Secure patient positioning using Badillo/Trendelenburg restraint strap during robotic surgery

Steep Trendelenburg position is routine during robotic urologic and gynecologic surgery in order to optimize exposure of the pelvis. This position requires that the patient be properly secured as to avoid any movement during the procedure. We analyzed the safety and tolerability of a reusable strap with disposable cushions used during robotic assisted radical prostatectomy. The Badillo/Trendelenburg restraint is a harness which is placed on the table prior to patient transfer. The restraint is a Class I FDA-registered device (Pintler Medical, Seattle, WA). Patients were marked at the beginning and end of the case to determine if any movement had occurred. The Badillo/Trendelenburg restraint was employed in 1,200 consecutive RARP cases. The restraint was used by a single surgeon at two institutions. The operating table was marked from edge of the patients shoulder to the end of the head of table at the beginning and end of the case to determine if any movement had occurred. Maximum movement observed was 1 cm. All patients were questioned and a physical examination were done in the post operative period for any shoulder or nerve injury. No reports of shoulder or brachial injury. For patients undergoing robotic surgery with steep Trendelenburg position the Badillo/Trendelenburg restraint provides a secure, reliable and safe means of maintaining proper position without any patient movement.     

Positioning of the patient during shoulder surgery: an inexpensive, safe and easy technique

The knowledge of shoulder pathology has improved tremendously in the last decades, and shoulder surgery is increasingly performed because of new treatment options and better operative results. Nowadays most surgical shoulder procedures are performed in the sitting or semi-sitting (beach chair) position. Stability of the patient and the ability to flex, extend and rotate the shoulder during surgery are crucial to improve exposure of the surgical field and lower the risk of perioperative complications. We developed an easy, safe and inexpensive surgical set-up providing a very good posterior, superior and anterior access to the shoulder in the sitting or semi-sitting position. In this technique, the patient is placed supine with the head at the foot end of the table and the body positioned slightly eccentrically with the back being supported by the leg plate contralateral to the operative side, avoiding any contact with the scapula of the operative side. A neck support is attached on an extra bar at the contralateral side and accommodated to the patient’s lordosis. Next, the leg plate on the operative side is removed, and the head and the body are secured to the table with adhesive dressing. This way a stable positioning of the patient is obtained during the whole procedure, and the shoulder girdle is completely free. The set-up can accommodate patients of different stature and weight without the need to adapt the technique. This position also gives the possibility to provide an excellent radiographic view of the shoulder during operative fracture treatment. Our technique further allows a significant reduction in costs. A surgical table, extra bar, additional arm support and neck support are usually available and can be used in different settings, without the need for a specific shoulder table.     

Bilateral phrenic nerve palsy associated with benign thyroid goiter

Phrenic nerve palsy secondary to benign thyroid enlargement is a previously unreported complication. Large goiters, particularly substernal, may impinge upon adjacent structures, often leading to significant symptoms such as dysphagia or dyspnea due to airway compression. The phrenic nerve may be stretched by a large goiter along its course in the neck, but the more likely site of injury is the point at which it enters the thoracic cavity adjacent to the first rib. Such an injury, caused by compression, may go unrecognized if unilateral, as symptoms would be uncommon. However, bilateral phrenic nerve palsy can cause significant dyspnea due to pulmonary insufficiency, particularly in an elderly patient with cardio-pulmonary disease. Early operative treatment of the goiter may prevent this complication or limit its severity, thus avoiding permanent nerve injury.     

