Isolated laceration to the deep motor branch of the ulnar nerve by a retained foreign body

This report describes an isolated laceration to the deep motor branch of the ulnar nerve by a retained foreign body. The patient sustained a laceration on the ulnar, volar aspect of his palm after a fall on gravel. He presented to the emergency room with motor deficits but a normal sensory examination. No foreign bodies were identified on initial wound exploration or review of plain radiographs, and the patient's wound was sutured closed without diagnosing the nerve injury or the retained foreign body. Confusion over the patient's intact sensory examination and lack of awareness of the complex distal anatomy of the ulnar nerve contributed to the misdiagnosed nerve lesion. Isolated injuries of the deep motor branch are very rare, but increased awareness and understanding of the complex ulnar nerve distal anatomy will help avoid future delays in diagnosis and treatment.     

Surgical treatment of cluster headache

Cluster headache is ordinarily managed medically, but may become refractory to such medical management. In this setting, surgical treatment has occasionally been performed, based on evidence that pertinent pain pathways and parasympathetic pathways may be interrupted at the main sensory root of the trigeminal nerve and at the nervus intermedius. Between 1976 and 1987, 13 patients underwent surgery for treatment of cluster headache that was refractory to medical therapy (15 procedures). Partial sectioning of the main sensory root and sectioning of the nervus intermedius were performed in nine patients; only partial sectioning of the main sensory root in one; only sectioning of the nervus intermedius in one; and nervus intermedius sectioning plus microvascular decompression of the trigeminal nerve in two. The average postoperative period for the 13 patients was 37 months (range 2 to 135 months). All patients had return of their headaches postoperatively except for one patient who obtained relief after a repeat procedure. Headache began to return between 2 days and 2 years postoperatively. Three patients are currently free of headache, including both patients who had nervus intermedius sectioning plus microvascular decompression of the trigeminal nerve. Together with recurrence of headache, cluster-associated autonomic disturbances recurred after 14 of the 15 operations but are currently absent in the three headache-free patients. Partial sectioning of the main sensory root and sectioning of the nervus intermedius, as performed in these patients, seem to have limited value in the treatment of cluster headache.     

Acute abducens nerve palsy following prostatitis due to prostate biopsy

This is a case of repeated acute abducens nerve palsy following prostatitis due to prostate biopsy. A 64-year-old man came to our hospital because of high prostate specific antigen (PSA; 25 ng/ml) on routine medical examination. Transrectal prostate needle biopsy revealed atypical small acinar proliferations in two cores taken from the apex of the prostate. One day after biopsy, the patient presented with chills and a fever. Prostatitis due to prostate biopsy was diagnosed, and hydration and intravenous antibiotics were administered. Although he showed signs of improvement, seven days after biopsy, he complained of double vision in the left gaze. Upon referral to the neurology, head MRI and CSF examination showed no particular abnormality. He was thus diagnosed with post-infection abducens nerve palsy and treated with steroid therapy. His symptoms gradually ameliorated. One year after biopsy, his PSA level was still high, although follow-up prostate biopsy was benign. One day after follow-up biopsy, he presented again with chills and a fever. He was retreated with hydration and intravenous antibiotics. Six days after follow-up biopsy, he complained of double vision in the left gaze as in the previous year. With the diagnosis of post-infection abducens nerve palsy, he was retreated with steroid therapy.     

Shoulder numbness in a patient with suprascapular nerve entrapment syndrome: cutaneous branch of the suprascapular nerve: case report

OBJECTIVE AND IMPORTANCE: The ability to diagnose peripheral nerve disorders is dependent on knowledge of the anatomic course and function of the nerves in question. The classic teaching regarding the suprascapular nerve (SScN) is that it has no cutaneous branches, despite the fact that a cutaneous branch was first reported in the anatomic literature 20 years ago. CLINICAL PRESENTATION: We describe a case of a 35-year-old male patient who presented with right shoulder pain and atrophy and weakness of the right supra- and infraspinatus muscles. During the examination, he was also noted to have an area of numbness involving the right upper lateral shoulder region. Electrical study results were consistent with SScN entrapment at the suprascapular notch. INTERVENTION: The patient underwent surgical decompression 7 months after the onset of his symptoms. The patient noted resolution of his shoulder pain immediately after the procedure, and his shoulder sensory disturbance had improved by 2 weeks. At 9 months after surgery, he remained pain-free, his shoulder sensation was normal, and his motor abnormalities had improved significantly. CONCLUSION: This case provides clinical evidence for the presence of a cutaneous branch of the SScN, as described in cadaveric studies. Although shoulder numbness demands a search for alternative diagnoses, it does not necessarily exclude the diagnosis of SScN entrapment.     

