Milan Lepic

Outcome after brachial plexus injury surgery and impact on quality of life

BackgroundThe aim of this study was to investigate outcomes after surgery for brachial plexus injury (BPI), not only motor outcomes but also the quality of life of the patients.MethodsWe operated on 128 consecutive patients with BPI from 1992 to 2012. We documented the information on the injured nerve, level of injury, type of treatment used, timing of surgery, patient age, and preoperative and postoperative motor deficits. In 69 patients who agreed to participate in a quality of life study, additional assessments included functionality, pain, quality of life, patient satisfaction, and psychosocial health.ResultsOf patients who underwent only exploration and neurolysis, 35.3% showed a good quality of recovery. Patients who underwent nerve reconstruction using nerve grafting showed a better rate of good quality recovery (56.7%), and the results following nerve transfer depended on the type of transfer used. After surgery, 82.6% of patients showed significant improvement, 82.6% were satisfied, and 81.2% responded positively when asked if they would undergo surgery again if they knew the current result beforehand. Overall, 69.6% patients continued working after surgery. The mean DASH disability score was high (58.7) in the study group. Patients who had early surgery showed a consistently higher DASH score. About 76% of patients reported having pain regularly, and 18.8% reported depression or anxiety.ConclusionsWe consider that it is important to report not only muscle recovery, but also other aspects of recovery.

Symptomatic migration of a Kirschner wire into the spinal canal without spinal cord injury: case report

The migration of Kirschner wires (K-wires) is a rare but significant complication of osteosynthesis interventions, and numerous cases of wire migrations have been reported in the literature. Nevertheless, migration into the spinal canal is very rare, with only 10 cases reported thus far. The authors present a case of K-wire migration into the spinal canal, together with a review of the relevant literature. A 30-year-old male who had suffered a right clavicle fracture in a motorcycle accident was treated with 2 K-wires. Four months after the initial fixation, while he was lifting his child, he experienced short-term pain in his back, numbness in all 4 extremities, followed by a spontaneous decrease in numbness affecting only the ulnar nerve dermatomes bilaterally, and a persistent headache. No urinary incontinence was present. Simple radiography studies of the cervical spine revealed a wire in the spinal canal, penetrating the T-2 foramen and reaching the contralateral foramen of the same vertebra. Computerized tomography showed the wire positioned in front of the spinal cord. Surgery for wire extraction was performed with the patient under general anesthesia, and he experienced relief of the symptoms immediately after surgery. This case is unique because the wire caused no damage to the spinal cord but did cause compression-related symptomatology and headache, which have not been reported in osteosynthesis wire migration to the thoracic region.

Iatrogenic Peripheral Nerve Injuries - Surgical Treatment and Outcome: 10-Years´ Experience

BACKGROUND Iatrogenic nerve injuries are nerve injuries caused by medical interventions or inflicted accidentally by a treating physician. METHODS We describe and analyze iatrogenic nerve injuries in a total of 122 consecutive patients who received surgical treatment at our Institution during a period of 10 years, from January 1, 2003, to December 31, 2013. The final outcome evaluation was performed 2 years after surgical treatment. RESULTS The most common causes of iatrogenic nerve injuries among patients in the study were the operations of bone fractures (23.9%), lymph node biopsy (19.7%), and carpal tunnel release (18%). The most affected nerves were median nerve (21.3%), accessory nerve (18%), radial nerve (15.6%), and peroneal nerve (11.5%). In 74 (60.7%) patients, surgery was performed 6 months after the injury, and in 48 (39.3%) surgery was performed within 6 months after the injury. In 80 (65.6%) patients, we found lesion in discontinuity, and in 42 (34.4%) patients lesion in continuity. The distribution of surgical procedures performed was as follows: autotransplantation (51.6%), neurolysis (23.8%), nerve transfer (13.9%), direct suture (8.2%), and resection of neuroma (2.5%). In total, we achieved satisfactory recovery in 91 (74.6%), whereas the result was dissatisfactory in 31 (25.4%) patients. CONCLUSIONS Patients with iatrogenic nerve injuries should be examined as soon as possible by experts with experience in traumatic nerve injuries, so that the correct diagnosis can be reached and the appropriate therapy planned. The timing of reconstructive surgery and the technique used are the crucial factors for functional recovery.

