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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.

Old calcified bilateral subdural hematoma in a patient after head trauma

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.

End-to-side neurorrhaphy in brachial plexus reconstruction

Object. Although a number of theoretical and experimental studies dealing with end-to-side neurorrhaphy (ETSN) have been published to date, there is still a considerable lack of clinical trials investigating this technique. Here, the authors describe their experience with ETSN in axillary and musculocutaneous nerve reconstruction in patients with brachial plexus palsy. Methods. From 1999 to 2007, out of 791 reconstructed nerves in 441 patients treated for brachial plexus injury, the authors performed 21 axillary and 2 musculocutaneous nerve sutures onto the median, ulnar, or radial nerves. This technique was only performed in patients whose donor nerves, such as the thoracodorsal and medial pectoral nerves, which the authors generally use for repair of axillary and musculocutaneous nerves, respectively, were not available. In all patients, a perineurial suture was carried out after the creation of a perineurial window. Results. The overall success rate of the ETSN was 43.5%. Reinnervation of the deltoid muscle with axillary nerve suture was successful in 47.6% of the patients, but reinnervation of the biceps muscle was unsuccessful in the 2 patients undergoing musculocutaneous nerve repair. Conclusions. The authors conclude that ETSN should be performed in axillary nerve reconstruction but only when commonly used donor nerves are not available, © 2013 AANS.

Large medulloblastoma with brain-stem invasion in an adult: Case report and review of the literature

We report the case of a 43-year-old woman with a large midline medulloblastoma invading the brain-stem. She underwent a radical resection followed by radio- and chemotherapy. The follow-up period was 2.5 years; she is now without recurrence of the tumor, but neurological deficits, mostly in the form of cerebellar dysfunction, persist. The aim of this case report is to increase awareness of the incidence, treatment and prognosis of primitive neuroectodermal tumors in adults. Medulloblastomas are rare and compared to the pediatric population, have a relatively good prognosis. The most important prognostic factors are completeness of the resection and presence of metastases.

Axillary nerve repair by fascicle transfer from the ulnar or median nerve in upper brachial plexus palsy

Object. Nerve repair using motor fascicles of a different nerve was first described for the repair of elbow flexion (Oberlin technique). In this paper, the authors describe their experience with a similar method for axillary nerve reconstruction in cases of upper brachial plexus palsy. Methods. Of 791 nerve reconstructions performed by the senior author (P.H.) between 1993 and 2011 in 441 patients with brachial plexus injury, 14 involved axillary nerve repair by fascicle transfer from the ulnar or median nerve. All 14 of these procedures were performed between 2007 and 2010. This technique was used only when there was a deficit of the thoracodorsal or long thoracic nerve, which are normally used as donors. Results. Nine patients were followed up for 24 months or longer. Good recovery of deltoid muscle strength was seen in 7 (77.8%) of these 9 patients, and in 4 patients with less follow-up (14-23 months), for an overall success rate of 78.6%. The procedure was unsuccessful in 2 of the 9 patients with at least 24 months of follow-up. The first showed no signs of reinnervation of the axillary nerve by either clinical or electromyographic evaluation in 26 months of follow-up, and the second had Medical Research Council (MRC) Grade 2 strength in the deltoid muscle 36 months after the operation. The last of the group of 14 patients has had 12 months of follow-up and is showing progressive improvement of deltoid muscle function (MRC Grade 2). Conclusions. The authors conclude that fascicle transfer from the ulnar or median nerve onto the axillary nerve is a safe and effective method for reconstruction of the axillary nerve in patients with upper brachial plexus injury.

A comparison of collateral sprouting of sensory and motor axons after end-to-side neurorrhaphy with and without the perineurial window

Background: Many experimental studies have confirmed collateral sprouting of axons after end-to-side neurorrhaphy and its possible clinical application. There is still controversy about how the surgical method should be carried out. The aim of the present study was to quantitatively evaluate collateral sprouting of motor and sensory axons after end-to-side neurorrhaphy with and without the perineurial window. Methods: End-to-side neurorrhaphy of the distal stump of transected musculocutaneous nerve with intact ulnar nerve with or without a perineurial window was performed in a rat model. Collateral sprouts were quantitatively evaluated by counting of motor and sensory neurons following their retrograde labeling by Fluoro-Ruby and Fluoro-Emerald applied to the ulnar and musculocutaneous nerves, respectively. Results: Our results show that significantly more motor and sensory axons sent their collateral branches into the recipient nerve in the group with a perineurial window. Some axons were injured during preparation of the perineurial window; the injured axons reinnervated directly into the recipient nerve to contribute to results of functional reinnervation. Conclusion: The authors conclude that it is necessary to create a perineurial window when using end-to-side neurorrhaphy in clinical practice, especially in brachial plexus reconstruction. © 2012 by the American Society of Plastic Surgeons.