Nerve lesions in proximal humeral fractures

In the literature nerve injury is not frequently considered a problem in proximal humeral fractures. Only a few studies exist concerning traction injury of nerves in fractures of the proximal humerus after low-velocity trauma. Almost all of them are retrospective and did not use electromyography. Patients with identical fractures can show quite different outcomes, which vary between complete recovery and severely limited shoulder function. On the assumption that nerve lesions can play a role in the recovery of conservatively and operatively treated proximal humeral fractures, we started a prospective follow-up study with electromyographic investigation. For this study, 143 consecutive proximal humeral fractures due to low-velocity trauma were included. According to the Neer classification, 93 were nondisplaced and 50 were displaced fractures. Denervation on the electromyogram was found in 96 patients (67%). The nerves most frequently involved were the axillary nerve (83 [58%]) and the suprascapular nerve (69 [48%]). Frequently a combination of nerve lesions was seen. Nerve lesions were much more frequent in displaced fractures (82% [41/50]) than in nondisplaced fractures (59% [55/93]). Complicating nerve lesions in patients older than 20 years of age were seen in about the same percentage of patients per decade. Nerve injury and the corresponding loss of muscle strength recovered well in all patients; however, the duration of the recovery was prolonged in cases with nerve lesions. Restoration of the function of the shoulder was less favorable. It is important to realize that, in both conservative and operative treatment of proximal humeral fractures, a paresis due to nerve injury can affect the restoration of shoulder motions. An electromyogram can be useful in the investigation of nerve lesions, because detection only by clinical examination proved to be very difficult. Because of the favorable electrophysiological recovery, no indication for exploration of nerve lesions was present in this series of fractures due to low-velocity trauma.     

Elusive tumor of the cauda equina. Case report

A patient with a mobile schwannoma of the cauda equina is described. There was considerable discrepancy between the localization of the tumor at myelography and the findings at both initial surgery and repeat myelography, confirmed by definitive surgery. Such mobility is rare, but should be kept in mind when surgery is performed for a tumor of the cauda equina.     

Cerebellar atrophy due to chronic bromisovalum abuse demonstrated by computed tomography.

Two patients with a severe cerebellar syndrome due to chronic bromisovalum usage are described. In both patients CT scan revealed severe cerebellar atrophy. The value of computed tomography in detecting irreversible cerebellar lesions due to bromisovalum is discussed.     

Ultrasound-guided steroid injection to treat mild ulnar neuropathy at the elbow

There exists no "gold standard" in the treatment of ulnar neuropathy at the elbow (UNE). We treated 7 patients with mild UNE using a local steroid injection with ultrasonographic monitoring. At clinical follow-up after 6 weeks, 4 patients had improved, 2 were stable, and 1 reported an increase in symptoms. Ultrasound-guided steroid injection in mild UNE is safe and could be effective. Further investigation is needed to prove its efficacy.     

Can sidestream dark field (SDF) imaging identify subtle microvascular changes of the bowel during colorectal surgery?

Background

Recognition of a non-viable bowel during colorectal surgery is a challenging task for surgeons. Identifying the turning point in serosal microcirculatory deterioration leading up to a non-viable bowel is crucial. The aim of the present study was to determine whether sidestream darkfield (SDF) imaging can detect subtle changes in serosal microcirculation of the sigmoid after vascular transection during colorectal surgery.

Methods

A prospective observational clinical study was performed at a single medical centre. All eligible participants underwent laparoscopic sigmoid resection and measurements were taken during the extra-abdominal phase. Microcirculation was measured at the transected bowel and 20 cm proximal to this point. Microcirculatory parameters such as Microvascular Flow Index (MFI), proportion of perfused vessels (PPV), perfused vessel density (PVD), total vessel density (TVD) and the Heterogeneity Index were determined. Data are presented as median (interquartile range) or mean?±?standard deviation.

Results

A total of 60 SDF images were acquired for 10 patients. Perfusion parameters and perfused vessel density were significantly lower at the transected bowel compared with the non-transected measurements [MFI 2.29 (1.96–2.63) vs 2.96 (2.73–3.00), p?=?0.007; PPV 74% (55–83) vs 94% (86–97), p?=?0.007; and PVD 7.61?±?2.99 mm/mm² versus 10.67?±?1.48 mm/mm², p?=?0.009]. Total vessel density was similar between the measurement locations.

Conclusions

SDF imaging can identify changes of the bowel serosal microcirculation. Significantly lower serosal microcirculatory parameters of the vascular transected bowel was seen compared with the non-transected bowel. The ability of SDF imaging to detect subtle differences holds promise for future research on microvascular cut-off values leading to a non-viable bowel.

     

Interobserver variation in the interpretation of SSEPs in anoxic-ischaemic coma.

OBJECTIVE: To study interobserver variation in the interpretation of median nerve SSEPs in patients with anoxic-ischaemic coma. METHODS: SSEPs of 56 consecutive patients with anoxic-ischaemic coma were interpreted independently by 5 experienced clinical neurophysiologists using guidelines derived from a pilot study. Interobserver agreement was expressed as kappa coefficients. RESULTS: Kappa ranged from 0.20 to 0.65 (mean 0.52, SD 0.14). Disagreement was related with noise level and failure to adhere strictly to the guidelines in 15 cases. The presence or absence of N13 and cortical peaks caused disagreement in 5 cases each. For recordings with a noise level of 0.25 microV or more, mean kappa was 0.34; for recordings with a noise level below 0.25 microV mean kappa was 0.74. CONCLUSIONS: Interobserver agreement for SSEPs in anoxic-ischaemic coma was only moderate. Since the noise level strongly influenced interobserver variation, utmost attention should be given to its reduction. If an artefact level over 0.25 microV remains, absence of N20 cannot be judged with sufficient certainty and the SSEP should be repeated at a later stage. SIGNIFICANCE: Because of its moderate interobserver agreement, great care has to be given to accurate recording and interpretation of SSEPs before using the recordings for non-treatment decisions.