Shane R. Tubbs

The neurologist's dilemma: a comprehensive clinical review of Bell's palsy, with emphasis on current management trends.

Background Recent advances in Bell’s palsy (BP) were reviewed to assess the current trends in its management and prognosis. Material/Methods We retrieved the literature on BP using the Cochrane Database of Systematic Reviews, PubMed, and Google Scholar. Key words and phrases used during the search included ‘Bell’s palsy’, ‘Bell’s phenomenon’, ‘facial palsy’, and ‘idiopathic facial paralysis’. Emphasis was placed on articles and randomized controlled trails (RCTs) published within the last 5 years. Results BP is currently considered the leading disorder affecting the facial nerve. The literature is replete with theories of its etiology, but the reactivation of herpes simplex virus isoform 1 (HSV-1) and/or herpes zoster virus (HZV) from the geniculate ganglia is now the most strongly suspected cause. Despite the advancements in neuroimaging techniques, the diagnosis of BP remains one of exclusion. In addition, most patients with BP recover spontaneously within 3 weeks. Conclusions Corticosteroids are currently the drug of choice when medical therapy is needed. Antivirals, in contrast, are not superior to placebo according to most reliable studies. At the time of publication, there is no consensus as to the benefit of acupuncture or surgical decompression of the facial nerve. Long-term therapeutic agents and adjuvant medications for BP are necessary due to recurrence and intractable cases. In the future, large RCTs will be required to determine whether BP is associated with an increased risk of stroke.

Regional anatomic structures of the elbow that may potentially compress the ulnar nerve

HYPOTHESIS Traumatic injuries to the ulnar nerve at the elbow are a frequent problem as it is vulnerable to stretching and compression with motion of the upper limb. The aim of the present study was to explore the course of the ulnar nerve at the elbow and forearm and to determine possible anatomical structures that may cause compression of this structure. MATERIALS AND METHODS We examined 12 upper limbs from cadavers. The length of any fibrous bands, and if present, their distance to the medial epicondyle was recorded. RESULTS On 5 sides a fibrous band originating from the medial intermuscular septum was observed to cross over the ulnar nerve. The average length of the fibrous band was 5.7 cm, and it attached to the medial epicondyle. The mean length of the ulnar nerve as it coursed in the cubital tunnel was 3.8 cm. In 4 of the cases, the ulnar nerve was covered by muscle fibers originating from the flexor digitorum superficialis and extending to the flexor carpi ulnaris. On 5 sides we observed fibrous thickenings, and on 8 sides vascular structures were found crossing over the ulnar nerve. DISCUSSION The cubital tunnel is the most common site of compression of the ulnar nerve. Numerous surgical procedures are recommended for cubital tunnel syndrome. Simple decompression is used most commonly. Although surgical procedures are reported to provide efficient pain relief and functional recovery, residual or recurrent symptoms have been reported. Reasons for such recurrences may be more proximal or distal compression of the ulnar nerve as seen in our study. CONCLUSION Knowledge of possible compression sites of the ulnar nerve is important to the surgeon so that complications are avoided and postoperative recurrence is decreased. LEVEL OF EVIDENCE Basic science study.

Amyand’s hernia: A review

Amyand’s hernia is defined as when the appendix is trapped within an inguinal hernia. While the incidence of this type of hernia is rare, the appendix may become incarcerated within Amyand’s hernia and lead to further complications such as strangulation and perforation. Incarceration of the appendix most commonly occurs within inguinal and femoral hernias, but may arise to a lesser extent in incisional and umbilical hernias. Incarcerated appendix has been reported in a variety of ventral abdominal and inguinal locations, yet its indistinct clinical presentation represents a diagnostic challenge. This paper reviews the literature on incarceration of the appendix within inguinal hernias and discusses current approaches to diagnosis and treatment of Amyand’s hernia and complications that may arise from incarceration of the appendix within the hernia.

Occipital encephalocele, lipomeningomyelocele, and Chiari I malformation: case report and review of the literature

Abstract Case report. We report a pediatric patient with encephalocele, lipomeningomyelocele, and Chiari I malformation. Discussion. We also review the extant medical literature regarding associations between these three entities. We propose that the combination of these three pathologies, which is reported here for the first time, is not serendipitous but rather a low-frequency association. Conclusions. After a literature review, we speculate that encephalocele and lipomeningomyelocele most probably occur by mechanisms similar to those that produce encephalocele and meningomyelocele and that the tonsillar ectopia in our patient is due to an abnormally small posterior cranial fossa resulting from the lack of neural tissue within the cranium at critical times during development or has its genesis, as some encephaloceles may, in inappropriate paraxial mesoderm formation.

