Leandro Pretto Flores

Estudo epidemiológico das lesões traumáticas de plexo braquial em adultos

OBJECTIVE This study aims to provide information about epidemiological factors related to traumatic brachial plexus injuries in adults. METHOD Prospective analysis of 35 consecutive cases, observed in a period of one year. RESULTS Most of the lesions were supraclavicular (62%). Twenty-one cases occurred due to traction (60%), 9 to gun shot wound (25%), 3 to compression (8.5%) and two perforation/laceration (5.7%). Motorcycle accidents were the cause of trauma in 54% of patients. CT myelography demonstrated root avulsion in 16 cases (76%). Partial spontaneous neurological recovery was observed in 43% of the patients. Neuropathic pain occurred in 25 (71%) cases, and the use of some oral intake drugs (as amitriptyline or carbamazepine) controlled it in 64% of times. CONCLUSION Traction is the most frequent mechanism related to brachial plexus injuries, and root avulsions are common in this cases. Pain and concomitant lesions are frequently observed in these group. In this series, the rate of incidence to the local population was 1.75/100000/year.

Surgical results of the Hypoglossal-Facial nerve Jump Graft technique.

SummaryBackground. The Hypoglossal-Facial nerve crossover has appeared as a surgical option for those scenarios where the facial nerve is injured in its intracranial course, but the conventional technique unequivocally leads to twelfth cranial nerve deficit. In recent years a number of different surgical approaches have been introduced with a view to avoiding the complete section of the hypoglossal nerve, such as the Jump Graft technique. This paper aims to present the results of the Hypoglossal-Facial nerve Jump Graft technique in relation to facial musculature reanimation capability and hemitongue function preservation. Methods. A retrospective analysis of the records of eight patients submitted to Hypoglossal-Facial nerve Jump Graft technique was performed. The surgical approach was characterised by the interposition of a short graft sutured to the distal stump of the transected facial nerve and sutured end-to-side to the hypoglossi, with cutting of only a third of the diameter of the latter. Findings. The facial nerve injuries were secondary to temporal bone trauma in five cases and to cerebellopontine angle tumour surgery in three. Grafts were harvested from the greater auricular nerve in six patients and from the sural nerve in two. The results of facial reanimation demonstrated facial symmetry and improvement in the facial tone in all cases, and classified as House-Brackmann grade IV in three (37.5%) and grade III in five (62.5%) patients. There was no incidence of definitive hemitongue atrophy and no patient complaint of swallowing or speech difficulty. Conclusions. The modification of the conventional technique of Hypoglossal-Facial nerve anastomosis by means of sectioning one third of the hypoglossal nerve area does not lead to dysfunction of this nerve and the surgical results in terms of facial reanimation are satisfactory.

Proximal motor branches from the tibial nerve as direct donors to restore function of the deep fibular nerve for treatment of high sciatic nerve injuries: a cadaveric feasibility study.

OBJECTIVE The results of surgical repair of the fibular division of the sciatic nerve have been considered unsatisfactory, especially if grafts are necessary to reconstruct the nerve. To consider the clinical application of the concept of distal nerve transfer for the treatment of high sciatic nerve injuries, this study aimed to determine detailed anatomic data about the possible donor branches from the tibial nerve that are available for reinnervation of the deep fibular nerve at the level of the popliteal fossa. METHODS An anatomic study was performed that included the dissection of the popliteal fossa in 12 lower limbs of 6 formalin-fixed adult cadavers. It focused on the detailed anatomy of the tibial nerve and its branches at the level of the proximal leg as well as the anatomy of the common fibular nerve and its largest divisions at the level of the neck of the fibula, i.e., the deep and superficial fibular nerves. RESULTS The branches of the tibial nerve destined to the lateral and medial head of the gastrocnemius had a mean length of 43 mm and 35 mm, respectively. The branch to the posterior soleus muscle had a mean length of 65 mm. Intraneural dissection of the common fibular nerve, isolating its deep and superficial fibular divisions, was possible to a proximal mean distance of 71 mm. A tensionless direct suture to the deep fibular nerve was made possible by using the nerve to the lateral head of the gastrocnemius and the nerve to the posterior soleus muscle in all specimens. Direct suture of the nerve to the medial head of the gastrocnemius was possible in all cases except 1. CONCLUSION The nerve to the lateral and medial heads of the gastrocnemius and the nerve to the posterior soleus muscle can be used as donors to restore function of the deep fibular nerve in cases of high sciatic nerve injury. However, proximal intraneural dissection of the deep fibular division of the common fibular nerve must also be performed. We recommend that the nerve to the posterior soleus muscle should be the first choice for a donor in the proposed transfer.

Fatores prognósticos do trauma raquimedular por projétil de arma de fogo em pacientes submetidos a laminectomia

The spinal trauma related to civilian gunshot missile still remains a serious neurological event that carries a dismal prognosis almost in all cases. Its surgical indication also is a matter of discussion. Our goal is to identify the aspects that could influence the prognosis after surgery to this kind of lesions. We conducted a retrospective study of 45 consecutive patients submitted to laminectomy at Hospital de Base do Distrito Federal (Brasilia, Brazil), testing the following aspects: initial neurological status, level of the deficit, surgical timing, use of methilprednisolone and presence of dural tearing. Among those, the initial clinical presentation and the level of the lesion (60% of the patients with cauda equina syndrome and 53% of that with lesions in the lombar region improved their neurological status after laminectomy) were the most important factors affecting the outcome. Seventy percent of the patients experienced a pain relief after the surgical procedure.

