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Background Clinical and electrophysiological assessments prevail in evaluation of traumatic nerve lesions and their regeneration following nerve surgery in humans. Recently, high-resolution neurosonography (HRNS) and magnetic resonance neurography have gained significant importance in peripheral nerve imaging. The use of the grey-scale-based "fascicular ratio" (FR) was established using both modalities allowing for quantitative assessment. Objective To find out whether FR using HRNS can assess nerve trauma and structural reorganization in correlation to postoperative clinical development. Methods Retrospectively, 16 patients with operated traumatic peripheral nerve lesions were included. The control group consisted of 6 healthy volunteers. All imaging was performed with a 15 to 6 MHz ultrasound probe (SonoSite X-Porte; Fujifilm, Tokyo, Japan). FR was calculated using Fiji () on 8-bit-images ("MaxEntropy" using "Auto-Threshold" plug-in). Results Thirteen of 16 patients required autologous nerve grafting and 3 of 16 extra-intraneural neurolysis. There was no statistical difference between the FR of nonaffected patients' nerve portion with 43.48% and controls with FR 48.12%. The neuromatous nerve portion in grafted patients differed significantly with 85.05%. Postoperatively, FR values returned to normal with a mean of 39.33%. In the neurolyzed patients, FR in the affected portion was 78.54%. After neurolysis, FR returned to healthy values (50.79%). Ten of 16 patients showed clinical reinnervation. Conclusion To our best knowledge, this is the first description of FR using HRNS for quantitative assessment of nerve damage and postoperative structural reorganization. Our results show a significant difference in healthy vs lesioned nerves and a change in recovering nerve portions towards a more "physiological" ratio. Further evaluation in larger patient groups is required.

Background The surgical treatment of spontaneous posterior interosseous nerve (PIN) palsy with hourglass-like fascicular constriction (HLFC) remains controversial. Objective To review 41 patients with complete spontaneous PIN palsy with HLFC to clarify the necessity and choice of surgery. Methods Interfascicular neurolysis (NY), neurorrhaphy, and autografting were performed on 10, 8, and 6 patients, respectively. The thinning extent of a nerve fasciculus ≤0.25, 0.25 to 0.75, and ≥0.75 was defined as mild, moderate, and severe constriction, respectively. Final British Medical Research Council muscle power grade ≥4 was defined as good recovery. Results Ultrasound showed the number, location, and thinning extent of HLFC of PIN well, with results that were highly consistent with intraoperative measurements. Of the 17 conservatively treated patients, 13 recovered well. Of the 24 surgically treated patients, 20 recovered well. For NY, 8 patients with mild to moderate PIN constriction recovered well, but 2 patients with severe PIN constriction recovered poorly. For 16 patients with severe HLFC, 12 of 14 patients who underwent neurorrhaphy or autografting recovered well; the surgical effects were much better than those of 2 patients who had undergone NY. Conclusion Ultrasound is a helpful diagnostic technique for spontaneous PIN palsy with HLFC. Surgery is necessary for PIN constriction if conservative treatments fail. Surgical choices depend largely on the thinning extent of the PIN constriction and the age of the patients. The outcomes of patients aged ≥50 years were much worse. We suggest NY for mild to moderate, and neurorrhaphy or autografting for severe PIN constriction.

Background The development of an hourglass-like constriction in the nerve is rare, and its origin is unknown. Its clinical manifestations are not well documented, and the treatment protocol has not been established. Objective To identify the cause, presentation, and possible treatment for patients with nerve palsies secondary to an hourglass-like constriction in the affected nerves. Methods Patients presenting with peripheral nerve palsy caused by an hourglass-like constriction of nerves were retrospectively investigated in 2 hand centers. The patients' presentation and neurological findings were reviewed, and the immunohistochemistry of excised specimens was studied. Results Forty-two patients who presented with 47 nerve palsies were examined. Forty-one patients experienced a sudden onset of pain in the upper limb, followed by flaccid paralysis in the affected muscles. Ten patients had multiple nerve involvement. Surgical exploration found 1 or more hourglass-like constrictions in the nerve. The treatments included internal neurolysis, neurorrhaphy, and nerve grafting. Thirty-one of 42 patients (36 nerves) were followed up for a mean of 48 months (range, 8-157 months). Fifteen of 16 nerves treated by neurolysis, 10 of 13 nerves treated by neurorrhaphy, and 4 of 7 nerves treated by nerve grafting had good recovery. CD8-positive T-lymphocyte infiltration was observed in all the excised specimens. Conclusion The clinical presentation of patients with hourglass-like constrictions in their nerves is similar to that of patients with neuralgic amyotrophy. Histochemical analysis suggests that the pathogenesis may be immunological in origin. The role of surgery in this condition is uncertain.

OBJECTIVE: To provide an overview of iatrogenic sciatic nerve injuries at the buttock and thigh levels, and to analyze results of the treatment provided at Louisiana State University Health Sciences Center-New Orleans. METHODS: The data from 196 patients were reviewed retrospectively. All patients had iatrogenic sciatic nerve injuries at the buttock and thigh levels and were evaluated and treated at the Louisiana State University Health Sciences Center between the years 1968 and 1999. One hundred sixty-four of these patients had injuries caused by injections at the buttock level, 15 sustained sciatic nerve injuries after a total hip arthroplasty, and 17 had iatrogenic damage at the thigh level. RESULTS: Patients with severe motor deficits underwent neurolysis if they had positive nerve action potentials, and end-to-end anastomosis or grafting if the nerve action potentials were negative. Operations were performed on 64 patients with injection injuries at the buttock level, on 15 with iatrogenic damage at the thigh level, and on 15 with deficits after total hip arthroplasty. Results were analyzed by the procedure performed and by the outcome in both the peroneal and tibial divisions. CONCLUSION: Patients with mild or no motor deficits and those with pain that was manageable did not undergo surgery and were treated conservatively. For patients with significant motor deficits and those with pain that was not responsive to pharmacological management, physical and occupational therapy required surgical intervention. Patients who had positive nerve action potentials required neurolysis only and had the best recovery, whereas those with negative nerve action potentials required more extensive intervention entailing reanastomosis or grafting and had worse outcome. In general, the outcome was better for the tibial than for the peroneal divisions, regardless of the type of intervention.

