C5 Palsy Following Cervical Spine Decompression.

BACKGROUND: Cervical spinal surgery is considered safe and effective. One of the few specific complications of this procedure is C5 nerve root palsy. Expressed primarily by deltoid muscle and biceps brachii weakness, it is rare and has been related to nerve root traction or to ischemic spinal cord damage. OBJECTIVES: To determine the clinical and epidemiological traits of C5 palsy. To determine whether C5 palsy occurs predominantly in one specific surgical approach compared to others. METHODS: A retrospective study of patients who underwent cervical spine surgery at our medical center during a consecutive 8-year period was conducted. The patient data were analyzed for demographics, diagnosis, and surgery type and approach, as well as for complications, with emphasis on the C5 nerve root palsy. RESULTS: The study group was comprised of 124 patients. Seven (5.6%) developed a C5 palsy following surgery. Interventions were either by anterior, by posterior or by a combined approach. Seven patients developed this complication. All of whom had myelopathy and were older males. A combined anteroposterior (5 patients) and posterior access (2 patients) were the only approaches that were associated with the C5 palsy. None of the patients who were operated via an anterior approach did develop this sequel. CONCLUSIONS: The incidence of the C5 root palsy in our cohort reached 5.6%. Interventions performed through a combined anterior-posterior access in older myelopathic males, may carry the highest risk for this complication.

Effects of an antiadhesive agent on functional recovery of the greater auricular nerve after parotidectomy: a double-blind randomized controlled trial.

PURPOSE: Periauricular sensory deficit occurs frequently after parotidectomy even in cases with preservation of the greater auricular nerve (GAN). This study was performed to evaluate the effects of antiadhesive agent in functional recovery of the GAN after parotidectomy. METHODS: Ninety-eight patients undergoing partial parotidectomy for benign parotid tumors were prospectively enrolled in this multicenter, double-blind randomized controlled study and randomly assigned to either the study or control group. Antiadhesive agent was applied in the study group. The results of sensory tests (tactile, heat, and cold sensitivity) and a questionnaire on quality of life (QoL) were acquired at postoperative 1, 8, and 24 weeks after surgery. Clinical parameters, and the results of the sensory tests and the questionnaire, were compared between the two groups. RESULTS: A total of 80 patients were finally enrolled. On sensory evaluation, tactile sensation and warm sensation in the ear lobule, and warm sensation in the mastoid area, showed significant improvement at 24 weeks postoperatively in the study group. There were no significant differences between the two groups on any questions in the QoL questionnaire, at any follow-up time point. CONCLUSIONS: Antiadhesive agents have some positive effects on functional recovery of the GAN after parotidectomy. Therefore, applying antiadhesive agents after parotidectomy can reduce discomfort in patients.

Tunnels and grooves for supraclavicular nerves within the clavicle: review of the literature and clinical impact.

Perforation of the clavicle by supraclavicular nerves is a common anatomical variation. This variation has been reported in several studies based on post-mortem, surgical and radiologic findings, with an overall frequency between 1 and 6.6 %. The penetrating branch passes either through a bony tunnel or a groove on the superior surface of the bone. Entrapment neuropathy of the perforating branch is a documented clinical entity reported in the literature. The intraosseous course of the supraclavicular nerves makes them vulnerable to injury in case of clavicular fractures or during surgical manipulations of these fractures. Furthermore, this variation should be taken into account during the interpretation of chest and shoulder radiographs. The purpose of the current study is to perform an extended review of the relevant literature, highlighting the clinical impact of this variation, as well as to incorporate our own findings into them.

Short longitudinal versus transverse skin incision for carotid endarterectomy: impact on cranial and cervical nerve injuries and esthetic outcome.

