Luciano Foroni

A prospective study comparing single and double fascicular transfer to restore elbow flexion after brachial plexus injury.

BACKGROUND The recovery of elbow flexion in upper brachial plexus injury can be achieved by the reinnervation of the biceps muscle (single reinnervation), but concomitant restoration of brachialis and biceps function (double reinnervation) has been recommended to improve elbow flexion strength. OBJECTIVE To prospectively compare morbidity and outcomes of single or double muscle reinnervation in restoring elbow flexion following incomplete injury to the brachial plexus. METHODS Forty consecutive patients were prospectively submitted to single or double muscle reinnervation. Elbow flexion strength was evaluated with a push-and-pull dynamometer 12 months after surgery. Hand morbidity related to the procedures was evaluated by the Semmes-Weinstein monofilaments test, quantification of static 2-point discrimination, and measurements of handgrip and lateral pinch strength in serial evaluations up to the final follow-up. RESULTS Similar results for the strength of elbow flexion were observed in both groups. A worsening of sensibility, measured by using Semmes-Weinstein monofilaments, was identified in 8 patients, all of whom showed recovery during follow-up. No worsening of 2-point discrimination was observed. A decrease in handgrip and lateral pinch strength was identified in 8 and 9 patients, respectively, which improved during follow-up. There was no difference between the groups in the incidence of hand motor morbidity parameters. CONCLUSION The strength of elbow flexion did not differ significantly between the groups treated with single or double muscle reinnervation. Deterioration of handgrip, lateral pinch strength, and sensibility measured by using Semmes-Weinstein monofilaments, was temporary, resulting in low morbidity for both techniques.

Morbidity following sural nerve harvesting: A prospective study

OBJECTIVE To evaluate donor site morbidity following sural nerve harvesting, with special attention to the recovery of sensory loss. METHODS We prospectively followed 38 subjects who underwent sural nerve harvest, including two with bilateral nerve excision. Symptoms related to sural nerve excision were evaluated and demarcation of the area with reduced touch sensation was quantified. Assessments were performed periodically up to 1 year after surgery and the results of different sensory evaluations were compared. RESULTS A significant reduction of sensory deficit was identified between consecutive evaluations (p<0.05). Decreases of 26.85%, 20.69% and 24.29% were observed 3, 6 and 12 months after surgery, respectively. Shock-like pain (7.5%), stabbing pain (7.5%), and numbness (5%) were the most frequently reported symptoms. All symptoms were brief and resolved spontaneously 3-6 months after surgery. CONCLUSION Sural nerve harvest can be performed with acceptable morbidity. When present, symptoms resolve between the third and sixth month after surgery and a significant reduction of sensory loss in the area innervated by the sural nerve was observed during the first year of follow-up.

The clip-wrap technique in the treatment of intracranial unclippable aneurysms

UNLABELLED Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. OBJECTIVE To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. METHOD In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. RESULTS The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. CONCLUSION Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

Saccular aneurysms at middle basilar trunk fenestration

Division of Neurosurgery, Hospital das Clinicas, University of Sao Paulo Medical School (USP) Sao Paulo, Sao Paulo SP, Brazil; Neuroradiological Intervention, Institute of Radiology, Hospital das Clinicas, University of Sao Paulo Medical School (USP) Sao Paulo, Sao Paulo SP, Brazil. Basilar artery (BA) fenestration is reported in 0.6% of angiograms and in about 5% of autopsy series. It may occur anywhere along the BA but it is most frequent in the proximal trunk, close to the junction of the vertebral arteries, and rarer in the middle and distal thirds. In these instances, they may represent therapeutic dilemmas. Surgical treatment of these aneurysms is difficult because of the complex geometry of the fenestration, the proximity to the lower cranial nerves, the presence of multiple small perforating arteries, and difficulties in obtaining adequate surgical exposure. Endovascular treatment of such aneurysms has been described with success in most cases, with little or no neurological deficits. We report a rare case of two berry aneurysms originating in a fenestration of the BA and discuss its pathophysiology and therapeutic nuances. CASE REPORT A 55-year-old woman presented sudden headache. Neurological examination disclosed quadrantanopia at the left inferior visual field. Computed tomography (CT) demonstrated intraparenchymal hemorrhage at the right parietal lobe. Angiogram demonstrated aneurysms at the right posterior communicating artery (PComA) and anterior choroidal artery (AChA), and two small aneurysms at a BA fenestration (Fig 1A and 1B). The fenestration measured 5.5 mm in length and it was located at the transition between the middle and distal thirds (Fig 2A and 2B). Magnetic resonance imaging (MRI) demonstrated a small cavernous angioma, an angiographically occult lesion. The two anterior circulation aneurysms were clipped uneventfully. The two BA fenestration aneurysms were successfully treated with embolization, using Guglielmi detachable

