Neil Ford Jones

Operative exposure and management of the petrous and upper cervical internal carotid artery.

The exposure and operative management of the petrous and upper cervical internal carotid artery (ICA) in 29 patients is detailed. Twenty-seven of these patients had extensive cranial base neoplasms (benign or malignant), 1 had an inflammatory cholesteatoma, and 1 had an aneurysm of the upper cervical ICA immediately proximal to the carotid canal. Preoperative studies useful in the evaluation of these patients included computed tomography, magnetic resonance imaging, cerebral and cervical angiography, and a balloon occlusion test of the ICA with evaluation of neurological status and of cerebral blood flow. The exposure of the upper cervical and petrous ICA was useful to obtain proximal control of the cavernous ICA, aided in the operative approach to extensive petroclival, intracavernous, and parapharyngeal neoplasms, and enabled the total resection of 23 of 27 such tumors. A subtemporal and preauricular infratemporal fossa approach was most commonly used for the exposure of the artery. Intraoperative arterial management consisted of exposure and decompression only, dissection from encasing neoplasm, resection of the invaded arterial segment and vein graft reconstruction, or intentional arterial occlusion. Vascular complications included 1 stroke due to delayed arterial occlusion, 1 stroke and death due to infection spreading from the nasopharynx with bilateral ICA rupture, and 1 pseudoaneurysm formation secondary to wound infection necessitating postoperative balloon occlusion of the ICA. Nonvascular complications included facial nerve paralysis in 10 patients (usually temporary), glossopharyngeal and vagal paralysis in 13 patients requiring Teflon injection of the vocal cord in 9, temporary difficulties with mastication in 9 patients, and wound infection in 3. The surgical exposure and management of the upper cervical and petrous ICA may permit a total operative resection of extensive cranial base neoplasms and is also an alternative for the management of vascular lesions involving these segments of the artery. With malignant neoplasms extending from the nasopharynx, postoperative infection remains a problem and may best be resolved by the use of a vascularized rectus abdominis muscle flap to reconstruct defects of the nasopharynx. Bilateral ICA encasement by neoplasms is also a major problem to be solved. The value of such an aggressive approach to the management of malignant neoplasms remains to be proven.

Surgery for scleroderma of the hand

The role of hand surgery in systemic sclerosis (scleroderma) has been documented infrequently. Out of a series of 813 consecutive patients with scleroderma, 31 have had one or more surgical procedures on their involved hands--a total of 52 operations. Raynauds phenomenon and digital tip ulcerations have been controlled medically by vasodilators and meticulous local wound care. Most digital ulcerations progressing to frank gangrene have been allowed to autoamputate to maximize the length of the salvaged finger, but 23 digital amputations have been performed when conservative measures failed. Digital sympathectomy and microsurgical revascularization have produced relief of symptoms in several patients. Severe flexion contractures of the proximal interphalangeal (PIP) joints, with secondary hyperextension of the metacarpophalangeal (MP) joints, have been effectively treated by arthrodesis of the PIP joints in 44 to 55 degrees of flexion. This has allowed both improved hand function and primary healing of dorsal ulcers in 53 PIP joints in 12 patients.

Reconstruction of the cranial base following tumour resection

Twenty-four patients have undergone resection of tumours involving the cranial base by a multidisciplinary team consisting of a neurosurgeon, ENT surgeon and plastic surgeon. The resultant defects of the cranial base have been reconstructed using local fascial flaps, transposition of local muscle flaps and microsurgical transfer of free muscle flaps. Indications for reconstruction have included obliteration of paranasal sinuses, coverage of tenuous dural repairs or dural grafts and separation of the nasopharynx from the dura of the frontal and temporal lobes and posterior fossa to prevent CSF leakage and meningitis.

Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis.

Fifty consecutive patients with acute and chronic ischemia of the hand were investigated by Allen testing, Doppler ultrasound, digital plethysmography, and angiography over a 4-year period. The pathophysiologic mechanism responsible for the ischemia was determined to be emboli in 6%, vasospasm in 10%, thrombosis or sludging in 28%, occlusive disease in 26%, and occlusive disease associated with either vasospasm or external compression in 30%. Ten patients required emergency medical treatment with intraarterial streptokinase, intravenous heparin, or dextran 40 and continuous stellate ganglion blocks, and three patients required emergency microsurgical revascularization because of radial artery thrombosis. Patients with chronic ischemia of the hand were maintained on nifedipine, 30 to 60 mg daily, and pentoxifylline, 1200 mg daily. Seven patients underwent digital sympathectomy and 14 patients underwent microsurgical revascularization as prophylactic procedures for chronic digital ischemia. Amputations were required in 18 patients because of end-stage gangrene. Long-term follow-up revealed a 20% incidence of recurrent digital ulcerations. There have been six deaths during follow-up, five of them due to myocardial infarction; this reflects the underlying systemic arteriopathy in many of these patients.