Transfer of a motor fascicle from the ulnar nerve to the branch of the radial nerve destined to the long head of the triceps for restoration of elbow extension in brachial plexus surgery: technical case report.

BACKGROUND AND IMPORTANCE: Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks. CLINICAL PRESENTATION: Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases. CONCLUSION: The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.

Long-term outcomes associated to video-assisted thoracic sympathotomy for palmar-axillar subtype of the hyperhidrosis

OBJECTIVE Surgery for both palmar and axillar hyperhidrosis usually includes the interruption of the sympathetic chain in multiple levels. This study aimed to determine the long-term outcomes associated to video-assisted thoracic sympathotomy (VATS) of T2, T3 and T4 ganglia for these cases. METHODS Analysis of the outcomes obtained from 36 patients regarding the rate of resolution of the symptoms and the compensatory sweating (CS). All subjects were followed-up for 36 months. RESULTS Good outcomes were observed in 98.6% for palmar and 60% for axillary hyperhidrosis (p=0.0423), respectively. Of the subjects, 86% reported some postoperative episode of CS, however only 45% (p=0.0031) still noticed it at the end of the follow-up period. CONCLUSIONS VATS is effective for the excessive palmar sweating, whereas it is fully efficient for only two thirds of the cases sustaining associated axillar hyperhidrosis. CS is expected as a rule following the proposed operative protocol, however it is usually self-limited.

The importance of the preoperative clinical parameters and the intraoperative electrophysiological monitoring in brachial plexus surgery

OBJECTIVE The study aims to demonstrate the impact of some preoperative clinical parameters on the functional outcome of patients sustaining brachial plexus injuries, and to trace some commentaries about the use of intraoperative monitoring techniques. METHOD A retrospective study one hundred cases of brachial plexus surgery. The analysis regarding postoperative outcomes was performed by comparing the average of the final result of the surgery for each studied cohort. RESULTS Direct electrical stimulation was used in all patients, EMG in 59%, SEPs in 37% and evoked NAPs in 19% of the cases. Patients in whom the motor function of the hand was totally or partially preserved before surgery, and those in whom surgery was delayed less than 6 months demonstrated significant (p<0.05) better outcomes. CONCLUSION The preoperative parameters associated to favorable outcomes in reconstruction of the brachial plexus are a good post-traumatic status of the hand and a short interval between injury and surgery.

Brachial plexus surgery: the role of the surgical technique for improvement of the functional outcome

OBJECTIVE The study aims to demonstrate the techniques employed in surgery of the brachial plexus that are associated to evidence-based improvement of the functional outcome of these patients. METHOD A retrospective study of one hundred cases of traumatic brachial plexus injuries. Comparison between the postoperative outcomes associated to some different surgical techniques was demonstrated. RESULTS The technique of proximal nerve roots grafting was associated to good results in about 70% of the cases. Significantly better outcomes were associated to the Oberlins procedure and the Sansaks procedure, while the improvement of outcomes associated to phrenic to musculocutaneous nerve and the accessory to suprascapular nerve transfer did not reach statistical significance. Reinnervation of the hand was observed in less than 30% of the cases. CONCLUSION Brachial plexus surgery renders satisfactory results for reinnervation of the proximal musculature of the upper limb, however the same good outcomes are not usually associated to the reinnervation of the hand.

The use of autogenous veins for microsurgical repair of the sural nerve after nerve biopsy.

OBJECTIVES This study evaluates the results of an alternative technique developed to minimize the risk of complications associated with sural nerve biopsy for histopathological analysis. METHODS Twelve subjects underwent sural nerve biopsy and the defect created in the nerve was bridged by a 50-mm-length segment of the saphenous vein; the control group enrolled 23 patients in whom the entire length of the nerve was harvested to be used as autograft for reconstruction of nerves in the upper limb. Sensory reinnervation was quantified by use of the monofilament test and the static 2-point discrimination test, after a follow-up period of 18 months. RESULTS The mean time for recovery of protective sensation was 8.7 months in patients submitted to nerve repair, and 10.3 months in the control group (P > .05). The monofilament test and static 2-point discrimination testing demonstrated a mean value of 3.22 and 8 mm (S3), respectively, in the group who underwent sural nerve repair; and 4.17 and 13 mm (S2), respectively, for the control group (P <.05). CONCLUSION The use of vein as conduits for the repair of the sural nerve did not shorten the time for sensory recovery at the autonomous zone of the nerve; however, the quality of the reinnervation was considered better than the control group. This study suggests that empty veins could be used as conduits to bridge gaps with a length up to 50 mm in cases of injuries of the sural nerve and, possibly, for injuries of other pure sensory nerves as well.

Descompressão do túnel do carpo pela técnica endoscópica: estudo comparativo com a técnica convencional aberta

OBJECTIVE The endoscopic carpal tunnel release became a minimally invasive alternative to the standard open technique, because of its theoretical benefits for reducing the postoperative morbidity. The present study goals to compare both techniques about the immediate results of such procedures. METHOD Two groups of 15 patients underwent, respectively, to the endoscopic and conventional carpal tunnel release surgery. There was no statistical difference between both groups about the preoperative clinical aspects. RESULTS In all of the cases there were complete resolution of the preoperative symptoms immediately after the procedures. One patient from the endoscopic technique group developed recidive of the symptoms one month after the surgery (6.6%). The oral analgesics intake time and the labor returning time was shorter in the group underwent to the endoscopic procedure. CONCLUSION The endoscopic carpal tunnel release is an efficient procedure, offering the advantage to shortening the postoperative recovery.