OBJECTIVE: Data from three Louisiana State University Health Sciences Center (LSUHSC) publications were summarized for median, radial, and ulnar nerve injuries. METHODS: Lesion types, repair techniques, and outcomes were compared for 1837 upper-extremity nerve lesions. RESULTS: Sharp laceration injury repair outcomes at various levels for median and radial nerves were equally good (91 % each) and better than those for the ulnar nerve (73%). Secondary suture and graft repair outcomes were better for the median nerve (78% and 68%, respectively) than for the radial nerve (69% and 67%, respectively) and ulnar nerve (69% and 56%, respectively). In-continuity lesions with positive nerve action potentials during intraoperative testing underwent neurolysis with good results for the median (97%), radial (98%), and ulnar nerves (94%). For radial, median, and ulnar nerve in-continuity lesions with negative intraoperative nerve action potentials, good results occurred after suture repair in 88%, 86%, and 75% and after graft repair in 86%, 75% and 56%, respectively. CONCLUSION: Good outcomes after median and radial nerve repairs are attributable to the following factors: the median nerve's innervation of proximal, large finger, and thumb flexors; and the radial nerve's similar innervation of proximal muscles that do not perform delicate movements. This is contrary to the ulnar nerve's major nerve supply to the distal fine intrinsic hand muscles, which require more extensive innervation. The radial nerve also has a motor fiber predominance, reducing cross-motor/sensory reinnervation, and radial nerve-innervated muscles perform similar functions, decreasing the chance of innervation of muscles with opposite functions.

OBJECTIVE: With the use of data from 3 Louisiana State University Health Sciences Center (LSUHSC) publications, various parameters for buttock/thigh-level sciatic nerve and tibial and common peroneal divisions/nerve injuries were summarized, and outcomes were compared. METHODS: Data from 806 buttock/thigh-level sciatic nerve and tibial and common peroneal division/nerve injury repairs were summarized. Lesion types, repair tech - niques, and outcomes were compared. RESULTS: Acute lacerations undergoing suture repair were best for the thigh-then-buttock-level tibial (93%/73%) and then same-level common peroneal divisions (69%/30%); at the knee level, tibial outcomes (100%) were better than those for the common peroneal nerve (CPN) (84%). Secondary graft repairs for lacerations had good outcomes for the thigh-then-buttock-level tibial (80%/62%), followed by common peroneal divisions at the same levels (45%/24%). The knee/leg-level tibial nerve (94%) did better than the CPN (40%) here. In-continuity lesions with positive intraoperative nerve action potentials underwent neurolysis with better results for the thigh-then-buttock-level tibial division (95%/86%) than for same-level CPN (78%/69%). The knee/leg-level tibial nerve did better than the CPN (95%/93%). CONCLUSION: Better recovery of buttock- and thigh-level tibial division/nerve occurs because: 1) the CPN is lateral and thus vulnerable to a more severe injury; 2) the tibial nerve is more elastic at impact owing to its singular-fixation site (the CPN has a dual fixation); 3) the tibial nerve has a better blood supply and regeneration; 4) the tibial nerve has a higher force-absorbing fascicle/connective tissue count than the CPN; and 5) the tibial nerve-innervated gastrocnemius soleus requires less reinnervation for functional contraction than deep peroneal branches, which innervate long, thin extensor muscles at multiple sites and require coordinated nerve input for effective contraction.

OBJECTIVE: To analyze retrospectively the outcomes of primary as well as secondary functional reconstructions in 49 patients with traumatic brachial plexus lesions from a single service. Guidelines for treatment might be extracted from this analysis. METHODS: Among 152 cases of traumatic lesion of the brachial plexus presented to our clinic, 58 underwent primary brachial plexus reconstructive surgery. On exploration, all patients showed stretching and scarring of plexus elements; root avulsions were found in 28 patients (48%). Outcome evaluation was carried out in 49 of these patients with a follow-up period of 1 year or longer (mean follow-up, 27.9 mo; range, 12-72 mo). A total of 43 secondary reconstructive procedures to improve functionality of the involved arm were performed at a later stage in 25 of 58 patients. Outcomes of the secondary functional restorative procedures were evaluated (mean follow-up, 11.5 mo; range, 3-60 mo in 43 procedures). RESULTS: Patients with neurolysis as a stand-alone procedure (11 patients) showed an outcome grade of 4 or 5. The average outcome of the 19 patients with C5, C6, and C7 grafting was Grade 3, the same as in patients with nerve transfers to the upper plexus elements (C5-C6 root avulsions, 13 patients). Patients with multiple root avulsions (five cases) showed an overall poor outcome (Grades 0-2). Secondary functional restorative surgery was performed in 43% of the patients and helped improve individual outcomes, providing a favorable effect on the general functionality of the arm. Among the restorative operations performed, the Steindler procedure, wrist extension restoration, claw hand correction, and free functional muscle flap transfer to the arm and forearm were the most rewarding. CONCLUSION: A combination of primary brachial plexus reconstruction and carefully evaluated, selected, and planned function-restorative secondary procedures might offer favorable outcomes in patients with partial or total brachial plexus lesions.

