Extratemporal facial nerve injury

Isolated traumatic facial nerve injury, frequently seen in wartime combat, may also be encountered among civilians. The clinical picture occurring as a result of such injury may be confusing because partial, or incomplete, damage to the peripheral nerve may mimic impairment of the central facial motor mechanism. In treating the patient with facial injury, life-threatening aspects of the injury must be assessed and stabilized first. Then, attention may be focused on the injured facial nerve, for which prompt surgical repair is the treatment of choice. Prior to surgery, the assessment of taste and hearing, as well as mastoid and skull x-ray films and electrodiagnostic tests are helpful in localizing the facial nerve injury.     

Central nervous pain in patients with spinal cord injury. Medical and surgical treatment

About 50% of patients with spinal cord injury suffer from persistent central neurogenic pain. The authors review the case of a patient with traumatic paraplegia who developed persistent central neurogenic pain. The pain was described as burning in the buttock area, icing in the rectum area and as lancinating pain to the lower extremities. The combination of amitryptilin and morphine had a slight, short-term effect, but the pain did not respond to treatment with simple analgetica, dextropropoxyphen or ketobemidone, neither administered alone nor in combination with tricyclic antidepressants, carbamazepine or baclophen. Transcutanous nerve stimulation and acupuncture had no effect. The patient was operated on by means of the computer-assisted dorsal root entry zone (DREZ)-microcoagulation technique 2.5 years after the trauma. This technique is described in brief. The prevalence and classification of neurogenic pain, and possible medical and surgical treatment, are also discussed.     

Iatrogenic injury of the spinal accessory nerve. Results of repair

We reviewed the results of repair of the spinal accessory nerve in seven patients seen between September 1994 and January 1996. The nerve had been injured during biopsy of a cervical lymph node in six patients and during removal of a bullet in one. The average interval between the time of the injury and the repair of the nerve was eight months (range, three to fourteen months). An end-to-end repair of the nerve was performed in six patients, and a neurolysis was done in one. The average duration of follow-up was thirty-two months (range, twenty-four to thirty-nine months). Postoperatively, all seven patients had relief of pain and stiffness in the shoulder girdle. Manual muscle-testing revealed normal strength of the trapezius, which was comparable with that on the unaffected side. Four patients regained normal function of the shoulder. Three patients reported a stretching sensation or discomfort in the neck, periscapular discomfort, and fatigue of the extremity when lifting heavy objects or performing overhead activities. However, these residual symptoms were mild and tolerable and thus were different in nature from the preoperative pain and stiffness. Iatrogenic injury of the spinal accessory nerve should be suspected if a patient has pain or stiffness in the shoulder girdle and a history of a recent operation on the neck. The nerve should be explored if spontaneous recovery does not occur.     

Percutaneous repair of a traumatic bile duct laceration in a liver transplant allograft

BACKGROUND: Phrenic nerve palsy in infants and young children usually results from birth injury or iatrogenic damage. The newborn almost invariably presents with severe respiratory distress, diaphragmatic elevation, and paradoxical movement at the affected side. METHODS/RESULTS: In this retrospective analysis a group of 23 patients below the age of 1 year with an obstetric or postoperative phrenic nerve injury was studied and compared with cases in the literature. All patients were admitted between 1986 and 1997 to the Pediatric Surgical Center, Amsterdam. Thirteen of 18 patients with an obstetric phrenic nerve injury underwent plication of the diaphragm after an average observation period of 100 days. In the remaining five children with an obstetric phrenic nerve injury, spontaneous recovery appeared within 1 month. Only one of five patients with a phrenic nerve palsy after a cardiac surgical procedure underwent plication of the diaphragm. Fifteen of the 34 patients described in the literature underwent plication of the diaphragm after an average of 54 days. CONCLUSIONS: If after 1 month no spontaneous recovery of the diaphragmatic paralysis caused by a phrenic nerve injury occurs, plication of the diaphragm is indicated. This operation proved to be successful for relief of symptomatic phrenic nerve injury in all cases. If the condition of the patient clinically deteriorates during this first month of life, the patient should be operated on immediately.     

