post Herpetic Neuralgia for life. The nerve fibres at post-mortem are found to be free of Myelin. It is negligent and indeed criminal not to give B.12 injections in all cases of Herpes Zoster. The first successful use of Vitamin B.12 in the treatment of Herpes Zoster was in a German Prisoner of War camp in 1944 using Liver Extract (BMJ 15 June 1946). Since then it has been used equally successfully in more refined presentations, but must be given within the first three weeks to be effective. One knows that Demyelination occurs in Multiple Sclerosis, Bell's Palsy, Idiopathic Vertigo, Guillane-Barre Syndrome, Machiafalva-Bignani Disease, Central Pontine Melinosis, Schilder's Disease, Neuromyelitis Optica, Motor Neurone Diseas or Amyotrophic Lateral Sclerosis. In most of these cases the diagnosis is long delayed until the Pundit declares "You have XYZ disease. There is no cure and you can do nothing about it! Do not take herbs. Do not waste your money. Do not take Chinese medicine. It is progressive and you will die! Good Morning!" It may well be that a virus is lurking as the cause of several or all of those afore-mentioned syndromes? With these Skin Biopsies one can have an early assurance that demyelination is there ("evidence-based") and treatment with Vitamin B.12 can begin instantly if not before. Herpes Zoster pain and signs can be relieved at once with daily injections of 2,500 mcg. of Vitamin B.12 as in 1944. Folic Acid 5 mg. can be added. In Bell's Palsy the facial paralysis is relieved quickly with administration of Vitamin B.12. So with Idiopathic Vertigo. It is time we came up to date. Once it was claimed that Demyelination did not occur in Amyotrophic Lateral Sclerosis. See then New England Journal of Medicine Vol: 355. 296 -304 of July 2006. The old man who died would have benefited from much earlier admnistration of Vitamin B.12 and been diagnosed sooner than at post-mortem with Drs. Lauria amd Lombardi's Skin biopsies. Martindale's Pharmacopoeia: Vitamin B.12 plays a biochemical role in the maintenance of Myelin in the nervous system. Deficienty results in demyelination (Ovesen. DRUGS. 27. 148. 1984). Competing interests: None declared |
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