Case report of a primary ectopic extradural and extraspinal meningioma of the brachial plexus.

Primary ectopic extradural and extraspinal meningiomas are rare. We present a unique case of this type of meningioma in the brachial plexus. A 25-year-old man consulted us because of neuropathic supraclavicular pain and the appearance of a supraclavicular mass whose volume had increased. Clinical examination found paresis of the deltoid, biceps brachii and brachialis muscles rated as M4 (MRC) and a strong Tinel sign at the supraclavicular fossa, over the palpable mass. There was no sign pointing towards central nervous system involvement or altered general condition. MRI revealed a mass measuring 53 × 24 mm invading the C5-C6 plexus roots and the primary upper trunk, but not the bone or spinal area. This lesion was hyperintense on DWI/ADC, hyperintense on T2 with hypointense spots, and hypointense on T1 with intense heterogeneous gadolinium enhancement. Excisional biopsy was done 6 months after symptoms started. The tumor had developed at the C5 root, which was fibrous and at the C6 root, which was grossly normal. Anatomical pathology confirmed the WHO grade 1 meningioma, meningothelial and psammomatous histological subtypes. At 6 months, a follow-up MRI found no postoperative tumor remnants or recurrence. During the postoperative course, persistent paralysis of the deltoid muscle at 5 months justified a nerve transfer. This is a rare case of ectopic extraspinal and extradural meningioma of the brachial plexus. The diagnosis of an ectopic meningioma must be considered when a patient presents with a brachial plexus tumor causing neurological deficits. The extradural nature is not sufficient to rule out this diagnosis.

Tendon transfers for C8-T1 palsy of the brachial plexus in adults.

Brachial plexus palsy after C8-T1 nerve root injury is rare, but causes a loss of finger flexion and extension, which greatly limits the patient's grip function. It can benefit from nerve transfers if the diagnosis is made early. Otherwise, tendon transfers may be proposed. Transfers of the extensor carpi radialis longus and brachioradialis to the flexor digitorum profundus and the flexor pollicis longus, respectively, restores finger flexion and thumb flexion. Tenodesis of the extensor digitorum communis allows passive extension of the fingers during active wrist flexion. Translocation of the flexor pollicis longus and the creation of a "lasso equivalent" on the flexor digitorum superficialis provides some recovery of the intrinsic function of the fingers and thumb. Finally, a nerve transfer of the lateral cutaneous nerve of forearm on the superficial branch of the ulnar nerve can improve sensitivity on the ulnar edge of the hand to limit the risk of cutaneous lesions, which frequently occur in this type of paralysis.

Transfer of the rhomboid nerve for restoration of shoulder external rotation in partial brachial plexus palsy.

Restoration of shoulder external rotation in partial brachial plexus palsies is a real challenge. The transfer of the spinal accessory nerve to the suprascapular nerve remains the gold standard. This transfer, however, cannot be always performed. Therefore, in these cases, we previously proposed the transfer of the rhomboid nerve to the suprascapular nerve through a posterior approach. The goal of the present study is to assess this technique through a short series. Eight male patients had a partial plexus palsy. Five patients had C5, C6 root injuries, two patients had C5, C6, C7 root injuries, and one patient had C5 to C8 root injuries. No patients had C5 or C6 root avulsions. In one patient, the spinal accessory nerve was injured and in seven patients, the proximal suprascapular nerve was not available. All patients underwent a transfer from the rhomboid nerve to the suprascapular nerve. Concerning shoulder elevation, transfers from the branch of the long head of the triceps or ulnar nerve fascicle were transferred to the axillary nerve. For elbow flexion, fascicles from the ulnar nerve, median nerve, or both were used. For elbow extension, three intercostal nerves in one patient and one fascicle from the ulnar nerve in two patients were transferred to the branch of the long head of the triceps. For wrist and finger extension, palliative surgery was proposed. All patients recovered external shoulder rotation (from 70-110º) and shoulder elevation (range, 80-140º). Active elbow flexion was coded M4 in seven patients and M3 in one patient. All patients recovered active elbow extension. The transfer of the rhomboid nerve to the suprascapular nerve is an efficient procedure for shoulder external rotation in partial brachial plexus palsies without C5 root avulsion. The results in terms of range-of-motion are, however, poorer than with the spinal accessory nerve. Therefore, this technique is appropriate if the spinal accessory nerve is injured or if the suprascapular nerve is not available in the cervical area. This technique must be associated with another transfer to the axillary nerve for shoulder elevation. The study of more patients will be necessary to confirm these results.