Tarsal tunnel syndrome after non-dislocated fracture of the outer ankle joint (case report with review of the literature)

The authors are going to report on the case of a 32-year-old female patient suffering from a non-dislocated external ankle fracture which was submitted to conservative treatment. This treatment was complicated by the occurrence of a tarsal tunnel syndrome which required surgical revision. The cause of this complication may be seen in the development of a minor local hematoma in the course of the tibial nerve as well as in a convolution of varicose veins located in the region of the internal ankle. By describing this case the authors wish to point out that development of a tarsal tunnel syndrome may not only be due to ankle fractures treated by osteosynthetic management (as described in relevant literature) but also to relatively uncomplicated and almost non-dislocated external ankle fractures receiving conservative management.     

Serratus anterior dysfunction. Recognition and treatment

Recognition of scapular winging may be difficult, and potential errors in treatment can result. Such treatment errors may cause morbidity for the patient. In addition, electrical evidence of long thoracic nerve injury usually is required to confirm the etiology of scapular winging as being caused by serratus anterior dysfunction. Although various conditions may result in scapular winging, primary serratus anterior dysfunction can be treated effectively by transfer of the pectoralis major tendon; however, this surgical approach sometimes may given an unacceptable cosmesis, and there may be local morbidity to the donor site of the iliotibial band graft that is used to augment the tendon transfer. The authors report eight patients with primary chronic scapulothoracic winging refractory to conservative treatment. Five of these patients had an incorrect diagnosis, and this resulted in 17 surgical procedures without resolution of their pain or improvement of function. Of the eight patients who required additional surgery to stabilize the scapula, only five patients had an electromyographic study that showed long thoracic nerve palsy, although all patients had profound scapulothoracic winging. All patients underwent a modified pectoralis major transfer with autogenous semitendinosus and gracilis tendon augmentation using two small incisions. Although one patient had a postoperative infection develop, the remaining seven patients had resolution of their winging, improved function, and satisfactory cosmesis.     

Submandibulectomy in the treatment of pathology of the submandibular gland: our experience 1970-1995

Submandibular gland excision is proposed in the treatment of neoplastic and non neoplastic diseases; this surgical procedure can be performed by transoral or transcervical approach. The aim of the study is to demonstrate that cervical approach must be preferred because it is safer and allows a wider exposition of the surgical field. From 1970 to June 1995, 54 patients (47 with chronic sialadenitis, 7 with benign tumors and 7 with malignant tumors) were submitted to excision of the submaxillary gland. Of the 54 resections performed, 2 were completed with "functional" cervical lymphadenectomy and 1 with Radical Neck Dissection in pts. with malignant neoplasms. There were no postoperative deaths; complications occurred in 1 patient (1/54 = 1.8%) as a iatrogenic permanent lesion of the maxillary branch of the facial nerve (in detail 0/47 patients with benign disease and 1/7 (14.7%) patients with malignant disease). The cervical approach for the resection of the submaxillary gland is preferred to the transoral approach for the lower risk of iatrogenic lesions of the lingual and hypoglossal nerves and the possibility of curative resections in case of malignant neoplasms. A regulated and experimented technique through the cervical approach also lowers the risk of a lesion of the maxillary branch of the facial nerve.     

Arthroscopic shoulder stabilization. Differentiated treatment strategy with Suretac, Fastak, Holmium: YAG-laser and electrosurgery

The goal for arthroscopic stabilization of anterior glenohumeral instability is to achieve an outcome equivalent to or better than open procedures. A number of arthroscopic procedures have been advocated to reestablish continuity of the inferior glenohumeral ligament complex (IGHLC) with the glenoid. Implantable suture anchors were developed to avoid the problems associated with arthroscopic staple capsulorrhaphy like iatrogenic injury of the glenoid or humeral surface, loosening and migration of the staple. Several transosseous techniques include the need for an accessory posterior incision, the possibility of neurovascular injury (Suprascapular or axillary nerve), and the loosening of the repair after typing over the fascia of the infraspinatus posteriorly. The preferred techniques are cannulated, absorbable fixation device (Suretac) and easy implantable suture anchors made of titanium (Fastak). Even in the hands of experienced arthroscopists, unacceptably high recurrence rates for arthroscopic shoulder stabilization have been reported, due to the steep learning curve for both technical performance and patient selection. Our experience suggests, that if proper selection criteria are employed, normal patients and overhead-athletes may benefit from the advantages of an arthroscopic repair without accepting an increased risk for recurrence. We performed a prospective analysis of 105 shoulders, who underwent arthroscopic stabilization with Suretac or Fastak between 4/96 and 7/98. 48 shoulders were available for followup at least one year. The redislocation rate was 6.25% (3 shoulders) and the rate of subluxation without dislocation also was 6.25%, but none of the shoulders required a second open stabilization. The reason for redislocation or subluxation were 5/6 traumatic injuries, participating in contact sports or in one case a generalized ligamentous laxity. In combination with the LACS-Procedure or the Electro thermally assisted capsular shift (ETACS) not only the capsular detachment but also the capsular redundancy may be adressed and a lower failure rate can be expected.     

