Management strategies for peripheral iatrogenic nerve lesions

For diagnostic or therapeutic reasons, various medical procedures may cause iatrogenic injury of peripheral nerves. The authors treated 82 patients for iatrogenic nerve injury between 1990 and 2000. The main reasons for iatrogenic nerve injury were surgical failure, traction or pressure lesions, hematoma, or inadequate positioning of the patient. The authors performed neurolysis in 67 cases, which included reconstruction by nerve graft in 26 patients and direct coaptation of the nerve in 3 patients. Their postoperative results emphasize the importance of early diagnosis and adequate treatment of iatrogenic peripheral nerve damage for optimal functional recovery. The authors highlight the different causes for iatrogenic injury in this study to alert surgeons as well as other medical specialists to simple strategies for avoiding nerve injury. They also indicate the need for physicians to make themselves familiar with early diagnostic steps for detecting iatrogenic injuries, like electroneurographic studies, and to document physical examinations well, to deal with this problem most effectively.     

Intrapelvic and thigh-level femoral nerve lesions: management and outcomes in 119 surgically treated cases

OBJECT: The authors present a retrospective analysis of 119 surgically treated femoral nerve lesions at intrapelvic and thigh levels seen at the Louisiana State University Health Sciences Center. METHODS: Femoral nerve lesions treated between 1967 and 2000, (89 traumatic injuries and 30 tumors and cystic lesions) were evaluated for injury mechanisms, resulting lesions, surgical management, and postoperative functional outcomes by using retrospective chart reviews. The most common injury mechanism was iatrogenic (52 cases), which occurred after hernia and hip operations (10 each), followed by arterial bypass and gynecological procedures (eight each), angiography (seven), abdominal surgery (five), appendectomy (two), a laparoscopy, and a lumbar sympathectomy. Other injury mechanisms included hip or pelvic fractures (19), gunshot wounds (10), and lacerations (eight). The 30 femoral nerve tumors and cystic lesions consisted of neurofibromas (16), schwannomas (nine), ganglionic cysts (two), neurogenic sarcomas (two), and a leiomyosarcoma. Forty-four patients underwent neurolysis. Some had recordable nerve action potentials (NAPs) across their lesions in continuity, despite severe distal loss. Others with recordable NAPs had mild loss, but also experienced a pain problem, which was helped in some by neurolysis. In 36 patients, in whom repairs were performed using long sural grafts for mostly proximal pelvic-level injuries, recovery of useful function occurred. Eight of nine thigh-level suture repairs led to improvement to good functional levels. Most of the tumors and cystic lesions were resected, with preservation of preoperative function. CONCLUSIONS: The majority of femoral nerve injuries resulted in lesions in continuity, and intraoperative NAP recordings were essential in evaluating axonal regeneration across these lesions. Despite severe and frequently proximal injury levels requiring repairs with long grafts, femoral nerve lesion repairs resulted in good functional recovery.     

Management and outcomes in 353 surgically treated sciatic nerve lesions

OBJECT: This is a retrospective analysis of 353 surgically treated sciatic nerve lesions in which injury mechanisms, location, time to surgical repair, surgical techniques, and functional outcomes are reported. Results are presented to provide guidelines for management of these injuries. METHODS: One hundred seventy-five patients with buttock-level and 178 with thigh-level sciatic nerve injury were surgically treated at the Louisiana State University Health Sciences Center between 1968 and 1999. Buttock-level injury mechanisms included injection in 64 patients, hip fracture/dislocation in 26, contusion in 22, compression in 19, gunshot wound (GSW) in 17, hip arthroplasty in 15, and laceration in 12; at the thigh level, GSW was the cause in 62 patients, femoral fracture in 34, laceration in 32, contusion in 28, compression in 12, and iatrogenic injury in 10. Patients with sciatic nerve divisions in which positive intraoperative nerve action potentials (NAPs) were found underwent neurolysis and attained at least Grade 3 functional outcomes in 108 (87%) of 124 and in 91 (96%) of 95 buttock- and thigh-level tibial divisions, respectively, compared with 84 (71%) of 119 and 75 (79%) of 95, respectively, in the peroneal divisions. For suture repair, recovery to at least Grade 3 occurred in eight (73%) of 11 buttock-level and in 27 (93%) of 29 thigh-level tibial division injuries, and in three (30%) of 10 buttock-level and 20 (69%) of 29 thigh-level peroneal division lesions. For graft repair, good recovery occurred in 21 (62%) of 34 and in 43 (80%) of 54 buttock- and thigh-level tibial divisions, respectively, even in proximal repairs requiring long grafts, and in only nine (24%) of 37 and 22 (45%) of 49 buttock- and thigh-level peroneal division lesions, respectively. CONCLUSIONS: Surgical exploration and neurolysis after positive NAP readings, or repair with sutures or grafts after negative NAP results are worthwhile in selected cases.     

