Difficult Airway of Fetus: Making a Safe Ex Utero Intrapartum Treatment.

Large neck masses involving the airway can lead to hypoxia or the demise of the newborn in case the airway is not secured in time. A planned ex utero intrapartum treatment (EXIT) enables to access the airway by various means under optimal conditions. Advancements in imaging and well-orchestrated teamwork enable to improve the survival by EXIT procedure.

Cystic Nephroma and its Varied Management Scenarios: A Report of two Cases.

Cystic nephroma is a rare benign cystic neoplasm of the kidney. The preoperative diagnosis with its malignant counterparts cystic partially differentiated nephroblastoma or cystic Wilms' tumor is not easy but is important when one is considering for nephron-sparing surgery.

The effect of free glycerol intake on cerebral glycerol concentration.

OBJECTIVE: Cerebral microdialysis (CMD) is a method used to measure the concentration of metabolites and glycerol in the interstitium of the brain. The aim of this study was to investigate the effect of parenterally applied medication and nutrition containing external free glycerol (EFG) on cerebral values of glycerol in patients monitored and treated for non-traumatic subarachnoid hemorrhage (SAH). METHODS: In 13 patients, the values of CG concentrations were measured using CMD. The amounts of parenterally applied EFG (in hourly intervals) were calculated from patient records. All data were gathered retrospectively. To analyze the association between the parameters of interest and their relationship, Spearman´s correlation and p-values were calculated. RESULTS: There was no evident relationship between the CG and EFG concentrations when the dataset was analyzed as a whole (r = -0.146). However, when the analysis was applied to single patients, a varying degree of correlations was discovered in 7 patients (r = 0.431-0.867). CONCLUSION: The possible effect of externally administered glycerol contained in pharmaceuticals and nutrition on its brain concentrations must be considered when interpreting data of CMD (Tab. 2, Fig. 4,Ref. 16) Keywords: glycerol, microdialysis, brain, subarachnoid hemorrhage.

Morphological features of the posterior intermalleolar ligament.

PURPOSE: In the present study, the posterior intermalleolar ligament (PIML) was classified by type using large-scale cadavers to provide basic information to help elucidate the mechanism of ankle joint posterior impingement syndrome. METHODS: This investigation examined 100 legs from 49 Japanese cadavers (mean age at death, 79 ± 11 years; 58 sides from men, 42 from women). In the classification method, an absent PIML was classified as Type I, a PIML with one fiber bundle (attachment to one place) was Type II, a PIML with two fiber bundles (attachment to two places) was Type III, and a PIML with three fiber bundles (attachment to three or more places) was Type IV. Furthermore, according to other adhering tissues, they were further subdivided and classified by type. RESULTS: There were various types of PIML: 19 (19%) Type I; 24 (24%) Type II; 23 (23%) Type III; and 34 (34%) Type IV. A PIML was present in 81 legs (81%). There were no significant differences between men and women and between left and right sides. CONCLUSIONS: The complex relationships of the PIML with the surrounding ligaments and tissues are considered to be among the factors that make interpretation of imaging findings difficult.

Correction to: Multidisciplinary approach in the treatment of spinal dural arteriovenous fistula-results of endovascular and surgical treatment.

The author J. Adamkov was incorrectly captured in the original article and is now corrected in this article.

Multidisciplinary approach in the treatment of spinal dural arteriovenous fistula-results of endovascular and surgical treatment.

BACKGROUND: The results of treatment for spinal dural arteriovenous fistula (SDAVF) have been controversial. The goal of this study was to compare results of endovascular and surgical treatments to contribute to determining an optimal treatment strategy. METHODS: A retrospective analysis of the set of 24 SDAVF patients (11 in the endovascular and 13 in the surgical group) was performed. The clinical effect (using the modified Rankin scale [mRS]), the radicality, and the number of clinical recurrences as well as the impact of age, the level of impairment, and the duration of symptoms before the treatment were evaluated. RESULTS: The average age was 60.1 ± 8.4 years. The median duration of symptoms before establishing a diagnosis was 12 (1-70) months. Clinical improvement was reported in 11 out of 24 (45.8%) patients (36.4% following embolization and 53.8% following surgery, p = 0.444). Radical performance was achieved in 47.4% of endovascular versus 92.9% of surgical procedures (p = 0.009). Clinical recurrence was reported in 35.3% of patients in the endovascular group, whereas no clinical recurrence was reported in the surgical group (p = 0.0133). The graphical residuum after 1 surgery out of 14 (7.1%) was cured early during the control angiography. Clinical improvement was reported 42.1% of patients with mRS ≤ 3 versus 60% of patients with mRS ≥ 4 and, in 57.1% of patients aged ≥ 60 versus in 30% of patients < 60 years (p > 0.05 in both cases). The impact of the duration of symptoms on the clinical results was not statistically significant. CONCLUSIONS: The surgical treatment of SDAVF appeared to be a more efficient method in terms of the clinical effect, radicality, and lower recurrence rate in comparison with the endovascular treatment. No statistically significant dependence of the clinical result on age, deficit burden, or symptom duration was found.

