Roganović Z

Missile-caused complete lesions of the peroneal nerve and peroneal division of the sciatic nerve: results of 157 repairs.

OBJECTIVE: There are few large-volume studies of the repair of complete missile-caused peroneal nerve and peroneal division lesions. In this prospective study, the outcomes of such repairs are studied and the factors influencing the outcomes are analyzed. METHODS: During a 3-year period, 157 patients with complete missile-caused lesions of the peroneal nerve or peroneal division were treated surgically in the Belgrade Military Medical Academy: 37 patients with high-level (above the middle of the thigh), 90 patients with intermediate-level (above the popliteal crease), and 30 patients with low-level repairs. After at least 4 years of follow-up, outcome was defined on the basis of motor recovery, neurophysiological recovery, and patient judgment of the quality of outcome (poor, insufficient, good, or excellent). Good and excellent outcomes were considered successful. The factors of repair level, defect length, manner of repair, preoperative interval, severity of tissue damage in the repair region, and patient age were studied for their effect on outcome. RESULTS: A successful outcome was obtained in 10.8% of high-level repairs, 31.1% of intermediate-level repairs, and 56.7% of low-level repairs (P < 0.001). Nerve defect and preoperative interval were significantly shorter for patients with a successful outcome compared with those with an unsuccessful outcome (P< 0.001). Worsening of the outcome began with the nerve defect larger than 4 cm and preoperative interval greater than 3 months (P< 0.001). Severity of local tissue damage significantly influenced the outcome (P= 0.008). Repair level (P< 0.001), preoperative interval (P= 0.001), severity of local tissue damage (P= 0.011), and length of nerve defect (P= 0.011) were independent predictors for a successful outcome. CONCLUSION: After peroneal nerve or peroneal division repairs, a successful outcome is most probable with low-level lesions repaired in the first 3 months after injury using grafts smaller than 4 cm. Conversely, high-level repairs delayed for more than 7 months after injury and using grafts larger than 8 cm are probably not worthwhile.

Peripheral nerve lesions associated with missile-induced pseudoaneurysms

OBJECT Reports of traumatic pseudoaneurysms associated with nerve compression are rare, and typically do not focus on the damaged nerves. This prospective study examines the clinical presentation, management, and treatment outcome of such nerve injuries. METHODS Between 1991 and 1995, 22 patients with a missile-induced nerve injury associated with a pseudoaneurysm were treated surgically at the Belgrade Military Medical Academy. The artery and nerves involved with the injury were treated using appropriate surgical procedures, and both the sensorimotor deficit and pain intensity were assessed. RESULTS The occurrence of a pulsatile mass depended on the location of the pseudoaneurysm (p = 0.003) and correlated significantly with the preoperative diagnosis (p < 0.001). In cases in which neurological worsening was due exclusively to the compressive effect of the pseudoaneurysm, the nerves involved were found to be in anatomical continuity intraoperatively, and recovery depended on the actual nerve damage and surgical procedure required (neurolysis or nerve grafting). A symptomatic nerve compression duration of more than 3.5 days was the critical factor that determined if neurapraxia developed into severe nerve damage (p = 0.014). Pain syndromes responded well and rapidly to the surgical treatment (p < 0.001). CONCLUSIONS Whether or not a missile-induced pseudoaneurysm associated with a nerve lesion will be recognized before surgery depends on its location and clinical presentation. The nerves involved almost invariably exhibit a lesion in continuity, but the resulting nerve damage can be severe, particularly if surgery is delayed for more than 3 to 4 days after neurological worsening has begun. A successful outcome may be expected if an appropriate surgical technique (neurolysis or grafting) is chosen on the basis of the intraoperative discovery of nerve action potentials.

Pain syndromes after missile-caused peripheral nerve lesions: part 2--treatment

OBJECTIVETo analyze treatment procedures and treatment outcomes of painful missile-caused nerve injuries and factors influencing the outcome. METHODSThe study included 326 patients with clinically significant pain syndromes, including complex regional pain syndrome Type II, deafferentation pain, reinnervation pain, and neuralgic pain. Treatment modalities included drug therapy, nerve surgery, sympatholysis, and dorsal root entry zone operation. Pain intensity was assessed before and after the treatment using a visual analog scale, and treatment outcome was defined as successful (pain relief >70%), fair (pain relief between 50 and 69%), or poor (pain relief <50%). The outcome was compared between different pain syndromes and different treatment modalities. RESULTSA successful outcome was achieved in 28.6% of patients with deafferentation pain, in 76.9% of patients with complex regional pain syndrome Type II, and in 87.9 to 100% of patients with other pain syndromes (P = 0.002). Each type of pain syndrome required a specific treatment algorithm, but average pain relief was similar for all definitive treatment modalities (range, 81–88%; P > 0.05). Ten factors were found to significantly influence the treatment outcome, but only three factors were independent predictors of a successful outcome: type of pain syndrome (P < 0.001), severity of nerve injury (P < 0.001), and absence of pain paroxysms (P = 0.03). CONCLUSIONThe treatment outcome of painful nerve injury depends on several factors, including the type of pain syndrome, severance of nerve injury, and absence of pain paroxysms. Drug therapy (carbamazepine, amitriptyline, or gabapentin) should be recommended, at least as a part of treatment, for patients with reinnervation pain, deafferentation pain, and complex regional pain syndrome Type II. Nerve surgery should be recommended for patients with posttraumatic neuralgia, either as the first treatment choice (acute nerve compression or intraneural foreign particles) or after unsuccessful pharmacological treatment (other causes of neuralgic pain).

