Managing Complications Related to Peripheral Nerve Surgery: Selected Illustrative Cases.

Peripheral nerve surgery mostly involves elective procedures; thus, the associated complications are of great clinical, social, and medicolegal importance. Apart from the general perioperative morbidity, complications during interventions on peripheral nerves are extremely rare. However, iatrogenic peripheral nerve injuries during unrelated surgical procedures performed by those not specialised in peripheral nerve surgery remain the most significant group of complications, accounting for up to approximately 17% of all cases. The aims of this review are to provide better insight into the multifaceted nature of complications related to peripheral nerve surgery-from the perspective of their causes, treatment, and outcome-and to raise surgeons' awareness of the risks of such morbidity. It should be emphasized that intraoperative complications in peripheral nerve surgery are largely "surgeon-related" rather than "surgery-related"; therefore, they have great potential to be avoided.

The Psychosocial Model of Absenteeism: Transition from 4.0 to 5.0.

The research provides insight into the factors that determine absenteeism in different types of organizations, in order to facilitate the adjustment of employees and organizations in the transition process from Industry 4.0 to Industry 5.0. The aim of the study is to predict the absenteeism of employees in the context of job characteristics and mental health. Additionally, the research investigated the effect of size, ownership, and sector of the companies on absenteeism, job characteristics, and mental health. The sample included responses from 502 employees of different sociodemographic characteristics that work in various types of organizations, performing white-collar and blue-collar jobs. A short mental health questionnaire-Mental Health Inventory, MHI-5-was used in order to measure mental health. The Job Characteristics Questionnaire was used to measure the employees' perceptions of their job characteristics-job variety, autonomy, feedback, dealing with others, task identity, and friendship. The absenteeism is operationalized with the question: "During the past 12 months, how many days were you absent from work for any reason?". The findings suggest that mental health and job characteristics significantly reduce absenteeism among different sectors. The result showed that the size, ownership, and sector of the organization significantly affect the absenteeism, job characteristics, and the mental health of the employees. The results support the premises of Industry 5.0 and offer a new human-centric approach to absenteeism through the promotion of mental health through long-term organizational strategies and a more inclusive approach to employees' preferences in relation to job characteristics. The study offers a new, double-sided model of absenteeism, determining causal factors from the perspective of personal and organizational factors.

Useful functional recovery and quality of life after surgical treatment of peroneal nerve injuries.

Closed injuries to the peroneal nerve recover spontaneously in about a third of patients, but surgery may be needed in the remaining 2/3. The recovery after surgery is not always satisfactory and the patients may need an orthosis or a walking aid to cope with regular daily activities. This study aimed to evaluate the useful functional recovery and quality of life (QoL) in surgically treated patients with peroneal nerve (PN) injuries. The study involved 51 patients who have undergone surgical treatment due to PN injury in our department, within a 15-year period (2006-2020). Thirty patients (59%) were treated with neurolysis, 12 (23%) with nerve repair techniques, and 9 (18%) with tendon transfer (TT). Neurolysis is employed in the least extensive nerve injuries when nerve continuity is preserved and yields a motor recovery ratio of almost 80%. Nerve repairs were followed by 58.33% of patients achieving M3+ recovery, while 41.66% recovered to the useful functional state (M4 or M5) With the use of TTs, all patients recovered to the M3+, while 66.7% recovered to M4. All our results correspond to the results of previous studies. No statistically significant differences were found regarding the QoL of the groups. There is an apparent advantage of neurolysis, over nerve repair, over TT procedure, both in terms of useful functional recovery, and foot-drop-related QoL. However, when involving all aspects of QoL, these advantages diminish. The individual approach leads to optimal results in all groups of patients.

Fatal Acute Pneumocephalus after Bilateral Drainage for Chronic Subdural Hematomas: Case Report.

BACKGROUND: Pneumocephalus is a well-known complication in the surgical treatment of chronic subdural hematomas; however, its influence remains controversial. The amount of subdural air may vary, and it may cause worsening of symptoms, increase reoccurrence rates, and worsen the outcomes. Lethal outcome following acute onset of massive pneumocephalus was not previously reported. CASE REPORT: An 81-year-old man with bilateral hematomas underwent surgery under local anesthesia. Both hematomas were approached in the same surgery, and the drains were placed subdurally. After initial improvement, severe hypertension developed, followed by vital function and neurologic deterioration. Massive pneumocephalus with subarachnoid and contralateral intracerebral hemorrhage was revealed, causing a severe midsagittal shift. Emergency irrigation to evacuate subdural air was performed. However, there was no improvement. Further computed tomography confirmed subdural air collection, but it also revealed hemorrhage progression and intraventricular propagation. No further surgery was indicated. CONCLUSION: Pneumocephalus is an underestimated but potentially devastating complication. Both intraoperative avoidance and postoperative prevention should be utilized to avoid subdural air ingress, and thus evade potentially fatal complications.

