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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.

The influence of seatbelts on the types of operated brachial plexus lesions caused by car accidents

Purpose: To determine whether there is a relationship between seatbelt use and type of brachial plexus injury seen in automobile accidents. Knowledge of such a relationship may help guide the surgical management of these patients. Methods: We retrospectively evaluated 43 surgical patients with brachial plexus palsy caused by car accidents. We recorded sex, age, and type of injury for each case. We also obtained data regarding the patients' position in the car at the time of the accident and whether they were wearing a seatbelt. Results: We obtained data on 39 men and 4 women. Of the seatbelted patients, 24 (100%) had upper plexus palsy on the side where the seatbelt crossed the shoulder. Of those who were not wearing seatbelts, 17 (86%) had complete plexus injuries. We also found 1 upper and 1 lower plexus injury in the unbelted group. Conclusions: We found a relationship between the type of brachial plexus injury sustained by the accident victim and the use and position of the seatbelt. Complete plexus injuries were more common in those who were not wearing seatbelts. We saw upper plexus injuries for those wearing seatbelts. Information about seatbelt use may be useful in clinical practice. When treating an unbelted car accident victim with a brachial plexus injury, it is reasonable to anticipate a more serious form of the injury. Type of study/level of evidence: Prognostic IV. © 2012 American Society for Surgery of the Hand.

Surgical treatment of a tarsal tunnel syndrome

Entrapment neuropathies of the lower limbs are rare. We present a series of four patients treated for tibial nerve compression in the tarsal tunnel. The symptoms developed spontaneously in two patients while the other two had a history of ankle injury. Transection of the flexor retinaculum and exoneurolysis of the tibial nerve and its branches was effective in all patients. The tarsal tunnel syndrome should be considered in all patients who develop pain and sensory disturbances in the sole and have a negative finding in the lumbar spine. EMG confirms the finding. Surgical treatment is simple and has good results.

Types and severity of operated supraclavicular brachial plexus injuries caused by traffic accidents

Background Brachial plexus injuries occur in up to 5% of polytrauma cases involving motorcycle accidents and in approximately 4% of severe winter sports injuries. One of the criteria for a successful operative therapy is the type of lesion. Upper plexus palsy has the best prognosis, whereas lower plexus palsy is surgically untreatable. The aim of this study was to evaluate a group of patients with brachial plexus injury caused by traffic accidents, categorize the injuries according to type of accident, and look for correlations between type of palsy (injury) and specific accidents. Methods A total of 441 brachial plexus reconstruction patients from our department were evaluated retrospectively (1993 to 2011). Sex, age, neurological status, and the type and cause of injury were recorded for each case. Patients with BPI caused by a traffic accident were assessed in detail. Results Traffic accidents were the cause of brachial plexus injury in most cases (80.7%). The most common type of injury was avulsion of upper root(s) (45.7%) followed by rupture (28.2%), complete avulsion (16.9%) and avulsion of lower root(s) (9.2%). Of the patients, 73.9% had an upper, 22.7% had a complete and only 3.4% had a lower brachial plexus palsy. The main cause was motorcycle accidents (63.2%) followed by car accidents (23.5%), bicycle accidents (10.7%) and pedestrian collisions (3.1%) (p<0.001). Patients involved in car accidents had a higher percentage of lower avulsion (22.7%) and a lower percentage of upper avulsion (29.3%), whereas cyclists had a higher percentage of upper avulsion (68.6%) based on the data from the entire group of patients (p<0.001). Lower plexus palsy was significantly increased in patients after car accidents (9.3%, p<0.05). In the two main groups (car and motorcycle accidents), significantly more upper and fewer lower palsies were present. In the bicycle accident group, upper palsy was the most common (89%). Conclusion Study results indicate that the most common injury was an upper plexus palsy. It was characteristic of bicycle accidents, and significantly more common in car and motorcycle accidents. The results also indicate that it is important to consider the potential of a brachial plexus injury after serious traffic accidents and to examine both upper extremities in detail even if some motor function is preserved. © Springer-Verlag 2012.

