David G. Kline

Management and outcomes of 42 surgical suprascapular nerve injuries and entrapments

OBJECTIVE:Retrospective chart reviews of 42 patients with surgical suprascapular nerve (SSN) injury/entrapment were performed. Presenting symptoms, findings, operative approach, and results are documented. METHODS:Forty-two patients with SSN injuries/entrapments underwent operations between 1970 and 2002. Charts were retrospectively reviewed for the presence of shoulder pain; spinati muscle function was evaluated with the Louisiana State University Health Sciences Center grading system. Side of lesion and sex were equally represented; mean follow-up was 18 months (range, 12–48 mo). SSN injuries/entrapments were associated with occupational overuse (19), sports-related injury (16), direct trauma (4) and ganglion cysts (3). Thirty-one (79%) of 39 patients with suprascapular notch SSN injuries/entrapments, excluding ganglion cysts, presented with mild to moderate shoulder pain and spinati weakness. RESULTS:Motor function for these 31 patients was graded on a scale of 0 to 5. Preoperatively, patients had supraspinatus function Grades 0 to 2 and infraspinatus function Grades 0 to 2. Supraspinatus function improved postoperatively to Grade 4 or better in 28 patients (90%) and to Grades 2 to 3 in 3 patients (10%). Infraspinatus function improved to better than Grade 3 in 10 patients (32%), to Grades 2 to 3 in 14 patients (45%), and to Grade 1 in 7 patients (23%). Preoperatively, eight (21%) of 39 patients presenting with persistent severe pain had Grade 3 spinati strength. Of these eight patients, seven (88%) had an improvement in pain postoperatively. Strength in this group remained the same or improved to Grade 4. Postoperatively, three patients with ganglion cysts had good improvement in spinati function. CONCLUSION:Although SSN injury/entrapment is rare, 42 patients are presented who responded well to SSN release. Supraspinatus muscle improvement was as good as or better than that achieved in the infraspinatus.

Surgical Management of 10 Genitofemoral Neuralgias at the Louisiana State University Health Sciences Center

OBJECTIVE:This is a retrospective review of the charts of 10 patients with genitofemoral neuralgia who underwent neurectomy at the Louisiana State University Health Sciences Center between 1967 and 2000. Operations associated with these neuralgias and postoperative pain outcomes were analyzed. METHODS:The charts of 10 patients with genitofemoral neuralgias were analyzed retrospectively. RESULTS:The distribution of the 10 genitofemoral neuralgias with regard to right or left side and sex was found to be equal. L1 and L2 nerve blocks had resulted in a complete or substantial decrease in pain before neurectomy was recommended. Of six iatrogenic injuries (60%), gynecological surgery, including two hysterectomy procedures, resulted in a total of three genitofemoral neuralgias (50%), and vasectomy procedures antedated two nerve injuries (33%). Four (40%) of the 10 patients had injury to the genitofemoral nerve after blunt abdominal trauma. Genitofemoral neurectomy was performed in all genitofemoral neuralgia patients after conservative therapy had failed. This procedure resulted in considerable pain relief in all 10 patients, whether their injury was the result of iatrogenic causes or trauma. CONCLUSION:Genitofemoral neuralgias are infrequent conditions; however, 10 patients were accrued and analyzed in this study, and most had considerable or complete pain relief after neurectomy.

Iatrogenic sciatic nerve injuries at buttock and thigh levels: the Louisiana State University experience review.

OBJECTIVETo 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. METHODSThe 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. RESULTSPatients 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. CONCLUSIONPatients 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: 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.

Advances in the neurological and neurosurgical management of peripheral nerve trauma

Peripheral nerve trauma frequently affects younger people and may result in significant and long-lasting functional disability. Currently, diagnosis and monitoring of peripheral nerve injury relies on clinical and electrodiagnostic information, supplemented by intraoperative electrophysiological studies. However, in a significant proportion of nerve injuries, the likelihood of spontaneous regeneration resulting in good functional outcome remains uncertain and unnecessary delays to treatment may be faced while monitoring for recovery. Advances in non-invasive imaging techniques to diagnose and monitor nerve injury and regeneration are being developed, and have the potential to streamline the decision-making process. In addition, advances in operative and non-operative treatment strategies may provide more effective ways to maximise functional outcomes following severe peripheral nerve trauma. This review discusses these advances in light of the current state of the art of management of peripheral nerve trauma.

