Surgical management and outcome in patients with radial nerve lesions

2001 ◽  
Vol 95 (4) ◽  
pp. 573-583 ◽  
Author(s):  
Daniel H. Kim ◽  
Andrew C. Kam ◽  
Padmavathi Chandika ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Surgical Management ◽  
Radial Nerve ◽  
Gunshot Wounds ◽  
Suture Repair ◽  
Content Type ◽  
Louisiana State University ◽  
Internal Neurolysis ◽  
End To End ◽  
Grade 3 ◽  
Fine Print

Object. The goal of this paper was to review surgical management and outcomes in patients treated for radial nerve (RN) lesions at Louisiana State University Health Sciences over a period of 30 years. Methods. Two hundred sixty patients with RN injuries were evaluated. The most common mechanisms of injuries involving the RN included fracture of the humerus, laceration, blunt contusions, and gunshot wounds. One hundred and eighty patients (69%) underwent surgery. Lesions not in continuity required primary or secondary end-to-end suture repairs or graft repairs. With the use of direct intraoperative nerve action potential recording, RN injuries in which the lesion was in continuity required external or internal neurolysis or resection of the lesion followed by end-to-end suture or graft repair. A minimum of 1.5 years follow-up review was available in 90% of the patients who underwent surgery. Motor function recovery to Grade 3 or better was observed in 10 (91%) of 11 patients who underwent primary suture repair, 25 (83%) of 30 who underwent secondary suture repair, 43 (80%) of 54 who received graft repair, and 63 (98%) of 64 in whom neurolysis was performed. Sixteen (71%) of 21 patients with superficial sensory RN injury achieved satisfactory pain relief after complete resection of a neuroma or neurolysis. Conclusions. This study clearly demonstrates that excellent functional recovery can be achieved with proper surgical management of RN injuries.

Surgical management and outcomes in patients with median nerve lesions

2001 ◽  
Vol 95 (4) ◽  
pp. 584-594 ◽  
Author(s):  
Daniel H. Kim ◽  
Andrew C. Kam ◽  
Padmavathi Chandika ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Median Nerve ◽  
Suture Repair ◽  
State University ◽  
Content Type ◽  
Louisiana State University ◽  
Internal Neurolysis ◽  
Common Causes ◽  
End To End ◽  
Grade 3 ◽  
Fine Print

Object. One hundred sixty-seven of 250 patients with median nerve (MN) lesions, excluding carpal tunnel syndrome and nerve sheath tumors, at the levels of the arm, elbow, forearm, and wrist, underwent surgical treatment at Louisiana State University Health Sciences over a 30-year period. The most common causes of MN injuries were laceration, fracture-associated stretch and contusion, gunshot wound, compression, and injection injuries. In this study, surgically treated patients were followed and evaluated retrospectively for favorable functional outcomes. Methods. Lesions not in continuity required primary or secondary end-to-end suture or graft repairs. With the aid of direct intraoperative recording of nerve action potentials (NAPs), MN injuries in which the lesion was in continuity underwent external or internal neurolysis, or resection of the lesion, followed by end-to-end suture or graft repair. A minimum of 12 months follow-up review (mean 18 months) was available in 85% of the surgically treated patients. For lesions in continuity, a functional recovery of Grade 3 or better was seen in 72 (95%) of 76 patients who underwent neurolysis, 18 (86%) of 21 who received suture repair, and 21 (75%) of 28 who received graft repair. In lesions not in continuity, favorable results (Grade ≥ 3) were seen in 10 (91%) of 11 patients who received primary suture repair, seven (78%) of nine who received secondary suture repair, and 15 (68%) of 22 who received graft repair. Conclusions. Surgical intervention for MN injuries with complete or severe deficits achieved favorable outcomes.