AIM: Nerve injuries, wound complications and especially poor cosmetic results still have an important impact on the carotid endarterectomy (CEA) morbidity. Introduction of the mini skin incision in clinical practice seems to be safe with reduction in postoperative pain and superficial and cranial nerves lesions, and better aesthetics outcomes. The objective of this retrospective study was to compare the results between the short longitudinal with the short transverse cervical incision and to evaluate their impact on cranial and cervical nerves and aesthetic outcomes. METHODS: From January 2007 to December 2009 266 patients underwent 300 consecutive primary CEA procedures. Two-hundred nineteen patients were submitted to short longitudinal cervical incision (group A), in eighty one a short transverse cervical skin incision (group B) was performed. The average of skin incision was about 4-5.5 cm. In all cases a preoperative CEA duplex ultrasounds (US) assisted skin marking was carried out. All patients were submitted to the general anesthesia with Remifentanyl conserved consciousness. Routinely synthetic patch and selective policy intraluminal shunts were used. Incisions were extended when shunts were required or in case of high carotid bifurcation. Preoperative and postoperative cranial nerves evaluation was always performed and a questionnaire about the satisfaction of the aesthetic outcome was proposed to all patients to the discharge and six months follow-up. Stroke/TIA, death, wound complications, cranial and cervical nerves injuries and restenosis rate were reported and analyzed through statistical analysis (χ2 and Student's t test). RESULTS: The 30 days mortality was 0.3% (1/300). The TIA rate was 0.91% in group A and 1.2 % in group B (P>0.9). Wound complications were 1.8% and 1.2 % respectively (P>0.1). No statistically differences were reported in the incidence of cranial and cervical nerves injuries between the two groups (P>0.9). No difference in restenosis rate was detected (P>0.9). In case of lengthening of the incision for high internal carotid (ICA) stenosis and especially to the need of shunt deployment, the longitudinal approach showed unequivocally to be easier and safer. CONCLUSION: No differences were achieved between short longitudinal and transverse incision in term of stroke, wound complications or nerves impairment. A good cosmetic outcome was gained in both groups. The Duplex US skin markings pre-CEA permitted localization and limits of the plaque with appropriate short incision. A longitudinal cervical approach is to prefer as can lead to an easier proximal and distal lengthening in cases of atherosclerotic extension of the plaque and shunt deployment.

[Anatomical study of the superficial cervical plexus: application to the prevention of the postoperative sensitive facial deficits]. / Étude anatomique du plexus cervical superficiel: application à la prévention des déficits sensitifs faciaux postopératoires.

INTRODUCTION: The cervical surgery can be complicated of postoperative facial sensory deficits, in particular in using the anterior presternocleidomastoid approach. The purpose of this study was to specify the routes and the links of nerves involved in these sensory deficits (great auricular nerve and transverse cervical nerve with the goal, to deducing, if possible, some modifications of the surgical practices to prevent the deficits. PATIENTS: Ten dissections of the superficial cervical plexus, on preserved anatomical subjects, were made from February till May 2009. Nerves and whole superficial venous network were dissected on all along their route to be able to make several measures of distances and angles. All the data were computerized treated by spreadsheet. RESULTS: The transverse cervical nerve appeared from the posterior edge of the sternocleidomasoid (SCM) muscle in 7.46 ± 1.81 cm s (5,1-10,0) of the clavicle, with an angle of 108.3 ± 8.15° (93-120). Its halving terminal branches was made in 2.92 ± 1.76 cm s (0,4-5,2) of the posterior edge of the SCM muscle, with an angle between these two branches of 74.0 ± 36.8° (40-120). The great auricular nerve appeared from the posterior edge of the muscle SCM in 8.96 ± 1.85 cm (6.4-12.0) of the clavicle, with an angle of 64.5 ± 23.39° (35-110), which modified secondarily to measure 39.5 ± 6.15° (27-45) in the middle of the SCM muscle. At this level, the great auricular nerve and the external jugular vein were almost parallel (1.3° of average difference) and the distance that separated them was 2.24 ± 0.79 cm (0.8-3.5). CONCLUSION: Our study gave us a precise description of the superficial cervical plexus. All the measures allowed the establishment of the routes and the links of these structures to propose peroperating actions to prevent these facial sensory deficits.

Superficial cervical plexus neuropathy after single-injection interscalene brachial plexus block.