Acute carpal tunnel syndrome secondary to prolonged pressure on the wrist during enolic coma

We report a case of acute carpal tunnel syndrome caused by prolonged compression. A 40-year-old man was admitted for an acute carpal tunnel syndrome secondary to direct compression of the wrist which was blocked in supination under his thorax for ten hours during a period of alcoholic coma. Total sensorial anesthesia of the median nerve territory was noted. The emergency procedure consisted in simple opening of the carpal tunnel without nerve exploration due to the risk of bacterial contamination resulting from skin lesions, devascularization and postoperative fibrosis. Initially, the skin on the volar aspect of the wrist had the aspect of a second degree burn. The patient recovered nerve function the next day and the skin wound healed within 15 days. The patient was seen at consultation at 13 months and exhibited complete recovery of wrist and hand motion with normal thumb opposition and no signs of sensorial or motor deficit. The retinaculum of the flexor system must be opened to guarantee full nervous recovery.     

Diagnosis of radial nerve palsy caused by ganglion with use of different imaging techniques

Clinical features of six cases of radial nerve compression syndrome as a result of ganglion at the elbow are reported. The usefulness of different imaging techniques for detecting the location of ganglion is compared. The posterior interosseous nerve was involved in two patients, the radial sensory nerve in one patient, and both nerves in three patients. Ultrasonography, computed tomography, and magnetic resonance imaging revealed the location of the ganglion in every patient. Ultrasonography was most convenient for screening examination when it was difficult to clearly define a ganglion by palpation. In all patients, a ganglion arose from the anterior capsule of the elbow joint. Dynamic factors in addition to compression of the nerve by ganglion may influence occurrence of the nerve palsy.     

Acute posterior interosseous nerve palsy caused by septic arthritis of the elbow: a case report

A rare case of acute posterior interosseous nerve palsy caused by septic elbow arthritis is reported. The nerve was compressed beneath the arcade of Frohse by hypertrophied synovium and joint fluid at the anterior aspect of the radial neck. Decompression of the nerve, synovectomy, and irrigation of the elbow joint were done. effective. Six months after the surgery the nerve palsy had recovered completely. Two years after surgery there was no recurrence of the infection or nerve palsy.     

Iatrogenic Sciatic Nerve Palsy Following Hemiarthroplasty of the Hip

Abstract We report a rare complication following insertion of an uncemented hip prosthesis that resulted in posterior perforation of the femoral stem and a sciatic nerve palsy. To our knowledge, sciatic nerve palsy due to the femoral stem perforating the cortex has not been previously described.     

"True" posterior communicating artery aneurysm presenting the abducens nerve palsy

Most of "so-called" posterior communicating artery aneurysms previously reported, originated from the internal carotid-posterior communicating junction. Aneurysms arising from the posterior communicating artery itself are very rare. The abducens nerve palsy caused by cerebral aneurysm is also very rare. We are reporting a case with the saccular aneurysm arising directly from the distal half of the posterior communicating artery presenting the abducens nerve palsy. This 73-year-old woman who had no treatment with hypertension for several years was admitted for sudden onset of severe headache, vomitting and unconsciousness on March 1, 1984. She opened her eyes when addressed and had disorientation, urinary incontinence, right-hemiparesis and left-abducens nerve palsy. A 4-vessel angiography revealed the saccular aneurysm originating directly from the distal half of the posterior communicating artery. The patient underwent left-frontotemporal craniotomy on the 27th day after subarachnoid hemorrhage under Hunt & Kosnic Grade 3. The aneurysm originated directly from the distal half of the posterior communicating artery and directed inferior-posterior-laterally below the oculomotor nerve. The neck was successfully clipped. Immediate post-operative course was uneventful until the 7th day after surgery. On the 8th day she had hypertensive intraventricular hemorrhage and expired. The autopsy could not be obtained. The saccular "true" posterior communicating artery aneurysm with isolated unilateral abducens nerve palsy as seen in our case has not been reported. Considering the operative findings, we thought the aneurysmal dome contacted directly with the abducens nerve.     

