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Epidemiology, etiology, and types of severe adult brachial plexus injuries requiring surgical repair: systematic review and meta-analysis.
The literature describing epidemiology, etiology, and types of serious brachial plexus injuries (BPIs) is sparse. The aim of this review was to investigate the epidemiological and etiopathogenetical data of serious BPIs undergoing surgical reconstruction. A systematic search was conducted from January 1985 to December 2017. All studies that reported data about prevalence of specific types and causes of BPIs in adults treated surgically were included and cumulatively analyzed. Ten studies including 3032 patients were identified. The pooled prevalence of closed BPIs was 93% (95% CI: 87-97%), lacerations accounted for 3% (95% CI: 1-6%), and gunshot wounds (GSWs) for 3% (95% CI: 0-7%). The prevalence of male patients was 93% (95% CI: 90-96%) and female cases 7% (95% CI: 4-10%). The most common cause of closed BPI was motorcycle accidents with 67% (95% CI: 49-82%) prevalence followed by car crashes with 14% (95% CI: 8-20%). Other causes were rare. Ninety percent (95% CI: 78-98%) of patients suffered from a supraclavicular or combined supra-/infraclavicular trauma, while 10% (95% CI: 2-22%) from isolated infraclavicular injury. The prevalence of complete lesions was 53% (95% CI: 47-58%) followed by upper plexus lesion with 39% (95% CI: 31-48%) and lower plexus injury with 6% (95% CI: 1-12%). This meta-analysis demonstrates that the typical patient suffering from severe BPI is a male after motorcycle accident with closed supraclavicular injury causing complete or slightly less commonly upper plexus palsy. Lacerations and GSWs of brachial plexus are rare.
Poly[N-(2-hydroxypropyl)methacrylamide]-Modified Magnetic γ-F2 O3 Nanoparticles Conjugated with Doxorubicin for Glioblastoma Treatment.
With the aim to develop a new anticancer agent, we prepared poly[N-(2-hydroxypropyl)methacrylamide-co-methyl 2-methacrylamidoacetate] [P(HP-MMAA)], which was reacted with hydrazine to poly[N-(2-hydroxypropyl)methacrylamide-co-N-(2-hydrazinyl-2-oxoethyl)methacrylamide] [P(HP-MAH)] to conjugate doxorubicin (Dox) via hydrazone bond. The resulting P(HP-MAH)-Dox conjugate was used as a coating of magnetic γ-Fe2 O3 nanoparticles obtained by the coprecipitation method. In vitro toxicity of various concentrations of Dox, P(HP-MAH)-Dox, and γ-Fe2 O3 @P(HP-MAH)-Dox nanoparticles was determined on somatic healthy cells (human bone marrow stromal cells hMSC), human glioblastoma line (GaMG), and primary human glioblastoma (GBM) cells isolated from GBM patients both at a short and prolonged exposition time (up to 7 days). Due to hydrolysis of the hydrazone bond in acid milieu of tumor cells and Dox release, the γ-Fe2 O3 @P(HP-MAH)-Dox nanoparticles significantly decreased the GaMG and GBM cell growth compared to free Dox and P(HP-MAH)-Dox in low concentration (10 nM), whereas in hMSCs it remained without effect. γ-F2 O3 @PHP nanoparticles alone did not affect the viability of any of the tested cells.
Radial nerve injury associated with humeral shaft fracture
Radial nerve palsy accompanies up to 20% of humeral shaft fractures. Two thirds of the findings occur in connection with the injury mechanism (primary palsy) and one third during conservative or surgical treatment (secondary, i.e., iatrogenic palsy). Although most of these injuries have a good prognosis and spontaneous return of function can be expected, there are situations where reinnervation cannot be achieved without surgical revision. These are lacerations or incarcerations of the nerve between bone fragments or severe traction lesions causing scarring and neuroma-in-continuity formation. Such serious findings are present in less than one half of the cases requiring surgical intervention. Early intervention has a higher success rate than conservative treatment (with possible late revision in case of persistence of denervation). Therefore, according to current literature data, early revision within 3 weeks is recommended in most cases of radial nerve palsy associated with humeral fracture with respect to the general condition of the patient, affected limb, mechanism of injury, and the results of complementary examinations.