BACKGROUND Depression has been associated with poor outcomes in neurosurgical patients, including increased pain, poorer functional recovery, delayed return to work, and decreased patient satisfaction. No reports exist regarding an association of psychiatric diagnoses with outcomes after brachial plexus reconstruction. As outcomes and patient satisfaction become increasingly important to payers and physician reimbursement, assessing modifiable preoperative risk factors for their association with poor outcome and patient satisfaction is imperative. OBJECTIVE To analyze patients undergoing brachial plexus reconstruction to assess the relationship of depression/anxiety with functional outcome. METHODS Data were collected retrospectively on all patients who underwent brachial plexus reconstruction to restore elbow flexion between 2005 and 2013. Elbow flexion, graded via the Medical Research Council scale, was assessed at latest follow-up. Multiple variables, including the presence of Axis I psychiatric diagnoses, were assessed for their association with the dichotomous outcome of Medical Research Council scale score ≥3 (antigravity) vs

OBJECTIVE To help clarify the optimal surgical strategy for idiopathic, symptomatic ulnar nerve compression at the elbow in terms of overall outcome and morbidity by using objective criteria. METHODS Forty-four surgical candidates were recruited prospectively and were randomized into the neurolysis (n = 23) or transposition (n = 21) arm of the study. Preoperative and postoperative outcomes were assessed symptomatically and by performance on McGowen and Louisiana State University Medical Center grading systems at 1 month, 6 months, and 1 year. RESULTS Both procedures were equally effective in producing objective neurological improvement (61% in the neurolysis group, 67% in the transposition group). Wound complications, however, were more significant in the transposition group. Three of 21 in the transposition group compared with 0 of 23 in the neurolysis group experienced a deep wound infection. CONCLUSION Idiopathic symptomatic ulnar nerve compression at the elbow is adequately treated by both neurolysis in situ and submuscular transposition. Submuscular transposition was associated with a higher incidence of complications. The authors therefore suggest the simpler procedure of neurolysis in situ as the treatment of choice. Submuscular transposition remains appropriate in certain circumstances.

Objective This study analyzes 318 operative knee-level common peroneal nerve lesions managed at the Louisiana State University Health Sciences Center between 1967 and 1999. Methods Each patient was retrospectively evaluated for injury mechanism, preoperative neurological status, electrophysiological studies, lesion type, and operative technique, i.e., neurolysis, suture, or graft repair. All lesions in continuity had intraoperative nerve action potential recordings. Results There were 141 stretch/contusions without fracture/dislocations (44%), 39 lacerations (12%), 40 tumors (13%), 30 entrapments (9%), 22 stretch/contusions with fracture/dislocations (7%), 21 compressions (7%), 13 iatrogenic injuries (4%), and 12 gunshot wounds (4%). After neurolysis, 107 (88%) of 121 knee-level common peroneal nerve lesions with recordable intraoperative nerve action potentials recovered useful function. Nineteen patients underwent end-to-end suture repair, and 16 (84%) of these achieved good recovery by 24 months. Graft repair was performed in 138 peroneal injuries. Thirty-six patients (26%) had grafts less than 6 cm long, of which 27 (75%) achieved Grade 3 or greater peroneal function. Twenty-four (38%) of 64 patients with 6- to 12-cm grafts, and only 6 (16%) of 38 patients with 13- to 24-cm grafts, attained good peroneal function. Longer grafts correlated with more severe injuries and thus poorer outcomes. Thirty-two (80%) of 40 tumors were resected with preservation of preoperative clinical function. Conclusion Surgical exploration and repair of peroneal nerve lesions achieved good results with timely operations and thorough intraoperative evaluations. Useful function was achieved in 27 (75%) of 36 patients with grafts less than 6 cm in length and in only 88 (44%) of 202 patients with grafts greater than 6 cm in length.

OBJECTIVE Iatrogenic injury to the spinal accessory nerve is not uncommon during neck surgery involving the posterior cervical triangle, because its superficial course here makes it susceptible. We review injury mechanisms, operative techniques, and surgical outcomes of 111 surgical repairs of the spinal accessory nerve. METHODS This retrospective study examines clinical and surgical experience with spinal accessory nerve injuries at the Louisiana State University Health Sciences Center during a period of 23 years (1978–2000). Surgery was performed on the basis of anatomic and electrophysiological findings at the time of operation. Patients were followed up for an average of 25.6 months. RESULTS The most frequent injury mechanism was iatrogenic (103 patients, 93%), and 82 (80%) of these injuries involved lymph node biopsies. Eight injuries were caused by stretch (five patients) and laceration (three patients). The most common procedures were graft repairs in 58 patients. End-to-end repair was used in 26 patients and neurolysis in 19 patients if the nerve was found in continuity with intraoperative electrical evidence of regeneration. Five neurotizations, two burials into muscle, and one removal of ligature material were also performed. More than 95% of patients treated by neurolysis supported by positive nerve action potential recordings improved to Grade 4 or higher. Of 84 patients with lesions repaired by graft or suture, 65 patients (77%) recovered to Grade 3 or higher. The average graft length was 1.5 inches. CONCLUSION Surgical exploration and repair of spinal accessory nerve injuries is difficult. With perseverance, however, these patients with complete or severe deficits achieved favorable functional outcomes through operative exploration and repair.

OBJECTIVE We analyzed the epidemiology, preoperative management, operative findings, operative treatment, and postoperative results in a group of 99 patients who sustained 100 injuries to the brachial plexus.METHODS The charts of 100 consecutive surgical patients with brachial plexus injuries were r

Objective and importance Infiltration of the brachial plexus with anesthetics can provide relief of upper-extremity pain from invasive cancer. Because the analgesia is short-lived, however, repeated invasive treatments are necessary. We describe the implantation of a catheter reservoir system, in which anesthetic injections through a subcutaneous port resulted in anesthetic infiltration of the brachial plexus. Clinical presentation A 47-year-old Hispanic man with squamous cell carcinoma of the larynx had undergone surgical resection, radiation treatment, and chemotherapy. Two years later, he had locally recurrent disease involving the brachial plexus, neck, and chest wall. The patient's pain was minimally responsive to narcotics, which also caused severe nausea and anorexia. Technique The brachial plexus was localized percutaneously with a needle electrode stimulator. Contrast injection under fluoroscopy confirmed entry into the plexus sheath. With use of the Seldinger technique, two Silastic catheters were placed within the brachial plexus and attached with a "Y" connector to a reservoir. The patient experienced complete relief of upper-extremity pain after a test injection with xylocaine. Thereafter, serial injections of bupivacaine with triamcinolone at 1-week intervals provided complete pain relief. After the treatments were initiated, the patient reported improved sleep and an improvement in his quality of life. Conclusion A catheter reservoir system for brachial plexus analgesia can provide safe and effective analgesia for upper-extremity pain. This technique negates the need for repeated invasive procedures and avoids the complications of neurolysis.

