Kirsty U. Boyd

Nerve reconstruction in the hand and upper extremity.

In the management of traumatic peripheral nerve injuries, the severity or degree of injury dictates the decision making between surgical management versus conservative management and serial examination. This review explores some of the recent literature, specifically addressing recent basic science advances in end-to-side and reverse end-to-side recovery, Schwann cell migration, and neuropathic pain. The management of nerve gaps, including the use of nerve conduits and acellularized nerve allografts, is examined. Current commonly performed nerve transfers are detailed with focus on both motor and sensory nerve transfers, their indications, and a basic overview of selected surgical techniques.

Wrist Ganglion Treatment: Systematic Review and Meta-Analysis

PURPOSE To review the clinical outcomes of treatment for adult wrist ganglions and to conduct a meta-analysis comparing the 2 most common options: open surgical excision and aspiration. METHODS The review methodology was registered with PROSPERO. We performed a systematic search of MEDLINE and EMBASE for articles published between 1990 and 2013. Included studies reported treatment outcomes of adult wrist ganglions. Two independent reviewers performed screening and data extraction. We evaluated the methodological quality of randomized controlled trials (RCT) and cohort studies using the Cochrane Handbook for Systematic Reviews and the Newcastle-Ottawa Scale, respectively; Grading of Recommendations, Assessment, Development, and Evaluation was used to evaluate the quality of evidence. RESULTS A total of 753 abstracts were identified and screened; 112 full-text articles were reviewed and 35 studies (including 2,239 ganglions) met inclusion criteria for data extraction and qualitative synthesis. Six studies met criteria for meta-analysis, including 2 RCTs and 4 cohort studies. In RCTs surgical excision was associated with a 76% reduction in recurrence compared with aspiration. Randomized controlled trial quality was moderate. In cohort studies surgical excision was associated with a 58% reduction in recurrence compared with aspiration. Cohort study quality was very low. In cohort studies aspiration was not associated with a significant reduction in recurrence compared with reassurance. Across all studies mean recurrence for arthroscopic surgical excision (studies, 11; ganglions, 512), open surgical excision (studies, 14; ganglions, 809), and aspiration (studies, 12; ganglions, 489) was 6%, 21%, and 59%, respectively. Mean complication rate for arthroscopic surgical excision (studies, 6; ganglions, 221), open surgical excision (studies, 6; ganglions, 341), and aspiration (studies, 3; ganglions, 134) was 4%, 14%, and 3%, respectively. CONCLUSIONS Open surgical excision offers significantly lower chance of recurrence compared with aspiration in the treatment of wrist ganglions. Arthroscopic excision has yielded promising outcomes but data from comparative trials are limited and have not demonstrated its superiority. Further RCTs are needed to increase confidence in the estimate of effect and to compare complications and recovery. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

Refining perforator selection for DIEP breast reconstruction using transit time flow volume measurements.

Transit time flow volume has been used in cardiac surgery to assess small vessel flow characteristics. This study examines the usefulness of transit time flow volume (TTFV) in assessing perforator vessels in deep inferior epigastric artery perforator (DIEP) flap harvesting. The purpose of this study was to evaluate the correlation among computed tomographic angiography (CTA), intraoperative TTFV measurements, and hand-held Doppler signals in identifying perforators. Ten consecutive free DIEP breast reconstructions were prospectively evaluated using CTA to identify abdominal wall perforators. Intraoperatively, perforating vessels >1 mm in diameter were evaluated with a conventional hand-held 8-MHz Doppler and a TTFV measurement device. Vessel location was correlated with preoperative CTA . Waveform patterns and TTFV measurements were recorded for each vessel and correlated with both CTA and hand-held Doppler signals. Of the 54 perforators identified, TTFV showed arterial flow waveforms in 15 of 16 perforators identified by CTA and in 2 of the remaining 38 vessels. The sensitivity and specificity of TTFV in identifying arterial perforators were 94 and 95%, respectively. In contradistinction, hand-held Doppler was misleading in 70% of vessels. TTFV distinguishes arterial from venous waveforms in vessels that appear arterial by hand-held Doppler signals. CTA and TTFV are highly correlated, and the use of TTFV may prevent poor perfusion seen in some DIEP flaps.