Surgical outcomes of 654 ulnar nerve lesions

2003 ◽  
Vol 98 (5) ◽  
pp. 993-1004 ◽  
Author(s):  
Daniel H. Kim ◽  
Kisoo Han ◽  
Robert L. Tiel ◽  
Judith A. Murovic ◽  
David G. Kline
Keyword(s):  
Ulnar Nerve ◽  
Surgical Outcomes ◽  
Suture Repair ◽  
Content Type ◽  
Nerve Sheath Tumors ◽  
Nerve Entrapments ◽  
Nerve Sheath ◽  
Internal Neurolysis ◽  
End To End ◽  
Fine Print

Object. In this article the authors present a retrospective analysis of 654 surgical outcomes in patients with ulnar nerve entrapments, injuries, and tumors during a 30-year period. Methods. Data were gathered between 1968 and 1998 at Louisiana State University Health Sciences Center. Mechanisms of injuries or lesions included 460 entrapments at the elbow level (70%), 76 lacerations (12%), 52 stretches/contusions (8%), 34 fractures/dislocations (5%), 12 gunshot wounds (2%), two injection-induced injuries (0.3%), and 13 nerve sheath tumors (2%). In cases of entrapment, direct operative recordings uniformly demonstrated a slowing of conduction at the elbow, even in cases in which preoperative noninvasive studies had been nondiagnostic. Intraoperative electrical “inching” studies also demonstrated significant conduction abnormalities that lie just proximal to and through the olecranon notch rather than distal, beneath the flexor carpi ulnaris muscle. There were only eight exceptions to this. Lesions not in continuity due to the injury required primary or secondary end-to-end sutures or graft repair. Aided by intraoperative nerve action potential recording, lesions in continuity received either external or internal neurolysis and split repair or resection followed by end-to-end suture or graft repair. Functional recoveries of Grade 3 or better were seen in 81 (92%) of 88 patients who underwent neurolysis, 42 (72%) of 58 patients who received suture repair, and 24 (67%) of 36 patients who received graft repair. Nevertheless, fewer Grade 4 or 5 recoveries were reached than those seen in patients with radial or median nerve injuries. Nerve sheath tumors were resected with preservation of preoperative function in five of seven patients. Conclusions. Although difficult to obtain, useful functional recovery can be achieved with proper surgical management of ulnar nerve entrapments and injuries.

Civilian gunshot wounds to the brachial plexus

1989 ◽  
Vol 70 (2) ◽  
pp. 166-174 ◽  
Author(s):  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Gunshot Wounds ◽  
Suture Repair ◽  
Loss Of Function ◽  
Content Type ◽  
Lower Trunk ◽  
Operative Indications ◽  
Grade 3 ◽  
Early Regeneration ◽  
Fine Print

✓ Many gunshot wounds (GSW's) to the brachial plexus do not improve spontaneously with time and are therefore candidates for surgery. Over an 18-year period, 141 patients with GSW's were evaluated, 90 of whom were operated on; 75 of the surgical cases were followed for 2 years or more. Thirty operative patients had initial vascular repair, while eight required thoracotomies. Total plexus palsy was present in 19 of those selected for operation. The average interval between injury and operation was 17 weeks. Six patients required early operation for an expanding aneurysm with progressive neural loss. Persistent complete loss of function in the distribution of one or more elements and/or noncausalgic pain not managed by medications provided the major operative indications. Four patients required sympathectomies for causalgia. Of 166 lesions in continuity believed to be complete, based on clinical examination and electromyography, 48 with preserved intraoperative nerve action potentials (NAP's) were spared resection or were treated with a split repair with excellent eventual results on a weighted grading system. By comparison, only seven of 55 elements believed to have incomplete loss or to be recovering did not have NAP's and required repair. Fifty-three of 98 lesions repaired by grafts and 18 of 26 wounds with suture repair recovered to a Grade 3 level or better. Most elements were in continuity but 14 were found “blown apart” and required repair, usually by grafting. The best outcome was achieved with upper trunk and lateral and posterior cord lesions, but recovery occurred with some C-7 to middle trunk and medial cord to median repairs. Results with lower trunk and most medial cord lesions were poor unless early regeneration was proved by operative NAP's, in which case either neurolysis or split repair could be performed. Surgery is warranted for selected GSW's to the plexus.

Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases

2005 ◽  
Vol 103 (4) ◽  
pp. 614-621 ◽  
Author(s):  
Julia A. Kandenwein ◽  
Thomas Kretschmer ◽  
Martin Engelhardt ◽  
Hans-Peter Richter ◽  
Gregor Antoniadis
Keyword(s):  
Brachial Plexus ◽  
Surgical Techniques ◽  
Functional Results ◽  
Content Type ◽  
Surgical Interventions ◽  
Louisiana State University ◽  
Surgical Measures ◽  
Grade 3 ◽  
Nerve Surgery ◽  
Fine Print