OBJECTIVE: Fifty-eight percent of patients who had undergone surgery for ulnar neuropathy at the elbow experienced pain after surgery. Severe pain, mostly radiating from the elbow into the hand, is the main indication for subsequent surgery. METHODS: During a period of 5.5 years, 25 patients underwent 28 operations for ulnar nerve entrapment at the elbow and experienced excruciating pain after surgery. Ten patients had undergone a simple decompression and 15 had undergone a nerve transposition. Seven patients underwent surgery at our hospital, whereas 18 patients underwent their primary surgery at other institutions. Various surgical techniques were used during the subsequent surgery, such as external or internal neurolysis, epineurectomy, anterior transposition, and subsequent transfer of the nerve back into the sulcus. RESULTS: The average follow-up after the last procedure was 17 months (2-55 mo). All five patients with subsequent transfer of the ulnar nerve into the sulcus became pain-free, whereas only two of five patients who had secondary intramuscular transposition for subluxation became free of pain. Results after internal neurolysis were unsatisfactory. Only one of six patients was free of pain after secondary surgery. Results after three or four procedures are approximately similar to the results after the first subsequent surgery. CONCLUSION: Simple and less extensive techniques for subsequent surgery have relatively good results in this complicated condition. Although our small number of patients does not allow us to draw general conclusions, we think our report makes a contribution because of the few reports in the literature dealing with the results of subsequent surgery for ulnar nerve neuropathy.

OBJECTIVE : To evaluate the indication of subsequent operations after failed microvascular decompression (MVD) for the treatment of trigeminal neuralgia, the intraoperative findings and long-term results of 16 subsequent operations are reported. METHODS : Subsequent exploration of the posterior fossa was performed for lack of pain relief (3 patients) and recurrent neuralgia (13 patients) after an average of 17 months (range, 4-62 mo). In all patients, typical arterial compression patterns at the root entry zone of the trigeminal nerve were found in the first procedure. The mean follow-up period after subsequent operation was 90 months (range, 78-104 mo). RESULTS : New arterial neurovascular conflicts were found in nine patients. After subsequent MVD procedures, seven patients were pain-free (with one recurrence after 6 mo), one had constant marked relief, and one was unchanged. Second exploration revealed no abnormalities in the other seven patients who experienced continued or recurrent pain ; only careful neurolysis of the trigeminal nerve was performed in those patients. Initially, all seven patients obtained complete pain relief, but two experienced late recurrences after 64 and 68 months, respectively. Thus, subsequent operations failed in all 4 patients who had undergone prior destructive procedures but were successful in those 12 patients who had undergone only previous MVD. Two patients developed severe sequelae, and the other nine had minor complications, especially permanent (four patients) or transitory (three patients) ipsilateral trigeminal hypoesthesia. CONCLUSION : Subsequent MVD seems to have good long-term results. However, because of the significantly high incidence of complications, the indication for subsequent operations should be restricted to younger patients to avoid destructive procedures. In general, glycerol rhizolysis or radiofrequency rhizotomy may be the treatment of choice after failed MVD.

TWO CASES OF delayed posterior interosseous nerve palsy after brachiocephalic arteriovenous fistula creation are presented. Both patients suffered from end-stage renal disease, necessitating chronic hemodialysis. After fistula construction, both developed progressive weakness of the muscles innervated by the posterior interosseous nerve. One patient also demonstrated sensory loss in the distribution of the superficial radial nerve. Electrophysiological studies confirmed posterior interosseous mononeuropathies in both cases. Surgical exploration demonstrated posterior interosseous nerve continuity, with severe compression from the hypertrophied venous limb of the arteriovenous fistula. The superficial radial nerve was also compressed in one patient. After neurolysis and fistula revision, both patients recovered neurological function.

OBJECTIVE AND IMPORTANCEMeralgia paresthetica is an entrapment neuropathy involving the lateral femoral cutaneous nerve. We describe an unusual case in which meralgia paresthetica occurred many years after iliac bone graft harvesting.CLINICAL PRESENTATIONAn 81-year-old man presented with a 1-year history of pain, dysesthesia, and hypesthesia in the anterolateral aspect of the right thigh. This patient had undergone iliac bone grafting when he sustained a calcaneal fracture 40 years previously. Radiographs and computed tomographic scans of the pelvis revealed a bony excrescence in the anterosuperior iliac spine.INTERVENTIONThe patient underwent neurolysis of the lateral femoral cutaneous nerve and excision of the bony excrescence. At surgery, the nerve was densely adherent to the bony excrescence.CONCLUSIONThe etiology of meralgia paresthetica in this patient is considered to be heterotopic ossification on the anterosuperior iliac spine and pubic symphysis degeneration. A significant relationship between pubic symphysis degeneration with increasing age and meralgia paresthetica has been reported. One should be aware of meralgia paresthetica as a late complication of iliac bone graft harvesting.

BACKGROUND: Sciatica is typically a clear-cut symptom complex commonly related to an impingement at the spinal nerve level. Etiologies of sciatic neuropathy outside the neural foramina are uncommon. OBJECTIVE: To describe 4 patients presenting with radiating leg pain due to sciatic nerve involvement, all with a vascular etiology. METHODS: Four patients presenting with neuropathic pain were retrospectively reviewed. Preoperative 3 Tesla magnetic resonance imaging was used to identify these lesions, which most commonly showed diffuse T2 changes with nerve enhancement upon administration of contrast. RESULTS: Exploration revealed vascular lesions. All patients went on to external and limited internal neurolysis of the involved sciatic nerve segment. Intraoperative histological study confirmed the presence of a venous angioma, an arteriovenous malformation, a venous malformation associated with Klippel-Trenaunay syndrome, and a capillary hemangioma. Follow-up demonstrated stable neurological examinations with reduction in pain at 1 year or greater. CONCLUSION: In patients with sciatic distribution symptoms and signs, after initial negative spine imaging, high-resolution imaging of the sciatic nerve itself should be undertaken to address rarer causes such as vascular abnormalities. In these cases, exploration and fascicular biopsy provided a diagnosis; external and limited internal neurolysis improved pain.