Peroneal nerve injury associated with sports-related knee injury

OBJECTnThis study analyzes 84 cases of peroneal nerve injuries associated with sports-related knee injuries and their surgical outcome and management.nnnMETHODSnThe authors retrospectively reviewed the cases of peroneal nerve injury associated with sports between the years 1970 and 2010. Each patient was evaluated for injury mechanism, preoperative neurological status, electrophysiological studies, lesion type, and operative technique (neurolysis and graft repair). Preoperative status of injury was evaluated by using a grading system published by the senior authors. All lesions in continuity had intraoperative nerve action potential recordings.nnnRESULTSnEighty-four (approximately 18%) of 448 cases of peroneal nerve injury were found to be sports related, which included skiing (42 cases), football (23 cases), soccer (8 cases), basketball (6 cases), ice hockey (2 cases), track (2 cases) and volleyball (1 case). Of these 84 cases, 48 were identified as not having fracture/dislocation and 36 cases were identified with fracture/dislocation for surgical interventions. Good functional outcomes from graft repair of graft length < 6 cm (70%) and neurolysis (85%) in low-intensity peroneal nerve injuries associated with sports were obtained. Recovery from graft repair of graft length between 6 and 12 cm (43%) was good and measured between Grades 3 and 4. However, recovery from graft repair of graft length between 13 and 24 cm was obtained in only 25% of patients.nnnCONCLUSIONSnTraumatic knee-level peroneal nerve injury due to sports is usually associated with stretch/contusion, which more often requires graft repair. Graft length is the factor to be considered for the prognosis of nerve repair.

Axillary nerve injury associated with sports

OBJECTnThe aim of this retrospective study was to present and investigate axillary nerve injuries associated with sports.nnnMETHODSnThis study retrospectively reviewed 26 axillary nerve injuries associated with sports between the years 1985 and 2010. Preoperative status of the axillary nerve was evaluated by using the Louisiana State University Health Science Center (LSUHSC) grading system published by the senior authors. Intraoperative nerve action potential recordings were performed to check nerve conduction and assess the possibility of resection. Neurolysis, suture, and nerve grafts were used for the surgical repair of the injured nerves. In 9 patients with partial loss of function and 3 with complete loss, neurolysis based on nerve action potential recordings was the primary treatment. Two patients with complete loss of function were treated with resection and suturing and 12 with resection and nerve grafting. The minimum follow-up period was 16 months (mean 20 months).nnnRESULTSnThe injuries were associated with the following sports: skiing (12 cases), football (5), rugby (2), baseball (2), ice hockey (2), soccer (1), weightlifting (1), and wrestling (1). Functional recovery was excellent. Neurolysis was performed in 9 cases, resulting in an average functional recovery of LSUHSC Grade 4.2. Recovery with graft repairs averaged LSUHSC Grade 3 or better in 11 of 12 casesnnnCONCLUSIONSnSurgical repair can restore useful deltoid function in patients with sports-associated axillary nerve injuries, even in cases of severe stretch-contusion injury.

MANAGEMENT OF ONE HUNDRED SEVENTY-ONE OPERATIVE AND NONOPERATIVE OBSTETRICAL BIRTH PALSIES AT THE LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER

OBJECTIVEnThe management of obstetrical brachial plexus injury, often called birth palsy, remains one of the most controversial topics in pediatric neurosurgery. Most birth palsies have acceptable spontaneous recoveries, whereas only a minority require surgical intervention. A selective approach for surgery was used in this Louisiana State University Health Sciences Center (LSUHSC) series, for which the operative rate was 9%. At LSUHSC, the patient with obstetrical brachial plexus injury is followed for 6 to 9 months before surgery, which is performed if there is no satisfactory biceps and/or shoulder function.nnnMETHODSnThis is a retrospective analysis of 169 patients with 171 palsies referred to LSUHSC for possible surgery. There were 76 patients with 77 birth palsies managed operatively and nonoperatively at LSUHSC between 1975 and 1991. An additional 93 patients with 94 palsies who were managed between 1992 and 2003 were included in this analysis. The results of initial and follow-up examinations using Engs criteria for impairment ratings (IRs) were available for 151 of 171 (88%) nonoperative and operative obstetrical brachial plexus injuries managed between 1975 and 2001.nnnRESULTSnFifty-two percent of the nonoperative patients evaluated at an initial visit had an IR of 4 or 5, which represents very poor function by comparison to IR of 1 in the Eng scale, which represents almost no abnormality. The percentage of patients in this category (4-5) improved to 30% after follow-up visits. For the 16 operative cases, the initial and follow-up percentages of patients with IRs of 4 or 5 were 67% and 22%, respectively. Ultimately, 47% of the nonoperative patients achieved a grade 2 IR after follow-up compared with 17% of the operative patients.nnnCONCLUSIONnUsing this selective approach at LSUHSC, in which the operative rate was 9%, acceptable outcomes were obtained both in patients not having surgery and also in those having surgical intervention.OBJECTIVEThe management of obstetrical brachial plexus injury, often called birth palsy, remains one of the most controversial topics in pediatric neurosurgery. Most birth palsies have acceptable spontaneous recoveries, whereas only a minority require surgical intervention. A selective approach for surgery was used in this Louisiana State University Health Sciences Center (LSUHSC) series, for which the operative rate was 9%. At LSUHSC, the patient with obstetrical brachial plexus injury is followed for 6 to 9 months before surgery, which is performed if there is no satisfactory biceps and/or shoulder function. METHODSThis is a retrospective analysis of 169 patients with 171 palsies referred to LSUHSC for possible surgery. There were 76 patients with 77 birth palsies managed operatively and nonoperatively at LSUHSC between 1975 and 1991. An additional 93 patients with 94 palsies who were managed between 1992 and 2003 were included in this analysis. The results of initial and follow-up examinations using Engs criteria for impairment ratings (IRs) were available for 151 of 171 (88%) nonoperative and operative obstetrical brachial plexus injuries managed between 1975 and 2001. RESULTSFifty-two percent of the nonoperative patients evaluated at an initial visit had an IR of 4 or 5, which represents very poor function by comparison to IR of 1 in the Eng scale, which represents almost no abnormality. The percentage of patients in this category (4–5) improved to 30% after follow-up visits. For the 16 operative cases, the initial and follow-up percentages of patients with IRs of 4 or 5 were 67% and 22%, respectively. Ultimately, 47% of the nonoperative patients achieved a grade 2 IR after follow-up compared with 17% of the operative patients. CONCLUSIONUsing this selective approach at LSUHSC, in which the operative rate was 9%, acceptable outcomes were obtained both in patients not having surgery and also in those having surgical intervention.

