Antonio Tedesco-Marchese

Surgical management of Guyon's canal syndrome, an ulnar nerve entrapment at the wrist: report of two cases

Guyons canal syndrome, an ulnar nerve entrapment at the wrist, is a well-recognized entity. The most common causes that involve the ulnar nerve at the wrist are compression from a ganglion, occupational traumatic neuritis, a musculotendinous arch and disease of the ulnar artery. We describe two cases of Guyons canal syndrome and discuss the anatomy, aetiology, clinical features, anatomical classification, diagnostic criteria and treatment. It is emphasized that the knowledge of both the surgical technique and anatomy is very important for a satisfactory surgical result.

Neuroma sintomático do nervo sural uma complicação rara após a retirada do nervo: relato de caso

The harvesting of the sural nerve for autologous grafting usually produces symptoms of low intensity and short duration. In rare occasions that procedure may lead to the formation of a symptomatic neuroma in the proximal stump. The symptoms of this complication are usually controlled by clinical treatment and the surgical procedure is left for the therapeutic failures. In this paper we present the case of a patient with a sural nerve neuroma submitted to surgical treatment by a variant of the centro-central anastomosis technique, developed for the treatment of amputation neuromas, that resulted in remission of the painful symptomatology. The different options of surgical treatment for this rare entity are discussed.

Microvascular surgery: Adjunct to renal transplantation

A new technique for microvascular anastomosis of the polar artery to the renal artery, end to side, is presented. It was performed in 5 cases of renal transplantation with a successful result in all.

Giant Traumatic Cervical Pseudomeningocele After Brachial Plexus Injury: A Report of 2 Cases

It is well known that a traction injury of the brachial plexus may produce tears in the root sleeves resulting in pseudomeningoceles, which are in most instances small and not noticed by the patient. We report 2 unusual cases of giant pseudomeningoceles due to brachial plexus injury presenting as a supraclavicular mass. Compression because of the mass resulted in headache, nausea, and dizziness in both cases. A computed tomography of the brain must be performed to rule out further causes of increased intracranial pressure. Ventriculoperitoneal and lumbar-peritoneal shunting procedures were the treatment of choice.

Revascularizaçao cerebral microcirúrgica

Sao feitas consideracoes a respeito das novas tecnicas de revascularizacao cerebral. Os resultados obtidos em uma serie de 5 doentes, submetidos a 6 anastomoses entre arteria temporal superficial e ramo da cerebral media, foram satisfatorios. Esta tecnica relativamente inocua e, quando bem indicada, bastante util.Techniques of microsurgical revascularization are reviewed. A series of 5 cases, submitted to 6 anastomosis of the superficial temporal artery is presented.

Microsurgical reconstruction of the cauda equina after traumatic transecting injury

IntroductionThe microsurgical reconstruction of the cauda equina nerve roots (MRCER) after traumatic injury is a highly controversial procedure with very few reports in the literature.MethodsWe report on four patients who had a penetrating traumatic injury in the lumbosacral area and underwent primary MRCER at our institution during the last decade.ResultsAll four patients presented complete distal sensory and motor palsy affecting the lower lumbosacral roots. Primary microsuture was feasible in three patients harboring stab wounds, whereas autologous nerve graft interposition was necessary in the patient who had a gunshot wound. At the 5-year follow-up, we observed a marked improvement in motor function in two patients, but no sensory recovery.

Topodiagnóstico na paralisia facial periférica

The topodiagnosis allows the physician to determine the topographic localization of pathology involving the facial nerve. It is based on clinical tests that evaluate the function of each one of the rami of the facial nerve. With a statistic of 873 patients, the Facial Nerve Group of Hospital das Clinicas, Sao Paulo University, found that suprageniculate lesions are responsible for 50% of the facial nerve involvement of several etiologies. Based on these results, the physician is able to develop a rationale for therapy and surgical access for facial nerve lesions.The topodiagnosis allows the physician to determine the topographic localization of pathology involving the facial nerve. It is based on clinical tests that evaluate the function of each one of the rami of the facial nerve. With a statistic of 873 patients, the Facial Nerve Group of Hospital das Clínicas, São Paulo University, found that suprageniculate lesions are responsible for 50% of the facial nerve involvement of several etiologies. Based on these results, the physician is able to develop a rationale for therapy and surgical access for facial nerve lesions.

Response to: Is it worth performing suture of the cauda equina roots after traumatic penetrating lumbar injury in a combat support hospital?

Dear Editor, We read with interest the recent paper entitled “microsurgical reconstruction of the cauda equina after traumatic transecting injury” by Tedesco-Marchese et al. [5]. The authors present four cases of symptomatic lumbar penetrating spinal injury with various degrees of cauda equina syndrome. The type of injury was a stab wound for three patients and a gunshot wound for one. Two patients were operated on within the first 3 days after injury, whereas the two others were operated on more than 3 years after the trauma occurred. Surgery consisted of extensive laminectomy, microsurgical suture of the roots with sural nerve grafts for the patient presenting with the gunshot injury. They only noticed improvement of bladder function for patients that were operated on in the acute phase. The mean duration of the surgery wasn’t mentioned nor was the existence of any postoperative complications. These results must be analyzed with precaution, considering the low number of patients in this study. In the war setting, penetrating lesions of the cauda equina are a rare situation. Blair et al. reported 598 US soldiers with spinal trauma evacuated from Iraq and Afghanistan from 2001 to 2009, corresponding to 5.45 % of all evacuated casualties during this period. Among them, 165 service members sustained penetrating injuries (1.5 % of all evacuated casualties) [1]. Blair mentioned nine patients with cauda equina syndrome without any precision about the type of injury (blunt or penetrating) for this small sample [2]. Management of such injuries is still controversial. Classically, the main aims of surgery are to perform root decompression in case of incomplete neurological deficit, stabilization if any instability exists, and achieve watertight closure of the wound in presence of persistent cerebrospinal fluid (CSF) leak [4]. The latter surgical procedure can be challenging, as for the case described by Kang et al., where a thecal sac ligation was finally inevitable [3]. Damage caused by bullets or improvised explosive devices may be devastating, leading to major difficulties in planning adequate surgical repair. During our deployment in Afghanistan, we had to manage penetrating spinal traumas among military but also among the civilian population. We keep in mind the case of a 15 year old civilian girl, victim of a gunshot aggression (AK 47 rifle). Her future husband shot her and her parents because the cost of the wedding was too elevated. She was firstly taken care of conservatively in a local medical centre before being evacuated, 2 days after injury, to our combat support Hospital. She complained of severe headache because of CSF leak and presented with an incomplete cauda equina syndrome (bladder dysfunction and left L5 paresis). There was a posterior wound with evidence of CSF leak. CT-scan showed the trajectory of the projectile from the true pelvis to the lumbosacral junction and the presence of multiple intracanalar fragments (Fig. 1). Surgery consisted of removal of all visible bone fragments by limited posterior approach through the existing wound. The dura was dilacerated and not suturable, and the root stumpswere unidentifiable in the spinal canal. It was decided to close the operating field with biological glue and perform sutures of all viable soft tissues from the spine to the skin in several layers. The patient observed 3 days of bed rest after surgery. A specific antibiotherapy was done because of abdominal infection and physiotherapy was R. Dulou (*) : J.