Stabilization of fatigue fractures of the dorsal pelvis with a trans-sacral bar. Operative technique and outcome

IntroductionDue to ageing of our population the number of fatigue fractures of the pelvic ring is steadily growing. These fractures are often treated with bed rest but may result in a disabling immobility with severe pain. An operative treatment is an option in these cases. The aim of operative treatment is bony healing obtained by stable fixation giving back to the patient's previous mobility. Optimal surgical treatment is currently under debate. Sacroiliac screw fixation and sacroplasty are used for stabilization of the dorsal pelvis. Due to the technique and the low density of spongious sacral bone, no or only low compression in the fracture site is obtained, which may inhibit bony healing. The trans-sacral bar compression osteosynthesis is presented as an alternative procedure. We present the outcome of 11 patients, who were treated with this method.MethodsThe patient is placed in prone position on the operation table. Under image intensifier control, a 5 mm threaded sacral bar is inserted through the body of S1 from the left to the right dorsal ilium. Nuts are placed over the bar achieving fracture compression. When anterior pelvic instability is present, an anterior osteosynthesis is also performed. Clinical and radiological outcome were evaluated one year after index surgery with different scoring systems.ResultsEleven patients (9 F and 2 M) were treated between 2005 and 2010. The mean age of the patients was 73 years at time of operation. There were no mechanical complications. Postoperatively there was a temporary nerve palsy of L5 in one case. The mean follow-up was 14 months. In all patients, a bony healing of the dorsal pelvic ring was achieved. Seven patients showed a major clinical improvement, in four patients a moderate.ConclusionsTrans-sacral bar osteosynthesis is a promising method for stabilization of fatigue fractures of the pelvic ring. Only with this method, a high interfragmentary compression is achieved, independent of the quality of the spongious bone of the sacral body.     

Pudendal nerve palsy in trauma and elective orthopaedic surgery

The incidence of pudendal nerve palsy following routine trauma and elective orthopaedic surgery procedures ranges from 1.9% to 27.6%. Excessive and/or prolonged traction against the perineal post of a traction table, leading to direct compression and localised ischaemia to the nerve are suggested mechanisms of injury. Misuse of traction and the inappropriate placement of the perineal post, leading to crushing and stretching of the pudendal nerve, are two main contributing factors leading to its postoperative palsy.     

Sleep palsy (Saturday-night palsy) of the deep radial nerve. Case report

A patient with a long-recognized asymptomatic lipoma adjacent to the deep radial nerve developed paralysis of this nerve from a compression similar to the sleep palsy, or "Saturday-night palsy," mechanism.     

Common Peroneal Nerve Palsy Due to Giant Fabella After Total Knee Arthroplasty

BackgroundCommon peroneal nerve palsy (CPNP) is a rare but serious complication following primary total knee arthroplasty (TKA). The common peroneal nerve is one of the main molecules of the sciatic nerve. CPNP is a series of symptoms caused by common peroneal nerve injury due to paralysis and atrophy of the fibula and tibia muscles. The main clinical symptoms are: ankle joint unable to extend back, toe unable to extend back, foot droop, walking in a steppage gait, and foot dorsal skin sensation having decreased or disappeared. If treatment is not timely, severe cases may result in atrophy of the anterior tibia and lateral calf muscles. The risk factors for CPNP include mechanical stretching of the nerve, disruption of the blood supply to the nerve, and compression of the nerve. The CPNP should be treated in a timely manner and according to the cause. Its function should be restored as soon as possible to avoid serious adverse consequences. It has negative effects on patients’ life and physical and mental health. To our knowledge, this is the first study to describe CPNP due to a giant fabella after TKA.Case presentationThe present study reported on a 70‐year‐old female patient. The patient underwent a primary TKA of the right knee for osteoarthritis. Relevant examinations were conducted and the operation went smoothly. Three hours postoperation, a right partial CPNP was observed, with progressive aggravation over time. On palpation, there was a 2 × 2‐cm fixed hard mass in the posterolateral aspect of the right knee, with mild tenderness to deep palpation. Radiographs demonstrated that a giant fabella was located at the posterolateral condyle of the right femur. Fabellectomy and neurolysis of the common peroneal nerve were performed. The peroneal nerve palsy resolved gradually after the operation. At 8‐month follow up after fabellectomy and neurolysis, the function of the common peroneal nerve had fully recovered.ConclusionsThe presence of giant feballa pressing on the common peroneal nerve should be considered when common peroneal nerve palsy occurs after TKA. Surgical exploration and release compression should be performed in a timely manner.     