Suprascapular neuropathy
Suprascapular neuropathy is a rare compressive neuropathy manifested by dorsal shoulder pain and weakness of shoulder abduction and external rotation. Complete symptoms are expressed in nerve compression under the suprascapular notch or in post-traumatic lesions. Isolated atrophy of the infraspinatus muscle with weakness of external rotation of the shoulder occurs in cases of compression of the distal part of the nerve by a paralabral cyst or in repetitive overhead activities, typically in elite volleyball or tennis players. Needle electromyography remains the gold standard in confirming dia gnosis. In the vast majority of cases, conservative treatment is sufficient. In 20% of patients, surgical decompression of the nerve is indicated, leading in most cases to pain relief and improvement in muscle strength.
Meralgia paresthetica.
Meralgia paresthetica is a compression neuropathy of the lateral femoral cutaneous nerve. Despite its rarity, it is the most common nerve entrapment of the lower limbs. It produces similar symptoms as those associated with the more common L4 or L5 radiculopathy. Therefore, it is often diagnosed late (sometimes only after several years of latency) or not at all. This diagnosis should be considered especially in patients with obesity and diabetes who have chronic irritation of the ventrolateral areas of the thigh not responding to conservative therapy and a negative finding on lumbar MRI. We present our experience with surgical nerve decompression in three patients with pain, paresthesias, and sensory loss within the distribution of the lateral cutaneous nerve of the thigh. They all suffered from severe abdominal obesity. All conservative treatments, including weight reduction attempts, were unsuccessful. Nerve release caused an immediate effect in two cases. One patient experienced a temporary worsening of pain, which gradually improved within one month. In spite of the controversy surrounding the surgical treatment of meralgia (neurolysis or nerve resection), it can be concluded that nerve decompression has a good effect. Nerve resection is, in our view, considered to be a reserve option when primary surgery fails. Key words: meralgia paresthetica - nerve entrapment - peripheral nerve.
Time Factor and Disc Herniation Size: Are They Really Predictive for Outcome of Urinary Dysfunction in Patients With Cauda Equina Syndrome?
BACKGROUND: Timing of surgery and the importance of the size of disc prolapse in cauda equina syndrome (CES) remain controversial. OBJECTIVE: To investigate whether there is a relationship between postoperative urinary function, preoperative duration of neurogenic lower urinary tract dysfunction (NLUTD), and the level of canal compromise. METHODS: Seventy-one patients operated for CES were prospectively identified between 2010 and 2013. Fifty-two cases with preoperative NLUTD were included. The "Prolapse: Canal ratio" (PCR) was calculated as a proportion of cross-sectional area of disc prolapse on total cross-sectional area of spinal canal. RESULTS: Median of preoperative duration of NLUTD was 72 h (48; 132) and period from first assessment to surgery 10.5 h (7; 18.5). Urinary incontinence was seen in 46.2% of patients, 38.4% had painless retention and 15.4% had painful retention. In 38.5% of cases, urinary symptoms persisted for more than 20 mo postoperatively. There was no correlation between duration of preoperative NLUTD and urinary dysfunction persistence (P = .921). The outcome was not significantly influenced by having surgery more than the 48 h after presentation (P = .135). Preoperative incontinence persisted in 58% and painless retention in 30% of cases. The mean PCR was 0.6 ± 0.18. There was no correlation between PCR and outcome (P = .537) even after adjusting for duration of preoperative NLUTD (P = .7264). CONCLUSION: No significant correlation was demonstrated between the preoperative duration of urinary dysfunction, the size of disc herniation relative to size of spinal canal, and postoperative urinary function in a large consecutive series of patients with CES.
Current concepts in peripheral nerve injury repair
Even though reconstructive surgery of the nerves underwent significant progress due to experimental and clinical research over the past 40 years, injuries to the peripheral nerves still remain a great challenge for microsurgery. Literature results of these procedures are often evaluated as very good but the final result is often characterized by an achievement of only a useful and not full function, which is rather rare. It is not only a simple suture; the success is also based on functional regeneration and interconnection of the nerve fibres. This is limited by correct surgical technique, the age of the patient, delay from the time of injury and the mechanism or localization of the injury. Some injuries even now remain untreatable (such as the most severe brachial plexus injuries or long traction injuries of the peroneal nerve). Apart from standard neurolysis and epi- or perineural suture with or without nerve grafts, distal nerve transfers (in case of proximal injuries) and end-to-side neurorrhaphy (mainly in trauma of sensitive nerves) have recently been frequently used. The future is however based on influence of nerve regeneration at the cellular level using substances with growth potential. The main prerequisite of successful surgery is however early indication of surgical revision in a specialized centre.
