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.

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.

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.

Evaluation and treatment of atlas burst fractures (Jefferson fractures)

1991 ◽  
Vol 75 (2) ◽  
pp. 213-220 ◽  
Author(s):  
Lee Kesterson ◽  
Edward Benzel ◽  
William Orrison ◽  
James Coleman
Keyword(s):  
State University ◽  
Content Type ◽  
X Ray ◽  
Jefferson Fracture ◽  
Louisiana State University ◽  
Burst Fractures ◽  
Long Term Result ◽  
Atlas Fractures ◽  
Fine Print

✓ Although several large series of atlas fractures have been reported recently, none has concentrated on the evaluation and treatment of atlas burst fractures (Jefferson fractures). The treatment of this fracture is challenging. Its diagnosis may easily be missed due to concerns about associated trauma and absence of neurological signs. In addition, the open-mouth anteroposterior x-ray study, which is usually pathognomonic for the diagnosis, is often inadequate or not obtained. In order to clarify the diagnosis and treatment of this disorder, 17 cases of Jefferson fracture treated between 1982 and 1989 at the Louisiana State University Affiliated Hospitals are presented. The diagnosis was delayed in three patients because of a low index of suspicion and inadequate x-ray films. Four patients were noted to have unstable Jefferson fractures; all of these had an associated Type II odontoid fracture and were treated with occiput-C-2 wiring and fusion. The remainder of the patients had stable Jefferson fractures and were managed with Minerva jackets or rigid collar stabilization. No significant complications related to the treatment of the Jefferson fracture occurred in this series. One patient died from associated injuries: however, the remaining patients enjoyed an excellent long-term result with the acquisition of spinal stability and the resolution of subjective complaints.

Surgical outcome for intra- and extrapelvic femoral nerve lesions

1995 ◽  
Vol 83 (5) ◽  
pp. 783-790 ◽  
Author(s):  
Daniel H. Kim ◽  
David G. Kline
Keyword(s):  
Femoral Nerve ◽  
Common Mechanism ◽  
Nerve Injuries ◽  
Inguinal Herniorrhaphy ◽  
Nerve Lesions ◽  
Content Type ◽  
Ganglion Cysts ◽  
Neurogenic Sarcoma ◽  
Grade 3 ◽  
Fine Print

✓ Seventy-eight traumatic neuropathies were seen in 94 patients with femoral nerve lesions; 54 of these were operated on because of persistent complete functional loss and/or pain. The most common mechanism of injury to the femoral nerve was iatrogenic due to inguinal herniorrhaphy, total hip replacement, intraabdominal vascular or gynecological operation, and, less commonly, appendectomy, lumbar sympathectomy, and laparoscopic procedures. Femoral nerve injuries also resulted from penetrating gunshot and stab wounds, laceration by glass, and stretch/contusive injuries associated with pelvic fractures. There were no signs of clinical or electrical recovery in 45 of 78 patients with traumatic nerve injuries. These and other partial injuries associated with pain were explored and evaluated by intraoperative nerve stimulation and recording of nerve action potentials (NAPs). Despite complete loss of nerve function preoperatively, 13 patients had recordable NAPs and underwent neurolysis; each recovered function to at least a Grade 3 level. Twenty-seven patients had sural graft repairs performed with graft lengths varying from 2.5 to 14 cm. Most patients had some nerve regeneration and regained function to Grade 3 to 4 levels by 2 years postoperatively. Four of five patients with suture repairs recovered to Grade 3 or better within 2 years postoperatively. Despite a proximal pelvic level for most of these injuries and, as a result, lengthy graft repairs, recovery of some useful function was the rule rather than the exception. Tumors involved the femoral nerve in 16 patients and included eight neurofibromas, four schwannomas, one neurogenic sarcoma, two ganglion cysts, and one leiomyosarcoma. All tumors were treated surgically and most were removed successfully.