Object. Surgical therapy for traumatic brachial plexus lesions is still a great challenge in the field of peripheral nerve surgery. The aim of this study was to present the results of different surgical interventions in patients with this lesion type. Methods. One hundred thirty-four patients with traumatic brachial plexus lesions underwent surgery between January 1991 and September 1999. In more than 50% of the patients, injury was caused by a motorbike accident. Patients underwent surgery a mean of 6.3 months posttrauma. The following surgical techniques were applied: neurolysis for nerve lesions in continuity (27 cases), grafting for lesions in discontinuity (149 cases), and neurotization for root avulsions (67 cases). Sixty-five patients were evaluated for at least 30 months (mean follow up 42.1 months) after surgery. Function was graded using the Louisiana State University Health Sciences Center classification system. Only 2% of the patients had Grade 3 or better function preoperatively, increasing to 52% postoperatively. The effect of surgical measures on the functional results for different muscles were compared (supra- or infraspinatus, deltoid, biceps, and triceps muscles); the best results were obtained for biceps muscle function (57% of patients with Medical Research Council Grades M3–M5 function). Graft reconstruction yielded a better outcome than neurotization. Surgery within 5 months posttrauma clearly resulted in improved recovery of motor function compared with later interventions. Sural nerve grafts (monofascicular nerves) showed better results. Conclusions. The results of neurosurgical interventions for brachial plexus lesions are satisfactory, especially when the operation is performed between 3 and 6 months after trauma.

Management and outcomes in 353 surgically treated sciatic nerve lesions

2004 ◽  
Vol 101 (1) ◽  
pp. 8-17 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert Tiel ◽  
David G. Kline
Keyword(s):  
Sciatic Nerve ◽  
Functional Outcomes ◽  
Surgical Techniques ◽  
Fracture Dislocation ◽  
Suture Repair ◽  
Nerve Lesions ◽  
Content Type ◽  
Injury Mechanisms ◽  
Grade 3 ◽  
Fine Print

Object. This is a retrospective analysis of 353 surgically treated sciatic nerve lesions in which injury mechanisms, location, time to surgical repair, surgical techniques, and functional outcomes are reported. Results are presented to provide guidelines for management of these injuries. Methods. One hundred seventy-five patients with buttock-level and 178 with thigh-level sciatic nerve injury were surgically treated at the Louisiana State University Health Sciences Center between 1968 and 1999. Buttock-level injury mechanisms included injection in 64 patients, hip fracture/dislocation in 26, contusion in 22, compression in 19, gunshot wound (GSW) in 17, hip arthroplasty in 15, and laceration in 12; at the thigh level, GSW was the cause in 62 patients, femoral fracture in 34, laceration in 32, contusion in 28, compression in 12, and iatrogenic injury in 10. Patients with sciatic nerve divisions in which positive intraoperative nerve action potentials (NAPs) were found underwent neurolysis and attained at least Grade 3 functional outcomes in 108 (87%) of 124 and in 91 (96%) of 95 buttock- and thigh-level tibial divisions, respectively, compared with 84 (71%) of 119 and 75 (79%) of 95, respectively, in the peroneal divisions. For suture repair, recovery to at least Grade 3 occurred in eight (73%) of 11 buttock-level and in 27 (93%) of 29 thigh-level tibial division injuries, and in three (30%) of 10 buttock-level and 20 (69%) of 29 thigh-level peroneal division lesions. For graft repair, good recovery occurred in 21 (62%) of 34 and in 43 (80%) of 54 buttock- and thigh-level tibial divisions, respectively, even in proximal repairs requiring long grafts, and in only nine (24%) of 37 and 22 (45%) of 49 buttock- and thigh-level peroneal division lesions, respectively. Conclusions. Surgical exploration and neurolysis after positive NAP readings, or repair with sutures or grafts after negative NAP results are worthwhile in selected cases.

Radial nerve palsy caused by spontaneously occurring nerve torsion

2001 ◽  
Vol 94 (4) ◽  
pp. 627-629 ◽  
Author(s):  
Eduardo Fernandez ◽  
Alessandro Di Rienzo ◽  
Enrico Marchese ◽  
Luca Massimi ◽  
Liverana Lauretti ◽  
...  
Keyword(s):  
Functional Recovery ◽  
Radial Nerve ◽  
Nerve Palsy ◽  
Radial Nerve Palsy ◽  
Content Type ◽  
Triceps Muscle ◽  
Internal Neurolysis ◽  
Fine Print

✓ An 18-year-old man presented with a spontaneously occurring radial nerve palsy that spared the triceps muscle. At surgery, the portion of the radial nerve located at the midarm level had an hourglass-like appearance. Under magnification, an external—internal neurolysis of the narrowed portion of the hourglass-shaped portion revealed nerve torsion. Straightening of the twisted nerve and fixation accomplished using epiperineurium—fascia stitches to avoid a new torsion resulted in complete functional recovery of the radial nerve.

Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center

2003 ◽  
Vol 98 (5) ◽  
pp. 1005-1016 ◽  
Author(s):  
Daniel H. Kim ◽  
Yong-Jun Cho ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Gunshot Wounds ◽  
Neurological Status ◽  
Health Sciences ◽  
State University ◽  
Content Type ◽  
Lower Trunk ◽  
Louisiana State University ◽  
Fine Print

Object. Outcomes of 1019 brachial plexus lesions in patients who underwent surgery at Louisiana State University Health Sciences Center during a 30-year period are reviewed in this paper to provide management guidelines. Methods. Causes of brachial plexus lesions included 509 stretches/contusions (50%), 161 plexus tumors (16%), 160 thoracic outlet syndromes (TOSs, 16%), 118 gunshot wounds (12%), and 71 lacerations (7%). Many features of clinical presentation, including prior treatment, patient's neurological status, results of electrophysiological studies, intraoperative findings, and postoperative level of function, were studied. The minimum follow-up period was 18 months and the mean follow-up period was 42 months. Repairs were best for injuries located at the C-5, C-6, and C-7 levels, the upper and middle trunk, the lateral cord to the musculocutaneous nerve, and the median and posterior cords to the axillary and radial nerves. Conversely, results were poor for injuries at the C-8 and T-1 levels, and for lower trunk and medial cord lesions, with the exception of injuries of the medial cord to the median nerve. Outcomes were most favorable when patients were carefully evaluated and selected for surgery, although variables such as lesion type, location, and severity, as well as time since injury also affected outcome. This was true also of TOSs and tumors arising from the plexus, especially if they had not been surgically treated previously. Conclusions. Surgical exploration and repair of brachial plexus lesions is technically feasible and favorable outcomes can be achieved if patients are thoroughly evaluated and appropriately selected.

scholarly journals Penetrating injuries due to gunshot wounds involving the brachial plexus

2004 ◽  
Vol 16 (5) ◽  
pp. 1-6 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Action Potentials ◽  
Gunshot Wounds ◽  
Complete Loss ◽  
Sensory Function ◽  
Suture Repair ◽  
State University ◽  
Penetrating Injuries ◽  
Louisiana State University ◽  
Grade 3

The authors review 118 operative brachial plexus gunshot wounds (GSWs), causing 293 element injuries that were managed over a 30-year period at Louisiana State University Health Sciences Center (LSUHSC). Retrospective chart reviews were performed. Using the LSUHSC grading system for motor sensory function, each element's grades were combined and averaged. Most of the 293 injured elements were found to have gross continuity at operation and of 202 elements with complete neurological loss, only 16 (8%) exhibited total disruption. Of 293 injuries, 128 elements with complete or incomplete loss were not only in continuity when explored but also had positive intraoperative nerve action potentials (NAPs). After neurolysis, 120 of 128 elements in continuity (94%) improved to greater than or equal to Grade 3 function. Elements not regenerating early usually required repair. One hundred fifty-six of 202 completely or incompletely injured elements (77%) required resection and suture or graft repair based on intraoperative NAPs. Neurolysis achieved greater than or equal to Grade 3 results in 42 (91%) of 46 elements with complete loss. Suture repair resulted in good outcomes in 14 (67%) of 21 and in 73 (54%) of 135 undergoing graft repairs (1 to 3.5 cm length) and presenting with complete loss. Of 91 incomplete elements, intraoperative NAPs were positive in 82 (90%) and 78 of 82 had good results. Nine had negative NAPs and six elements required suture repair. Three required grafts with results of greater than or equal to Grade 3 in five (83%) of six and two (67%) of three, respectively. Based on 118 patient results with 293 injured elements, guidelines for the management of GSWs were established as described in this paper.