Enhancement of musculocutaneous nerve reinnervation after vascular endothelial growth factor (VEGF) gene therapy

Background: Vascular endothelial growth factor (VEGF) is not only a potent angiogenic factor but it also promotes axonal outgrowth and proliferation of Schwann cells. The aim of the present study was to quantitatively assess reinnervation of musculocutaneous nerve (MCN) stumps using motor and primary sensory neurons after plasmid phVEGF transfection and end-to-end (ETE) or end-to-side (ETS) neurorrhaphy. The distal stump of rat transected MCN, was transfected with plasmid phVEGF, plasmid alone or treated with vehiculum and reinnervated following ETE or ETS neurorrhaphy for 2 months. The number of motor and dorsal root ganglia neurons reinnervating the MCN stump was estimated following their retrograde labeling with Fluoro-Ruby and Fluoro-Emerald. Reinnervation of the MCN stumps was assessed based on density, diameter and myelin sheath thickness of regenerated axons, grooming test and the wet weight index of the biceps brachii muscles.Results: Immunohistochemical detection under the same conditions revealed increased VEGF in the Schwann cells of the MCN stumps transfected with the plasmid phVEGF, as opposed to control stumps transfected with only the plasmid or treated with vehiculum. The MCN stumps transfected with the plasmid phVEGF were reinnervated by moderately higher numbers of motor and sensory neurons after ETE neurorrhaphy compared with control stumps. However, morphometric quality of myelinated axons, grooming test and the wet weight index were significantly better in the MCN plasmid phVEGF transfected stumps. The ETS neurorrhaphy of the MCN plasmid phVEGF transfected stumps in comparison with control stumps resulted in significant elevation of motor and sensory neurons that reinnervated the MCN. Especially noteworthy was the increased numbers of neurons that sent out collateral sprouts into the MCN stumps. Similarly to ETE neurorrhaphy, phVEGF transfection resulted in significantly higher morphometric quality of myelinated axons, behavioral test and the wet weight index of the biceps brachii muscles.Conclusion: Our results showed that plasmid phVEGF transfection of MCN stumps could induce an increase in VEGF protein in Schwann cells, which resulted in higher quality axon reinnervation after both ETE and ETS neurorrhaphy. This was also associated with a better wet weight biceps brachii muscle index and functional tests than in control rats. © 2012 Haninec et al.; licensee BioMed Central Ltd.

The end-to-side neurorrhaphy in axillary nerve reconstruction in patients with brachial plexus palsy

Surgery for sciatic nerve injuries

PURPOSE OF THE STUDY Injury to the sciatic nerve is a rare event. Apart from war time surgery, it usually presents as a closed lesion caused by traction. The aim of the study was to evaluate a group of patients treated for sciatic nerve injury, with an analysis of the cause for and the outcome of surgery. MATERIAL AND METHODS In this prospective study, the results in ten patients treated surgically were evaluated. Five patients underwent exoneurolysis, two were treated by end-to-end suture of the nerve and three by suture and sural nerve grafting. One patient was lost to follow-up and nine were followed up for minimally 24 months after surgery. RESULTS In the patients treated by exoneurolysis, sciatic nerve function recovered in the peroneal division in 60%, and in the tibial portion in 100% of them. The result depended mainly on the interval between injury and surgery. Of four patients with direct suture of the nerve or with sural nerve grafting, function of the tibial portion recovered in three (75%) and that of the peroneal portion in one (25%). CONCLUSIONS Although the course of the sciatic nerve is very long, its surgical treatment is fully justified because it shows good results even in buttock-level and thigh-level nerve injuries.