Can MRI Predict Flexibility in Scheuermann Kyphosis Patients?
Study Design: Retrospective, blinded analysis of imaging studies. Objective: The aim of this study is compare the use of magnetic resonance imaging (MRI) to lateral radiograph using bolster in the evaluation of Scheuermann kyphosis (SK) curve flexibility measurement. Summary and Background Data: The flexibility of the thoracic curve [thoracic kyphosis (TK)] in SK is of primary importance in its preoperative planning. Several methods have been described for SK curve flexibility measurement. The most commonly used method is lateral hyperextension radiography on hard bolster [hyperextension radiograph (HE)]. No current methods use MRI for flexibility assessment. Materials and Methods: Flexibility of TK in SK patients was measured as a difference between standing radiograph and bolster-assisted lateral HE or supine MRI. The sagittal Cobb angle of the TK was measured between the superior endplate of T4 and the inferior endplate of T12 vertebral body. Flexibilities measured by these 2 methods were compared and analyzed using the generalized estimating equation analysis and the correlation analysis. Results: We assessed 18 SK patients (14 males and 4 females) with mean age of 20.06±6.03 years. The standing TK X-rays showed 83.8±6.1 degrees. On HE, TK curve reduced by 39.3 degrees (95% confidence interval, 35.8-42.9) to 44.5±6.2 degrees (P<0.001). Preoperative MRI images showed TK of 53.8±5.9 degrees which means reduction by 30 degrees (95% confidence interval, 26.6-33.4) from the standing radiographs (P<0.001). Linear dependency between HE and MRI flexibility with a mean difference of 9.3 degrees was found (R 2 =0.61, P<0.001). Conclusions: Our study shows that preoperative MRI can be used for SK flexibility assessment with similar predictive value as routinely used bolster-assisted hyperextension lateral radiograph. Consequently, patient exposure to preoperative hyperextension ionizing radiation may be reduced.
Staged Correction of Severe Thoracic Kyphosis in Patients with Multilevel Osteoporotic Vertebral Compression Fractures
Study Design Technical report. Objective Multilevel osteoporotic vertebral compression fractures may lead to considerable thoracic deformity and sagittal imbalance, which may necessitate surgical intervention. Correction of advanced thoracic kyphosis in patients with severe osteoporosis remains challenging, with a high rate of failure. This study describes a surgical technique of staged vertebral augmentation with osteotomies for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures. Methods Five patients (average age 62 ± 6 years) with multilevel osteoporotic vertebral compression fractures and severe symptomatic thoracic kyphosis underwent staged vertebral augmentation and surgical correction of their sagittal deformity. Clinical and radiographic outcomes were assessed retrospectively at a mean postoperative follow-up of 34 months. Results Patients' self-reported back pain decreased from 7.2 ± 0.8 to 3.0 ± 0.7 (0 to 10 numerical scale; p < 0.001). Patients' back-related disability decreased from 60 ± 10% to 29 ± 10% (0 to 100% Oswestry Disability Index; p < 0.001). Thoracic kyphosis was corrected from 89 ± 5 degrees to 40 ± 4 degrees (p < 0.001), and the sagittal vertical axis was corrected from 112 ± 83 mm to 38 ± 23 mm (p = 0.058). One patient had cement leakage without subsequent neurologic deficit. Decreased blood pressure was observed in another patient during the cement injection. No correction loss, hardware failure, or neurologic deficiency was seen in the other patients. Conclusion The surgical technique described here, despite its complexity, may offer a safe and effective method for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures.
Surgical treatment of lower extremity peripheral nerve injuries
Peripheral nerve injuries of the lower extremities are not frequent. The most common are traction injury of the peroneal nerve at the knee level or Iatrogenic trauma of the pelvic nerves during abdominal surgery. Civil sharp injuries are rare. Indications for surgical revision follow the general rules of nerve surgery. Sharp Injury should be treated as soon as possible, Ideally within 72 hours. Closed lesions are indicated for surgery if a complete denervation remains unchanged three months after the Injury. Best results can be achieved within six months from the injury. Irritations caused by bone fragments or scarring or by iatrogenic injury (clamps, cement, screws, etc.) may be revised later. However, the most Important is early clinical examination in a specialized neurosurgical department.