OBJECTIVE: The purpose of this article is to provide our experience with intraoperative nerve action potential (NAP) recordings. In particular, we focus on a discussion of the technical considerations of intraoperative NAP with emphasis on identifying and remedying problems and pitfalls. METHODS: We report, perhaps, the largest operative series of peripheral nerve lesions in continuity with intraoperative NAP recording derived from 1736 patients with 3459 lesions in continuity with operative outcomes. We pay special attention to patients for whom we felt that NAP recordings were either difficult or misleading. RESULTS: A positive NAP across a lesion resulting in neurolysis gave grade 3 or better function using the Louisiana State University Health Science Center grading system in 94.7% of neural elements. Differential fascicular recordings resulted in split repair in 62 nerves with recovery in 58. The absence of an NAP correlated histologically with a neurotmetic lesion. With resultant repair, 1111 of 1975 nerves recovered to grade 3 or better. CONCLUSION: Visual inspection of a nerve lesion in continuity can be misleading. Aithough there is no "head-to-head" comparison of our data with data obtained without the use of intraoperative NAP recordings, we feel strongly that with experience and knowledge of the problems and pitfalls regarding intraoperative recording techniques, one may take advantage of the great benefits of this very useful and informative surgical tool.

Objective In this study, we compare different surgical procedures regarding the functional outcome of traumatic peroneal nerve lesions. Methods In a retrospective study, 48 patients with traumatic lesions (17 iatrogenic) of the peroneal nerve were evaluated. Twenty-two patients presented with lesions in continuity displaying regenerative potential by nerve action potential recording. In these cases, surgery was restricted to either external (12/) or interfascicular neurolysis (10/). Twenty-two cases had no regenerative potential (10/) or showed discontinuity (12/) and thus were reconstructed with autologous sural nerve grafts. In four cases, a reconstructive procedure was intraoperatively abandoned as a result of the large extent of the lesion. Results Thirty-six patients with an adequate follow-up period of at least 18 months were included in this study. Among those with external neurolysis, 73% (eight out of 11) showed a good functional outcome, obviating the need for a kick-up foot brace (M >or= 4). In the interfascicular neurolysis group, 71% (five out of seven) exhibited a similar outcome. In the grafted group, however, only 28% (five out of 18) obtained a functionally useful result dependent on graft length. A graft length under 6 cm led to a functionally useful outcome in 44% of patients (four out of nine) compared with 11% (one out of nine) when the graft length was greater than or equal to 6 cm. In six patients, muscle-tendon transfers were performed, resulting in strong, useful foot lift. Conclusion Peroneal nerve lesions lacking regenerative signs should be explored. A functionally useful result (M >or=4) was achieved in 72% of the patients with either external or internal neurolysis and in 28% of the patients after a nerve graft procedure. Patients in whom nerve surgery failed to reconstitute useful foot lift need to be evaluated for their suitability to undergo a tendon transfer procedure.

Objective Obturator neuralgia consists of pain radiating from the obturator nerve territory to the inner thigh. Methods We report a case of idiopathic obturator neuralgia resulting from compression of the obturator nerve in the obturator canal, causing a case of nerve entrapment syndrome. The pain was characterized by its localization in the inguinal region and anterointernal side of the thigh, going down to the internal side of the knee. It was worse when standing or in a monopodal stance. Walking caused pain and a limp. Results The diagnosis was confirmed by an analgesic block. The analgesic was infiltrated using a posterior approach and computer-assisted tomography, allowing the quality and specificity of the infiltration to be judged. Conclusion We describe, for the first time, a treatment of obturator neuralgia by a minimally invasive laparoscopic approach. This involved an obturator nerve neurolysis and section of the internal obturator muscle and the obturator membrane.

The question of the superior operative technique for meralgia paresthetica is unsettled. Operative treatment by either neurolysis or transection of the lateral femoral cutaneous nerve was performed in 21 patients with meralgia paresthetica after complete failure of conservative treatment; neurolysis in 10 patients and transection in 11 patients were performed by five neurosurgeons. The average follow-up period was 74 months (+/- 52 mo). The results were scored as complete relief, partial relief, or failure. Direct comparison of neurolysis and transection confirmed the superiority of transection as a treatment for meralgia paresthetica (Mann-Whitney-U test, P = 0.022; one-sample sign test, P = 0.0020).

OBJECTIVE Scar tissue is an inevitable result of peripheral nerve surgery. A variety of substances have been used to prevent epineurial scarring. In this study, the effect of low-dose radiation therapy on epineurial scarring was investigated. METHODS Seventy-eight male Sprague-Dawley rats were studied. A total of 60 rats were subjected to one of three types of surgical procedure on the sciatic nerve, as follows: Procedure 1, external neurolysis (n = 20); Procedure 2, abrasive injury (n = 20); and Procedure 3, anastomosis (n = 20). On the left sciatic nerves, 700 cGy external beam radiation was administered 24 hours after surgery, and the right sciatic nerves served as a control group (surgery only). Eighteen animals without surgical intervention were used to establish the fibrotic effect of radiotherapy on normal nerves. A neurological examination was performed weekly. Six weeks after surgery, the extent of extraneural scarring was examined by gross microdissection by means of a numerical grading scheme and histological analysis. Cellular density and surface measurements of scar tissue were also evaluated. RESULTS The dissection around the nerve was easier in rats treated with low-dose radiation compared with the control group. Furthermore, grading scores in both nerve adherence and nerve separability were significantly lower in treated nerves than in the control group (P < or = 0.05). Low-dose radiotherapy decreased the scores of cellular density and surface measurement of scar tissue (P < or = 0.05). In normal nerves, radiotherapy did not produce any fibrotic effects and the density of fibroblasts/fibrocytes was also very low. CONCLUSION In the case of surgery or local trauma to peripheral nerve, the use of low-dose radiation therapy may be a safe method of limiting postoperative epineurial scar formation.