BACKGROUND: Interscalene brachial plexus block (ISB) using the modified lateral approach provides a well-established method of anesthesia and analgesia for patients undergoing shoulder surgery. Considering the neural anatomy at the site of injection, the superficial cervical plexus may be at risk of injury. We evaluated the incidence and characteristics of superficial cervical plexus neuropathy. METHODS: During a 1-yr period, 273 consecutive patients requiring single-injection ISB for shoulder or proximal arm surgery were studied. Patients were examined for symptoms compatible with superficial cervical plexus injury before surgery, 24 h postoperatively, and contacted by telephone 31 days after surgery. Symptomatic patients received an additional phone call 6 mo after surgery. RESULTS: Twenty-four hours after shoulder surgery, 21 patients (7.7%) showed symptoms consistent with superficial cervical plexus neuropathy. Symptoms consisted of hypesthesia in 1-4 cutaneous branches of the cervical plexus. Five patients (1.8%) reported symptoms that lasted for >31 days. All symptoms had entirely resolved after 6 mo. CONCLUSIONS: Superficial cervical plexus neuropathy is not uncommon after ISB using the modified lateral approach and the possibility should be discussed with patients preprocedurally.

The Greater Occipital Nerve and Obliquus Capitis Inferior Muscle: Anatomical Interactions and Implications for Occipital Pain Syndromes.

BACKGROUND: The compression/injury of the greater occipital nerve has been identified as a trigger of occipital headaches. Several compression points have been described, but the morphology of the myofascial unit between the greater occipital nerve and the obliquus capitis inferior muscle has not been studied yet. METHODS: Twenty fresh cadaveric heads were dissected, and the greater occipital nerve was tracked from its emergence to its passage around the obliquus capitis inferior. The intersection point between the greater occipital nerve and the obliquus capitis inferior, and the length and thickness of the obliquus capitis inferior, were measured. In addition, the nature of the interaction and whether the nerve passed through the muscle were also noted. RESULTS: All nerves passed either around the muscle loosely (type I), incorporated in the dense superficial muscle fascia (type II), or directly through a myofascial sleeve within the muscle (type III). The obliquus capitis inferior length was 5.60 ± 0.46 cm. The intersection point between the obliquus capitis inferior and the greater occipital nerve was 6.80 ± 0.68 cm caudal to the occiput and 3.56 ± 0.36 cm lateral to the midline. The thickness of the muscle at its intersection with the greater occipital nerve was 1.20 ± 0.25 cm. Loose, tight, and intramuscular connections were found in seven, 31, and two specimens, respectively. CONCLUSIONS: The obliquus capitis inferior remains relatively immobile during traumatic events, like whiplash injuries, placing strain as a tethering point on the greater occipital nerve. Better understanding of the anatomical relationship between the greater occipital nerve and the obliquus capitis inferior can be clinically useful in cases of posttraumatic occipital headaches for diagnostic and operative planning purposes.

Surgical Approach to Injuries of the Cervical Plexus and Its Peripheral Nerve Branches.

BACKGROUND: Located in the neck beneath the sternocleidomastoid muscle, the cervical plexus comprises a coalition of nerves originating from C1 through C4, which provide input to four cutaneous, seven motor, and three cranial nerves and the sympathetic trunk. Sporadic instances of injury to these superficial nerves have been reported. Nevertheless, this specific anatomical cause of neurogenic pain remains incompletely described and underrecognized. METHODS: Twelve patients presented with pain and were diagnosed with various combinations of injury to the lesser occipital, great auricular, transverse cervical, and supraclavicular nerves. Inciting events included prior face lift, migraine, and thoracic outlet procedures; and traumatic events including seatbelt trauma, a fall, and a clavicular fracture. History and examination suggested injury to the cervical plexus, and nerve blocks confirmed the diagnoses. Neurectomy with intramuscular transposition was performed for three nerve branches in one patient, two branches in two patients, and one branch in the remaining nine patients. RESULTS: Nine of the twelve patients had complete relief of their cervical plexus-related pain. The three failures were in patients with pain after previous face-lift surgery. Residual perception of neck tightness and choking sensation persisted despite relief of cheek and ear pain. CONCLUSIONS: Knowledge of the cervical plexus anatomy and its branches is crucial for surgeons operating in this area to minimize iatrogenic nerve injury. In addition, neuromas should be considered a likely cause of pain and dysesthesia following surgery or injury. Proper diagnosis and surgical intervention can have a significantly positive effect on these debilitating problems. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

The relationship between shoulder pain and damage to the cervical plexus following neck dissection.