The value of preoperative examination and MRI for the diagnosis of graftable roots in total brachial plexus palsy.

The objective of our study was to evaluate the reliability of clinical examination paired with MRI to determine whether one or both of the superior C5 and C6 roots are graftable in cases of complete brachial plexus palsy. We conducted a retrospective study from 2013 to 2018. Twenty-seven patients who had total brachial plexus palsy and were more than 18 years of age were included. The Horner and the Tinel signs, potential phrenic nerve injury and anterior serratus muscle function were investigated. MRI with STIR 3D sequence was performed in each patient. Surgical exploration of the C5 and C6 roots confirmed if they were avulsed and, if found to be ruptured, assessed the possibility of grafting them. Serratus anterior testing had a specificity and a positive predictive value of 100% and diagnostic accuracy of 78%. The presence of the Tinel sign had a sensitivity and a negative predictive value of 100% and diagnostic accuracy of 93%. MRI had a sensitivity, specificity and diagnostic accuracy of 89%. A decision tree to determine whether or not C5 and/or C6 can be grafted has been developed. Its sensitivity and negative predictive value were 100%. This study provides initial validation of this diagnostic method for the diagnosis of graftable C5 and/or C6 roots. It could help prevent needless cervical exploration.

The first case of hourglass-like constriction neuropathy of a digital nerve.

Neuropathies of digital nerves are an infrequent phenomenon and their causes are most often mechanical. A rare cause of acute neuropathy is hourglass-like fascicular constriction of a nerve due to torsion. Although several cases of hourglass-like constriction have been described in the literature, none to our knowledge involved digital nerves. In this report, we present the first case of hourglass-like constriction of a digital nerve.

[Acute schistosomiasis in French travellers]. / La bilharziose d'importation chez les voyageurs: enquête en France métropolitaine.

OBJECTIVE: The clinical presentation of acute schistosomiasis in travellers differs from those observed with chronic schistosomiasis in people from endemic areas. The objective of this study is to describe the main clinical and biological characteristics of the acute schistosomiasis in French travellers. METHODS: Retrospective study conducted in 42 hospital laboratories of parasitology in France, based on a questionnaire filled out for each case of schistosomiasis diagnosed in subjects non-originating from an endemic country and returning from of a stay in Africa, between 2000 and 2004. RESULTS: Seventy-seven cases of acute schistosomiasis diagnosed between 2000 and 2004 were reported by 15 of the 33 laboratories having taken part in the study. The patients were 26 years old on average and 60% were contaminated in West Africa. Seventy patients (91%) presented at least one symptom at the moment of the diagnosis, but only 44 (57%) presented sufficiently intense symptoms to justify a medical consultation spontaneously. The most frequently reported clinical signs were fever (44%), diarrhoea (40%), pruritus (25%), cough (21%) and hematuria (20%). Hypereosinophilia (82%), elevated liver enzymes and positive serology were respectively reported in 82, 23 and 90% of the cases. Ova were found in the urines or the stool in 60% of the cases. Eleven patients were hospitalized. DISCUSSION: Acute schistosomiasis must be evoked in patients returning from endemic country and presenting with non-specific symptoms; including patients whose bathes in contaminated water was limited to a short contact of the feet in a river. The high frequency of the asymptomatic or paucisymptomatic forms exposes the infected people to a delayed diagnosis and therefore to an evolution towards the chronic form of schistosomiasis. The increase in tourism towards the endemic areas could be accompanied by an increase in the frequency of the schistosomiasis, and encourages setting-up an active monitoring of acute schistosomiasis.

