Gabriel C. Tender

Gilliatt-Sumner hand revisited: a 25-year experience.

OBJECTIVE:Thirty-three patients with true neurogenic thoracic outlet syndrome, or Gilliatt-Sumner hand, underwent surgical treatment at Louisiana State University during a 25-year period. This study retrospectively evaluated the outcome referable to pain and motor function in these patients. METHODS:All patients had the typical Gilliatt-Sumner hand, secondary to compression of C8, T1, and/or lower trunk. Nineteen patients underwent an anterior supraclavicular approach, and 15 patients underwent a posterior subscapular approach to the brachial plexus. Nerve action potential recordings showed plexus involvement close to the spine, at the level of the junction of the spinal nerves to the lower trunk. RESULTS:Pain, present in 22 patients, improved in 21. Mild motor deficit improved in 12 of 14 patients. Severe motor deficit improved partially in 14 of 20 patients. CONCLUSION:The diagnosis of true neurogenic thoracic outlet syndrome provides a clear operative indication. Surgical decompression needs to involve the medial portion of the plexus, and especially the spinal nerves. An anterior supraclavicular approach is preferred in most cases. If there is a large cervical rib or there has been a prior anterior operation, then a posterior subscapular approach is indicated.

Posterior subscapular approach to the brachial plexus

THE POSTERIOR SUBSCAPULAR APPROACH to the brachial plexus is commonly indicated in patients with neural entrapment (neurogenic thoracic outlet syndrome, especially when associated with a large C7 transverse process or cervical rib) and paraspinal tumors or lacerating injuries involving the spinal nerves close to the spine. This approach is also preferred in patients with previous anterior neck operations and/or morbid obesity. We describe the anatomy and operative technique of this approach, which has been used by the senior author (DGK) for the past 25 years.

Percutaneous pedicle screw reduction and axial presacral lumbar interbody fusion for treatment of lumbosacral spondylolisthesis: A case series

IntroductionTraditional surgical management of lumbosacral spondylolisthesis is technically challenging and is associated with significant complications. The advent of minimally invasive surgical techniques offers patients treatment alternatives with lower operative morbidity risk. The combination of percutaneous pedicle screw reduction and an axial presacral approach for lumbosacral discectomy and fusion offers an alternative procedure for the surgical management of low-grade lumbosacral spondylolisthesis.Case presentationThree patients who had L5-S1 grade 2 spondylolisthesis and who presented with axial pain and lumbar radiculopathy were treated with a minimally invasive surgical technique. The patients-a 51-year-old woman and two men (ages 46 and 50)-were Caucasian. Under fluoroscopic guidance, spondylolisthesis was reduced with a percutaneous pedicle screw system, resulting in interspace distraction. Then, an axial presacral approach with the AxiaLIF System (TranS1, Inc., Wilmington, NC, USA) was used to perform the discectomy and anterior fixation. Once the axial rod was engaged in the L5 vertebral body, further distraction of the spinal interspace was made possible by partially loosening the pedicle screw caps, advancing the AxiaLIF rod to its final position in the vertebrae, and retightening the screw caps. The operative time ranged from 173 to 323 minutes, and blood loss was minimal (50 mL). Indirect foraminal decompression and adequate fixation were achieved in all cases. All patients were ambulatory after surgery and reported relief from pain and resolution of radicular symptoms. No perioperative complications were reported, and patients were discharged in two to three days. Fusion was demonstrated radiographically in all patients at one-year follow-up.ConclusionsPercutaneous pedicle screw reduction combined with axial presacral lumbar interbody fusion offers a promising and minimally invasive alternative for the management of lumbosacral spondylolisthesis.

Genitofemoral nerve protection during the lateral retroperitoneal transpsoas approach.