Hypoglossal nerve injury caused by halo-suspension traction. A case report

STUDY DESIGN: A case report of injury to the hypoglossal nerve (CN XII) resulting from the use of halogravity traction in a child with severe cervicothoracic kyphosis after an anterior and posterior spinal release. OBJECTIVE: To describe one of the potential dangers of halo-suspension (gravity) traction, which has not been reported previously in the orthopedic literature. SUMMARY OF BACKGROUND DATA: Cranial nerve injuries resulting from halo-skeletal traction are a recognized complication of such treatment, especially in patients with myelomeningocele. Halo-suspension traction using the patient's body weight as counter-traction has been recommended to provide a less rigid force and to reduce complications. METHODS: The authors report on the mechanism of injury and clinical course in a 12-year-old boy with myelomeningocele and a bilateral CN XII injury caused by halo-suspension traction from onset to resolution. RESULTS: This patient had dysphagia and difficulty swallowing 5 days after surgery. His wheelchair traction at this point was approximately 40% of his body weight. The traction was reduced, and a corticosteroid was administered. The patient's symptoms began to abate 5 days later. At 6 weeks after injury, his cranial nerve function was normal. CONCLUSIONS: Although halo-suspension traction or halo-wheelchair traction may be less rigid, injury to the hypoglossal nerve can be produced with traction exceeding 40% of body weight. In the patient in the current report, resolution of this injury was complete within 5 weeks, an outcome that is consistent with those of other reported cases of CN XII injury.     

Surgical treatment of Wolff-Parkinson-White syndrome: a "retrospectroscopic" view

The surgical treatment of the Wolff-Parkinson-White syndrome made its appearance in 1968 when Dr W. C. Sealy performed the first direct surgical intervention for ablating an accessory connection in a patient with incessant atrioventricular reentrant tachycardia. The surgical approach fell into disfavor in 1990 when catheter ablation using radiofrequency energy was adopted into widespread use. In this presentation, I will attempt to assess the scientific value of the surgical experience using the scholarly tool, the "retrospectroscope," and also to answer the questions, Was it worth it? What was learned? and What was achieved? We conclude that a large body of scientific knowledge and skill was brought to light by this experience and, of even more importance, passed on for best use to the catheter surgeons.     

REM sleep without atonia at early stage of sporadic olivopontocerebellar atrophy

Independent clinical neurological evaluation and intraoperative somatosensory evoked potential (SSEP) monitoring was performed on 30 vertically unstable hemipelvis fractures in 28 patients undergoing acute open reduction and internal fixation. Preoperative ipsilateral neurologic injury of the sciatic/lumbosacral plexus was noted in 15 of 30 fractures (50%). Significant unilateral SSEP changes occurred during manipulative reduction of two displaced sacroiliac joints and one sacral fracture. Because of the expeditious response of the surgical team, with release of traction/retraction, SSEP returned to baseline and no patient sustained an iatrogenic nerve injury or worsening of their preoperatie neurologic status. The incidence of postinjury lumbosacral plexopathy in unstable pelvic fractures is high (50%) when careful preoperative evaluation including SSEP is performed. The use of intraoperative SSEP monitoring is feasible in acute posterior pelvic fracture surgery and can help identify potential intraoperative iatrogenic lumbosacral neurological compromise.     

Iatrogenic diaphragmatic hernia following abdominal esophagogastrofundoplication: report of a case

The authors describe diagnosis and surgical treatment of a patient with iatrogenic diaphragmatic hernia following esophagogastrofundoduplication by Nissen's operation. The patient had presented a hiatal hernia with esophagitis chronic regurgitation and was submitted to esophagogastrofundoduplication. On the third postoperative day, the patient showed signs of dysphagia and intense dyspnea. The computerized tomography showed the presence of the gastric fundus and it's contents inside the leftpleural cavity. The patient was submitted to a left posterolateral thoractomy and an ischemic peptic ulcer in the gastric fundus, blocked by lung parenchyma was sutured. Then, the stomach was reduced into the abdominal cavity with diaphragmatic suture associated with esophageal and gastric fundus fixation to the right diaphragmatic pilar. The patient presented satisfactory immediate and late postoperative follow-up (1 year). The authors discuss and document aspects of diagnosis as well as surgical indication.     