[Patient information in carpal tunnel release]. / Syndrome du canal carpien: information et consentement eclairé.

Patients must be informed of the benefits and risks before any surgical procedure. This information must be clear, honest, specific and complete in order that the patient can give his or her informed consent. This information has to be given face to face, however paper may be used to emphasize certain points and aid retention of information. We studied information sheets for carpal tunnel release given out in ten different hand surgery centres. Different points were identified to analyse each form. From this analysis, a literature review and recent law texts, we propose a new information sheet for carpal tunnel release.

[Scapho-trapezio-trapezoidal arthrodesis for scapho-trapezio-trapezoidal osteoarthritis]. / Traitement de l'arthrose scaphotrapézotrapézoidienne isolée par arthrodèse scaphotrapézotrapézoidienne: une série de 13 cas.

Scapho-trapezio-trapezoid arthrodesis was originally performed for the treatment of scapho-lunate instability. However, only a few publications have described this technique for treatment of osteoarthritis of the scapho-trapezio-trapezoid (STT) joint. The purpose of this paper is to analyze the results of triscaphoid arthrodesis for STT osteoarthritis with a long-term follow-up. Thirteen cases of osteoarthritis of the STT joint in twelve patients, all treated by STT arthrodesis, were reviewed with an average follow-up of 60 months. Pain was classified according to Alnot's classification: eight patients were classified as grade III, two as grade IV and two as grade II. The average preoperative range of motion of the wrist was 51 degrees for flexion, 39 degrees for extension, 9 degrees for radial deviation and 28 degrees for ulnar deviation. Grip strength was compared to the contralateral side. Radiographic changes were classified according to Crosby's classification, including sublevels for carpal instability. Four wrists were classified 2a and nine wrists were classified 2b. The average radio-lunate and scapho-lunate angles were 14 and 45 degrees respectively. Pain was improved in all patients (P = 0.05) all of whom were subjectively satisfied. Strength and range-of-motion did not statistically decrease after STT arthrodesis except for wrist extension (P = 0.03). Radio-lunate and scapho-lunate angles were unchanged in five patients and improved in five patients. There were four non-unions of whom two patients without pain were not re-operated. The other two were re-operated with the same technique leading to fusion. Scapho-trapezio-trapezoid arthrodesis is an efficient procedure for STT osteoarthritis with regard to pain reduction. Strength and global range-of-motion are not modified by this procedure. Moreover, as it limits carpal instability, this procedure is preferable in active patients.

Rhomboid nerve transfer to the suprascapular nerve for shoulder reanimation in brachial plexus palsy: A clinical report.

Recovery of shoulder function is a real challenge in cases of partial brachial plexus palsy. Currently, in C5-C6 root injuries, transfer of the long head of the triceps brachii branch is done to revive the deltoid muscle. Spinal accessory nerve transfer is typically used for reanimation of the suprascapular nerve. We propose an alternative technique in which the nerve of the rhomboid muscles is transferred to the suprascapular nerve. A 33-year-old male patient with a C5-C6 brachial plexus injury with shoulder and elbow flexion palsy underwent surgery 7 months after the injury. The rhomboid nerve was transferred to the suprascapular nerve and the long head of the triceps brachii branch to the axillary nerve for shoulder reanimation. A double transfer of fascicles was performed, from the ulnar and median nerves to the biceps brachii branch and brachialis branch, respectively, for elbow flexion. At 14 months' follow-up, elbow flexion was rated M4. Shoulder elevation was 85 degrees and rated M4, and external rotation was 80 degrees and rated M4. After performing a cadaver study showing that transfer of the rhomboid nerve to the suprascapular nerve is technically possible, here we report and discuss the clinical outcomes of this new transfer technique.

Surgical management of trapezius palsy.