The relationship between intracranial pressure and lactate/pyruvate ratio in patients with subarachnoid haemorrhage.

AIM: The aim of this study was to analyse the relationship between intracranial pressure (intracranial pressure monitoring) and lactate pyruvate ratio (cerebral microdialysis) in patients with ruptured intracranial aneurysms. METHODS: In a group of fifteen patients, intracranial pressure and lactate/pyruvate ratios were measured and logged in hourly intervals. The relationship between these two variables was subsequently analysed in two ways. 1) Intracranial hypertension (ICP > 20 mmHg) in the presence of energy deprivation (L/P ratio > 30) was noted. 2) The dynamics of L/P ratio changes in relation to immediate ICP and CPP values was analysed. RESULTS: Out of a total of 1873 monitored hours we were able to record lactate/pyruvate ratios higher than 30 in 832 hours (44 %). Of those 832 hours during which lactate/pyruvate ratios were higher than 30, ICP was higher than 20 in 193 hours (23 %). Out of 219 hours of monitoring, in which ICP was higher than 20, a simultaneously increased L/P ratio higher than 30 was recorded in 193 hours (88 %). L/P ratio values above 30 were associated with decreased CPP values (p = 0.04), but not with increased ICP values (p = 0.79). CONCLUSION: Intracranial hypertension coincides with energetic imbalance in approximately one quarter of cases. This points to the shortcomings of the most common form of neuromonitoring in SAH patients - ICP monitoring. This method may not be reliable enough in detecting hypoxic damage, which is the major cause of morbidity and mortality in SAH patients (Fig. 5, Ref. 11).

[Prevalence and risk factors for sickle retinopathy in a sub-Saharan comprehensive Sickle Cell Center]. / Prévalence et facteurs de risque de la rétinopathie drépanocytaire dans un centre de suivi drépanocytaire d'Afrique subsaharienne.

INTRODUCTION: Retinopathy is a chronic complication with severe functional consequences in patients with sickle cell disease. Its prevalence is not well known in sub-Saharan Africa because of the absence of screening. We report here the results of a routine screening for sickle retinopathy in a Comprehensive Sickle Cell Center in Sub-Saharan Africa. METHODS: Screening of sickle retinopathy was carried out in all sickle cell patients aged 10 and over, followed between 2010 and 2012. Retinopathy was screened by dilated indirect fundoscopic examination and retinal angiography, if necessary. The gender, age and hematological parameters of patients with sickle retinopathy were compared with those of controls randomly selected from the cohort of sickle cell patients without retinopathy followed during the same period. RESULTS: The overall prevalence of sickle cell retinopathy was 8.8% (142/1604): 12.4% (91/731) in SC, 5.2% (38/734) in SS, 9.4% (5/53) in Sß°-thalassemia patients and 9.3% (8/86) in Sß+-thalassemia patients. Proliferative retinopathy was more common in SC patients (P<0.01). High levels of hemoglobin or of hematocrit were associated with retinopathy in all patients and with proliferative retinopathy in SC patients. In SS or Sß0thalassemia patients, high leukocyte count was associated with proliferative retinopathy. Low fetal hemoglobin level was associated with retinopathy in all groups. CONCLUSION: The prevalence of sickle cell retinopathy is high and negatively associated to the level of fetal hemoglobin. The efficiency of a routine screening for sickle cell retinopathy must be assessed in Africa as well as the benefit of phlebotomy and hydroxyurea therapy as a preventive treatments.