先天性及神经肌肉所致髋关节不稳定之髋臼

目的：通过对髋臼的影像学变化的分析,了解先天性及神经肌肉性原因导致的髋关节不稳。方法：利用CT及X线平片对髋臼的改变进行评估。共研究了27名儿童,计33个不稳定髋关节。结果：先天性髋关节发育异常儿童的关节显示了随骨盆髋臼前倾角的增大其前缘及上缘的缺损,在脑瘫及脊柱裂者则显示了髋臼的多方面缺损。在脑瘫患者中具有典型的后缘缺陷,并且是所研究群体中髋臼最浅的。结论：髋关节不稳患儿的髋臼缺损在不同疾病的表现不同,但存在交叉。     

Isolated oculomotor nerve palsy following apoplexy of a pituitary adenoma.

An isolated oculomotor nerve palsy is very rarely the presenting sign of a pituitary adenoma. It may occur slowly due to mechanical compression or rapidly, secondary to pituitary apoplexy. Magnetic resonance imaging (MRI) with and without gadolinium DTPA enhancement provides excellent anatomical detail and is useful in the planning of the operative procedure. When correctly diagnosed and treated, the third nerve dysfunction appears to be reversible. We report a case of a pituitary adenoma presenting with an isolated, partial oculomotor nerve palsy in the setting of apoplexy. The pathophysiology, prognostic factors and MRI findings of this entity are discussed.     

Transient simultaneous sciatic and femoral nerve palsy secondary to iliacus and gluteal hematomas following heparinization for pulmonary embolus in a patient with posterior hip dislocation

Sciatic nerve palsy as a result of a posterior hip dislocation has been reported in the literature. Femoral nerve palsy as a result of a iliacus hematoma has also been documented. However, a simultaneous sciatic and femoral nerve palsy occurring after heparinization for a pulmonary embolus in a patient with a posterior hip dislocation has not been reported. This combined nerve palsy was found in a 64-year-old white woman who had been involved in a motor vehicle accident and sustained a posterior hip dislocation. This patient subsequently had a pulmonary embolism, was heparinized, and then developed a large iliacus and gluteal hematoma, resulting in a simultaneous sciatic and femoral nerve palsy. Without treatment, the patient regained motor and sensory of the sciatic nerve in a few days, and a gradual improvement of function of her femoral nerve was evident over several months.     

Paralysie cubitale secondaire à un drainage thoracique prolongé

In intensive therapy patients, thoracic drains are usually inserted in the lateral part of thorax with the extension tube crossing the posterior aspect of the upper limb. We report the cases of two sedated patients who experienced ulnar palsy from a thoracic drain located behind their elbow.     