Awake surgery in sitting position for chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common pathology in neurosurgery, especially in the elderly patients, and its incidence is likely to double in the next decade. Considering various features of CSDH and the procedure itself, a sitting position may retain the best characteristics of classic positioning, while offering additional comfort for both the patient and the surgeon. The aim of this study was to describe the technical aspects of this procedure in the sitting position, to evaluate safety and discuss the benefits and shortcomings of this modification. METHOD: This study included a series of 55 patients surgically treated for CSDH in a sitting position at our department between December 2017 and September 2019, representing all the patients operated on during the study period by a single surgeon. Bilateral hematomas were present in 19 patients. Outcomes, during the 6-month follow-up period, were defined as good (CSDH and symptoms resolved) or poor (lethal outcome or reoccurrence). All complications were noted, with emphasis on pneumocephalus, and complications related to the sitting position: tension pneumocephalus, venous air embolism, and compression nerve injury. RESULTS: Complications previously associated with the sitting position were not noted. The Glasgow Coma Scale and Markwalder Grading Scale scores improved significantly after the surgery (p < 0.001 and p = 0.018). Complications were noted in 17 patients (30.9%), and included 5 cerebrospinal fluid drainages, 3 hematoma reoccurrences, 2 wound infections, and 9 more single-occurring complications. The in-hospital mortality was 5.4% (3 out of 55 patients), while the overall mortality was 16.4% within the 6-month follow-up period. CONCLUSIONS: In our series, even the severely ill patients tolerated the position well. No complications associated with the sitting position were noted. Future studies should confirm the safety of this position and evaluate the potential advantages for both the patient and the surgeon.

Viable C5 and C6 Proximal Stump Use in Reconstructive Surgery of the Adult Brachial Plexus Traction Injuries.

BACKGROUND: In patients with only upper (C5, C6) brachial plexus palsy (BPP), the pooled international data strongly favor nerve transfers over nerve grafts. In patients with complete BPP, some authors favor nerve grafts for the restoration of priority functions whenever there is a viable proximal stump. OBJECTIVE: To evaluate functional recovery in cases of upper and complete BPP where only direct graft repair from viable proximal stumps was performed. METHODS: The study included 36 patients (24 with complete BPP and 12 with only upper BPP) operated on over a 15-yr period. In all cases, direct graft repair from C5 to the musculocutaneous and the axillary nerve was performed. In cases with complete BPP, additional procedures included either direct graft repair from C6 to the radial nerve and the medial pectoral nerve or the dorsal scapular nerve transfer to the branch for the long head of the triceps. RESULTS: The use of C5 proximal stump grafts (in both complete and upper BPP) resulted in satisfactory elbow flexion in 26 patients (72.2%) and satisfactory shoulder abduction in 22 patients (61.1%). The use of C6 proximal stump grafts in patients with complete BPP resulted in satisfactory elbow extension in 5 (50%) and satisfactory shoulder adduction in another 5 (50%) patients. CONCLUSION: Although nerve transfers generally enable better restoration of priority functions, in cases of infraganglionary injuries, especially in shorter defects, it is also necessary to consider direct graft repair, or at least its combination with nerve transfers, as a potentially beneficial treatment modality.

A Spontaneous Cervical Epidural Hematoma Mimicking a Stroke: A Challenging Case.

BACKGROUND: A spontaneous cervical epidural hematoma (SCEH) is a rare occurrence, with < 500 cases reported to date. Clinically, it usually presents with quadriparesis, but in extremely rare cases it can present with hemiparesis or hemiplegia, and can easily be misdiagnosed as stroke. The cervical epidural hematoma by itself is an urgent condition that requires a quick and accurate diagnosis and a prompt surgical treatment. CASE REPORT: We present a case where an SCEH mimicked the much more frequent condition of a stroke, and discuss the importance of diagnostics procedures that help differentiate SCEH from acute cerebral infarction. The patient's history of neck pain and spondylosis render this case more challenging. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Considering that the emergency tissue plasminogen activator treatment for acute cerebral infarction can worsen the state of an SCEH patient, or even lead to permanent damage or death, it is of great importance to rapidly and accurately differentiate these two conditions.

MANAGEMENT OF BRACHIAL PLEXUS MISSILE INJURIES.