The results of ulnar nerve decompression in Guyon

PURPOSE OF THE STUDY The aim of the study was to evaluate a group of patients treated for Guyon's canal syndrome with analysis of the cause for and outcome of surgery. MATERIAL AND METHODS The group comprised 13 patients operated on for compressive neuropathies of the ulnar nerve in the canal of Guyon in the period from 2007 to 2010. The clinical parameters evaluated were the adduction strength of the fifth digit, degree of interosseous primus muscle hypotrophy and degree of hypoesthesia in the area innervated by the ulnar nerve. EMG parameters included motor and sensory nerve conduction through Guyon's canal. Patients' subjective evaluations of the treatment outcomes were also recorded. The results were not compared with a control group. RESULTS Post-operative improvements in all clinical and EMG parameters were significant (p=0.02-0.003). All but one patient (90%) reported an improved subjective condition after surgery; on the other hand, pre-operative severe impairment of motor nerve conduction highly affected the post-operative motor function. Guyon's canal syndrome accounted for 0.8% of all compressive neuropathies of the upper extremity in our patients. DISCUSSION Ulnar nerve compression at the wrist is a relatively rare condition amongst the compressive neuropathies of the upper extremity, and literature data concerning this disease are very few. Although many causes of ulnar nerve compression at the wrist have been reported, only one of our patients had ganglion. We conclude that the majority of cases can be diagnosed as a neuritis due to chronic microtrauma produced by pressure of a hypertrophic palmar ligament. CONCLUSIONS Syndrome of Guyon's canal can easily be treated by surgery. As in other compression syndromes, the sooner a surgical decompression is performed, the better outcomes are achieved. © Česká společnost pro ortopedii a traumatologii 2006.

[Degeneration and regeneration of the peripheral nerve].

The peripheral nerve's degeneration and regeneration after its injury was described by Waller in 1850. The distal stump and small part of the proximal part of the transected fibre disintegrate. Proliferating Schwann cells create the band of Büngner for the guiding of the regrowing axon. Even if the suture of the nerve is quickly and well performed, the reinervation is never absolute. Regrowing axons can grow into wrong endoneurial tubes or outside the area of the suture and long-lasting denervation leads to progressive atrophy of the target organs. In the future, the neurotrophic factors might improve the outcome of the reinervation.

Surgical treatment of brachial plexus injury

Brachial plexus injury has been attracting increasing attention in recent times, partly because of an increasing incidence arising out of higher survival rates for patients after polytrauma and also due to higher success rates for surgical treatment. Obstetric brachial plexus palsy has recently become the focus of interest for a number of articles. Many injured elements of the brachial plexus are reconstructed by a donor nerve transferred onto the recipient nerve, i.e. by neurotization. This method leads to better outcomes than suture of the injured nerve in the proximal part of the plexus, the main advantage of which is the opportunity to place the suture as close to the muscle as possible. There are two newer methods - Oberlin's technique and end-to-side anastomosis. It remains unclear as to which donor nerve is better to use for neurotization in specific recipients due to a lack of large, randomized clinical trials. Generally, neurotization using the intraplexal nerve as a donor of motor nerve fibres is more successful than neurotization using the extraplexal nerve.

[Vascular endothelial growth factor].

VEGF, vascular endothelial growth factor, is a substance firstly described in 1983 as a tumor-secreted protein which causes the development of ascitic fluid in case of abdominal tumors. Its influence on angiogenesis was ascertained by many studies. The strongest stimulus for its production is hypoxia, which leads to higher secretion of VEGF and new angiogenesis of so affected tissue. The neurogenic effect was firstly mentioned in 1999. Its protective and proliferative influence both on CNS and peripheral nerves is now widely accepted. It was demonstrated that VEGF has more wide ranging effect than previously thought.

Experience with a burr-hole craniostomy for chronic subdural hematoma

Chronic subdural haematoma is a very common disease of advanced age. Although often considered a trivial affection, its treatment in frequent recurrence may be difficult and its course may be fatal even if mini-invasive methods are used. The most-often used technique is evacuation via a burr-hole craniostomy, increasingly also via a simple twist-drill craniostomy. We present our experience of a group of 180 patients and a total of 201 symptomatic haematomas treated primarily by evacuation and irrigation via a small, burr-hole craniostomy. Drainage was employed in most of the cases. Risk of recurrence of haematoma led to 14.9% of the cases being re-operated. Mortality was low: 0.5% of the patients died soon after the operation. The risk of the recurrence was higher in cases of septated hematoma.