Benign symptomatic lesions of the pineal gland. Report of seven cases treated surgically

Summary Seven patients with non-neoplastic symptomatic lesions of the pineal gland have been operated on in our department since 1988. Clinical symptoms were slight and there were intermittent signs of a space occupying lesion in the quadrigeminal area, i.e. visual and gait disturbances. In three patients, obstructive hydrocephalus with related symptoms was found. Diagnosis was confirmed by use of MRI in sagittal planes, revealing a cystic lesion in five and a solid tumour in two patients. All patients were operated on without complications using an infratentorial supracerebellar approach. Histological examination showed glial cysts of the pineal gland in five patients. In the two solid specimens, normal pineal tissue was found. These lesions seem to be of special interest, as the only pathological property are their size: Both lesions — too large pineal glands — caused obstruction of the outlet of the third ventricle with subsequent hydrocephalus. Surgical treatment was curative in all cases with prompt relief of the symptoms. Clinical symptoms and signs, diagnostic and pathological findings, as well as the surgical results of these cases will be reported.     

医源性周围神经损伤分析

目的:对医源性周围神经损伤进行分析,以引起手术医生高度重视.方法:39例医源性周围神经损伤中,神经离断伤27例,神经捆扎伤5例,神经牵拉伤7例.对所有患者发生医源性神经损伤的原因、部位及治疗方法进行介绍.结果:3例桡神经牵拉伤经针灸等治疗功能恢复,4例桡神经损伤采用腕伸指伸功能重建术,余32例医源性周围神经损伤经显微外科方法修复,优良率达87%.结论:对医源性周围神经损伤应高度重视,正确使用止血带,熟悉解剖,杜绝粗暴手术,一旦发生应当积极采取各种措施补救,尤应尽早采用显微外科技术修复.     

Missed and iatrogenic nerve lesions in surgery

Missed and iatrogenic nerve lesions are not encountered very often. Nevertheless, they represent an increasingly important subject because of their implications for the patient and the physician and their legal aspects. We present an overview of the patients with missed or iatrogenic nerve lesion treated at the Division for Plastic and Reconstructive Surgery of the Inselspital in Berne from 1980 to 1989. After a look at the legal aspects a few typical lesions and their treatments are illustrated. The diagnosis of a missed or iatrogenic nerve lesion differs in no way from that in other nerve lesions. Therefore, we favor an early surgical revision in all cases where the possibility of a transsected nerve must be suspected postoperatively.     

Retrospective analysis of peripheral nerve sheath tumors of the second cervical nerve root in 60 surgically treated patients