Persistent median artery as a cause of pronator syndrome

Pronator syndrome may be caused by a persistent median artery that passes completely through the proximal median nerve and then gives origin to a vascular leash to the flexor muscles that compresses the nerve. A double crush compression of the median nerve caused by persistent median artery producing first a carpal tunnel syndrome and then a pronator syndrome is described.

Hypopharyngeal reconstruction: A comparison of two alternatives

Gastric pull‐up or free jejunal interposition was used for reconstruction after total laryngopharyngectomy in 31 patients. Complications and functional outcomes of the two methods are compared. Primary swallowing was achieved in 86% of patients after gastric pull‐up and in 82% of patients after jejunal interposition. Patients who underwent jejunal interposition were able to swallow sooner and had a shorter hospital stay than patients who underwent gastric pull‐up. Esophageal tumor recurrence after jejunal interposition was not observed. Hepatic failure occurred in two gastric pull‐up patients, leading to perioperative death in one. Flap necrosis occurred in two jejunal interposition patients and one gastric pull‐up patient. Two additional fistulas occurred in jejunal interposition patients as a result of microvascular complications. Stricture developed in four jejunal interposition patients, requiring revision surgery in two. Minor complications were more common in the gastric pull‐up group. Long‐term speech and swallowing function are compared. Our current choice of jejunal interposition or gastric pull‐up for reconstruction after total laryngopharyngectomy primarily depends on the location of the tumor.

The cervicopectoral rotation flap: a valuable technique for facial reconstruction

Four cases of lower cheek reconstruction using the cervicopectoral rotation-advancement flap are reported. This fasciocutaneous flap can be raised quickly, provides excellent colour and texture match for the tissues of the face, and donor site morbidity is minimal. It is an especially useful method for lower cheek reconstruction following wide excision of melanomas of the cheek and for advanced parotid tumours where skin replacement is required following resection.

Microsurgical revascularisation of the hand in scleroderma

Raynauds phenomenon is a prominent manifestation of systemic sclerosis (scleroderma) affecting the hand. The resulting digital ischaemia may progress to digital tip ulceration or gangrene. Four patients with scleroderma, presenting with severe unremitting unilateral pain in the hand, were evaluated by arteriography and plethysmography. In addition to the usual changes of narrowing and occlusion of the digital arteries themselves, arteriography revealed more proximal occlusion of the radial and ulnar arteries at the wrist and the superficial palmar arch. Plethysmography confirmed virtual absence of pulsatile digital blood flow. Two patients underwent microsurgical reconstruction of the radial and ulnar arterial inflow into the hand and the superficial palmar arch using reversed interposition vein grafts, with immediate subjective resolution of their severe pain and rapid healing of the digital ulcers. Both remain pain free 1 year post-operatively, and pulse-volume recordings have confirmed objectively the restoration of pulsatile blood flow to the fingers.

Experimental and clinical monitoring of free jejunal transfers using an implantable ultrasonic Doppler probe

Postoperative assessment of the continued viability of a buried free jejunal transfer remains a difficult problem. The reliability of a 20 MHz pulsed ultrasonic Doppler probe to detect arterial or venous occlusion has been investigated experimentally in isolated vascularised jejunal segments in dogs. Clinically, the probe has been used intraoperatively to confirm normal flow in both the mesenteric artery and mesenteric vein of free jejunal transfers. Continuous recording of the acoustic signal from the probe during closure of the incisions has allowed immediate detection of any adverse effect due to pedicle kinking or excessive skin tension. Sixteen patients undergoing free jejunal transfer have been monitored continuously using the implantable 20 MHz pulsed ultrasonic Doppler probe positioned on the inflow mesenteric artery.

Epidemiologie study of the mallet finger deformity

An epidemiologic survey of 24 members of a three-generation family revealed an unusually high incidence of mallet fingers. Twenty mallet fingers were found in seven family members by clinical examination, suggesting a familial predisposition to develop this deformity. Multiple mallet fingers (range, two to six) occurred in four individuals. Classification of these mallet fingers based on the mechanism of injury demonstrated a high incidence (85%) resulting from minimal trauma or occurring spontaneously. Symptoms and signs of bilateral carpal tunnel syndrome were documented in five family members with mallet fingers (71%), and three individuals with mallet finger deformities also had associated trigger fingers (43%).