The aim of our study was to evaluate the relationship between shoulder pain and damage to the cervical plexus after neck dissection. The study was performed prospectively on 34 neck sides of 17 patients with laryngeal cancer who underwent laryngectomy plus bilateral selective neck dissection (II, III, IV, +/- VI) at the Department of Otorhinolaryngology of Uludag University between December 2003 and October 2004. The cervical plexus was protected on one side of the neck and sacrificed on the other, while the accessory nerve was spared on both sides. The degree of sensorial innervation of the cervical plexus and shoulder pain were evaluated in the preoperative period and postoperatively at 2 weeks, 1 month, 3 months, and 6 months. Data obtained from both sides of the neck were compared. Sensory reception scores were statistically higher in the neck sides in which the cervical plexus was spared than in those where the plexus was sacrificed (P < 0.05). However, the degree of shoulder pain was similar on both sides of the neck (P > 0.05). Damage to the cervical plexus during neck dissection causes loss of sensorial innervation of the neck, but sacrificing the cervical plexus during selective neck dissection has no negative effect on shoulder pain.

Unilateral cervical nerve injuries: brachial plexopathies.

Brachial plexus injuries are frequently encountered in sports. Classically, the symptoms include transient burning, pain, and occasionally weakness of an isolated upper extremity resulting from a peripheral nerve injury of varying degrees. Persistent symptoms or recurrent injuries may necessitate imaging such as electromyography. Medical personnel should be familiar with brachial plexus anatomy and the common nerve injury mechanisms of compression or traction. On-field assessment includes evaluation for potentially more serious neurologic injuries and possible return to play when symptoms have resolved and the athlete has good range of motion and strength. Evidence-based guidelines are largely lacking, resulting in challenging evaluation and return-to-play decisions. Management focuses on improving neck range of motion and strength in addition to assessing for proper sport-specific technique. Additionally, enhancing protective equipment may prevent brachial plexus injuries. Currently, global screening via imaging of athletes is not recommended.

Oncologic safety of cervical nerve preservation in neck dissection for head and neck cancer.

BACKGROUND: Although the functional merits of preserving cervical nerves in neck dissection for head and neck cancer have been reported, the oncologic safety has not yet been determined. Therefore, the purpose of this study was to evaluate the safety of cervical nerve preservation. METHODS: A retrospective chart review was performed on patients with head and neck cancer who had been treated by neck dissection between 2009 and 2014 at Kyoto Medical Center. Management of cervical nerves and clinical results were analyzed. RESULTS: A total of 335 sides of neck dissection had been performed in 222 patients. Cervical nerves were preserved in 175 neck sides and resected in 160 sides. The 5-year overall survival (OS) rate calculated by the Kaplan-Meier method was 71%. The 5-year neck control rate was 95% in cervical nerve preserved sides and 89% in cervical nerve resected sides. CONCLUSION: Preserving cervical nerves in neck dissection is oncologically safe in selected cases.

Nerve root transfer from C4 to C5 in brachial plexus injuries. Anatomical study and description of the surgical technique / Transferência nervosa da raiz de C4 para C5 em lesões do plexo braquial. Estudo anatômico e descrição de técnica cirúrgica

Abstract Objective This is an anatomical study of C4 and C5 roots for nerve transfers in upper brachial plexus injuries, with surgical technique demonstration. Methods Fifteen brachial plexuses from both male and female cadavers were dissected. Morphological features of C4 and C5 roots were recorded and analyzed, followed by a neurotization simulation. Results In all dissections, C4 and C5 roots morphological features allowed their mobilization and neurotization with no need for a nerve graft. The surgical technique spared important regional nerve branches. Conclusion Based on these data, we conclude that C4-C5 nerve transfers are feasible and result in no additional neurological deficit in upper brachial plexus injuries.