Recurrent non-epileptiform seizure-like phenomena secondary to propofol administration

To the Editor, Propofol is a short-acting, lipophilic anesthetic and has been used to treat refractory status epilepticus. However, there have been reports of propofol-induced ‘‘seizure-like phenomena’’ (SLP). Little is known regarding the underlying pathophysiology or electroencephalographic correlates of SLP, and no reports of recurrent SLP exist. We report a case of a 57-yr-old male, admitted for ulnar nerve transposition. Past medical history included mitral valve prolapse, gastro-esophageal reflux, dyslipidemia, and no known drug allergies. There was no history of seizures or alcohol/illicit drug abuse. Prior anesthetic history was unremarkable. Induction of anesthesia was achieved with midazolam (2 mg), fentanyl (200 lg), propofol (200 mg), and dexmedetomidine (44 lg). General anesthesia was maintained using sevoflurane and a dexmedetomidine infusion. Reversal of anesthesia, including awakening and extubation, were unremarkable. Total surgical time was 90 min. The patient was monitored in the postanesthesia care unit for ongoing nausea. Four hours postoperatively, the patient was witnessed to have a 15-min episode of what appeared to be uncontrollable shivering. Bilateral arm and leg movements were observed, with associated tachycardia (heart rate 204 beats min, tachypnea (respiratory rate 24 beats min) and subsequent desaturation (SpO2 85%). He was able to speak throughout. Oxygen saturation improved to 95% with supplemental oxygen, and temperature was 36.5 C at the time of the incident. The etiology of this unusual motor activity was not clearly established. Eight months later, he returned for revision decompression. Induction of anesthesia was achieved with midazolam (3 mg), fentanyl (150 lg), propofol (150 mg), remifentanil (150 lg), and succinylcholine (60 mg). Anesthesia was maintained using desflurane (1.0 MAC) and hydromorphone boluses (1.6 mg total). Total surgical time was 100 min. Emergence was initially uneventful, with the patient extubated awake and following commands. Two minutes following extubation, he no longer followed commands. Subsequently, generalized movements of all four extremities appeared (SLP, video: available as Electronic Supplementary Material), and he was treated with intravenous midazolam (2 mg, followed by an additional 1 mg). The movements stopped after approximately one minute. Despite subsequent treatment with propofol and additional midazolam, intermittent episodes of movements with similar duration followed with increasing frequency throughout the patient’s stay in Electronic supplementary material The online version of this article (doi:10.1007/s12630-017-0869-1) contains supplementary material, which is available to authorized users.

Obtaining high cure rates for challenging facial malignancies: A new method for producing rapid, accurate, high-quality frozen sections

PURPOSE The authors developed a new system to provide rapid, accurate, full-face frozen sections. OBJECTIVE To evaluate the efficacy of the system when applied to the treatment of nonmelanoma cutaneous malignancies using Mohs micrographic surgery (MMS). METHODS Patients undergoing MMS procedures between 2003 and 2007 for nonmelanoma head and neck cutaneous malignancies were prospectively collected. Specimens were prepared either in a traditional cryostat-based manner or using the new system. RESULTS A total of 196 patients with 234 head and neck nonmelanoma cutaneous malignancies were included. The majority of tumours were basal cell carcinomas (89.5%). Of these, 38% demonstrated aggressive histologies (sclerosing or micronodular), and 30% were recurrent. On average, two levels (range one to six) and four blocks (range two to 23) were required to obtain clear margins. The mean defect size was 3.68 cm(2) (range 0.13 cm(2) to 37.68 cm(2)). Over the five-year study period, there were two recurrences in 234 cases (less than 1%), which compares favourably with other MMS series. The new system was associated with a shorter operative time than traditional specimen preparation (102 min versus 131 min; P=0.004). The new and traditional specimen preparation groups were similar in terms of the number of previous recurrences (29% versus 30%; P=1.00), defect size (3.7 cm(2) versus 4.0 cm(2); P=0.81) and the number of levels required (1.9 versus 1.5; P=0.05). CONCLUSIONS The new system enables fast, accurate, full-face frozen section specimens that are ideal for MMS. The speed of specimen preparation is demonstrated by faster operative times, and a low recurrence rate attests the accuracy and quality of the sections.

Anomalous Extratemporal Facial Nerve in Oculoauriculovertebral Spectrum

Facial nerve dysfunction is common in oculoauriculovertebral spectrum (OAVS). However, the course of the nerve has rarely been described. A 23-year-old woman with OAVS underwent excision of microtic ear remnants in preparation for an osseointegrated prosthesis and suffered iatrogenic transection of the facial nerve—the pes anserinus was within the subcutaneous tissue 15 mm posterior and 15 mm cephalad to the external acoustic meatus. The patient underwent primary nerve repair and regained nearly complete preoperative function. When considering reconstruction for OAVS patients, clinicians should have a high index of suspicion for anomalous facial nerve anatomy.

Clinical Outcomes of Nerve Transfers in Peroneal Nerve Palsy: A Systematic Review and Meta-Analysis