BACKGROUND: The minimally invasive lateral retroperitoneal approach for lumbar fusions is a novel technique with good results, but also with significant sensory and motor complications. OBJECTIVE: To present the early results of a modified surgical technique, in which the psoas muscle is dissected under direct visualization. METHODS: Thirteen consecutive patients with L4-5 or L3-4 pathology were prospectively followed after being treated using a minimally invasive lateral approach with direct exposure of the psoas muscle before dissection. There were 7 woman and 6 men with a mean age of 52.3 years. Perioperative parameters like operative time, estimated blood loss, and length of stay, were noted. Pain, paresthesia, and motor weakness, as well as any other complications, were evaluated at 2 weeks and 3 months postoperatively. RESULTS: The mean operative time, estimated blood loss, and length of stay were 163 minutes, 126 mL, and 3 days, respectively. One patient exhibited anterior thigh pain and paresthesia at 2 weeks, both of which resolved by 3 months. Two patients experienced superficial wound infections that healed with antibiotics. The genitofemoral nerve was identified and protected in 7 patients; in 4 patients, it had a more posterior anatomic location than expected. The femoral nerve was not exposed or detected in the operative field by neuromonitoring, nor were there any symptoms related to a femoral nerve injury in any patient. CONCLUSION: Dissection of the psoas muscle under direct visualization during the minimally invasive lateral approach may provide increased safety to the genitofemoral and femoral nerves.

Actinomycotic Brain Abscess and Subdural Empyema of Odontogenic Origin: Case Report and Review of the Literature

v a Actinomyces are gram-positive, nonacid-fast, branching filamentous prokaryotic microorganisms with anaerobic or microaerophilic requirements. Actinoyces species are part of the normal flora of the ropharyngeal cavity, specifically concentrated in he tonsillar crypts, the surface of carious teeth, and he gingival pocket. Actinomycosis is rarely a athologic concern because of the organism’s low irulence and does not appear to be an opportunistic isease because there is no specific predisposition oward immunocompromised individuals. Diect trauma, tooth extraction, root canal therapy, and eriodontal or periapical abscesses compromise the ntegrity of the oral mucosa and are believed to be the ost common mechanisms of pathogenesis. The principal bacteria in humans is Actinomyces israelii, a normal inhabitant of the oral cavity. Other members of the Actinomycetaceae family that are involved in human pathogenesis include A viscosus (40%), A naeslundii (5%), A odontolyticus (2%), and A meyeri (1%). Cervicofacial actinomycosis presnts as a chronic suppurative infection that typically gnores traditional fascial planes and is associated ith multiple fistulae tracts. The granulation-type leions harbor colonies of actinomyces and other baceria and promote a significant inflammatory response n the surrounding tissues. If the disease follows a ong-term course, the inflammation leads to fibrosis nd scar tissue formation, which in turn decreases xygen perfusion and creates an anaerobic environ-

Neurotrophin-3 and Tyrosine Kinase C Have Modulatory Effects on Neuropathic Pain in the Rat Dorsal Root Ganglia

BACKGROUND:Neurotrophin-3 (NT3) and its cognate receptor, tyrosine kinase C (TrkC), have recently been shown to modulate neuropathic pain. Another receptor, the transient receptor potential vanilloid 1, is considered a molecular integrator for nociception. Transient receptor potential vanilloid 1–positive cells can be selectively ablated by Resiniferatoxin (RTX). NT3 changes in the dorsal root ganglia (DRG) after RTX treatment may further define their role in pain modulation. OBJECTIVE:To demonstrate the role of NT3 and TrkC in intraganglial RTX-induced pain suppression and in neuropathic pain development. METHODS:Fifty-three rats underwent a photochemical left sciatic nerve injury. Neuropathic animals were treated by RTX injection in the ipsilateral L3-6 DRG. NT3 and TrkC presence in the DRG was evaluated before and after the nerve injury, as well as after RTX treatment. RESULTS:The RTX injection resulted in pain inhibition. NT3 normally expressed mainly in large- and medium-size neurons. NT3 presence was increased mainly in the small DRG cells of neuropathic animals, and the medium- and large-size neurons of nonallodynic rats. RTX treatment of allodynic rats changed the NT3 distribution to a nonallodynic pattern. TrkC expressed mainly in large/medium-size neurons. After nerve injury, TrkC expression was also increased in the small DRG cells of allodynic animals (although less than NT3), and the medium- and large-size cells of nonallodynic ones. After RTX, TrkC expression gradually decreased, but with persistence in the large DRG cells. CONCLUSION:NT3 may have antinociceptive effects in the DRG. These effects may be mediated, at least in part, by TrkC in the medium- and large-size DRG neurons.