The cubital tunnel: a radiologic and histotopographic study

Entrapment of the ulnar nerve at the elbow is the second most common compression neuropathy in the upper limb. The present study evaluates the anatomy of the cubital tunnel. Eighteen upper limbs were analysed in unembalmed cadavers using ultrasound examination in all cases, dissection in nine cases, and microscopic study in nine cases. In all cases, thickening of the fascia at the level of the tunnel was found at dissection. From the microscopic point of view, the ulnar nerve is a multifascicular trunk (mean area of 6.0 ± 1.5 mm2). The roof of the cubital tunnel showed the presence of superimposed layers, corresponding to fascial, tendineous and muscular layers, giving rise to a tri‐laminar structure (mean thickness 523 ± 235 μm). This multilayered tissue was hyperechoic (mean thickness 0.9 ± 0.3 mm) on ultrasound imaging. The roof of the cubital tunnel is elastic, formed by a myofascial trilaminar retinaculum. The pathological fusion of these three layers reduces gliding of the ulnar nerve during movements of the elbow joint. This may play a role in producing the symptoms typical of cubital tunnel syndrome. Independent from the surgical technique, decompression should span the ulnar nerve from the triceps brachii muscle to the flexor carpi ulnaris fascia.

Impact of fibular torsion and rotation on chronic ankle instability

BACKGROUND The fibula is known not to involve in transmission of weight but known simply as an ankle stabilizer. However, its main function in stabilizing the ankle remains obscure. Since the fibula has an impact on torsion and rotation of the ankle, its effect on lateral ankle instability should be investigated. MATERIALS AND METHODS Twenty patients with lateral ankle instability (Group 1) and 19 healthy volunteers (Group 2) were included in the study. The tibiofibular and talofibular relationships were evaluated using MRI images. Fibular torsion and rotation angles were calculated using a new method. Range of motion of the ankle joint was investigated while the knee was at flexion (90°) and extension (0°). The comparisons performed between the 2 groups and independent from the groups were statistically evaluated and, the p value of <0.05 was considered as statistically significant. RESULTS A significant difference was found between the two groups for age (p<0.05). There were no statistically significant differences between the right and left sides for all measurements in the group 1 and 2 (p>0.05). There was a statistically significant difference between the two groups in dorsal flexion when the knee is at flexion (90°) and extension (0°) position. There was also a statistically significant difference between the two groups in plantar flexion which was measured while the knee was at extension (0°) position. No statistically significant difference was found between both groups in terms of fibular torsion and rotation. However, independent from the groups when the patients were divided into 2 groups according to whether the fibula localized posteriorly or not, in patients with posteriorly localized fibula it was demonstrated that the fibular torsion and rotation was increased significantly. CONCLUSION We did not detect any relationship between fibular torsion and rotation and ankle instability. However, independent from the groups when the patients were divided into 2 groups according to whether the fibula localized posteriorly or not, we realized that in patients with posteriorly localized fibula, fibular torsion and rotation significantly increased. This finding did not explain the cause of instability. However, it may gain significance with new further studies regarding ankle instability.

Hyperbaric oxygen therapy for chronic post-concussive syndrome.

In this editorial, the value of hyperbaric oxygen therapy in the management of chronic post-concussive syndrome following mild traumatic brain injury is discussed.

Thrombotic microangiopathy in the early post-renal transplant period.

The aim of this study was to identify cases of post-renal transplant thrombotic microangiopathy in a single transplant center over a period of five years. In a retrospective study, we reviewed the renal biopsy specimens of 57 renal transplant recipients with allograft dysfunction. The presence of fibrin thrombi within the glomerular capillaries or arterioles was used to define thrombotic microangiopathy. Systemic thrombotic microangiopathy was justified with the presence of thrombocytopenia and evidence of microangiopathic hemolysis. Patients with the biopsy findings compatible with thrombotic microangiopathy but without any systemic findings were categorized as having localized thrombotic microangiopathy. Four out of 57 patients had systemic thrombotic microangiopathy, while two had localized disease. The characteristics of each patient are discussed. Post-transplant thrombotic microangiopathy constitutes 10.5% of cases of early renal allograft dysfunction. A high index of suspicion is needed for diagnosing this entity as a potential cause of post-kidney transplant allograft dysfunction. Further studies with a greater number of patients may be required to highlight the risk factors for post-renal transplant thrombotic microangiopathy.

Sagittal synostosis in twin girls.

Abstract Introduction. Sagittal synostosis has been found to occur in families at a low frequency. All previous reports of sagittal synostosis in twins have been of males. Case report. We now report a case of female twins concordant for sagittal synostosis. Conclusion. Our hopes are that this information will further our understanding of the genetics of sagittal synostosis not only in single births but also in that of twins.

Vaginal Extrusion of a Ventriculoperitoneal Shunt: A Case Report and Review of Literature.

BACKGROUND Ventriculoperitoneal shunting is the most common treatment for hydrocephalus (excessive cerebrospinal fluid accumulation in the brain), but has the potential for serious complications such as shunt migration. Potential migration sites include the lateral ventricle mediastinum, gastrointestinal tract, abdominal wall, bladder, vagina, and scrotum. CASE Here, we present a rare case of vaginal extrusion of a ventriculoperitoneal shunt. SUMMARY AND CONCLUSION Neurosurgeons and gynecologists should be aware of the potential occurrence of this rare complication.