Innovation in neurosurgery: Walter Dandy in his day

In 1925, Walter Dandy published a preliminary report of an innovative operative procedure for patients with tic douloureux. Dandy reported treating tic by selectively sectioning the trigeminal nerve at the brain stem. His operative field was the cerebellopontine angle, which he exposed using a cerebellar approach. It is commonly acknowledged among neurosurgeons that Dandy's technique was overlooked in favor of the Spiller - Frazier procedure during Dandy's lifetime and for at least 15 years after his death. This article examines historically Doctor Dandy's ideas regarding the treatment of tic and evaluates them within the context of the emerging development of the profession of neurological surgery from 1920 to 1945. It documents that his operative approach was accepted and used among an elite group of neurosurgeons. It also discusses political, personal, social, and technological issues that contributed to the overall rejection of the Dandy procedure.     

Posterior interosseous nerve palsy in a man in a lateral position for laparoscopic adrenalectomy--a case report

A 51-year-old man with aldosteronism underwent laparoscopic left adrenalectomy. Anesthesia was induced with fentanyl 0.1 mg, propofol 140 mg and vecuronium 7 mg. Following endotracheal intubation, he was placed in a right lateral position with extension of his left side, and fixed with the Magic Bed. Canulation of the right radial artery was smoothly performed. Anesthesia was maintained with sevoflurane and thoracic epidural anesthesia (mepivacaine and ropivacaine). The operation lasted for 270 minutes and was uneventful. A few hours after surgery, he complained of inability to extend his right fingers without any sensory loss, and the local oppressive pain on his right forearm. Neurological examination revealed a posterior interosseous palsy. Symptoms improved gradually and disappeared completely in two months with the administration of vitamin B12 and physical therapy. Postoperative reproduction of the positioning of this case disclosed that the edge of the Magic Bed might potentially compress the posterior interosseous nerve at the point where the nerve is bifurcated from the radial nerve and travels within the supinator muscle going into the muscle again. This case indicated that we must be careful of nerve injuries due to devices used to maintain the patient in lateral position.     

Among the first: the career of John Henry Evans, MD

During his 46-year career, John Henry Evans, MD, significantly guided anesthesia's evolution from a field dominated by lay practitioners toward one in which the preeminent role was played by physicians. Widely recognized as an expert on supplemental oxygen therapy as well as the developer of subcutaneous oxygen as an adjuvant treatment for several chronic diseases, Evans throughout his years of practice held an academic appointment at the University of Buffalo. From that post he tirelessly employed professional political persuasion, combined with a high order of organizational skill, to help create and expand the importance of residency-trained anesthesiologists. As president of the Associated Anesthetists of the United States and Canada, complemented by a quarter-century tour on the International Anesthesia Research Society's Board of Governors, he significantly contributed to the development of anesthesiology into its current form.     

Reflections on the contributions of Harvey Cushing to the surgery of peripheral nerves

By the time Harvey Cushing entered medical school, nerve reconstruction techniques had been developed, but peripheral nerve surgery was still in its infancy. As an assistant surgical resident influenced by Dr. William Halsted, Cushing wrote a series of reports on the use of cocaine for nerve blocks. Following his residency training and a hiatus to further his clinical interests and intellectual curiosity, he traveled to Europe and met with a variety of surgeons, physiologists, and scientists, who likely laid the groundwork for Cushing's increased interest in peripheral nerve surgery. Returning to The Johns Hopkins Hospital in 1901, he began documenting these surgeries. Patient records preserved at Yale's Cushing Brain Tumor Registry describe Cushing's repair of ulnar and radial nerves, as well as his exploration of the brachial plexus for nerve repair or reconstruction. The authors reviewed Harvey Cushing's cases and provide 3 case illustrations not previously reported by Cushing involving neurolysis, nerve repair, and neurotization. Additionally, Cushing's experience with facial nerve neurotization is reviewed. The history, physical examination, and operative notes shed light on Cushing's diagnosis, strategy, technique, and hence, his surgery on peripheral nerve injury. These contributions complement others he made to surgery of the peripheral nervous system dealing with nerve pain, entrapment, and tumor.     