Background Given the unsatisfactory outcomes with traditional treatments, there is growing interest in nerve transfers to reestablish ankle dorsiflexion in peroneal nerve palsy. The objective of this work was to perform a systematic review and meta‐analysis of the primary literature to assess the effectiveness of nerve transfer surgery in restoring ankle dorsiflexion in patients with peroneal nerve palsy. Methods Methodology was registered with PROSPERO, and PRISMA guidelines were followed. MEDLINE, EMBASE, and the Cochrane Library were systematically searched. English studies investigating outcomes of nerve transfers in peroneal nerve palsy were included. Two reviewers completed screening and extraction. Methodological quality was evaluated with Newcastle‐Ottawa Scale. Results Literature search identified 108 unique articles. Following screening, 14 full‐text articles were reviewed. Four retrospective case series met inclusion criteria for meta‐analysis. Overall, 41 patients underwent nerve transfer for peroneal nerve palsy. The mean age of the patients was 36.1 years, mean time to surgery was 6.3 months, and the mean follow‐up period was 19.0 months. Donor nerve was either tibial (n = 36) or superficial peroneal branches/fascicles (n = 5). Recipient nerve was either deep peroneal (n = 24) or tibialis anterior branch (n = 17). Postoperative ankle dorsiflexion strength demonstrated a bimodal distribution with a mean Medical Research Council of 2.1. There were no significant differences in dorsiflexion strength between injury sites (p = 0.491), injury mechanisms (p = 0.125), donor (p = 0.066), or recipient nerves (p = 0.496). There were no significant correlations between dorsiflexion strength and patient age (p = 0.094) or time to surgery (p = 0.493). Conclusions There is variability in dorsiflexion strength following nerve transfer in peroneal nerve palsy, whereby there appear to be responders and non‐responders. Further studies are needed to better define appropriate patient selection and the role of nerve transfers in the management of peroneal nerve palsy.

Efficacy and safety of bilateral thoracic paravertebral blocks in outpatient breast surgery

Unilateral thoracic paravertebral blocks (TPVBs) have demonstrated reliable intraoperative analgesia, low postoperative pain scores, and an opioid‐sparing effect in breast cancer surgery. However, secondary to the perceived risk of complications, bilateral TPVB have been less well accepted and are less frequently used. The purpose of this study was to evaluate the feasibility of using bilateral TPVBs in outpatient surgery for patients undergoing bilateral mastectomy with immediate implant‐based reconstruction. Electronic medical records were retrospectively reviewed for patients receiving bilateral TPVBs for bilateral mastectomy with immediate implant‐based reconstruction performed by a single surgeon from September 2012 to September 2015. Records were reviewed for incidence of complications, time to discharge, and incidence of unplanned admission or readmission. Clopper‐Pearson method for binomial distribution was used to calculate confidence intervals for proportions. Forty‐five patients undergoing bilateral mastectomy with immediate reconstruction received bilateral TPVBs. There were 4 TPVB‐related complications, all of which were symptomatic hypotension or bradycardia (9%; 95% CI, 2%‐21%). There was no incidence of symptomatic pneumothorax. Mean time to discharge readiness from the postanesthesia care unit (PACU) was 1.9 hours (SD = 1.0). Overall, 91% (n = 29) of the 32 patients scheduled for day surgery were discharged home as planned. Mean time from entry to PACU to home discharge for day surgery patients (n = 32) and planned admissions (n = 13) was 5.9 hours (SD = 4.3) and 16.3 hours (SD = 3.6), respectively. There was no incidence of readmission following discharge. Bilateral TPVBs can safely facilitate day surgery in carefully selected patients undergoing bilateral mastectomy with immediate implant‐based reconstruction.

Complementary and Alternative Medicines and Patients With Breast Cancer: A Case of Mortality and Systematic Review of Patterns of Use in Patients With Breast Cancer:

Background: The use of complementary and alternative medicines (CAMs) is common among women being treated for breast cancer. A recent mortality associated with CAM at our center precipitated a systematic review of the Cochrane, EMBASE, and PubMed databases to identify English manuscripts including “CAM” and “breast cancer.” Methods: Papers included for review were selected based on predefined inclusion and exclusion criteria. The primary outcome was the use of CAM by women with breast cancer. Secondary outcomes included timing of use along disease trajectory, attitudes toward CAM by allopathic practitioners, and patient disclosure of CAM use to treating allopathic physicians. Results: Of 701 titles identified by the search strategy, 36 met the inclusion criteria. The weighted average proportion of women with breast cancer who use CAM was 40% (standard deviation: 18%). The diagnosis of breast cancer also prompts the initiation or increase of CAM use. However, up to 84% of patients do not disclose the use of CAM to their allopathic practitioners. Conclusions: Although CAM is often dismissed as a harmless addition to allopathic therapy, significant complications and interactions can occur. Our review and the dramatic case example provided highlight the need for physicians to educate themselves regarding CAM and to engage with their patients regarding its use.

The Use of Neuronavigation as an Adjunct in Facial Reconstructive Surgery.

Neuronavigation, a ubiquitous tool used in neurosurgery, is rarely used in maxillofacial reconstructive surgery despite it offering many advantages without any disadvantage to the patient. The present report describes one patient with complex gun-shot wound facial injury and one patient with a rare malignant peripheral nerve sheath tumor involving the skull base, in which neuronavigation was used to improve the accuracy of bony reduction and minimize surgical invasiveness. Although neuronavigation is not necessary for all maxillofacial surgery, it can be a useful adjunct in complex maxillofacial reconstruction and maxillofacial tumor resection.