- Missile injuries are among the most devastating injuries in general traumatology. Traumatic brachial plexus injuries are the most difficult injuries in peripheral nerve surgery, and most complicated to be surgically treated. Nevertheless, missile wounding is the second most common mechanism of brachial plexus injury. The aim was to evaluate functional recovery after surgical treatment of these injuries. Our series included 68 patients with 202 nerve lesions treated with 207 surgical procedures. Decision on the treatment modality (exploration, neurolysis, graft repair, or combination) was made upon intraoperative finding. Results were analyzed in 60 (88.2%) patients with 173 (85.6%) nerve lesions followed-up for two years. Functional recovery was evaluated according to functional priorities. Satisfactory functional recovery was achieved in 90.4% of cases with neurolysis and 85.7% of cases with nerve grafting. Insufficient functional recovery was verified in ulnar and radial nerve lesions after neurolysis, and in median and radial nerve lesions when graft repair was done. We conclude that the best time for surgery is between two and four months after injury, except for the gunshot wound associated with injury to the surrounding structures, which requires immediate surgical treatment. The results of neurolysis and nerve grafting were similar.

Outcome after brachial plexus injury surgery and impact on quality of life.

BACKGROUND: The aim of this study was to investigate outcomes after surgery for brachial plexus injury (BPI), not only motor outcomes but also the quality of life of the patients. METHODS: We operated on 128 consecutive patients with BPI from 1992 to 2012. We documented the information on the injured nerve, level of injury, type of treatment used, timing of surgery, patient age, and preoperative and postoperative motor deficits. In 69 patients who agreed to participate in a quality of life study, additional assessments included functionality, pain, quality of life, patient satisfaction, and psychosocial health. RESULTS: Of patients who underwent only exploration and neurolysis, 35.3% showed a good quality of recovery. Patients who underwent nerve reconstruction using nerve grafting showed a better rate of good quality recovery (56.7%), and the results following nerve transfer depended on the type of transfer used. After surgery, 82.6% of patients showed significant improvement, 82.6% were satisfied, and 81.2% responded positively when asked if they would undergo surgery again if they knew the current result beforehand. Overall, 69.6% patients continued working after surgery. The mean DASH disability score was high (58.7) in the study group. Patients who had early surgery showed a consistently higher DASH score. About 76% of patients reported having pain regularly, and 18.8% reported depression or anxiety. CONCLUSIONS: We consider that it is important to report not only muscle recovery, but also other aspects of recovery.

Iatrogenic Peripheral Nerve Injuries-Surgical Treatment and Outcome: 10 Years' Experience.

BACKGROUND: Iatrogenic nerve injuries are nerve injuries caused by medical interventions or inflicted accidentally by a treating physician. METHODS: We describe and analyze iatrogenic nerve injuries in a total of 122 consecutive patients who received surgical treatment at our Institution during a period of 10 years, from January 1, 2003, to December 31, 2013. The final outcome evaluation was performed 2 years after surgical treatment. RESULTS: The most common causes of iatrogenic nerve injuries among patients in the study were the operations of bone fractures (23.9%), lymph node biopsy (19.7%), and carpal tunnel release (18%). The most affected nerves were median nerve (21.3%), accessory nerve (18%), radial nerve (15.6%), and peroneal nerve (11.5%). In 74 (60.7%) patients, surgery was performed 6 months after the injury, and in 48 (39.3%) surgery was performed within 6 months after the injury. In 80 (65.6%) patients, we found lesion in discontinuity, and in 42 (34.4%) patients lesion in continuity. The distribution of surgical procedures performed was as follows: autotransplantation (51.6%), neurolysis (23.8%), nerve transfer (13.9%), direct suture (8.2%), and resection of neuroma (2.5%). In total, we achieved satisfactory recovery in 91 (74.6%), whereas the result was dissatisfactory in 31 (25.4%) patients. CONCLUSIONS: Patients with iatrogenic nerve injuries should be examined as soon as possible by experts with experience in traumatic nerve injuries, so that the correct diagnosis can be reached and the appropriate therapy planned. The timing of reconstructive surgery and the technique used are the crucial factors for functional recovery.

Cranial Reconstruction Using Autologous Bone and Methylmethacrilate.