OBJECTIVE:To assess the effects of Hyaloglide gel (or auto-cross-linked polysaccharide [ACP] gel; Fidia Advanced Biopolymers, Abano Terme, Italy), a hyaluronan-derivative polymer, on peripheral nerve scarring and nerve regeneration.METHODS:We performed two surgical procedures in adult rats: 1) neurolysis of the sciatic nerve and separation of its tibial and peroneal branches, and 2) transection and immediate suture of the sciatic nerve. After nerve manipulation, ACP gel was applied onto the site of operation. We tested two solutions of ACP gel having different viscosities. Additional animals received Adcon-T/N (Gliatech, Inc., Cleveland, OH), an antiadhesive agent currently available for clinical use. No gel was applied on the contralateral side, which served as a control side. Four weeks later, the animals underwent reoperation. We assessed the quality of wound healing, the presence of perineural adherences, and the separability of nerves from surrounding tissues.RESULTS:Significantly fewer perineural adhesions were found in animals treated with ACP gel (high viscosity) and Adcon-T/N compared with controls. Quantitative histological analysis revealed a statistically significant reduction in the amount of scar tissue surrounding the nerves treated with ACP gel. No evidence of toxicity was found, and the gel did not interfere with nerve regeneration (counts of regenerating myelinated axons).CONCLUSION:ACP gel with high viscosity seems to be safe and effective in reducing perineural adhesions and scar formation after peripheral nerve surgery.

OBJECTIVEThis retrospective study presents 33 years of clinical and surgical experience with 135 tibial nerve lesions to review operative techniques and their results and to provide management guidelines for the proper selection of surgical candidates.METHODSBetween 1967 and 1999, 135 patients with tibial nerve lesions at the knee level or below were managed surgically at the Louisiana State University Health Sciences Center. We reviewed these cases.RESULTSOf the 135 cases, traumatic injury accounted for 71, tarsal tunnel syndrome for 46, and nerve sheath tumor for 18. Of 22 lesions not in continuity, functional recovery of Grade 3 or better was achieved in 4 (67%) of 6 patients who required end-to-end suture repair and 11 (69%) of 16 patients who required graft repair. One hundred thirteen tibial nerve lesions in continuity underwent primarily external or internal neurolysis or resection of the lesions. A few received end-to-end suture or graft repair. Direct intraoperative recording of nerve action potentials guided case management decisions. Among the 113 patients with lesions in continuity, 76 (81%) of 94 patients receiving neurolysis, 5 (83%) of 6 receiving suture repair, and 11 (85%) of 13 receiving graft repair recovered function to Grade 3 or better. Repair results were best in patients with recordable nerve action potentials treated by external neurolysis. Results were poor in a few patients with very lengthy lesions in continuity and in reoperated patients with tarsal tunnel syndrome.CONCLUSIONSurgical exploration and repair of tibial nerve lesions, including nerve sheath tumors and tarsal tunnel syndromes, achieved excellent outcomes.

Cough attacks elicited by movement of the neck and right arm are reported in a patient who had sustained several shoulder injuries and who had an anterior scalenectomy. The coughing was accompanied by weakness in the right upper limb. At exploration, the phrenic nerve was found adhered to the brachial plexus. The cough attacks disappeared, and the weakness of the right upper limb improved somewhat after lysis of the adhesions between the phrenic nerve and the plexus and after external neurolysis of the upper, middle, and lower trunks. Postoperatively, the patient could elevate his right arm without coughing.

The authors present two cases of severe radial nerve injury with different sites of pathology but a similar mechanism: the "windmill" pitching motion of competitive softball. Both patients required surgical intervention with neurolysis, and both improved postoperatively. The literature on related radial nerve injuries is briefly reviewed and pathophysiological mechanisms are discussed.

OBJECTIVETo report the outcomes of cubital tunnel surgery for patients with absent ulnar sensory nerve conduction.METHODSThe charts of 34 patients who exhibited clinical symptoms of ulnar nerve entrapment at the elbow and who had electromyography-confirmed prolonged motor nerve conduction across the cubital tunnel in association with absent sensory nerve conduction were reviewed. The mean age was 63 years, and the mean symptom duration was 17 months. Four patients had bilateral symptoms. Surgery was performed for 38 limbs, i.e., neurolysis for 21 limbs and subcutaneous transposition for 17 limbs. Fifteen limbs demonstrated associated ulnar nerve-related motor weakness. The mean postoperative follow-up period was 4 years (range, 3 mo to 11 yr).RESULTSSensory symptoms (i.e., pain, paresthesia, and two-point discrimination) improved in 20 limbs (53%), and muscle strength improved in 2 limbs (13%). Improvements in sensory symptoms were not related to patient age, symptom duration, cause, severity of prolonged motor nerve conduction, select psychological factors, associated medical diseases, associated cervical pathological conditions, or type of surgery. Improvements in sensory symptoms were significantly decreased among patients who had experienced cervical disease for more than 1 year and patients with bilateral symptoms.CONCLUSIONPatients with cubital tunnel syndrome who have absent sensory nerve conduction seem to experience less improvement of sensory symptoms after surgery, compared with all patients with cubital tunnel syndrome described in the literature. Bilateral symptoms and delayed surgery secondary to associated cervical spine disease seem to be significant negative factors for postoperative improvement of sensory symptoms. Sensory symptoms improved similarly among patients who underwent neurolysis or subcutaneous transposition