Factors influencing the outcome after the operative treatment of cerebral aneurysms of anterior circulation.

BACKGROUND The influence of various factors on the outcome after the operative occlusion of the cerebral aneurysm was to be defined through the retrospective study on 111 surgically treated patients with aneurysm of anterior cerebral circulation. METHODS Preoperative clinical condition was graded from 0 to V, according to Hunt & Hess. Postoperative outcome, defined as good or bad according to modified Glasgow Outcome Scale, was correlated in homogenous experimental groups with the following factors: gender, age, aneurysmal size, preoperative interval, nimodipine therapy, experience of surgical team and existence of chronic vascular diseases. RESULTS Surgical outcome was good in 74.4% of males and 71.4% of females (p > 0.05); in 83.3% of patients with and 41.2% of patients without chronic diseases (p < 0.01); in 71.4% of patients underwent early, 83.3% of ones underwent postponed and 85% of those underwent late surgery (p > 0.05); in 81.5% of patients treated by nimodipine and in 41.7% of those untreated by the same drug (p < 0.01); in 78.9% of patients operated by the experienced surgical team and in 40% of those operated by less experienced surgical team (p < 0.01). In patients with both good and bad outcome, the mean age was 50.6 and 47.6 years (p > 0.05), and the mean aneurysmal size was 12.3 mm and 13.3 mm, respectively (p > 0.05). Before rupture, the mean size for aneurysms on the bifurcation of the middle cerebral artery was 14.3 mm, and for posterior communicating artery aneurysms only 9.7 mm (p < 0.05). CONCLUSION Surgical outcome was significantly influenced by the existence of chronic diseases, nimodipine therapy and experience of surgical team, whereas gender, age, timing for surgery and aneurysmal size were not of significant influence.

PAIN SYNDROMES AFTER MISSILE-CAUSED PERIPHERAL NERVE LESIONS

OBJECTIVE To analyze treatment procedures and treatment outcomes of painful missile-caused nerve injuries and factors influencing the outcome. METHODS The study included 326 patients with clinically significant pain syndromes, including complex regional pain syndrome Type II, deafferentation pain, reinnervation pain, and neuralgic pain. Treatment modalities included drug therapy, nerve surgery, sympatholysis, and dorsal root entry zone operation. Pain intensity was assessed before and after the treatment using a visual analog scale, and treatment outcome was defined as successful (pain relief >70%), fair (pain relief between 50 and 69%), or poor (pain relief <50%). The outcome was compared between different pain syndromes and different treatment modalities. RESULTS A successful outcome was achieved in 28.6% of patients with deafferentation pain, in 76.9% of patients with complex regional pain syndrome Type II, and in 87.9 to 100% of patients with other pain syndromes (P = 0.002). Each type of pain syndrome required a specific treatment algorithm, but average pain relief was similar for all definitive treatment modalities (range, 81-88%; P > 0.05). Ten factors were found to significantly influence the treatment outcome, but only three factors were independent predictors of a successful outcome: type of pain syndrome (P < 0.001), severity of nerve injury (P < 0.001), and absence of pain paroxysms (P = 0.03). CONCLUSION The treatment outcome of painful nerve injury depends on several factors, including the type of pain syndrome, severance of nerve injury, and absence of pain paroxysms. Drug therapy (carbamazepine, amitriptyline, or gabapentin) should be recommended, at least as a part of treatment, for patients with reinnervation pain, deafferentation pain, and complex regional pain syndrome Type II. Nerve surgery should be recommended for patients with posttraumatic neuralgia, either as the first treatment choice (acute nerve compression or intraneural foreign particles) or after unsuccessful pharmacological treatment (other causes of neuralgic pain).

Treatment of arterial aneurysms of anterior cerebral circulation

Objectives: To analyze the outcome of either surgical or conservative treatment of patients with aneurysms on cerebral arteries. Design Retrospective study on 114 patients (89 operated and 25 not operated). Methods: Clinical state was graded from 0 to V, according to Hunt & Hess (HHG), and the treatment outcome was defined as favorable or poor, according to the modified Glasgow Outcome Score. The outcome was correlated with the type of treatment (operative or conservative), clinical state and aneurysmal localization. Results: Aneurysm was localized mostly on the anterior communicating (33.6%) and middle cerebral arteries (32.8%) and the patients were mostly in HHG II or III (34.4% and 25.2%). HHG after the aneurysmal rupture did not depend on the aneurysmal location (p>0.05). Favorable treatment outcome was noted: in 74.1% of all operated and in 60% of all conservatively treated patients (p>0.05)( in 81.6% of operated and in 33.3% of not operated patients with HHG=II-III (p 0.05)( in 73.1% of patients with HHG=III and in 25% of patients with HHG=IV (p<0.01).Conclusions: Clinical state after the aneurysmal rupture did not depend on its localization. Results were better after the surgical, than after the conservative treatment. Outcome after the surgery depended on the clinical state of the patient, but not on the aneurysmal localization.