Iatrogenic accessory nerve injury.

Accessory nerve injury produces considerable disability. The nerve is most frequently damaged as a complication of radical neck dissection, cervical lymph node biopsy and other surgical procedures. The problem is frequently compounded by a failure to recognise the error immediately after surgery when surgical repair has the greatest chance of success. We present cases which outline the risk of accessory nerve injury, the spectrum of clinical presentations and the problems produced by a failure to recognise the deficit. Regional anatomy, consequences of nerve damage and management options are discussed. Diagnostic biopsy of neck nodes should not be undertaken as a primary investigation and, when indicated, surgery in this region should be performed by suitably trained staff under well-defined conditions. Awareness of iatrogenic injury and its consequences would avoid delays in diagnosis and treatment.     

Patient self-reported outcome after ulnar nerve transposition

Subjective outcome was assessed in 100 patients with cubital tunnel syndrome at least 2 years after anterior transmuscular transposition of the ulnar nerve. The mean time from surgery was 37 months (standard deviation, 10 months). The patient sample of 119 operated cases included 81 unilateral procedures and 19 patients had bilateral procedures. The mean time between surgeries was 7 months. Sixty-one patients who underwent unilateral procedures reported improvement, and there was no difference in 13 unilateral cases. Thirteen patients who underwent bilateral procedures reported improvement in both arms. Postoperatively symptoms were significantly less than those preoperatively: pain, p = 0.001; cold sensitivity, p = 0.001; tingling, p = 0.05; and numbness p = 0.08. In 51 cases, patients reported normal sensation and in 45 cases patients reported normal strength. Reported outcome was significantly better in nonsmokers than in smokers (p = 0.02) but was not significantly different in patients with workers' compensation/litigation (p = 0.51), obesity (p = 0.16), abnormal preoperative nerve conduction studies (p = 0.21), concomitant carpal tunnel syndrome (p = 0.95), or brachial plexus nerve compression (p = 0.35).     

Patient outcome after common peroneal nerve decompression

OBJECT: This study examines common peroneal nerve decompression and its effect on nerve function. METHODS: Fifty-one peroneal nerve decompressions were retrospectively reviewed. All patients were evaluated preoperatively and postoperatively for motor and sensory function of the peroneal nerve as well as for pain. RESULTS: Postoperatively, 40 (83%) of 48 patients who had preoperative motor weakness had improvement in motor function. Likewise, 23 (49%) of 47 patients who had sensory disturbances and 26 (84%) of 31 patients who had preoperative pain improved after surgical decompression of the peroneal nerve. CONCLUSIONS: Common peroneal nerve decompression is a useful procedure to improve sensation and strength as well as to decrease pain.     

The surgical management of facial nerve injury

Treatment of facial nerve injuries depends upon a detailed understanding of its anatomic course, accurate clinical examination, and timely and appropriate diagnostic studies. Reconstruction depends upon the extent of injury, the availability of the proximal stump. and the time since injury and duration of muscle denervation. Although no alternative is perfect, these techniques, in combination with static and ancillary procedures. can protect the eye, prevent drooling, restore the smile, and improve facial symmetry. New techniques (including single-stage free tissue transfers and bioengineered nerve grafts), further research on the characteristics of the facial musculature, and methods of preserving the neuromuscular junction will undoubtedly manifest themselves as further refinements of established surgical techniques.     

Spinal accessory nerve injury

Injury to the spinal accessory nerve can lead to dysfunction of the trapezius. The trapezius is a major scapular stabilizer and is composed of three functional components. It contributes to scapulothoracic rhythm by elevating, rotating, and retracting the scapula. The superficial course of the spinal accessory nerve in the posterior cervical triangle makes it susceptible to injury. Iatrogenic injury to the nerve after a surgical procedure is one of the most common causes of trapezius palsy. Dysfunction of the trapezius can be a painful and disabling condition. The shoulder droops as the scapula is translated laterally and rotated downward. Patients present with an asymmetric neckline, a drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination. If diagnosed within 1 year of the injury, microsurgical reconstruction of the nerve should be considered. Conservative treatment of chronic trapezius paralysis is appropriate for older patients who are sendentary. Active and healthy patients in whom 1 year of conservative treatment has failed are candidates for surgical reconstruction. Studies have shown the Eden-Lange procedure, in which the insertions of the levator scapulae, rhomboideus minor, and rhomboideus major muscles are transferred, relieves pain, corrects deformity, and improves function in patients with irreparable injury to the spinal accessory nerve.     

Iatrogenic injury to the accessory nerve.

We describe two patients with uncommon causes of iatrogenic injuries and review the anatomy, presentation, possibilities of repair, and results. The incidence of such nerve injuries during lymph node biopsies is 3%-10%, but the diagnosis is often delayed. Symptoms are shoulder pain and inability to abduct the arm beyond the horizontal plane. Surgical repair may improve function and pain and should be performed early, preferably within six months, but prevention of nerve injury is most important.     

Peripheral nerve injuries: principles of surgical management and outcome

The author reviews the neuroanatomical and physiological principles underlying surgical repair of injured peripheral nerves. Current surgical techniques are presented and the need for a comprehensive scale of assessment of neurologic recovery is emphasized.     