Objective The goals of the study were to investigate the value of intraoperative electrically evoked nerve action potentials (NAPs) in the surgical treatment of traumatic peripheral nerve injuries (nerve lesions in continuity). Methods Sixty-four patients with 76 traumatic nerve lesions in continuity were investigated intraoperatively by stimulating and recording NAP from the whole nerve across the suspected lesion site. Among the 76 nerves (nerve lesions) were 43 with incomplete and 33 with complete loss of function. In cases (nerves) with complete loss of function (n = 33), the surgical procedure (external neurolysis, internal neurolysis, or nerve repair) was performed according to the microscopic aspect of the nerve and the result of the intraoperative electrophysiological testing. In cases (nerves) with incomplete loss of function (n = 43), the surgical procedure was performed solely according to the microscopic aspect of the nerve and independently from the result of the intraoperative electrophysiological testing. Results Of 43 nerves with incomplete loss of function, we were able to record reproducible NAPs in 41 (95%) across the lesion site, thus demonstrating a high reliability of the method. Of 33 nerves with complete loss of function, a reproducible NAP could be recorded only in 3. Assuming an axonotmetic lesion in regeneration, we did nothing else on the nerve with excellent clinical results (full recovery). Of the remaining nerves with no NAP, 24 showed a caliber shift of the nerve (in 20 cases a thickening of the nerve, suggesting a neuroma in continuity). A grafting procedure was performed, and the histological evaluation revealed a neurotmetic lesion. However, in six patients with no NAP, there was no clear caliber shift of the nerve. The epineurium was opened and an internal neurolysis performed showing fascicles in continuity. Three patients had good and three had partial (but useful) recovery. Conclusions In nerve lesions in continuity with complete loss of nerve function, intraoperative NAPs are able to detect axonotmetic lesions in regeneration. Thus, unnecessary further surgical procedures can be avoided. On the other end of the spectrum, no recordable NAP together with a caliber shift of the nerve (suggesting a neuroma in continuity) may facilitate the surgeon's decision for a grafting procedure without a time-consuming internal neurolysis. But there is also evidence from our data that not every nerve lesion in continuity without a NAP needs to be grafted.

A retrospective analysis of clinical results in a relatively large series of peroneal nerve lesion is presented. Historically, such lesions have been difficult to manage successfully.Between 1967 and 1991, 302 patients with either injury or tumor of the peroneal nerve at the knee were evaluated at Louisiana State University Medical Center. Mechanisms of injury included stretch injury with or without fracture, "sharp" or "blunt" laceration, gunshot wound, compression, entrapment, and iatrogenic injury. Surgery was performed on 183 of 276 patients (66%). If spontaneous recovery had not occurred 4 to 6 months after injury, patients were operated on and lesions in continuity were usually evaluated using nerve action potential recordings.Eighty-six patients required interfascicular grafts. Graft lengths varied from 4 to 20 cm (average, 10 cm). Grafts measured5.5 cm in some patients with blunt laceration, gunshot wound, or iatrogenic injury. Eighteen of 24 of those patients (75%) recovered peroneal function to Grade 3 or better, and a kickup foot brace was no longer needed to walk with a reasonable gait. Fourteen of 40 patients (35%) with graft lengths of 6 to 12 cm and only 3 of 22 patients (14%) with graft lengths of 13 to 20 cm recovered function to Grade 3 or better. Seventeen patients received end-to-end suture repair, and 14 (82%) recovered to Grade 3 or better by 24 months. After neurolysis, 71 of 80 patients (89%) with transmittable nerve action potentials across lesions in continuity recovered useful function despite severe preoperative functional loss in most cases. In addition, 24 tumors intrinsic to the peroneal nerve and two lesions caused by hypertrophic neuropathy were resected.Neural repair is the first priority in selected patients with peroneal nerve palsy. As with other nerve lesions, a timely operation and thorough intraoperative evaluation are necessary for optimal results.

The effects of ADCON-T/N (Gliatech, Inc., Cleveland, OH), a carbohydrate polymer gel, on peripheral nerve scarring and regeneration were studied in rodents undergoing three types of surgical intervention. Procedure I involved external neurolysis of the sciatic nerve from surrounding tissues and separation of its tibial and peroneal components. Procedure II involved the addition of an abrasive injury. Procedure III involved transection and suture anastomosis of the tibial component. ADCON-T/N or a control gel was locally applied in a blind fashion. Additional animals received no gel, as a further control. Animals underwent second operations 4 weeks after Procedures I and II and 6 weeks after Procedure III. The surgical sites were evaluated using a numerical grading scheme to assess wound healing, sciatic nerve adherence to surrounding tissues, and separability of its tibial and peroneal components. Animals receiving ADCON-T/N demonstrated reduced nerve adherence to surrounding tissues and enhanced separability of the tibial and peroneal components, compared with animals receiving control gel or no gel. Quantitative histological analysis revealed a statistically significant reduction in the amount of dense scar tissue surrounding nerves treated with ADCON-T/N. No evidence of nerve toxicity caused by ADCON-T/N was noted. Counts of regenerating myelinated axons in animals undergoing nerve transection and suture repair did not statistically differ in treated and untreated animals. In conclusion, ADCON-T/N seems to be both safe and effective in reducing extraneural scar formation after peripheral nerve surgery and local trauma.

Two patients with delayed radial nerve palsy occurring a month after penetrating missile wounds are presented. The history and presence of a pulsatile mass over the posterolateral aspect of the arm were highly suggestive of a traumatic aneurysm of a collateral radial artery, confirmed by angiography in one patient and at surgery in the other. After removal of the aneurysm and radial nerve neurolysis, the patients' symptoms were relieved. In a thorough review of the literature, we found these to be the first examples of traumatic aneurysms of collateral radial arteries causing unusual delayed neural palsies.

We report a series of 12 cases of isolated lesions of the axillary nerve treated surgically. We discuss the pathogenesis, clinical pattern, and surgical treatment of this lesion together with the results obtained.

One hundred seventy patients with radial nerve disorders were reviewed at the Louisiana State University Medical Center over a 15-year period. Of these, 32 had involvement of the posterior interosseous nerve exclusively. Findings included weak wrist extension with a radial drift, inability to extend the fingers, paralysis of thumb extension, and weak thumb abduction. Causes included entrapment at the arcade of Froshe (14 patients), laceration (6 patients), fracture (6 patients), compression or contusion (3 patients), and loss associated with tumor (3 patients). The ratio of men to women was 2:1, and the right arm was involved twice as often as the left. Preoperative evaluation included physical examination, electrophysiological testing (electromyogram/nerve conduction velocity), and roentgenograms of the elbow and forearm. Of the 30 patients (2 patients had bilateral lesions), 26 underwent operation. In the operative series, all 28 nerves had a function of Grade 3 or more of a possible 5 after 4 years of follow-up. Seventeen had achieved Grade 4/5, and 7 had obtained Grade 5/5. At operation, 23 nerves were found to be in continuity. Fourteen lesions of nerves in continuity were associated with entrapment and. not unexpectedly, transmitted a nerve action potential with slowed conduction and low amplitude across the lesion. Four nerves in continuity that had lesions caused by injury had nerve action potentials and were treated by neurolysis, and another 4 had no nerve action potentials and were treated by graft or suture repair. Five injured nerves were not in continuity. Two could be repaired by end-to-end suture, and 3 required graft repair. A large ganglion cyst involving the posterior interosseous nerve was also resected.