Age delays the recovery of distal motor latency after carpal tunnel syndrome surgery.

BACKGROUND: Studies have shown slow healing of peripheral nerve injury in elderly patients. Carpal tunnel syndrome (CTS) is the most frequent compressive mononeuropathy, affecting mostly older people and females. Few studies have assessed electrophysiological differences between younger and older patients. We aimed to evaluate age-dependent differences in electrophysiological parameters preoperatively and postoperatively over a 100-day postoperative period. METHOD: This retrospective study included 258 hands of patients who underwent conventional open-technique carpal tunnel syndrome surgery. Patients with paresthesia in the median nerve distribution or with impaired sensation or abnormal findings in sensory and motor median nerve conduction studies were enrolled. The age dependence of the preoperative values of distal motor latency, amplitude of the compound motor action potential and sensory conduction velocity was estimated using regression analysis. RESULTS: Statistically significant age dependence was found for the preoperative distal motor latency, compound motor action potential, amplitude and sensory conduction velocity. The repair of segmental demyelination was nearly twice as slow in the older group, at a 5 % significance level, even when comparing groups with the same preoperative distal motor latency. CONCLUSIONS: Analysis of preoperative nerve conduction parameters indicates that surgery for carpal tunnel syndrome is performed later in older patients.

Malignant schwannoma of the obturator nerve.

Lesions of obturator nerve are rare. Tumours and mainly malignant schwannoma of this nerve are extremely rare. The authors describe an unusual case of a gigantic schwannoma of the obturator nerve in 69 year old woman. Due to tumour expansion in the proximal part of the thigh MRI was performed and demonstrated extensive tumour originating most probably from the obturator nerve. The patient had no neurological symptoms. Biopsy from the lesion was taken at the Department of Orthopaedics with the following conclusion: malignant schwannoma. The patient received neoadjuvant chemotherapy due to diffuse metastatic spread on the chest X ray, after which metastatic spread subsided. The main lesion reduced its size by 1 cm. In 4 months after biopsy the patient was referred for operation to neurosurgery. The tumour was removed along its borders and except of minimal weakness of adduction of the right thigh there was no neurological deterioration. She was subsequently referred for further care to oncology and radiotherapy.The goal of this work is to emphasize the extremely rare occurrence of tumours of this nerve and suggest therapeutic options (Fig. 4, Ref. 11).

[Peripheral nerve injury during laparoscopic procedures]. / Poranení periferních nervu pri laparoskopických operacích.

Laparoscopic approach predominates in almost all surgical procedures. In comparison with classical surgery the laparoscopic procedures are more considerable for most tissues. Nevertheless, after learning of laparoscopic surgical techniques, iatrogenic peripheral nerve lesions still occure. The authors present a review of the most frequent laparoscopic operations and occurrence of peripheral nerve injuries in particular procedures. They try to point to the situations leading to iatrogenic lesions, to identify different causes of nerve damage and to deduce necessary preventive measures.

[Radial nerve palsy caused by a nonunion of the humeral shaft--a case report]. / Paréza radiálního nervu zpusobená pakloubem diafýzy humeru--kazuistika.

This is a case of late-onset radial nerve palsy associated with the nonunion of the humeral shaft. Nonunion formation was caused by insufficient osteosynthesis and lack of proper biomechanical conditions for fracture healing. A good final outcome was achieved by simultaneous surgical treatment both nonunion of the humerus and radial nerve palsy. Radial nerve palsy presenting without delay after trauma or after reduction is well known complication of the humeral fracture. Case of late-onset palsy is very rare.

[Compressive syndromes of the suprascapular nerve--experience with surgery]. / Kompresivní syndromy n. suprascapularis--zkusenosti s chirurgickou lécbou.