Delayed acute subdural hematoma

The development of acute subdural haematoma occurs typically soon after a head trauma and its presence shows on CT scan immediately after admission. Spontaneous haematomas are also described, especially those associated with coagulopathies, as well as delayed haematomas occurring with latency after a known head injury. A group of 116 patients who had suffered from acute subdural haemorrhage was analyzed retrospectively. Most of them (96.6%) were operated upon soon after admission. In four cases (3.4%), a deterioration of clinical status occurred after an interval of 1-4 days. Second CT scans revealed the development of delayed acute subdural haemorrhage and all of them were operated upon immediately. The first CT was negative only in one case; subarachnoid haemorrhage or skull fracture was found in three cases. Two patients were given warfarin, one was thrombocytopenic and another had serious hepatic coagulopathy.

Mild brain injury - Intracranial complications and indication criteria for CT imaging

Intracranial bleeding is revealed by CT scan in about 10% of patients who are examined after mild traumatic brain injury. The objective of this study is to analyze retrospectively the incidence of intracranial haemorrhage in patients admitted to our department with a diagnosis of concussion. A total of 274 patients were admitted to our department with such a diagnosis during the year 2009. CT examinations were requested in 188 cases. The indication criteria were age over 60 years, skull fracture, coagulopathy or dangerous mechanism of injury (e.g. traffic accident). Intracranial bleeding had occurred in 41 patients (21.8%) examined by CT scan even if their clinical status appeared good. Two of them had to be operated upon in the light of deterioration in their neurological findings. The purpose of this study is to warn against the danger intrinsic to these injuries, because even if the patient's clinical status appears good, they may have intracranial bleeding, which may, in turn - if rarely - require operation.

Treatment of peroneal nerve injury by operation

The peroneal nerve is the most frequently injured nerve of the lower extremities, most often as traction injury caused by knee distortion or iatrogenic injury. We analyze retrospectively a group of 16 of our patients. Eight of them underwent external neurolysis with functional recovery in 62%. Outcome appears to depend on the time interval between injury and operation. Another eight nerves were reconstructed with a graft from the sural nerve with a good outcome in 50% of cases. In these cases, both the timing of operation and the length of the graft used proved important- the best effect was achieved if graft length was kept below 6 cm, which corresponds with other studies. Recovery of motor function was considered satisfactory when muscle power exceeded level M3 in the standard muscle test.

Organised chronic subdural haematoma - Case reports

Chronic subdural haematoma is a very common disease of older age. The treatment is usually simple, consisting of evacuation, usually via a burr-hole craniotomy. A more complicated clinical course may be presented by the presence of subdural membranes arising out of increasing fibrotization. Very occasionally, this may predominate and lead to development of an organized mass. Diagnosis based on CT is not possible, because only hyperdense membranes are usually shown. Repeated evacuations with irrigation are unsuccessful; all these cases are finally treated by removal of an organized mass by craniotomy. We present three such cases from 201 (1.5%) chronic subdural haematomas treated at our department between 2005 and 2010. Clinical status and CT findings improved after radical elimination of organized matter in all cases.

Lumbo-Pelvic Stabilisation following Subtotal Sacrectomy due to a Giant Invasive Schwannoma. Case Report

The case of a rare giant invasive schwannoma of the sacrum is presented. This is a slow-growing tumour reaching a large size because of non-specific symptoms. Even though it is benign in nature, it has characteristics markedly differing from commonly-known neurinomas; it invades and destroys bone, on MR examination it shows a heterogeneous structure reminiscent of a malignant process and its growth around the nerve roots makes nerve dissection in the cauda equina very complicated. At the time of diagnosis a major part of the sacral bone is usually destroyed and nerve root dissection is very difficult. In this case, because of removal of most of the tissue, an almost complete sacrectomy was necessary including the sacral roots with the exception of S1. At the second stage, lumbo-pelvic stabilisation was carried out using the modified Galveston technique. Since only a very few similar cases have been reported, it is not possible to predict the post-operative outcome in terms of potential recurrence or residual progression. In our patient a small residuum was stable even at 37 months after surgery. She remained incontinent after surgery, but able to walk unaided. Radiographic examination showed the osteosynthetic material without signs of loosening and in a good position.