Surgical outcomes of 156 spinal accessory nerve injuries caused by lymph node biopsy procedures

OBJECTnIatrogenic injuries to the spinal accessory nerve (SAN) are not uncommon during lymph node biopsy of the posterior cervical triangle (PCT). In this study, the authors review the operative techniques and surgical outcomes of 156 surgical repairs of the SAN following iatrogenic injury during lymph node biopsy procedures.nnnMETHODSnThis retrospective study examines the authors clinical and surgical experience with 156 patients with SAN injury between 1980 and 2012. All patients suffered iatrogenic SAN injuries during lymph node biopsy, with the vast majority (154/156, 98.7%) occurring in Zone I of the PCT. Surgery was performed on the basis of anatomical and electro-physiological findings at the time of the operation. The mean follow-up period was 24 months (range 8-44 months).nnnRESULTSnOf the 123 patients who underwent graft or suture repair, 107 patients (87%) improved to Grade 3 functionality or higher using the Louisiana State University Health Science Center (LSUHSC) grading system. Neurolysis was performed in 29 patients (19%) when the nerve was found in continuity with recordable nerve action potential (NAP) across the lesion. More than 95% of patients treated by neurolysis with positive NAP recordings recovered to LSUHSC Grade 3 or higher. Forty-one patients (26%) underwent end-to-end repair, while 82 patients (53%) underwent graft repair, and Grade 3 or higher recovery was assessed for 90% and 85% of these patients, respectively. The average graft length used was 3.81 cm. Neurotization was performed in 4 patients, 2 of whom recovered to Grade 2 and 3, respectively.nnnCONCLUSIONSnSAN injuries present challenges for surgical exploration and repair because of the nerves size and location in the PCT. However, through proper and timely intervention, patients with diminished or absent function achieved favorable functional outcomes. Surgeons performing lymph node biopsy procedures in Zone I of the PCT should be aware of the potential risk of injury to the SAN.

Thoracic outlet syndrome: Part II. Management and outcomes of 133 operative neurogenic thoracic outlet syndrome cases

Neurogenic thoracic outlet syndrome (NTOS) is the most common variant of thoracic outlet syndrome. This article presents a 25-year experience of management of 133 operative NTOS patients, at the Louisiana State University Health Sciences Center, which have been divided into 2 subcategories of “disputed NTOS” or “true NTOS.” The clinical presentations, results of neurologic examinations, radiologic evaluations, operative procedures, intraoperative findings, and nerve action potential results and outcomes of the management are evaluated.

Surgical management and outcome of iatrogenic radial nerve injection injuries

OBJECTIVEnIatrogenic injury to the radial nerve can occur following intramuscular or intravenous injections of the upper extremity. In this study, we review the injury mechanism, operative techniques, and outcomes of patients evaluated for radial nerve injection injuries.nnnMETHODSnData from 33 patients evaluated by the senior authors (DGK and DHK) from 1970-2011 with radial nerve injection injuries were reviewed retrospectively. All patients had injury of the nerve during injection. All corrective operations involved the use of direct intraoperative nerve action potential (NAP) recordings and either neurolysis, neurectomy, or suture/graft repair. The Louisiana State University Health Science (LSUHS) grading system was used for clinical assessment.nnnRESULTSnOf the 33 patients, 23 underwent surgical intervention for persistent neurological deficit and/or pain. Of the 24 patients evaluated for injuries at the arm level, 17 required surgical exploration and repair for persistent symptoms. Nine patients required external neurolysis because the lesions were in continuity and positive NAP recording was across the lesion. All of these patients achieved a Grade 4 or better in functional recovery. Eight patients with lesions in continuity but in which NAP could not be recorded underwent either end-to-end suture (7) or graft repair (1) following resection of a 3.0 cm non-recordable segment. All patients achieved Grade 3 or 4 functional recovery. Six patients with forearm injuries involving the superficial sensory branch of radial nerve underwent either neurolysis (3) or neurectomy (3).nnnCONCLUSIONSnSurgical exploration may be indicated when pain or disabling motor deficits persist. Early diagnosis and operative intervention can achieve favorable outcomes through exploration and radial nerve repair.