Die Hypospadie und Infertilität von Heinrich II von Frankreich (1519–1559)

Henry II (1519–1559) of France was the second son of Francis I (1494–1547) and Claude de France (1498–1524) born in 1519 in St. Germain-en-Laye. After his older brother’s and his father’s death in 1547, he was anointed the French king in Reims. In 1533 already, as a 14-year-old boy, for reasons of state, he was married to the same aged Catherine de Medici (1519–1589), as her uncle was Pope Clement VII (1478–1534). The marriage remained childless for 11 years since Henry, due to a distinct hypospadia and a completely sexually inexperienced wife was unable to conceive children with her. His existing liaison to Diane de Poitiers (1499–1566) – a 19-year-older maid of honor of his father Francis I from 1537 until his death – influenced his sexual life immensely. The blame for the childless marriage was placed primarily on his wife, as Henry had become father of an illegitimate daughter with a mistress. Catherine then underwent all possible medical and alchemical procedures to finally give birth to the hoped Dauphin. Ironically, her rival for the favor of her husband, Diane de Poitiers was one of her greatest allies. She made clear that the cause lay with Henry and not with his wife. This was confirmed by the added solid physician Jean Fernel (1497–1558). His treatment of Henry and the simultaneous training of the unexperienced Catherine by Diane de Poitiers led to success. The result was the birth of Francis II (1544–1560) in 1544, the first of 10 children in 12 years. Thus, the dynasty was saved. After the death of Henry in a tragic tournament accident in 1559, three of his sons became kings of France. But the line of Valois remained without further descendants and was continued by Henry IV, the first Bourbon king in 1589.     

Chloroform for the King? Joseph Clover, Henry Thompson and the King of the Belgians

In May 1863 the British surgeon, Henry Thompson, departed for Belgium to attend Leopold, King of the Belgians. The King was in agony: he had suffered with bladder stones for months and multiple procedures, without anaesthesia, had failed to relieve his symptoms. Henry Thompson was therefore consulted about the possibility of operating under the influence of chloroform. He could see no objection if the chloroform were given by an experienced administrator such as Mr Clover "who indeed was generally believed at that day to have no equal". History records that the successful operation was performed under chloroform anaesthesia administered by Joseph Clover. But a letter from Henry Thompson, discovered in Clover's personal papers, raises a number of questions about this operation. This was the procedure that made Henry Thompson rich and famous, but was it actually performed under anaesthesia? And if not, why not?     

Division of the median nerve at the carpal tunnel caused by a high-pressure injection injury of the hand: a case report

We describe a patient who was injected water into the palm of his left hand. He injured the median nerve at the carpal tunnel. The injected water did not cause serious damage to the soft tissue, but caused the division of the median nerve brought about serious pain and sensory and motor disturbance. The patient was taken to the operating room to undergo a nerve graft operation on the same day. Two years after the injury, numbness was reduced his index, middle, and ring fingers up to the distal interphalangeal joint. Except for thumb abduction, we did not observe contracture of the joints of his left hand. The strength of his grip was 47?kg in the right hand and 42?kg in the left hand. His ability to make a perfect O improved from the previous year. His thenar muscle remained slightly atrophied. He still could not support anything with his left hand, but he no longer felt hindered in his work since he was accustomed to his work.     

Henry Woltman (1889-1964): pioneering American neurologist

Henry Woltman became the first neurologist at the Mayo Clinic in Rochester, Minnesota at a time when there were few practitioners working full-time in this field in North America. The remarkable growth in the neurology section at Mayo mirrored the expansion that occurred in the Mayo Clinic in the early 20th century. His leadership was instrumental in establishing neurology as a viable specialty, distinct from psychiatry and aligned more closely with internal medicine. The distinctive features he instituted included an original scoring and notation system, and a close collaboration with neurosurgery. He is also remembered for Woltman's sign, the finding of slow relaxation of the muscle when the tendon reflex is elicited in hypothyroidism.     