A series of 397 peripheral neural sheath tumors: 30-year experience at Louisiana State University Health Sciences Center

2005 ◽  
Vol 102 (2) ◽  
pp. 246-255 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert L. Tiel ◽  
Gregory Moes ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Surgical Techniques ◽  
Neurofibromatosis Type ◽  
Health Sciences ◽  
High Morbidity ◽  
State University ◽  
Content Type ◽  
Louisiana State University ◽  
Neural Sheath ◽  
Fine Print

Object. This is a retrospective review of 397 benign and malignant peripheral neural sheath tumors (PNSTs) that were surgically treated between 1969 and 1999 at the Louisiana State University Health Sciences Center (LSUHSC). The surgical techniques and adjunctive treatments are presented, the tumors are classified with respect to type and prevalence at each neuroanatomical location, and the management of malignant PNSTs is reviewed. Methods. There were 361 benign PNSTs (91%). One hundred forty-one benign lesions were brachial plexus tumors: 54 schwannomas (38%) and 87 neurofibromas (62%), of which 55 (63%) were solitary neurofibromas and 32 (37%) were neurofibromatosis Type 1 (NF1)—associated neurofibromas. Among the brachial plexus lesions supraclavicular tumors predominated with 37 (69%) of 54 schwannomas; 34 (62%) of 55 solitary neurofibromas; and 19 (59%) of 32 NF1-associated neurofibromas. One hundred ten upper-extremity benign PNSTs consisted of 32 schwannomas (29%) and 78 neurofibromas (71%), of which 45 (58%) were sporadic neurofibromas and 33 (42%) were NF1-associated neurofibromas. Twenty-five benign PNSTs were removed from the pelvic plexus. Lower-extremity PNSTs included 32 schwannomas (38%) and 53 neurofibromas (62%), of which 31 were solitary neurofibromas and 22 were NF1-associated neurofibromas. There were 36 malignant PNSTs: 28 neurogenic sarcomas and eight other sarcomas (fibro-, spindle cell, synovial, and perineurial sarcomas). Conclusions. The majority of tumors were benign PNSTs from the brachial plexus region. Most of the benign PNSTs in all locations were neurofibromas, with sporadic neurofibromas predominating. Similar numbers of schwannomas were found in the upper and lower extremities, whereas neurofibromas were more prevalent in the upper extremities. Despite aggressive limb-ablation or limb-sparing surgery plus adjunctive therapy, malignant PNSTs continue to be associated with high morbidity and mortality rates.

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.

Femoral nerve repair with nerve autografts

1977 ◽  
Vol 47 (5) ◽  
pp. 751-754 ◽  
Author(s):  
Ole Osgaard ◽  
Jakob Husby
Keyword(s):  
Nerve Repair ◽  
Femoral Nerve ◽  
Nerve Lesions ◽  
Content Type ◽  
Pelvic Region ◽  
Femoral Triangle ◽  
Fine Print

✓ Two cases of femoral nerve lesions are reported, one in the pelvic region, and one in the femoral triangle. In both cases, secondary microsurgical autografting resulted in a good functional and electrophysiological recovery.

Computerized tomography of peripheral nerve lesions

1983 ◽  
Vol 59 (1) ◽  
pp. 131-136 ◽  
Author(s):  
Stephen K. Powers ◽  
David Norman ◽  
Michael S. B. Edwards
Keyword(s):  
Peripheral Nerve ◽  
Computerized Tomography ◽  
Anatomical Location ◽  
Nerve Lesion ◽  
Peripheral Nerve Lesion ◽  
Nerve Lesions ◽  
Content Type ◽  
Peripheral Nerve Lesions ◽  
Relationship Of ◽  
Fine Print

✓ Nine patients with a peripheral nerve lesion (six intrinsic and three extrinsic) were evaluated with computerized tomography (CT). In all but one instance, the CT scans gave useful information regarding the anatomical location, size, and relationship of the lesion to surrounding structures. These cases illustrate the usefulness of CT as a diagnostic tool in the evaluation of peripheral nerve lesions.