BACKGROUND: Injury to the spinal accessory nerve in the posterior cervical triangle leads to paralysis of the trapezius muscle. The aim of this study was to determine the indications for nerve repair or reconstructive surgery according to the etiology, the duration of the preoperative delay, and specific patient characteristics. METHODS: Of twenty-seven patients with a trapezius palsy, twenty were treated with neurolysis or surgical repair (direct or with a graft) of the spinal accessory nerve and seven were treated with the Eden-Lange muscle transfer procedure. Lymph node biopsy was the main cause of the nerve injury. The nerve repairs were performed at an average of seven months after the injury, and the reconstructive procedures were done at an average of twenty-eight months. Nerve repair was performed for iatrogenic injuries of the spinal accessory nerve, within twenty months after the onset of symptoms, and in one patient with spontaneous palsy. Reconstructive surgery was performed for cases of trapezius palsy secondary to radical neck dissection, for spontaneous palsies, and after failure of nerve repair or neurolysis. The mean follow-up period was thirty-five months. The functional outcome was assessed clinically on the basis of active shoulder abduction, pain, strength of the trapezius on manual muscle-testing, and level of subjective patient satisfaction. RESULTS: The results were good or excellent in sixteen of the twenty patients treated with nerve repair and in four of the seven patients treated with the Eden-Lange procedure. Poor results were seen in older patients and in patients with a previous radical neck dissection. CONCLUSIONS: Good results can be expected from a repair of the spinal accessory nerve if it is performed within twenty months after the injury, as the nerve is basically a purely motor nerve and the distance from the injury to the motor end plates is short. Muscle transfer should be performed in patients with spontaneous trapezius palsy, when previous nerve surgery has failed, or when the time from the injury to treatment is over twenty months. Treatment is less likely to succeed when the patient is older than fifty years of age or the palsy was due to a radical neck dissection, penetrating injury, or spontaneous palsy.

[Ralstonia pickettii osteomyelitis of the trapezium]. / Osteite du trapèze a Ralstonia pickettii: a propos d'un cas et revue de la littérature.

An immunocompromised 29-year-old man presented with a Ralstonia pickettii osteomyelitis affecting the trapezium bone. The patient underwent two surgical debridement stages, including trapezectomy and long-term drainage. The type of the contaminant organism and the trapezium localization make this observation atypical.

Transfer of the rhomboid nerve to the suprascapular nerve: An anatomical feasibility study.

Paralysis of the suprascapular nerve, in partial injuries of the brachial plexus, most often warrants a nerve transfer. Transfer of the spinal accessory nerve to the suprascapular nerve is performed most often. We propose to directly transfer the nerve of the rhomboid muscles (branch of the dorsal scapular nerve) to the suprascapular nerve in the supraspinatus fossa. This anatomical study included 10 shoulders. Dissection of the suprascapular nerve and the branch of dorsal scapular nerve to rhomboid muscles (rhomboid nerve) was performed through a posterior approach. Once the nerves were freed, the possibility of suturing the two nerves together was evaluated. Tensionless suture of the rhomboid nerve to the suprascapular nerve was possible in all shoulders in this study. In addition, the diameter of the two nerves was macroscopically compatible: the average diameter of the rhomboid and suprascapular nerve was 2.9 and 3mm, respectively. The diameter of the rhomboid nerve is more suitable than that of the spinal accessory nerve for a transfer to the suprascapular nerve. Moreover, the spinal accessory nerve is preserved in this technique, thereby preserving the function of the trapezius muscle, which could be used for muscle transfer if the nerve surgery fails. In addition, use of the rhomboid nerve allows the suture to be performed downstream to the suprascapular notch and avoids poor results linked to multilevel injuries of this nerve. Finally, if the posterior approach is extended laterally, associated transfer of the nerve to the long head of the triceps brachii to the axillary nerve is also possible. Rhomboid nerve transfer to the suprascapular nerve is anatomically possible. A clinical study will now be necessary to confirm this hypothesis and set out preliminary results.

Occurrence of hyperhomocysteinemia 1 year after gastroplasty for severe obesity.