Management of desmoid-type fibromatosis involving peripheral nerves

Desmoid-type fibromatosis is an uncommon and aggressive neoplasia, associated with a high rate of recurrence. It is characterized by an infiltrative but benign fibroblastic proliferation occurring within the deep soft tissues. There is no consensus about the treatment of those tumors. We present a surgical series of four cases, involving the brachial plexus (two cases), the median nerve and the medial brachial cutaneous nerve. Except for the last case, they were submitted to multiple surgical procedures and showed repeated recurrences. The diagnosis, the different ways of treatment and the prognosis of these tumoral lesions are discussed. Our results support the indication of radical surgery followed by radiotherapy as probably one of the best ways to treat those controversial lesions.

Prognostic value of thumb pain sensation in birth brachial plexopathy

OBJECTIVE To evaluate the prognostic value of absent thumb pain sensation in newborns and young infants with birth brachial plexopathy. METHODS We evaluated 131 patients with birth brachial plexopathy with less than two months of age. Pain sensation was evoked by thumb nail bed compression to evaluate sensory fibers of the upper trunk (C6). The patients were followed-up monthly. Patients with less than antigravity elbow flexion at six months of age were considered to have a poor outcome. RESULTS Thirty patients had absent thumb pain sensation, from which 26 showed a poor outcome. Sensitivity of the test was 65% and specificity was 96%. CONCLUSION Evaluation of thumb pain sensation should be included in the clinical assessment of infants with birth brachial plexopathy.

Expanded endonasal approach to skull base meningiomas

1Neurosurgery Division, Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo SP, Brazil; 2Otorhinolaryngology Department, Hospital das Clínicas, USP, São Paulo SP, Brazil. Correspondence: Bernardo Assumpção de Monaco; Instituto Central HCFMUSP Neurocirurgia; Avenida Doutor Enéas de Carvalho Aguiar 255 / sala 5084; 05403-900 São Paulo SP Brasil; E-mail: bernardo.neuro@gmail.com Confl ict of interest: There is no confl ict of interest to declare. Received 25 February 2012; Received in fi nal form 18 September 2012; Accepted 25 September 2012.

Critical analysis of extra peritoneal antero-lateral approach for lumbar plexus

UNLABELLED Lesions of lumbar plexus are uncommon and descriptions of surgical access are derived from vertebral spine approaches. METHOD The extraperitoneal anterolateral approach to the lumbar plexus was performed in six adult fresh cadavers. The difficulties on dissection were related. RESULTS An exposure of all distal elements of lumbar plexus was possible, but a cranial extension of the incision was needed to reach the iliohypogastric nerve in all cases. Ligation of vessels derived from common iliac artery was necessary for genitofemoral and obturator nerves exposure in two cases. The most proximal part of the lumbar roots could be identified only after dissection and clipping of most lumbar vessels. CONCLUSION The extraperitoneal anterolateral approach allows appropriate exposure of terminal nerves of lumbar plexus laterallly to psoas major muscle. Cranial extension of the cutaneous incision may be necessary for exposure of iliohypogastric nerve. Roots exposure increases the risk of vascular damage.

Perineurioma of the posterior interosseous nerve: surgical treatment.

Intraneural perineurioma is a benign tumor that occurs in less than 1% of peripheral nerve tumors; no more than 90 cases have been reported1,2. Tumorous lesions of the posterior interosseous nerve (PIN) have rarely been described3–5. An 18-year-old woman presented with a longstanding his tory of spontaneous progressive weakness in the PIN dis tribution (Figure 1). Ultrasonography and MRI studies (Figure 2) showed a nodular lesion in the PIN, measuring 1.0 cm at its greatest diameter. At surgical exploration a tumor (Figure 3) involving all the nerve fascicles was entirely re sected. The nerve was repaired by termino-terminal neurorrhaphy. Figure 4 shows the histological examination.