Anterior Supraclavicular Approach to the Brachial Plexus

The anterior supraclavicular approach to the brachial plexus is commonly indicated in patients with traumatic injuries, tumors, or entrapment of the brachial plexus elements. We describe the anatomy and operative technique of this approach, which has been used by the senior author (DGK) for the past 30 years.

Brain-derived neurotrophic factor redistribution in the dorsal root ganglia correlates with neuropathic pain inhibition after resiniferatoxin treatment.

BACKGROUND CONTEXT Brain-derived neurotrophic factor (BDNF) and its cognate receptor, the tyrosine kinase B (TrkB), are normally expressed in neurons and implicated in multiple pathological conditions. Brain-derived neurotrophic factor is produced in the central nervous system microglia in response to noxious stimuli and appear to potentiate central sensitization. Resiniferatoxin (RTX) is an excitotoxic agonist of the vanilloid receptor 1 (VR1), a cation channel protein considered an integrator for nociception. Resiniferatoxin, administered into the dorsal root ganglia (DRG), selectively eliminates the VR1-positive neurons and improves tactile allodynia in a neuropathic pain rat model. PURPOSE The goal of the present study was to evaluate the role of BDNF in RTX-induced neuropathic pain suppression. STUDY DESIGN The study design was a sciatic nerve injury animal model with intraganglionic RTX injection. METHODS Resiniferatoxin was injected into the DRG of the L3-L6 spinal nerves after the rats displayed tactile allodynia and thermal hyperalgesia produced by a photochemical injury to the sciatic nerve. Behavioral testing and immunohistochemical and mRNA analysis of the DRG were performed to determine BDNFs role in pain modulation. RESULTS Brain-derived neurotrophic factor expression in the DRG of neuropathic rats was upregulated in the small- and medium-size neurons, whereas the upregulation was observed in the large-size neurons of non-neuropathic rat DRG. A high-dose RTX injection in the DRG of neuropathic rats led to elimination of both thermal hyperalgesia and tactile allodynia and also upregulated BDNF in the large-size neurons, similar to the nonallodynic rats. Tyrosine kinase B changes mirrored the BDNF ones. CONCLUSION Resiniferatoxin injection in the DRG of neuropathic rats upregulates BDNF expression in the same pattern as in the large-size neurons of non-neuropathic rats. Therefore, BDNF upregulation may have pain suppressive effects. These effects are likely mediated by TrkB.

Submuscular transposition of the ulnar nerve for the treatment of cubital tunnel syndrome.

THE ULNAR NERVE is compressed at the cubical notch in patients with cubital tunnel syndrome. To definitively alleviate this compression, the nerve can be transposed under the pronator teres and flexor carpi ulnaris muscles. This procedure is also known as medianization of the ulnar nerve because it then courses parallel to the median nerve. In the current article the procedure is described in a step-by-step fashion.

Primary cervical spine carcinoid tumor in a woman with arm paresthesias and weakness: a case report

IntroductionCarcinoid tumors are neuroendocrine neoplasms derived from the enterochromaffin cells. Central nervous system involvement is rare and has been reported either as metastases to the brain and spine or primary tumors involving the sacrococcygeal spine. We report the first case of a primary carcinoid tumor of the cervical spine.Case presentationA 50-year-old African-American woman presented with a 4-month history of numbness, paresthesias, and mild left-hand weakness. Magnetic resonance imaging of her cervical spine revealed a homogenously enhancing extradural mass, indenting the cervical cord and expanding the left neural foramen at C7–T1. A C7 corpectomy, en bloc resection of the tumor, and anterior C6–T1 fusion were performed to decompress the spinal cord and nerves and provide stability. Postoperative histopathologic examination and immunohistochemical analysis were consistent with carcinoid tumor. There has been no recurrence at the 6-year follow-up visit.ConclusionsPrimary cervical carcinoid tumor is extremely rare, but should be included in the differential diagnosis of enhancing expansile extradural masses compressing the spinal cord and nerves. Surgical resection may provide a definitive cure.