OBJECT: This study is a retrospective analysis of 60 surgically treated patients with 64 peripheral nerve sheath tumors (PNSTs) at the second cervical (C-2) nerve root. The anatomical subtleties of these tumors and their implications for surgical strategy when compared with other spinal PNSTs and other tumors in the foramen magnum region are reviewed. METHODS: Sixty patients with C-2 PNSTs treated surgically in the Department of Neurosurgery at King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College between 1992 and 2006 were studied. All patients underwent magnetic resonance imaging. Tumors were divided into 3 groups depending on their anatomical location identified during surgery. Those tumors located within or extending into the spinal dural tube were called Type A, those located within the dural tube of the C-2 ganglion were labeled as Type B, and tumors extending laterally into the paraspinal region were labeled as Type C. Follow-up durations ranged from 6 months to 15 years (mean 64 months). RESULTS: There were 38 male and 22 female patients in the study, who ranged in age from 6 to 62 years (mean 28 years). Nine patients had clinical features indicative of neurofibromatosis (NF). The mean duration of symptoms at the time of presentation was 27 months (range 4 days-5 years). Two patients had no specific symptoms related to the C-2 PNST, 6 patients had only local symptoms such as neck pain or stiffness, and 52 patients had symptoms of varying degrees of myelopathy. There were 5 solely Type A tumors, 7 Type A + B tumors, 31 Type B tumors, and 21 Type B + C tumors. All Type A, A + B, and B tumors were totally resected. Seven of 21 Type B + C tumors were partially resected, and the remainder were completely resected. All patients postoperatively reported varying improvement in their preoperative symptoms. Except for patients with NF who were disabled by other tumors, the rest of the patients resumed their normal life style. There have been no cases of symptomatic tumor recurrence. CONCLUSIONS: The majority of PNSTs located at the C-2 level in these patients probably arose from the large C-2 ganglion and are limited within the dural confines or are interdural in location. In contrast to other spinal PNSTs, the location of C-2 PNSTs is in most cases posterior to the lateral mass of the atlas and axis and the atlantoaxial joint and is exposed to the posterior without any bone cover. Radical tumor resection is safe, resolution of clinical symptoms is rapid, and recurrence rates are extremely low. In a selected number of cases, bone work for tumor exposure and resection can be entirely avoided.     

Metachronous bronchial neoplasm. 20 cases surgically treated

The authors present a series of twenty metachronous lung carcinomas operated upon in the Thoracic Surgery Unit of Nancy between 1975 and 1987. These lesions occur after a first lung tumor resected for stade 1 TNM in 19 cases, with a 59 month's mean free interval and they are surgically treated by 14 controlateral lobectomies and 6 completion pneumonectomies. In spite of 4 post-operative deaths, the survival rates reach 51% at 3 years and 32% at 5 years. This study with a review of the literature emphasize the relatively high incidence of metachronous lung carcinomas in the patient resected for a tumor of good pronostic factors, their occurrence after a prolonged interval, the difficulty to prove their primary nature and the justification of a surgical approach because the long-term results are comparable with that of patients operated upon for a single carcinoma.     

Pyogenic spondylitis. Analysis of three surgically treated cases.

During a period of 10 years (1964--1973) three patients developing pyogenic spondylitis were operated on. The patients suffered from severe localized back pain and showed sings of infection, as elevation of temperature and raised ESR. The earliest radiological changes were diagnosed on the average after 3 months. As treatment with antibiotics could not cure the infection, the patients were operated on by evacuation of a vertebral focus, and this measure was complemented with bone transplantation. All patients were cured from the fulminant spondylitis, and two of them returned to regular work. No recurrence was noted during an observation period averaging 8 years. Surgery seems to be indicated in some cases of nonspecific spondylitis, especially when a paravertebral spread of the infection is recorded and antibiotic treatment does not primarily show sufficient effect.     

Vaginal hydrocele. Report of 55 surgically treated cases

The authors analyze retrospectively the files of patients who have been operated on for hydrocele between 6th January 2000 and 27th November 2001 (23 months) in Talanga? hospital at Brazzaville. The overall operation rate for that pathology was 4.44%. Prevalence according to age group is as follows: 14 infants (25.45%), three adolescents (5.45%); 14 adults (25.45%); 24 old persons (43.64%). The localization of hydrocele was right in 54.55% of cases, left in 27.27% and bilateral in 18.18% of cases. In all patients, there was a case of idiopathic hydrocele. Patients got the surgical cure more frequently through the homolateral scrotal route than inguinal and the post-therapeutic healing occurs in all cases without recurrence. The authors make comments on those results and they specify certain current data about the disease.     