Penetration of cryotherapy in treatment after shoulder arthroscopy

The authors describe the case of a female patient affected with large symptomatic gastric leiomyoma, six centimeters in diameter, who presented to clinical observation referring gastric pain and melena. The first gastroscopy showed massive bleeding from a submucosal gastric lesion. The lesion was not endoscopically resectable and the injective endoscopic treatment of bleeding failed. The patient was surgically treated with laparotomic excision of the leiomyoma. She was back home in ten days. The authors describe this case to discuss the possibility to resect large gastric leiomyomas using endoscopic resection indeed surgical approach. They also enhance the validity of surgical treatment for its safety and radical approach to large lesions.     

Multiple accessory pathways in patients with the pre-excitation syndrome

We have studied 135 patients with the pre-excitation syndrome and have demonstrated evidence of multiple accessory pathways in 20 patients. Five patients had two distinct accessory atrioventricular (A-V) connections, associated with enhanced A-V node conduction in one patient. Twelve patients had a single accessory A-V connection associated with enhanced A-V conduction. In one of these there was an additional fasciculo-ventricular connection. One patient had an accessory A-V connection associated with a nodoventricular bundle. Two patients had fasciculo-ventricular connections combined with enhanced A-V conduction. The latter two patients had electrocardiograms suggestive of a complete accessory A-V connection. Patients with enhanced A-V conduction had shorter cycle lengths during reciprocating tachycardia, primarily because of a short A-H during the dysrhythmia, than those without such conduction. In addition, patients with enhanced A-V conduction demonstrated more rapid conduction from atrium to His bundle during induced atrial fibrillation and two developed life-threatening ventricular responses during atrial fibrillation. A nodo-ventricular pathway was documented to participate in reciprocating tachycardia in one patient. Surgery was undertaken in 13 patients. In 11, the intraoperative mapping studies confirmed the preoperative predictions. In two patients, the presence of a second accessory A-V connection was documented after ablation of one.     

Randomized study of chemotherapy and surgery versus radiotherapy for stage IIIA non-small-cell lung cancer: a National Cancer Institute of Canada Clinical Trials Group Study

We treated two children with the unusual complication of ulnar nerve palsy after closed both-bone forearm fractures. Both patients developed an ulnar claw-hand deformity within 7 weeks of injury that resolved spontaneously by 20 weeks postinjury with nonoperative treatment. No patient showed any signs or symptoms of an ischemic compartment syndrome. Both nerve injuries were identified immediately at the time of fracture by a careful neurologic examination. This avoids confusion with a postreduction nerve entrapment injury or ischemic injury after a localized compartment syndrome, which may have considerably different treatments and outcomes. We recommend that a careful neurologic examination be recorded before any manipulative reduction of forearm fractures in children. If an ulnar nerve palsy is detected, it is probably a result of nerve contusion and should resolve without the need for surgical exploration.     

Lasers in dermatologic surgery

The authors review their experiences with the use of carbon-dioxide (CO2) lasers in dermatological surgery in a group of 3000 patients, with a total number of 3920 tumorous skin lesions, during a three-year period. The word LASER is an acronym for L-ight A-mplification by S-timulated E-mission of R-adiation. It must be pointed out that it is electromagnetic radiation, not X-irradiation. In regard to the spectrum laser light is between infrared and ultraviolet light, mainly in the visible spectrum, so its application does not produce new generations of iatrogenic malignancies as in the case of ionizing radiation. The laser is a new scalpel which differs from the metal surgical scalpel (also called "optical knife" and "light scalpel"). In the conclusion authors state that using (CO2) complete success was achieved in treatment of the following skin lesions: common viral warts, senile keratosis, seborrhoeic keratosis, plantar viral warts, papillomas, capillary telangiectasias of the face, hemangiomas, juvenile viral warts of the face, ingrown nails, condyloma acuminata, pendular fibromas, xanthelasmas, atheromas, pyogenic granulomas, keratoacanthomas, tattooed skin and basocellular epitheliomas.     