The radial nerve in the brachium: an anatomic study in human cadavers

PURPOSE: To explore the course of the radial nerve in the brachium and to identify practical anatomic landmarks that can be used to avoid iatrogenic injury during humerus fracture fixation. METHODS: Data were collected from 27 adult cadaveric specimens, including 18 embalmed cadavers and 9 fresh-frozen limbs. Measurements were taken using osseous landmarks to define the relationship of the radial nerve and the posterior and lateral humerus. The extremities were studied further to determine the association of the radial nerve and anatomic landmarks on both longitudinal and cross-sectioned specimens. RESULTS: A 6.3 cm +/- 1.7 segment of radial nerve was found to be in direct contact with the posterior humerus from 17.1 cm +/- 1.6 to 10.9 cm +/- 1.5 proximal to the central aspect of the lateral epicondyle, centered within 0.1 cm +/- 0.2 of the level of the most distal aspect of the deltoid tuberosity. The radial nerve lay in direct contact with the periosteum in all specimens, without evidence of a structural groove in the humerus in any specimen. On entering the anterior compartment, the radial nerve had very little mobility as it was interposed between the obliquely oriented lateral intermuscular septum and the lateral aspect of the humerus. As it extended distally, the nerve coursed anterior to the humerus and became protected by brachialis muscle at the level of the proximal aspect of the lateral metaphyseal flare. CONCLUSIONS: The radial nerve is at risk of injury with fractures of the humerus and with subsequent operative fixation in 2 areas. The first is along the posterior midshaft region for a distance of 6.3 cm +/- 1.7 centered at the distal aspect of the deltoid tuberosity. The second is along the lateral aspect of the humerus in its distal third from 10.9 cm +/- 1.5 proximal to the lateral epicondyle to the level of the proximal aspect of the metaphyseal flare. The deltoid tuberosity is a consistent and practical anatomic landmark that can be used to determine the level of the radial nerve along the posterior aspect of the humerus during operative fixation from an anterior approach.     

Incidence of Sciatic Nerve Palsy After Revision Hip Arthroplasty Through a Posterior Approach

Sciatic nerve palsy after revision hip arthroplasty is rare, but can have substantial impacts. The purpose of this study is to report the safety and reliability of limited sciatic nerve exposure during revision surgery. A retrospective case series of 350 revision hip surgeries performed by a single surgeon underwent sciatic nerve identification. In each case, the sciatic nerve was identified and tagged loosely with a Penrose drain. Three hundred forty-eight of 350 patients (99.4%) underwent successful revision hip arthroplasty. One patient developed a transient sensory palsy; and another patient, a delayed palsy. Both nerve palsies recovered by the 1-year visit. We advocate visual nerve identification and tagging in revision hip surgery as 1 possible method to potentially reduce the risks of sciatic nerve injury.     

Trochlear nerve palsy after repeated percutaneous balloon compression for recurrent trigeminal neuralgia: case report and pathogenic considerations

OBJECTIVE AND IMPORTANCE: Repeated percutaneous balloon compression for the treatment of idiopathic trigeminal neuralgia is infrequent. When a second procedure is performed, the outcome is unknown. A patient developed an isolated trochlear nerve palsy after undergoing percutaneous trigeminal ganglion balloon compression for a second time. The mechanism of diplopia and the complications associated with this technique were studied. CLINICAL PRESENTATION: The patient was a 67-year-old woman with a history of medically refractory idiopathic trigeminal neuralgia involving all three divisions of the right trigeminal nerve. INTERVENTION: Percutaneous balloon compression was performed. Despite initial total relief from pain without complications, the patient again displayed manifestations of trigeminal neuralgia 3 months after the procedure. The pain disappeared after she underwent a second balloon compression procedure, but she developed an isolated trochlear nerve palsy, which spontaneously resolved in 2 months. CONCLUSION: Isolated trochlear nerve palsy is a rare and reversible complication after percutaneous balloon compression for trigeminal neuralgia. This case illustrates that the mechanism of injury to the fourth nerve is the result of an erroneous technique: excessive penetration of the Fogarty catheter in Meckel's cave beyond the porus trigemini and compression of the cisternal segment of the trochlear nerve when the inflated balloon is pushed against the tentorium.     

Quadrilateral space syndrome: a case report

Quadrilateral space syndrome is a rare entity caused by isolated compression of the axillary nerve in the quadrilateral space. A twenty-seven-year-old male patient presented with a poorly localized shoulder pain and point tenderness on the posterior aspect of the shoulder. Magnetic resonance imaging showed a fibrous band causing quadrilateral space syndrome. Surgical excision of the fibrous band was performed and the axillary nerve was released. The patient became symptom-free after surgical decompression.