A complete relief of intractable postherpetic neuralgia with intrathecal methylprednisolone acetate

A 72-year-old man, 154 cm tall, weighing 53 kg was suffering from severe herpetic neuralgia on his left 10th intercostal nerve area. His pain continued even he was treated with frequent epidural nerve block (4 to 5 times per week) by an anesthesiologist. He was referred to our hospital on his 105th pain day. He complained severe continuous pain and numbness on his left 10th intercostal nerve area. Touching the painful skin induced lightning pain. His pain was so severe that his sleeping was disturbed and also he could not maintain his usual life. Epidural nerve block at 10th thoracic nerve was done with 20mg methylprednisolone acetate and 5ml of 1% lidocaine. After the treatment, his pain was reduced to 3/10 of the one he had on admission, and also his sleep was not disturbed further. Epidural nerve blocks with methylprednisolone weekly for a month induced no more remission. At his 154th pain day, a dose of 20mg methyl prednisolone acetate and 1% lidocaine 5ml was given intrathecally through 2nd lumber intervertebral space. The pain was relieved completely after the block. And he complained nothing about the skin area which had been disturbing his life for a long time. Auditory brainstem response which was recorded during the block showed prolongation of the latency of phase III and phase V at 40 minutes after the intrathecal injection of lidocaine.     

Intrathoracic vagus nerve neurofibroma and sudden death in a patient with neurofibromatosis.

A 21 year old man with type 1 neurofibromatosis was found dead in the middle of the night. Postmortem examination revealed a large neurofibroma arising from the right intrathoracic vagus nerve, which might have contributed to his sudden death.     

Clinical analysis and outcomes of amyotrophic lateral sclerosis with demyelinating polyneuropathy

Abnormalities of both motor and sensory nerve action potentials, similar to those found in demyelinating polyneuropathy, may occur in patients with amyotrophic lateral sclerosis (ALS). We analyzed the clinical features of unusual ALS patients with demyelinating polyneuropathy (DPN) to delineate the characteristics and outcomes of this rare condition. We reviewed three ALS patients with DPN who were confirmed to meet the electrophysiological nerve conduction criteria for DPN among 157 patients with ALS. At the initial neurological examination, one patient had both subjective sensory symptoms and abnormal results of sensory examinations, and one patient had sensory symptoms. Motor weakness of the limbs was present in all patients, and fasciculation was present in two patients. Anti-GalNAc-GD1a IgG antibodies were evident in one. Sural nerve biopsy showed a moderate, marginal reduction in myelin thickness, and teased fiber analysis revealed segmental demyelination and remyelination, but axonal degeneration was found in one patient. The mean interval from disease onset to respiratory failure or death in our three patients and seven previously documented ALS patients with DPN was 43.1 ± 18.7 months. Our findings suggest that survival in ALS with DPN is similar to that in classic ALS.     

Thoracic intramedullary neurinoma with multiple intracranial meningiomas; case report]

A 42-year-old man suffered from numbness in his right leg in May, 1989, and was admitted to another hospital for examination. Computed tomography and magnetic resonance imaging revealed thoracic intramedullary tumor and multiple intracranial tumors in the right frontal convexity, the right lower surface of the tentorium and the right parietal parasagittal region. In December, he underwent craniotomy and the right frontal tumor was totally removed. It was diagnosed histologically as meningioma. Because of continuing numbness in his right leg, he visited a neurologist at our university and was referred to us for removal of the spinal tumor on April 25, 1990. Neurological examination on admission revealed mild weakness of his right leg and exaggerated right knee jerk. Though he complained of numbness in his right leg, no sensory disturbance was demonstrated objectively. His bladder-bowel function was normal. There were no café au lait spots or subcutaneous neurofibromas. He and his mother were positive for anti-HTLV-1 (human T-lymphotrophic virus type 1) antibody. On May 1, laminectomy was performed at Th-7 to Th-9, and a yellowish brown tumor was found occupying the right posterolateral portion of the cord and extending to the surface. The dorsal root of Th-9, which was involved in the tumor, was cut and the tumor was subtotally removed. Histological examination showed interlacing bundles of spindle cells and loose areolar region. Immunohistochemically, the tumor was positive for S-100 protein and negative for GFAP. From these findings, the tumor was diagnosed as neurinoma. The postoperative course was uneventful, numbness disappeared, and the patient was discharged without neurological deficits.     

A case of schwannoma of intrathoracic right phrenic nerve

A 22-year old man was admitted because of an abnormal shadow on his chest X-ray film. Radiographic findings revealed that the tumor was located in the right middle mediastinum. At operation a smooth round tumor was found arising from the right phrenic nerve. The tumor was removed with phrenic nerve. Pathohistological examination revealed this tumor was benign schwannoma. Intrathoracic schwannoma usually arise from intercostal and sympathetic nerve and that arising from phrenic nerve is very rare. We removed the tumor by means of cutting his right phrenic nerve because of complete resection. Postoperatively he did well without any respiratory distress. And his respiratory function studies recovered normal 9 months after the operation. We think that schwannoma arising from phrenic nerve should be removed completely and in such a case cutting of the one side phrenic nerve is at ease if the patient have normal respiratory function.     