Environmental and take-home lead exposure in children living in the vicinity of a lead battery smelter in Serbia

ABSTRACT Blood lead levels (BLLs) have been falling steadily worldwide due to restricted use of lead (Pb) and its compounds. although they remain above preindustrial Pb levels. Elevated BLL can still be found in children living near secondary Pb smelters that represent around 50% of Pb production. There have been no studies on Pb exposure in children living in Serbia ever since the 1980s. The aim of this study was to evaluate the BLLs in children living in two villages in Serbia (Zajača, the location of a secondary lead smelter, and Paskovac, 5 km away), identify the primary determinants of children’s BLLs, and investigate the impact of BLLs on children’s health symptoms and school achievement. The study was conducted in 2011 on 127 children, aged 1–18 years, whose BLLs were measured using inductively coupled argon plasma mass spectrometry (ICP‐MS). The median BLL in children was 12 &mgr;g/dl, with a significantly higher value of 17.5 &mgr;g/dl in Zajača, compared to 7.6 &mgr;g/dl in Paskovac. Only 1 out of 75 and 12 out of 52 children from Zajača and Paskovac, respectively, had BLLs below the CDC recommended 5 &mgr;g/dl level. Living near the smelter resulted in 19 times, and having a father who works in the plant 4 times higher odds of elevated BLLs. No significant effects of elevated BLLs health symptoms were seen in this study. BLLs of children living near a battery recycling plant in Serbia, an upper‐middle income European country, were in the range and even higher than those of children living in developing countries. For the first time, the contribution of environmental and take‐home lead exposure was quantified using mixed‐effect modeling, and our results indicate a contribution of 25–40% of the take‐home lead exposure to the BLLs of children living in the vicinity of a secondary lead smelter. HighlightsChildren living near a battery recycling plant had elevated blood lead levels (BLLs).Children 0–6 years old living closest to the plant had the highest BLLs.Higher lead exposure was found in children whose fathers worked in the plant.The contribution of take‐home lead exposure was between 25% and 40%.

Cranial Reconstruction Using Autologous Bone and Methylmethacrilate

Background: Having in mind the importance of reconstruction of the calvaria, our goal was to compare the complication rates following the use of autologous bone and methylmethacrilate grafts, and explain the factors influencing them. Methods: The authors collected information of all the patients undergoing cranial reconstructive surgery (N = 149) at the Military Medical Academy in Belgrade. Procedures were performed either using a craniotomy bone flap, removed and replaced in the same act, or using methylmethacrilate. These 2 groups were compared using the Chi-squared test, controlling for the confounding influence of the size of the defect. Results: Intracranial neoplasms were the cause for the reconstruction in 71.1% of patients. The total complication rate was 7.4%, while the infection rate was 5.4%. The infection rate was significantly higher in those procedures done using methylmethacrilate (11.3% compared with 2.1%, P = 0.017), but when controlling for the confounding effect of the size of the defect treated, the difference in infection rate was significant only in large defects (13.9% compared with 2%, P = 0.031), while for small defects the difference was not statistically significant. Conclusions: Our study suggests that the material used for reconstruction of calvaria influences the infection rate only in large and complicated defects. Considering the importance of the reconstruction, further studies should explore and confirm the role of material type on the rate of complications.

KOMBINIRANO LIJEČENJE RUPTURIRANE ANEURIZME SREDNJE MOŽDANE ARTERIJE PRAĆENE SUBARAHNOIDNIM KRVARENJEM I AKUTNIM SUBDURALNIM HEMATOMOM U VIŠESTRUKOJ ANEURIZMATSKOJ BOLESTI KRVNIH ŽILA MOZGA: PRIKAZ SLUČAJA

Aneurysms of blood vessels at the base of the brain are pathological focal out-pouchings, usually found at the branching points of the arteries. Aneurysm can remain silent for life. Clinical presentation is due to rupture and bleeding. In only 1.3% of cases it results in subdural hematoma, which is associated with direct interaction of the aneurysm with the basal arachnoid membrane. Multiple aneurysms are present in 15% to 33% of cases with subarachnoid hemorrhage. Assessment of these patients is more complicated, as there are no specific signs to pinpoint/detect the aneurysm that has ruptured. This report presents a 44-year-old female patient suffering from multiple cerebral aneurysm disease, who was urgently treated after rupture by both endovascular (for multiple aneurysms) and surgical (for acute subdural hematoma) approach in the same act under general anesthesia, which resulted in complete recovery of the patient.