Paraspinal muscle volume in patients with Scheuermanńs Kyphosis
To measure the cross-sectional area (CSA) of paraspinal muscles in Scheuermanńs kyphosis patients. Preoperative MRI images of 16 Scheuermanńs kyphosis patients were analysed and compared to 16 patients with normal MRI images (control group). The CSAs were measured at L3-4 and L4-5. Both groups showed similar demographics and patient characteristics. The multifdus muscles CSA were found to be signifcantly smaller at L3/4 level in Scheuermanńs kyphosis patients (p = 0.022 on the left and p = 0.016 on the right side compared to control group). There was no signifcant change in multifdus CSA found at L4/5. The mean CSA of the extensor spinae muscles group were signifcantly smaller at all levels in Scheuermanńs kyphosis patients : p = 0.001 bilaterally at L3/4 and p = 0.015 right side and p = 0.009 left side at L4/5 level. This study shows that patients with Scheuermanńs kyphosis deformity have signifcantly smaller CSA of lumbar multifdus and extensor spinae muscles.
Surgical correction of kyphotic deformity in a patient with Proteus syndrome
Background context: Proteus syndrome (PS) is an extremely rare congenital disorder causing asymmetric overgrowth of different tissues. The etiology remains unclear. Limb deformities are common and often necessitate amputations. Only a few cases associated with spinal deformities have been described. Purpose: The aim was to report a rare case of PS associated with spinal deformity and its surgical management. Study design: A case of young boy with PS causing vertebral hypertrophy and kyphoscoliotic deformity, which was surgically corrected, is presented. Methods: The patient was assessed clinically and with whole spine plain radiographs, computed tomography, and magnetic resonance imaging. Surgical correction was performed. Results: Satisfactory correction of the deformity was achieved by posterior spinal fusion with instrumentation from T4-L5, five Ponte osteotomies T8-L1, and an L2 pedicle subtraction osteotomy. The kyphosis was corrected from 87° to 55°; there was improvement in all spinopelvic parameters. One year after surgery, there was maintenance of the deformity correction with no deterioration of the sagittal balance, and the patient was free of pain and had no loss of neurologic function. Conclusions: Proteus syndrome can be associated with spinal stenosis and deformity. Although the syndrome can be progressive in nature, the symptomatic spinal pathology should be treated appropriately.
Usefulness of screening tools in the evaluation of long-term effectiveness of DREZ lesioning in the treatment of neuropathic pain after brachial plexus injury
Background: Despite high success rate of DREZ lesioning in the treatment of intractable central pain, there is still a significant incidence of patients without satisfactory post-operative effect. The aim of the study was to evaluate the long-term effect of DREZ lesioning using both a subjective assessment using a visual analog scale (VAS) to quantify residual pain and an assessment using the screening tool (painDETECT Questionnaire, PD-Q). Methods: DREZ lesioning was performed in 52 patients from a total 441 cases with brachial plexus injury (11.8%) during a 17-year period (1995-2011). The effect of surgery was retrospectively assessed in 48 patients. Results: A decrease in pre-operative pain by more than 75% (Group I) was achieved in 70.8% of patients and another 20.8% reported significant improvement (Group II). The surgery was unsucessful in 8.4% (Group III). We found a significant correlation between 'improvement' groups from both methods of assessments. Patients from Group I usually complained of residual nociceptive pain according to PD-Q, patients from Group II typically had pain of unclear origin, and all cases those in Group III suffered from neuropathic pain, Cramer's V = .66, P < .001. Overall, 66.7% of patients had resolved neuropathic pain, 20.8% patients had more serious complaints and may also suffer from residual neuropathic pain, while 12.5% had unresolved neuropathic pain. Conclusion: DREZ lesioning is a safe and effective method with success rates of about 90%. PD-Q scores correspond to subjective satisfaction with the surgery and it seems to be a suitable screening tool for finding patients with residual neuropathic pain after surgery.