BACKGROUND: Having in mind the importance of reconstruction of the calvaria, our goal was to compare the complication rates following the use of autologous bone and methylmethacrilate grafts, and explain the factors influencing them. METHODS: The authors collected information of all the patients undergoing cranial reconstructive surgery (N = 149) at the Military Medical Academy in Belgrade. Procedures were performed either using a craniotomy bone flap, removed and replaced in the same act, or using methylmethacrilate. These 2 groups were compared using the Chi-squared test, controlling for the confounding influence of the size of the defect. RESULTS: Intracranial neoplasms were the cause for the reconstruction in 71.1% of patients. The total complication rate was 7.4%, while the infection rate was 5.4%. The infection rate was significantly higher in those procedures done using methylmethacrilate (11.3% compared with 2.1%, P = 0.017), but when controlling for the confounding effect of the size of the defect treated, the difference in infection rate was significant only in large defects (13.9% compared with 2%, P = 0.031), while for small defects the difference was not statistically significant. CONCLUSIONS: Our study suggests that the material used for reconstruction of calvaria influences the infection rate only in large and complicated defects. Considering the importance of the reconstruction, further studies should explore and confirm the role of material type on the rate of complications.

Symptomatic migration of a Kirschner wire into the spinal canal without spinal cord injury: case report.

The migration of Kirschner wires (K-wires) is a rare but significant complication of osteosynthesis interventions, and numerous cases of wire migrations have been reported in the literature. Nevertheless, migration into the spinal canal is very rare, with only 10 cases reported thus far. The authors present a case of K-wire migration into the spinal canal, together with a review of the relevant literature. A 30-year-old male who had suffered a right clavicle fracture in a motorcycle accident was treated with 2 K-wires. Four months after the initial fixation, while he was lifting his child, he experienced short-term pain in his back, numbness in all 4 extremities, followed by a spontaneous decrease in numbness affecting only the ulnar nerve dermatomes bilaterally, and a persistent headache. No urinary incontinence was present. Simple radiography studies of the cervical spine revealed a wire in the spinal canal, penetrating the T-2 foramen and reaching the contralateral foramen of the same vertebra. Computerized tomography showed the wire positioned in front of the spinal cord. Surgery for wire extraction was performed with the patient under general anesthesia, and he experienced relief of the symptoms immediately after surgery. This case is unique because the wire caused no damage to the spinal cord but did cause compression-related symptomatology and headache, which have not been reported in osteosynthesis wire migration to the thoracic region.

Combined Treatment of Ruptured Middle Cerebral Artery Aneurysm Followed by Subarachnoid Hemorrhage and Acute Subdural Hematoma in Multiple Aneurysm Disease of Cerebral Blood Vessels: Case Report

Aneurysms of blood vessels at the base of the brain are pathological focal out-pouchings, usually found at the branching points of the arteries. Aneurysm can remain silent for life. Clinical presentation is due to rupture and bleeding. In only 1.3% of cases it results in subdural hematoma, which is associated with direct interaction of the aneurysm with the basal arachnoid membrane. Multiple aneurysms are present in 15% to 33% of cases with subarachnoid hemorrhage. Assessment of these patients is more complicated, as there are no specific signs to pinpoint/detect the aneurysm that has ruptured. This report presents a 44-year-old female patient suffering from multiple cerebral aneurysm disease, who was urgently treated after rupture by both endovascular (for multiple aneurysms) and surgical (for acute subdural hematoma) approach in the same act under general anesthesia, which resulted in complete recovery of the patient.

Cranial reconstruction with prefabricated 3D implant after a gunshot injury: A case report.

Introduction: Complex defects of skull bones with different etiology, still present the challenge in reconstructive surgery. The goldstandard for cranioplasty is the autologous calvarial bone graft removed during surgery which cannot be always applied, especially in gunshot wounds for sometimes complete bone destruction. Autologous reconstruction with split calvarial, rib bones or iliac bone graft is also possible. Materials routinely used for reconstructions like titanium mesh, polymethyl metacrylate (PMMA), and other have numerous disadvantages and limitations. Case report: We presented a patient with gunshot injury to the head with residual large bone defect in the frontal region, with involvement of the skull base, and open frontal sinus. After conservative treatment, six months after the injury, reconstruction of the residual bone defect was performed. The chosen material was computerdesigned PEEK-OPTIMA® implant, manufactured on the basis of MSCT scan. This material has not been used in this region so far. The postoperative and follow-up period of the next 12 months passed without surgical complications, neurological deficit, with satisfactory functional and aesthetic results. Conclusion: Implanted bone replacement was designed and manufactured precisely according to the skull defect, and we found it suitable for the treatment of complex defects of the cranium. Early results are in favor of this cranioplasty method over standardized materials. Therefore, this material is expected to become a method of choice for reconstructive surgery of bony defects of the face and skull especially in complex cases.