Local steroid injections for symptomatic relief of carpal tunnel syndrome have become common in the evaluation and treatment of this disorder; yet reports of median nerve injection injury from this practice are rare. We present a case of nerve injury from a steroid injection in a 24-year-old man with carpal tunnel syndrome that was successfully treated by division of the transverse carpal ligament and neurolysis. The histopathological characteristics of the lesion are presented. and the pathogenesis and treatment of this injury are discussed. Means of avoiding this complication include careful attention to anatomic landmarks as well as to the patient's subjective response during injection and avoidance of the use of local anesthetics.

The treatment of spasticity in severely paralyzed patients undergoing rehabilitation constitutes a significant neurosurgical challenge that requires comprehensive management. In this study, 118 patients were treated with invasive modalities when medical therapy failed. The results of percutaneous radiofrequency foraminal rhizotomy were initially successful in 95% of the 77 patients who underwent this procedure; the rate of minor complications was 5%. This procedure was satisfactorily supplemented with percutaneous radiofrequency sciatic neurectomy in 32 of these 77 patients. Four myelotomies were performed with complete success and no major complications in patients in whom percutaneous techniques had proven inadequate. In 35 instances of focal spasticity and incomplete paralysis, intramuscular neurolysis by phenol injection was used. The success rate was 89%. In 9 patients with persistent recurrent spasticity of the lower limb, open tenotomies and peripheral neurectomies were done. Success was complete and without complications. Multiple modalities must be available for the comprehensive management of patients with paralytic spasticity. (Neurosurgery 26:300-306, 1990)

Eighty-three consecutive patients with extracranial accessory nerve injury seen over a 12-year period are reviewed. The most common etiology was iatrogenic injury to the nerve at the time of previous surgery. Such operations were usually minor in nature and often related to lymph node or benign tumor removal. Examination usually distinguished winging due to trapezius weakness from that of serratus anterior palsy. Trapezius weakness was seen in all cases. Sternocleidomastoid weakness was unusual. Patients with accessory palsy were evaluated by both clinical and electromyographic studies. Patients who exhibited no clinical or electrical evidence of regeneration were operated on (44 cases). Based on intraoperative nerve action potential studies, 8 lesions in continuity had neurolysis alone. Resection with repair either by end-to-end suture or by grafts was necessary in 31 cases. One case had suture removed from nerve, two had nerve placed into target muscle, and two had more proximal neurotization. Function was usually improved in both operative and nonoperative patients. Related anatomy is discussed.

The technique of radiofrequency neurolysis guided by computed tomography for the treatment of glossopharyngeal neuralgia is described. This technique has the advantage of being performed in a neutral head position, affording excellent visualization of the jugular foramen, and also of simulating radiographically the precise trajectory of the electrode. This procedure is of particular value in treating patients with neoplastic disease and those in whom the outlines of the jugular foramen are poorly visualized on fluoroscopy or plain radiography.

In a 36-month period, 103 consecutive patients have been treated for classical trigeminal neuralgia with either percutaneous radiofrequency trigeminal neurolysis (PTN) (48 patients) or microvascular decompression (MVD) via a suboccipital craniectomy (55 patients). The results of these two procedures are tabulated, emphasizing especially the complications that have occurred with each. Successful initial relief of pain was achieved in 88% of the patients with PTN and 96% of the patients with MVD. Two significant complications occurred in the former group. Severe recurrences have occurred to date in 13% of the patients with PTN and in 5% of those with MVD. It is concluded that both procedures are effective, but that microvascular decompression offers the advantage of avoiding sensory loss and associated dysesthetic sensations. Follow-up is too short to conclude that MVD is a curative procedure, but the early results are very encouraging.

A 33-year-old woman with a 22-year history of juvenile rheumatoid arthritis developed right lower extremity sciatica 32 months after total hip arthroplasty. Physical examination and electromyography localized the abnormality to the sciatic nerve proximal to the midthigh level, involving the branch to the short head of the biceps femoris muscle. At surgical exploration, a sharp spur of methyl methacrylate, used to cement the acetabular prosthesis to the acetabulum, was found to have eroded through the lateral half of the sciatic nerve. The sciatica was relieved by neurolysis. The etiology of sciatic neuropathy after total hip replacement is reviewed.

Sixty-six patients with ulnar nerve entrapment at the elbow underwent neurolysis and the application of a Silastic envelope in an attempt to prevent postoperative scarring and recurrence of symptoms. All patients were evaluated pre- and postoperatively using a numerical scoring system that included clinical, motor, and sensory evaluation as well as nerve conduction studies. The Silastic material was well tolerated in the 70 cases. The overall 66% score improvement was more closely related to clinical relief (64%) than to improvement in motor conduction velocities (45%). Our 10-year experience indicates that ulnar neurolysis with Silastic envelope interposition is a safe surgical method of treatment for ulnar nerve entrapment at the elbow.

Six patients representing seven cases of spontaneous (nontraumatic) saphenous neuralgia secondary to entrapment of the nerve in the subsartorial canal are presented. All patients complained of medial knee and leg pain. Clinical findings included tenderness over the subsartorial canal and sensory changes in the cutaneous distribution of one or both terminal branches of the saphenous nerve. The diagnosis was confirmed by saphenous nerve block in all cases. All patients were treated operatively, which resulted in symptomatic improvement. All six patients initially underwent external neurolysis; however, three patients required saphenous neurectomy for recurrent symptoms. Saphenous neuralgia should be considered in the differential diagnosis of medial lower extremity pain.