Continuation of poor surgical outcome after elderly brain injury

BACKGROUND: In spite of the decline in mortality among trauma patients, with advanced trauma care, the outcome for elderly patients remains poor. Both operative and nonoperative outcome for elderly patients after head trauma has resisted improvement. METHODS: Forty-five consecutive patients 70 years or older were included in the study. All these patients were admitted from January 2000 to June 2005. Road-traffic accidents caused most of the head injuries. RESULTS: Most of the patients (n = 33) belonged to severe head injury category. Contusions were the commonest CT scan finding (n = 27), for which surgery was indicated. Unexplained clinical deterioration, in spite of timely surgery and satisfactory postoperative CT scans, in a significant number of patients (n = 29) was noteworthy. Over the same period, the comparative group of younger patients (20-40 years, n = 1026) was also analyzed. CONCLUSION: Elderly patients experienced higher mortality and poorer functional outcome. The natural history of traumatized brain among elderly patients remains unchanged till the present times. The nihilistic scenario asks for reevaluation of interventions, relook into the neurobiology of aging brain, and aggressive research for remedial measures for such patients, especially among severe head injury group.     

Surgical treatment for spinal accessory nerve injury

We report on the surgical results of spinal accessory nerve injuries between 1992-2003. We operated on 10 patients (9 female, and 1 male) who had injuries of the spinal accessory nerve. All injuries were iatrogenic. The mean age of patients was 39.2 years (range, 20-57 years). The average interval between date of injury and surgery was 7 months (range, 4-12 months). All patients had stiffness and pain in the shoulder girdle. The average active abduction of the shoulder joint was 79.5 degrees (range, 60-100 degrees ) before surgery. End-to-end repairs were performed in 7 cases, and graft repairs were indicated in 3 cases. The mean follow-up period was 18.4 months (range, 8-36 months). The average active abduction of the shoulder joint was 171 degrees (range, 140-180 degrees ) at time of final follow-up.     

Iatrogenic spinal accessory nerve injury in children

Injury to the spinal accessory nerve in the posterior triangle of the neck results in trapezius paralysis and shoulder dysfunction. The most common etiology is iatrogenic and has been reported extensively in adults. We report 3 cases of spinal accessory nerve injury recognized postoperatively in children and discuss the microsurgical treatment, results, and simple strategies to avoid this complication.     

Treatment outcome after surgical management of osseous breast carcinoma metastases. Preventive stabilization vs. management after pathological fracture

AIM OF THE STUDY, METHOD: The advantages of a prophylactic care of fracture-endangered, osseous metastasis of the mammary cancer stand opposite to the perioperative risk and to conservative alternatives. As a pathologic fracture cannot surely be excluded while performing a conservative proceeding, a retrospective trial was set up to compare the results of treatment after a pathologic fracture (n = 35) with those undergoing a prophylactic attendance (n = 44). RESULTS: The intraoperative, cardio-pulmonary complications were distributed in balance totally amounting to 20.3% (n = 16). Intraoperative complications concerning surgical procedure (n = 3) exclusively occurred within the fracture group. Generally, postoperative complications arose in 20.3% (n = 16) of all cases, in which the patients belonging to the fracture group were increasingly afflicted [28.6% (n = 11/35) vs. 11.4% (n = 5/44); p < 0.02]. While there were no differences between both groups concerning the postoperative, surgery-technical complications, significantly more patients (91.8% [n = 40/44]) of the prophylactic-care group achieved a complete postoperative usability of the operated area than in the fracture-group [74.3% (n = 26/35)] (p < 0.05). The average survival time tended to be longer within the prophylactic-care group [19.3 +/- 15.6 month (prophylactic-care group) vs. 15.0 +/- 16.9 month (fracture group)]. CONCLUSIONS: The prophylactic treatment of fracture endangered, osseous metastasis of the mammary cancer leads to reduction of the general, postoperative complications compared to the patients with a pathologic fracture. Further, those patients have a better chance to recover full mobility after surgery. Considering the long survival time after the incidence of osseous metastasis at the mammary cancer a prophylactic treatment represents the method of first choice compared with the conservative treatment which persistently contains the risk of fracturing.     

Reconstruction of spinal accessory nerve after radical neck dissection.

Resection of the spinal accessory nerve in cases of radical neck dissection often causes considerable damage to the function of the shoulder girdle; it leads to limitation of the motion of the upper limb and pain in the shoulder girdle. It seems a sensible compromise to reconstruct the spinal accessory nerve in one-stage operation with radical neck dissection, which can often prevent extensive atrophy of the trapezius muscle, with a resultant improvement in the chance of successful rehabilitation. The technique of the operation is described: after completion of radical neck dissection, in one-stage operation an autogenous nerve transplant from the n. auricularis magnus is sewn onto the central and peripheral stumps of the spinal accessory nerve, which are protected by a "vein-muff" and the fascia of the muscle. After such spinal accessory nerve reconstruction, subjective complaints and objective symptoms were much milder in 6 patients than in the control group, which consisted of 10 patients who underwent a similar operation but without spinal accessory nerve reconstruction.