Injuries associated with serious brachial plexus involvement in polytrauma among patients requiring surgical repair
Background: Brachial plexus injury occurs in up to 5% of polytrauma cases involving motorcycle crashes and in approximately 4% of severe winter sports injuries. One of the conditions for the success of operative therapy is early detection, ideally within three months of injury. The aim of this study was to evaluate associated injuries in patients with severe brachial plexus injury and determine whether there is a characteristic concomitant injury (or injuries), the presence of which, in the polytrauma, could act as a marker for nerve structures involvement and whether there are differences in severity of polytrauma accompanying specific types of brachial plexus injury. Methods: We evaluated retrospectively 84 surgical patients from our department, from 2008 to 2011, that had undergone brachial plexus reconstruction. For all, an injury severity scale (ISS) score and all major associated injuries were determined. Results: 72% of patients had an upper, 26% had a complete and only 2% had a lower brachial plexus palsy. The main cause was motorcycle crashes (60%) followed by car crashes (15%). The average ISS was 35.2 (SD = 23.3), although, values were significantly higher in cases involving a coma (59.3, SD = 11.0). The lower and complete plexus injuries were significantly associated with coma and fractures of the shoulder girdle and injuries of lower limbs, thoracic organs and head. Upper plexus injuries were associated with somewhat less severe injuries of the upper and lower extremities and less severe injuries of the spine. Conclusion: Serious brachial plexus injury is usually accompanied by other severe injuries. It occurs in high-energy trauma and it can be stated that patients involved in motorcycle and car crashes with multiple fractures of the shoulder girdle are at high risk of nerve trauma. This is especially true for patients in a primary coma. Lower and complete brachial plexus injuries are associated with higher injury severity scale. © 2012 Elsevier Ltd.
Obturator nerve injury in laparoscopic inguinal hernia mesh repair
Injury to pelvic nerves during laparoscopy mostly occurs in gynecological and urological procedures. In abdominal surgery, these complications are infrequent. We present a case report of a patient who suffered a rare obturator nerve injury during a laparoscopic hernioplasty caused by clipping the nerve to the edge of the mesh. After revision and release of nerve from the clip and scars tissue, the associated pain rapidly disappeared and thigh adduction strength improved. Now, 4 years later, MRI and EMG show no sign of nerve compression. © 2012 Springer-Verlag.
Serious axillary nerve injury caused by subscapular artery compression resulting from use of backpacks
A palsy of the brachial plexus elements caused by carrying a heavy backpack is a very rare injury usually occurring in soldiers or hikers, and recovery is usually spontaneous. We describe here the case of male civilian presenting with an isolated serious axillary nerve palsy associated with chronic backpack use. During the surgery, a dumbbell-shaped neuroma-in-continuity was found which was caused by direct pressure from the subscapular artery. After resection of the neuroma, a nerve graft from the sural nerve was used to reconstruct the nerve. Reinnervation was successful and the patient was able to abduct his arm to its full range, with full muscle strength, within 24 months. © 2013 Georg Thieme Verlag KG Stuttgart New York.
Surgical treatment of supinator canal syndrome
Supinator canal syndrome, caused by compression of the deep branch of the radial nerve by the arcade of Frohse in the elbow, is rare. We present our experience with surgical treatment of four patients with this compressive neuropathy at our department between 2007 and 2010. This group accounted for 0.24% of non-traumatic nerve lesions of the upper extremities. Indication for surgery was based both on an EMG-confirmed nerve lesion and failure of conservative therapy. All patients had severe paresis of extensors on the forearm that improved after nerve deliberation. None of them, however, improved completely. This corresponds to international experience.
Scapular fracture related to polytrauma severity in patients with serious brachial plexus palsy
PURPOSE OF THE STUDY Brachial plexus palsy is often accompanied by other injuries. Scapular fracture is thought to be amarker of polytrauma severity. The aim of this study was to evaluate associated injuries in patients with serious brachial plexus involvement and to determine whether there is arelationship between scapular fracture and severity of polytrauma in such patients. MATERIAL AND METHODS: We retrospectively evaluated 84 surgical patients who underwent brachial plexus reconstruction at our department between 2008 and 2011. In all of them, data on scapular fracture and major associated injuries were recorded. RESULTS Of the 84 patients, 22 (26.2%) had ascapular fracture. Of 61 patients with upper plexus palsy only 10 (16.4%) suffered ascapular fracture while of 23 patients with more severe plexus lesions 12 (52.2%, p < 0.001) had fractured scapula. The ISS score in the patients with fractured scapula was significantly higher (51.8, SD = 11, range = 18-75, p < 0.001). The patients with scapular fractures also had asignificantly higher number of rib, clavicle, upper and lower limb fractures, and injuries to the thoracic organs and the head. CONCLUSIONS Both scapular fracture and serious brachial plexus injury are usually associated with other severe injuries. They occur due to high-energy trauma. Generally, patients who sustain scapular fractures and upper limb impairment in motorcycle and car crashes are at high risk of other associated injuries and more severe polytrauma. © Česká společnost pro ortopedii a traumatologii 2006.