Christian Heinen

Patient satisfaction and disability after brachial plexus surgery.

OBJECTIVELittle is known about patient satisfaction and disability after brachial plexus surgery. Would patients undergo the procedure again, if they knew the current result beforehand? How do they rate their result and their disability? METHODSOf 319 plexus patients who had undergone surgery between 1995 and 2005, 199 received a 65-item questionnaire. Measurement instruments included a new plexus-specific outcome questionnaire (Ulm Questionnaire) with categories of satisfaction, functionality, pain, comorbidities, and work; and the disability of the arm, shoulder, and hand questionnaire (DASH; scale, 0–100). RESULTSOf 99 returned questionnaires, 70 were returned in a useful form for evaluation. The results of patients with C5–C6 lesions (21 of 70) are as follows: 90% (19 of 21) would undergo surgery again, 95% (20 of 21) were satisfied with the result, and 86% (18 of 21) subjectively improved. The mean DASH score was 41 (standard deviation [SD], 24). The results of patients with C5–C7 lesions (6 of 70) are as follows: 50% (3 of 6) were satisfied and would undergo surgery again, and 67% (4 of 6) improved. The mean DASH score was 46 (SD, 13). The results of patients with C5–T1 lesions (43 of 70) are as follows: 67% (29 of 43) would undergo surgery again, 81% (35 of 42) were satisfied, and 74% (32 of 43) reported improvement. The mean DASH score was 58 (SD, 26). The overall mean DASH score was 52 (SD, 26). Pain since the injury was prevalent in 86% of patients (60 of 70), back pain in 53%, and depression/anxiety in 21%. Fifty-two percent of those who worked before their injury (27 of 53 patients) remained unemployed or incapacitated for work. Forty-five percent of previous workers (24 of 53) returned to their former occupation. Occupational retraining was successful for 70% of patients (16 of 23). The mean duration until return to work was 9 months overall and 5 months for those who returned to their previous occupation. CONCLUSIONEighty-seven percent of patients were satisfied with the results and 83% would undergo the procedure again. Despite a high satisfaction rate, patients remained considerably disabled, and half of the previous workers did not return to work. Occupational retraining is effective.

Iatrogenic Nerve Injuries

As long as humans have been medically treated, unfortunate cases of inadvertent injury to nerves afflicted by the therapist have occurred. Most microsurgically treated iatrogenic nerve injuries occur directly during an operation. Certain nerves are at a higher risk than others, and certain procedures and regions of the body are more prone to sustaining nerve injury. A high degree of insecurity regarding the proper measures to take can be observed among medical practitioners. A major limiting factor in successful treatment is delayed referral for evaluation and reconstructive surgery. This article on iatrogenic nerve injuries intends to focus on relevant aspects of management from a nerve surgeons perspective.

Health-Related Quality of Life After Spontaneous Subarachnoid Hemorrhage Measured in a Recent Patient Population

OBJECTIVE This study sought to determine the impact of spontaneous subarachnoid hemorrhage (SAH) on health-related quality of life (HRQOL). METHODS Data were taken retrospectively from 601 patients (219 male, 382 female) treated between 1998 and 2008. Questionnaires concerning HRQOL were circulated prospectively, and the responses from 253 patients (81 male, 172 female) were analyzed. The questionnaires comprised the standardized Short-Form 36 (SF-36) and Short-Form 12 (SF-12) Health Surveys, a number of nonstandardized questions, and visual analogue scales. Statistical analysis of the results was exploratory, using unifactorial ANOVA (Scheffe), multivariate analyses of variance. RESULTS The HRQOL is reduced considerably by SAH and remains so for a period of 10 years. Physical and emotional domains are primarily affected, but also cognitive functions, including memory and concentration in particular. Similarly, certain roles are affected that prove difficult to rehabilitate after acute care and cause serious debility in the long term. The Hunt and Hess Scale, Glasgow Outcome Scale, and seizures were found to have the greatest impact on HRQOL. CONCLUSIONS Documentation of HRQOL after 6 to 12 months is useful because patients are often found to have a diminished HRQOL in the absence of a clear physical impairment. Because psychological, emotional, cognitive, and social functioning influence HRQOL in the long term, efforts at rehabilitation should focus in particular on improving such factors. Documentation of HRQOL is a useful, additive tool for consolidating and evaluating the outcome, and a treatment end point after SAH, respectively.