Intraoperative monitoring of ulnar nerve function during replacement of the rheumatoid elbow via the lateral approach

Neurography of the ulnar nerve was performed pre-, intra- and postoperatively in 8 arms of 7 patients with rheumatoid arthritis operated on with total elbow replacement via the lateral approach. Ulnar nerve decompression was performed in 4 elbows before implantation. A reduction in the amplitude of compound muscle action potential (CMAP) recorded from the abductor digiti minimi on stimulation of the ulnar nerve in the axilla, was observed during elbow dislocation at surgery in all patients, in 5 cases transiently and in 3 cases until the end of surgery. The ulnar nerve had been decompressed in all patients with lasting amplitude reduction. One of them had a mild sensory ulnar nerve palsy, while the other 2 had normal nerve function at the postoperative clinical examination. All 3 had a reduction in the amplitude of compound sensory nerve action potential (SNAP) and 2 of them also in CMAP amplitude at the postoperative neurographic examination. In patients with transient reduction during surgery, the CMAP amplitude quickly normalized on relocation of the elbow and both the SNAP and the CMAP were preserved at the postoperative neurographic examination. The authors conclude that dislocation of the laterally approached elbow carries a risk of ulnar nerve injury, which is not prevented by decompression of the ulnar nerve, but frequent relocation of the elbow during surgery seems important. It is suggested that the ulnar nerve should not be decompressed routinely, and that the dislocated elbow should be frequently relocated.     

Acute transverse myelitis with urinary retention due to mycoplasma pneumoniae infection: a case report

We report a case of urinary retention complicated with acute transverse myelitis caused by Mycoplasma pneumoniae. A 16-year-old man visited a clinic because of urinary retention, fever, muscle weakness and sensory disturbance of lower extremities. He was referred to our hospital for further examination. He was diagnosed with acute transverse myelitis due to M. pneumoniae infection based on cerebrospinal fluid examination, serum titer of antibody to M. pneumoniae and magnetic resonance imaging. He was treated with corticosteroids for acute myelitis. A urethral catheter was indwellt for urinary retention. His muscle strength and sensory of lower extremities improved after 2 months of treatment, and he was discharged from our hospital. However, since urinary frequency, urge incontinence and weak urinary stream persisted, he was referred to us for further examination. A pressure-flow study examination showed a decreased maximum urinary flow rate and the findings of detrusor sphincter dyssnergia. We diagnosed him with uninhibited bladder and detrusor sphincter dyssnergia. We administered propiverine hydrochloride and imipramine hydrochloride, and his symptoms subsided significantly. Now, (8 months) after this medication, he still has incontinence at night.     

Intraoperative monitoring of ulnar nerve function during replacement of the rheumatoid elbow via the lateral approach

Neurography of the ulnar nerve was performed pre-, intra- and postoperatively in 8 arms of 7 patients with rheumatoid arthritis operated on with total elbow replacement via the lateral approach. Ulnar nerve decompression was performed in 4 elbows before implantation. A reduction in the amplitude of compound muscle action potential (CMAP) recorded from the abductor digiti minimi on stimulation of the ulnar nerve in the axilla, was observed during elbow dislocation at surgery in all patients, in 5 cases transiently and in 3 cases until the end of surgery. The ulnar nerve had been decompressed in all patients with lasting amplitude reduction. One of them had a mild sensory ulnar nerve palsy, while the other 2 had normal nerve function at the postoperative clinical examination. All 3 had a reduction in the amplitude of compound sensory nerve action potential (SNAP) and 2 of them also in CMAP amplitude at the postoperative neurographic examination. In patients with transient reduction during surgery, the CMAP amplitude quickly normalized on relocation of the elbow and both the SNAP and the CMAP were preserved at the postoperative neurographic examination. The authors conclude that dislocation of the laterally approached elbow carries a risk of ulnar nerve injury, which is not prevented by decompression of the ulnar nerve, but frequent relocation of the elbow during surgery seems important. It is suggested that the ulnar nerve should not be decompressed routinely, and that the dislocated elbow should be frequently relocated.