Severe obesity exposes one to an increased risk of cardiovascular mortality. Gastroplasty has been shown to induce substantial weight loss and to improve the atherogenic profile of severely obese subjects. However, vitamin deficiencies after gastroplasty have been reported. Because hyperhomocysteinemia, an independent risk factor for cardiovascular disease, is influenced by nutritional status (and especially by folate intake), we hypothesized that a marginal folate deficiency induced by gastroplasty could promote hyperhomocysteinemia. Thus, plasma homocysteine concentrations were measured by high-performance liquid chromatography in 53 severely obese patients (body mass index = 42 +/- 1), before and 1 yr after vertical gastroplasty. Plasma homocysteine concentrations increased, on an average, from 9.9 +/- 0.4 to 12.8 +/- 0.6 micromol/L (P < 0.0001). This increase in homocysteine levels was observed in two thirds of the subjects, leading to clear-cut hyperhomocysteinemia (>15 micromol/L) in 32%. The changes in homocysteine concentrations were correlated to weight loss (P < 0.001) and to decrease in plasma folate concentrations (P < 0.01). Whereas gastroplasty induced a mean 32-kg weight loss and a striking improvement in conventional risk factors, the occurrence of iatrogenic hyperhomocysteinemia might hamper the benefit of surgery on cardiovascular risk in most of the patients. Our results further support use of a systematic efficient folate supplementation after gastroplasty.

Massive weight loss does not restore normal insulin secretory pulses in obese patients with type 2 (non-insulin-dependent) diabetes mellitus.

To study the effects of massive weight loss on insulin secretion, we analysed the oscillations of fasting peripheral insulin levels in obese patients who underwent vertical banded gastroplasty as treatment for morbid obesity. Patients were studied before and 6 months after surgery. Serial measurements of plasma free insulin levels were obtained in duplicates from 0 to 60 min at one-minute intervals. Insulin levels were then analysed by autocorrelation and Fourier transformation. In normal controls and obese patients, the first oscillatory insulin component was detected between 10 and 14 min. Compared to obese controls (n = 4), overt Type 2 diabetic patients (n = 4) had reduced amplitudes of insulin pulses and no oscillatory component. These defects were not as pronounced in patients with impaired glucose tolerance (IGT) after an oral glucose tolerance test (OGTT) (n = 5). When detected, the periodicity of the oscillations occurred at different periods. In 3/5 IGT patients, the first positive peak of correlation was found at 13.3 +/- 2.3 min. Weight loss (mean +/- SD) after 6 months was 24.3 +/- 3.7 for subjects with normal glucose tolerance (NGT), 37.9 +/- 9 for those with IGT and 29.8 +/- 5 kgs for Type 2 diabetic subjects. After weight loss, insulin oscillatory activity was detected in 4/5 IGT patients, with a period of 13 +/- 3 min. Weight loss did not reverse the defects observed in obese diabetic patients despite a significant reduction in peripheral insulin levels from 28.6 +/- 6 to 15.6 +/- 6 mU/l (p < 0.05). Insulin values remained higher than in obese controls (7.82 +/- 2, p < 0.05), and Type 2 patients remained mildly hyperglycaemic. These findings indicate that beta-cell activity is abnormal in Type 2 diabetic patients. The absence of modification after weight loss suggests that inherent beta-cell defects may contribute to hyperglycaemia.

Surgical management of trapezius palsy.

BACKGROUND: Injury to the spinal accessory nerve in the posterior cervical triangle leads to paralysis of the trapezius muscle. The aim of this study was to determine the indications for nerve repair or reconstructive surgery according to the etiology, the duration of the preoperative delay, and specific patient characteristics. METHODS: Of twenty-seven patients with a trapezius palsy, twenty were treated with neurolysis or surgical repair (direct or with a graft) of the spinal accessory nerve and seven were treated with the Eden-Lange muscle transfer procedure. Lymph node biopsy was the main cause of the nerve injury. The nerve repairs were performed at an average of seven months after the injury, and the reconstructive procedures were done at an average of twenty-eight months. Nerve repair was performed for iatrogenic injuries of the spinal accessory nerve, within twenty months after the onset of symptoms, and in one patient with spontaneous palsy. Reconstructive surgery was performed for cases of trapezius palsy secondary to radical neck dissection, for spontaneous palsies, and after failure of nerve repair or neurolysis. The mean follow-up period was thirty-five months. The functional outcome was assessed clinically on the basis of active shoulder abduction, pain, strength of the trapezius on manual muscle-testing, and level of subjective patient satisfaction. RESULTS: The results were good or excellent in sixteen of the twenty patients treated with nerve repair and in four of the seven patients treated with the Eden-Lange procedure. Poor results were seen in older patients and in patients with a previous radical neck dissection. CONCLUSIONS: Good results can be expected from a repair of the spinal accessory nerve if it is performed within twenty months after the injury, as the nerve is basically a purely motor nerve and the distance from the injury to the motor end plates is short. Muscle transfer should be performed in patients with spontaneous trapezius palsy, when previous nerve surgery has failed, or when the time from the injury to treatment is over twenty months. Treatment is less likely to succeed when the patient is older than fifty years of age or the palsy was due to a radical neck dissection, penetrating injury, or spontaneous palsy.