Hypocalcaemia as a prognostic factor of early mortality in moderate and severe traumatic brain injury

Abstract Objectives: Our main objective was to evaluate whether serum hypocalcaemia on the third day [defined as < 2·1 mmol/l (8·5 mg/dl)] is a prognostic factor for early mortality after moderate and severe traumatic brain injury (TBI). Methods: We developed an ambispective comparative case control study. We evaluated clinical profiles from included patients from January 2005 to July 2009 and we prospectively recruited additional patients from August 2009 to July 2011. Patients were between 1 and 89 years old and had a Glasgow Coma Scale of 3–12 points following TBI. Results: We calculated an Odds Ratio of 5·2 (Confidence Intervals 95%: 4·48 to 6·032) for hypocalcaemia on day three, which was associated with death. Retrospectively (January 2005 to July 2009) we compiled data from 81 patients. Prospectively (August 2009 to July 2011) we recruited 41 patients. The adjusted variables in the logistic regression final model were: serum calcium on day three (Odds Ratio 3·5, Confidence Intervals 95%: 1·12 to 13·61, P < 0·028) and anisocoria (Odds Ratio 8·24, Confidence Intervals 95%: 1·3 to 67·35, P < 0·019) obtaining an adjusted R2 of 0·22 (P < 0·005). Discussion: The serum levels of calcium on day three could be useful for the prediction of mortality in patients with moderate and severe TBI.

Iatrogenic Injuries of the Nerves

Abstract Inadvertent, physician-induced injury to peripheral nerves, termed iatrogenic nerve injury, is not rare. In many instances, nerves are substantially injured or destroyed to a degree that precludes spontaneous recovery. The treatment of such injury should follow the same principles as any other traumatic nerve injury, except for radiation- or injection-induced lesions. Nevertheless, failure to advise for exploration and repair and delay of necessary surgical treatment is common. In this chapter we describe current data on iatrogenic peripheral nerve injury, its surgical and nonsurgical causes, expose regions at risk, and procedures that have an immanently higher risk to produce iatrogenic damage. Nerves frequently injured to degrees necessitating repair are discussed with their specifics from pathogenesis and anatomy to repair/surgery and prognosis. With the exception of the spinal accessory nerve, this compilation is limited to peripheral nerve injury and does not cover cranial nerve injury. In a concluding section, medicolegal aspects are presented.

Retractorless Surgery of Vascular Lesions

The introduction of the operating microscope enabled modern neurosurgery. For usually deep-seated vascular lesions and confining, overhanging brain parenchyma walls, self-retaining retractors were necessary to enable open and safe dissection corridors. However, retractors also exert secondary pressure effects and can limit the degree of manual freedom [1].

Surgery of IC-Anterior Choroidal Aneurysms

Anterior choroidal artery aneurysms (AChAA) are comparatively rare and appear with a frequency from around 2–4% to 10% in larger series, e.g., M Lawton personal series of 2500 clipped aneurysms: n = 98 AChA = 4% [1]. Number of AChAA in treated aneurysms of BRAT study 2.2%, median aneurysm size 7 mm, 9 of 408 treated; 209 clipped +199 coiled [2]. Kuopio aneurysm data base 1977–2005 of 3005 patients with 4253 aneurysms there were 99 (10%) AChAA in 70 (8%) patients [3].

Retraktorlose Neurochirurgie, Operationsfluss und Zugänge

Retraktorloses Operieren zwingt zu einem sehr effektiven und gewebeschonenden Praparationsstil. Es setzt die Verwendung einer Mundstuck- und Fuspedalsteuerung des Mikroskops voraus. Es kombiniert altbewahrte mikrochirurgische Prinzipien mit modernen Methoden der Zugangsminimierung. Wir stellen die einzelnen Elemente des retraktorlosen Operierens im Zusammenhang dar und erlautern, warum es in letzter Konsequenz den Operationsfluss verbessert. Neben Hinweisen fur das Erlernen der retraktorlosen Methode und den damit einhergehenden Vorteilen werden gangige Zugangswege in ihrer Abfolge exemplarisch dargestellt.

Geplant erzeugter Herzstillstand

Fur komplexe Aneurysmen und im Notfall bei einer Gefasruptur ohne proximale Kontrolle kann ein iatrogen induzierter Herzstillstand die entscheidende Masnahme sein, um die Gefaspathologie adaquat versorgen zu konnen. Die klassische Masnahme des Herzstillstands unter tiefer Hypothermie wurde heute in den meisten Fallen durch andere, weitaus weniger aufwendige Verfahren verdrangt. Das Kapitel gibt einen komprimierten Uberblick uber die Verfahren und deren Vor- und Nachteile.

Fall 14: Symptomatische nicht rupturierte okzipitale AVM

Beschrieben wird der Fall einer mit Kopfschmerzen symptomatischen AVM Spetzler-Martin Grad II die in typischer Technik reseziert wird.