A series of 146 peripheral non—neural sheath nerve tumors: 30-year experience at Louisiana State University Health Sciences Center

2005 ◽  
Vol 102 (2) ◽  
pp. 256-266 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert L. Tiel ◽  
Gregory Moes ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Surgical Techniques ◽  
Health Sciences ◽  
Benign Tumors ◽  
State University ◽  
Pelvic Plexus ◽  
Content Type ◽  
Louisiana State University ◽  
Neural Sheath ◽  
Fine Print

Object. This is a retrospective review of 146 surgically treated benign and malignant peripheral non—neural sheath tumors (PNNSTs). Tumor classifications with patient numbers, locations of benign PNNSTs, and surgical techniques and adjunctive treatments are presented. The results of a literature review regarding tumor frequencies are presented. Methods. One hundred forty-six patients with 111 benign and 35 malignant PNNSTs were treated between 1969 and 1999 at the Louisiana State University Health Sciences Center (LSUHSC). The benign tumors included 33 ganglion cysts, 16 cases of localized hypertrophic neuropathy, 12 lipomas, 12 tumors of vascular origin, and 11 desmoid tumors. There were four each of lipofibrohamartomas, myositis ossificans, osteochondromas, and ganglioneuromas; two each of meningiomas, cystic hygromas, myoblastoma or granular cell tumors, triton tumors, and lymphangiomas; and one epidermoid cyst. The locations of benign PNNSTs were the following: 33 in the brachial plexus region, 39 in an upper extremity, one in the pelvic plexus, and 38 in a lower extremity. The malignant PNNSTs included 35 surgically treated carcinomas, 15 of which originated in the breast and nine in the lung. There were two melanomas metastatic to nerve and one tumor each that had metastasized from the bladder, rectum, skin, head and neck, and thyroid, and from a primary Ewing sarcoma. There was a single lymphoma that had metastasized to the radial nerve and one chordoma and one osteosarcoma, each of which had metastasized to the brachial plexus. Conclusions. There were more benign PNNSTs than malignant ones. Benign tumors were relatively equally distributed in the brachial plexus region and upper and lower extremities, with the exception of the pelvic plexus, which had only one tumor.

Axillary nerve repair in 99 patients with 101 stretch injuries

2003 ◽  
Vol 99 (4) ◽  
pp. 630-636 ◽  
Author(s):  
David G. Kline ◽  
Daniel H. Kim
Keyword(s):  
Nerve Repair ◽  
Axillary Nerve ◽  
Fracture Dislocation ◽  
State University ◽  
Shoulder Injury ◽  
Focal Lesions ◽  
Content Type ◽  
Louisiana State University ◽  
Operative Exploration ◽  
Fine Print

Object. The purpose of this paper was to analyze outcomes in patients at the Louisiana State University Health Sciences Center (LSUHSC) who presented with contusion—stretch injuries to the axillary nerve. These injuries resulted from shoulder injury either with or without fracture/dislocation. Although recovery of deltoid function can occur spontaneously, this was not always the case. Methods. Severe deficits persisting for several months led the patients to undergo surgery. Operative categories included isolated axillary palsy (56 procedures), combined axillary and suprascapular palsies (11 procedures), axillary and radial palsies (14 procedures), and axillary palsy with another deficit, usually infraclavicular plexus loss (20 procedures). Deltoid function was evaluated pre- and postoperatively by applying the LSUHSC grading system. An anterior infraclavicular approach was usually followed during surgery, but in three patients an additional posterior approach was used. Axillary lesions usually began in the proximal portion of the posterior cord. Although several patients had distraction of the nerve, lesions in continuity were found in more than 90% of cases. Intraoperative nerve action potential (NAP) recordings were performed to determine the need for resection. Most repairs were made using grafts, although in three patients with relatively focal lesions suture was used. When an NAP was recorded across the lesion and neurolysis was performed, recovery was judged to be a mean Grade 4 according to the LSUHSC in 30 cases. Recovery following suture repairs was a mean Grade 3.8, whereas recovery after 66 graft repairs was a mean Grade 3.7. In cases in which suprascapular palsies were associated with axillary injuries, the former recovered but the latter did not necessarily do so without surgery. If the radial nerve was also injured, recovery of the triceps and brachioradialis muscles and wrist extension was usually obtained, but it was far more difficult to reverse the loss of finger and thumb extension. Although few in number, complications did occur and they are important. Conclusions. Operative exploration of axillary contusion—stretch lesions is worthwhile in carefully selected cases. If indicated by inspection and intraoperative electrical studies, nerve repair can lead to useful function.

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