Acute quadriplegia with delayed onset and rapid recovery. Case report

The authors describe a patient with severe head injury and sepsis who became acutely quadriplegic 3 days postinjury because of a critical illness polyneuropathy (CIP) and critical illness myopathy (CIM), which resolved rapidly after treatment of the underlying infection. In only 3 days the patient developed septic shock together with flaccid quadriplegia and absent deep tendon reflexes with no clinical or radiological evidence of central nervous system deterioration. Neurophysiological studies showed an acute axonal sensorimotor polyneuropathy, whereas the clinical course strongly suggested a concurrent myopathy. A severe Staphylococcus epidermidis infection accompanied by bacteremia was treated and the patient recovered fully within a few days. Although the case described here is unique because of its very early onset and rapid resolution, CIP and CIM are frequent complications of sepsis and multiple organ failure. The authors suggest that severely head injured patients with sepsis should be evaluated for CIP and CIM when presenting with unexplained muscle weakness or paralysis.     

Malignant peripheral nerve sheath tumors. A clinicopathologic study of 28 cases

BACKGROUND: In order to improve management, the files and tissue sections of 28 cases of malignant peripheral nerve sheath tumors (MPNST) diagnosed at the University of Virginia Health Sciences Center between 1960 and 1990 were reviewed. METHODS: Clinical data tabulated included age, sex, race, the presence or absence of von Recklinghausen neurofibromatosis type 1 (NF-1), tumor size, tumor location, type of treatment, and status of surgical margins. Pathologic study included assessment of mitotic rate, divergent differentiation, cellular atypia, necrosis, and vascular reaction. RESULTS: The median disease-free survival time was 11 months, and the median overall survival time was 44 months. Overall survival and disease-free survival were significantly influenced by patient age, tumor location, tumor size, extent of surgery, and quality of margins. Patients with a family history of neurofibromatosis also had better disease-free survival. None of the other clinical variables correlated with survival. CONCLUSIONS: The authors recommended that patients with NF-1 be followed closely for MPNST development. For most cases, treatment should include aggressive surgery with wide surgical margins combined with adjuvant radiation therapy. Chemotherapy may have a role for treatment failures.     

Intracranial repair of a divided trochlear nerve. Case report

The authors report the case of a 37-year-old woman in whom the trochlear nerve was transected during removal of a meningioma in the cavernous sinus and subsequently repaired by using microsurgical techniques. This patient presented with a tumor in the posterior part of the right cavernous sinus with expansion over the tentorium. Preoperatively, she suffered from partial deficit of the right trochlear nerve. Intraoperatively, the trochlear nerve was noted to be completely encased by the tumor and was totally divided during removal of the lesion. After tumor resection, the trochlear nerve was repaired by using a sural nerve fascicle secured with sutures and fibrin glue. Six months after the operation, trochlear nerve regeneration became evident as the patient's binocular vision gradually improved. The patient regained normal functioning of the superior oblique muscle 3.5 years after surgery. It is concluded that repair of a divided trochlear nerve is worthwhile and can be followed by successful regeneration and an excellent functional recovery of the superior oblique muscle.     

Neuropathies associated with malignancy

Patients with malignancy can develop peripheral neuropathies as (1) a direct effect of the cancer by invasion or compression of nerves, (2) a remote or paraneoplastic effect, or (3) an iatrogenic effect of treatment. Focal or multifocal cranial neuropathies, radiculopathies, and plexopathies typically result from tumor infiltration, herpes zoster infection, or radiation-induced injury. Sensorimotor polyneuropathies are the most frequently encountered peripheral nerve syndromes, but motor neuropathies, sensory neuronopathies, polyradiculoneuropathies, and autonomic neuropathies can also occur. Although uncommon, paraneoplastic mechanisms should be considered in a patient with malignancy and an associated peripheral nerve disorder, especially in the setting of small-cell lung cancer or lymphoproliferative cancer. Toxic neuropathies occur with exposure to several chemotherapeutic agents, including the vinca alkaloids, cisplatin, taxanes, and suramin. These neuropathies are usually dose-related, sensory-predominant, and at least partially reversible, with an axonopathic or ganglionopathic mechanism. Suramin is unique in causing subacute, demyelinating polyradiculoneuropathy.