Compression of suprascapular nerve at the suprascapular notch or spinoglenoid notch can be a cause of a rare mononeuropathy. Patients complain of pain in scapula and shoulder, and selective wasting and weakness of the supraspinatus and infraspinatus muscles. Tenderness at the suprascapular notch and pain by forced abduction of arm are typical and useful signs. Electromyographic signs of various grade denervation are regularly found in both muscles. Development of entrapment syndromes is associated with chronic overload, shoulder injuries, with surgical procedures, or with shoulder-arm fixation. The authors present their own group of 10 patients, who were operated on for entrapment syndrome of suprascapular nerve during 7 year period. Direct or indirect traumatic mechanisms of development of nerve compression were disclosed in most patients. During postoperative period there was not only substantial decrease of pain, but also regression of weakness and wasting of both muscles. In discussion, necessity of differential diagnostic procedures in case of pain and muscle wasting, use of appropriate imaging techniques, demand of purposeful EMG examination, and postoperative follow-ups are emphasized.

The role of embolization in radical surgery of renal cell carcinoma spinal metastases.

BACKGROUND: Radical surgery of renal cell carcinoma spinal metastases carries a high risk due to potentially life-threatening extreme blood loss. Radical preoperative embolization of renal cell carcinoma metastases alone is not necessarily a guarantee of extreme blood loss not occurring during operation. METHODS: A retrospective analysis of 15 patients following radical surgery for a spinal metastases of a renal cell carcinoma was performed. Eight patients were embolized preoperatively and 7 were not. We analysed features influencing peroperative blood loss: size and extent of tumour, complexity of surgical approaches and radicality of embolization. RESULTS: The embolized and non embolized groups were not comparable before treatment. They differed markedly in size of tumour as well as the complexity of approach. In the embolized group the size of the tumour was, on average, twice as large as that in non embolized patients and more complex approaches were used twice as frequently. Despite findings suggesting that embolization was effective, blood loss was greater in the embolized group of 8 patients (4750 ml), compared to the non-embolized group of 7 patients (1786 ml). CONCLUSION: Metastasis size, extent of tumour, technical complexity of surgery and the completeness of preoperative embolization had an important effect on the amount of peroperative blood loss. The evaluation of the benefits of preoperative embolization only on the basis of blood loss is not an adequate method.

[Present view on the spinal haemangioma]. / Soucasný pohled na problematiku páterního hemangiomu.

Ethiopathogenesis, diagnostic and treatment of spinal haemangioma remains suggestive topic not only for surgeons. The development of diagnostic imaging methods allows more precise evaluation of the pathology and optimal therapeutic planning. We have many therapeutic modalities: selective embolisation, radiotherapy, vertebroplasty, alcohol ablation and surgery. It depends on radiologic findings and clinical status which of them is used. The treatment of emergent compression is still the domain of surgeon. In the therapy of haemangiomas causing local pain, we prefer less invasive procedures. The interdisciplinary cooperation is required for the successful treatment.

[The usefulness of carpal tunnel pressure measurement during endoscopic surgery of carpal tunnel syndrome]. / Vyuzití merení tlaku v karpálním tunelu behem operace syndromu karpálního tunelu.

The usefulness of carpal tunnel pressures measurement during surgery of carpal tunnel syndrome is documented by the authors. 31 patients underwent endoscopic uniportal approach, the pressure in different positions (neutral position, flexion and extension in wrist, grip of the fingers) and in different levels (distal forearm, proximal, central and distal part of carpal tunnel, palm) was measured. The significant drop of pressure was observed after dissection of ligament in all levels. The results are presented in the form of several graphs.

[Measurement of carpal tunnel pressure during surgery of carpal tunnel syndrome]. / Merení tlaku v karpálním tunelu pri operacích syndromu karpálního tunelu.

A significance of carpal tunnel pressure measurement during surgery of carpal tunnel syndrome (endoscopic and twin incision technique) was evaluated. The pressure in different levels of palm and in different positions of the hand was measured by ICP sensor Codman during operation of 10 patient. The results are presented in the form of several graphs. In all 10 cases excellent results were obtained.

[Personal experience with the surgical treatment of thoracic outlet syndrome]. / Nase zkusenosti s chirurgickou lécbou thoracic outlet syndromu.

The authors describe their experience with surgery of suspected TOS (8 cases) and traumatic TOS after clavicular fracture (1 case) in the last 2 years. In the group there were 7 women and 2 men aged 39-59 years with a history from 6 months to 26 years. Seven patients reported complete or almost complete relief of symptoms. In one case we observed progressive deterioration during 6 weeks postoperatively. All patients underwent decompression of the brachial plexus and subclavian artery from a supraclavicular approach. There was one case of reoperation after 15 years after primary surgery.