Drainage after thyroidectomy: a randomized clinical trial.

A randomized clinical trial of surgical drainage in thyroid surgery was performed on 97 patients. Morbidity was not significantly different between both groups. The length of hospital stay was shorter in the undrained group. However, this RCT is not an indication of the value of drainage after thyroid surgery because the series is too small. Using a meta-analysis of the RCTs reported it is possible to show that to drain is not useful.

[Analysis of the medical decision]. / L'analyse de la décision médicale.

Analysis of clinical decision making is a quantitative method using probabilities to evaluate the process in uncertain situations. It provides a model of clinical decision making by integrating experimental and epidemiological data, the opinions of specialists and an assessment of the patient's state of health. There is also a place for the integration of the patients' opinions and of their quality of life. Using this information and eventually associating the cost of management, analysis of decision making tries to demonstrate a preference for a given strategy in a given clinical or public health problem. This article presents the methodological basis of analysis of decision making using a simple example of clinical cardiological practice and discusses the value of this method for debating a clinical choice with criteria integrating the patients' quality of life and the cost to society.

[Treatment of sclerodermic esophagitis: value of duodenal diversion]. / Traitement de l'oesophagite sclérodermique: intérêt de la diversion duodénale.

Between 1985 and 1990, six patients were operated on using duodenal diversion for reflux esophagitis with scleroderma. Duodenal diversion was performed twice as initial procedure and 4 times as treatment of unsuccessful antireflux procedure performed ten years previously. Duodenal diversion was associated with truncal vagotomy. In cases of reoperation the initial reconstruction procedure was removed. An esophageal stricture was resected in one case. One patient with previous truncal vagotomy and pyloroplasty underwent supra papillary diversion. There was no postoperative death. The mean follow-up was 28 months with one patient lost to follow-up. For 4 patients, the postoperative weight gain was 10 per cent. Abnormalities of lower esophageal motility in scleroderma account for the poor results after classical antireflux procedures. In these cases duodenal diversion is indicated as primary treatment. In cases of reoperation removal of the initial anti-reflux device is required in association with duodenal diversion.

[Prophylactic drainage after thyroidectomy: a randomized trial]. / Drainage prophylactique après thyroïdectomie: un essai randomisé.

A randomized clinical trial of surgical drainage in thyroid surgery was performed with 97 patients. Using equivalence testing it is reported that morbidity was not significantly different between the two groups and the length of hospital stay was shorter in the undrained group. It is possible to perform thyroidectomy without drainage in a selected population.

[Gastroplasty calibrated by a silastic ring. A new technique of vertical gastroplasty in obesity]. / Gastroplastie calibrée par un anneau de silastic. Nouvelle technique de gastroplastie verticale pour obésité.

Among the various procedures used for surgical treatment of morbid obesity, the vertical silastic ring calibrated technique is in full development. Using a linear suture stapler with 4 rows of staples makes it possible to create a gastric partition without excision of a gastric outlet. The channel is calibrated by means of a 4.5 cm long silastic ring. In a small series of 20 cases, the loss of excess weight over one year was 47 +/- 12 percent at 6 months and 59 +/- 21 percent at 12 months without mortality or morbidity.