Intrapelvic and thigh-level femoral nerve lesions: management and outcomes in 119 surgically treated cases

2004 ◽  
Vol 100 (6) ◽  
pp. 989-996 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Femoral Nerve ◽  
Gunshot Wounds ◽  
Nerve Lesion ◽  
Cystic Lesions ◽  
State University ◽  
Nerve Lesions ◽  
Content Type ◽  
Louisiana State University ◽  
Injury Mechanisms ◽  
Fine Print

Object. The authors present a retrospective analysis of 119 surgically treated femoral nerve lesions at intrapelvic and thigh levels seen at the Louisiana State University Health Sciences Center. Methods. Femoral nerve lesions treated between 1967 and 2000, (89 traumatic injuries and 30 tumors and cystic lesions) were evaluated for injury mechanisms, resulting lesions, surgical management, and postoperative functional outcomes by using retrospective chart reviews. The most common injury mechanism was iatrogenic (52 cases), which occurred after hernia and hip operations (10 each), followed by arterial bypass and gynecological procedures (eight each), angiography (seven), abdominal surgery (five), appendectomy (two), a laparoscopy, and a lumbar sympathectomy. Other injury mechanisms included hip or pelvic fractures (19), gunshot wounds (10), and lacerations (eight). The 30 femoral nerve tumors and cystic lesions consisted of neurofibromas (16), schwannomas (nine), ganglionic cysts (two), neurogenic sarcomas (two), and a leiomyosarcoma. Forty-four patients underwent neurolysis. Some had recordable nerve action potentials (NAPs) across their lesions in continuity, despite severe distal loss. Others with recordable NAPs had mild loss, but also experienced a pain problem, which was helped in some by neurolysis. In 36 patients, in whom repairs were performed using long sural grafts for mostly proximal pelvic-level injuries, recovery of useful function occurred. Eight of nine thigh-level suture repairs led to improvement to good functional levels. Most of the tumors and cystic lesions were resected, with preservation of preoperative function. Conclusions. The majority of femoral nerve injuries resulted in lesions in continuity, and intraoperative NAP recordings were essential in evaluating axonal regeneration across these lesions. Despite severe and frequently proximal injury levels requiring repairs with long grafts, femoral nerve lesion repairs resulted in good functional recovery.

Surgical management of spinal cord hemangioblastomas in patients with von Hippel—Lindau disease

2003 ◽  
Vol 98 (1) ◽  
pp. 106-116 ◽  
Author(s):  
Russell R. Lonser ◽  
Robert J. Weil ◽  
John E. Wanebo ◽  
Hetty L. Devroom ◽  
Edward H. Oldfield
Keyword(s):  
Spinal Cord ◽  
Surgical Management ◽  
Postoperative Outcome ◽  
Tumor Location ◽  
Neurological Dysfunction ◽  
Autosomal Dominant Disorder ◽  
Content Type ◽  
Von Hippel Lindau ◽  
Vhl Disease ◽  
Fine Print

Object. Von Hippel—Lindau (VHL) disease is an autosomal-dominant disorder frequently associated with hemangioblastomas of the spinal cord. Because of the slow progression, protean nature, and high frequency of multiple spinal hemangioblastomas associated with VHL disease, the surgical management of these lesions is complex. Because prior reports have not identified the factors that predict which patients with spinal cord hemangioblastomas need surgery or what outcomes of this procedure should be expected, the authors have reviewed a series of patients with VHL disease who underwent resection of spinal hemangioblastomas at a single institution to identify features that might guide surgical management of these patients. Methods. Forty-four consecutive patients with VHL disease (26 men and 18 women) who underwent 55 operations with resection of 86 spinal cord hemangioblastomas (mean age at surgery 34 years; range 20–58 years) at the National Institutes of Health were included in this study (mean clinical follow up 44 months). Patient examination, review of hospital charts, operative findings, and magnetic resonance imaging studies were used to analyze surgical management and its outcome. To evaluate the clinical course, clinical grades were assigned to patients before and after surgery. Preoperative neurological status, tumor size, and tumor location were predictive of postoperative outcome. Patients with no or minimal preoperative neurological dysfunction, with lesions smaller than 500 mm3, and with dorsal lesions were more likely to have no or minimal neurological impairment. Syrinx resolution was the result of tumor removal and was not influenced by whether the syrinx cavity was entered. Conclusions. Spinal cord hemangioblastomas can be safely removed in the majority of patients with VHL disease. Generally in these patients, hemangioblastomas of the spinal cord should be removed when they produce symptoms or signs.

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