Intracranial meningiomas. Analysis of 344 surgically treated cases

The authors present 344 (230 females, 114 males) surgical cases of intracranial meningioma. A total of 370 interventions (344 primary procedures, 10 reexplorations for neurologic deterioration, 16 operations for recurrence) were made. Mean follow-up was 38 months. The overall evaluation revealed that 306 (88.95%) patients were completely normal or in a better condition than before operation. 18 (5.23%) were in a worse condition after operation and 20 (5.81%) died. Results suggested that complications and mortality were mostly related to localization and large volume; we also still have problems with aggressive and malignant meningiomas.     

Postoperative eventrations. Apropos of 247 surgically treated cases

The 247 eventrations operated upon concerned 230 patients (60% women and 40% men) mean age 54.5 years. Eventrations were large (collar greater than 10 cm) in 18, 5% and were in the median line in 81%. Serial laparotomies by the same approach had been performed in 21%, the principal causes of eventration being biliary and gynecologic surgery. Parietal sepsis developed in 31,5% of cases after operation for the original affection. Classical favoring factors found included obesity (51%), multiparity (42% of women) and chronic lung disease (14%). Preoperative preparation involved the use of Goni Moreno's progressive pneumoperitoneum in 18,5% of patients. Procedures used were parietal repair by raphe (22%), the same but with the addition of a dacron prosthesis (6%) or the large dacron tulle prosthesis for wide reinforcement of the visceral sac (67% of cases). Early sepsis was a slightly more frequent occurrence after dacron tulle, predisposing factors being the prosthesis itself, a previous history of parietal sepsis, swabs and the number of Redon tubes. After use of dacron tulle complications were mainly also hematoma (3.2%) and skin necrosis (2,6%). Postoperative course in general was uncomplicated in 91% of the 247 operations. Follow up of 67% of operated patients for a mean of 5 1/2 years showed recurrence in 50% of raphe procedures and 18.5% of prosthesis implantations; factors of aseptic recurrence (16,5%) were multiparity and chronic lung disease. Delayed sepsis after dacron tulle use affected 8% of patients and were related to chronicity of early sepsis, nonresorbable sutures and sepsis complicating the primary laparotomy. Doming of the parietal wall was noted in 4% of cases repaired by prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Determinants for malignancy in surgically treated adrenal lesions

Purpose  

It is difficult to definitively rule out or establish malignancy pre-operatively in patients with adrenal lesions referred for adrenal surgery. The aim of this study was to identify risk factors for a malignant diagnosis in patients treated with adrenalectomy.     

Arterial stenosis in transplanted kidneys. 86 surgically treated cases

Eighty-six patients who had undergone renal transplantation three months to five years before, were operated on for a stenosis of the artery supplying the grafted kidney. The diagnosis was made by angiography performed because of refractory hypertension with or without impaired renal function. Surgical repair of the stenosis cured or improved arterial hypertension in 48 patients and improved renal function in 17 of 29 with impaired renal function. Different types of stenosis were recognized: stenosis of the recipient artery, stenosis of the suture line, stenosis of the donor renal artery (segmental or diffuse) and multiple stenoses. The most frequent site of stenosis was the donor artery. There seems to be no single cause of stenosis: atheroma of the recipient vessels, trauma to donor or recipient arteries, faulty suture techniques, hemodynamic disturbances account for some cases whereas in other cases the evidence points to an immune mechanism. This complication of renal transplantation appears now as the most frequent one; therefore, routine vascular investigations should be performed at repeated intervals in all transplanted patients. Surgical repair is indicated in tight stenoses with impending thrombosis and in stenoses responsible for severe hypertension which does not respond to anti-hypertensive treatment. The other patients with mild to moderate hypertension responding to medical treatment, without renal function impairment, and with moderate stenosis can be managed medically. In our experience, surgical correction of the stenosis is indicated approximately in one half of the patients in whom a stenosis has been discovered.(ABSTRACT TRUNCATED AT 250 WORDS)