Resumo Objetivo Estudo anatômico das raízes usadas na transferência nervosa de C4 para C5 nas lesões altas do plexo braquial, com demonstração da técnica cirúrgica. Métodos Dissecção de 15 plexos braquiais de cadáveres de ambos os sexos, registro e análise das características morfológicas das raízes de C4 e C5 e simulação de neurotização. Resultados As características morfológicas encontradas nas raízes de C4 e C5 em todas as dissecções permitiram a mobilização das mesmas e a realização de uma neurotização sem a necessidade de usar enxerto nervoso. A técnica cirúrgica permitiu preservar ramos nervosos importantes na região abordada. Conclusão Com base nos dados encontrados no presente estudo, podemos concluir que é possível realizar a transferência entre C4 e C5 sem provocar déficit neurológico adicional nas lesões altas de plexo braquial.

Combined injuries of the brachial plexus and spinal cord.

A total of 11 patients with combined traumatic injuries of the brachial plexus and spinal cord were reviewed retrospectively. Brachial plexus paralysis in such dual injuries tends to be diagnosed and treated late and the prognosis is usually poor. The associated injuries, which were all on the same side as the plexus lesion, were to the head (nine cases), shoulder girdle (five), thorax (nine) and upper limb (seven). These other injuries were responsible for the delayed diagnosis of brachial plexus paralysis and the poor prognosis was probably because of the delay in starting treatment and the severity of the associated injuries. When such injuries are detected in patients with spinal cord trauma, it is important to consider the possibility of involvement of the brachial plexus.

Bezier surface reformation: an original visualization technique of cervical nerve roots on myelographic CT.

PURPOSE: The aim of this study was to assess the feasibility of an original reformation method of cervical myelographic computed tomography (CT) using the Bezier surface technique. MATERIAL AND METHODS: Presurgical myelographic computed tomography (CT) scans using a multidetector row CT scanner were performed in 25 patients with avulsion injury of the cervical nerve roots. Each volumetric data set was reformatted using Bezier surface technique to depict the individual nerve root in a single image. In the reformatted images, visualization of the dorsal and ventral nerve roots between C4 and T1 on the uninjured side (300 nerves) was rated. RESULTS: Bezier surface reformation (BSR) images depicted the dorsal and the ventral nerve roots between C4 and C8 in 125 (100%) and 125 (100%) of 125 nerves, respectively. The dorsal and the ventral nerve roots of T1 were depicted in 25 (100%) and 22 (88%) in 25 nerves, respectively. CONCLUSION: The BSR technique of cervical myelographic CT enables simultaneous display of multiple cervical nerve roots in one image. BSR is a feasible technique for the assessment of the cervical nerve roots.

[Permanent local nerve injuries after carotid endarterectomy]. / Trwale miejscowe uszkodzenia nerwów po udroznieniu tetnicy szyjnej wewnetrznej.

UNLABELLED: Functional assessment of nerves, especially motor rami of cranial nerves, in patients at postoperative period after carotid endarterectomy (CEA), is particularly important in case of necessity of contralateral carotid artery surgery. Bilateral damage to recurrent laryngeal or hypoglossal nerve is a potentially life-threatening complication. Sensory disturbances due to intraoperative injuries of cervical plexus branches may cause residual discomfort in numerous patients. The aim of this study was the assessment and comparison of frequency of persistent (for more than 12 months postoperatively) manifestations of cranial and cervical nerves injuries in patients after CEA performed either in the standard or eversion technique. A prospective study evaluating cranial and cervical nerves dysfunction after carotid endarterectomies in 144 out of 193 patients operated on from January 1999 until June 2001 was undertaken at the Department of General and Vascular Surgery, Pomeranian Medical University in Szczecin, Poland. CEA was performed in the standard way (i.e. by primary closure) in 92 patients, while 52 others were operated on by eversion technique. Neurological examination with careful functional assessment of cranial nerves: V, VII, IX, X, XII and cervical plexus, was performed according to a standard protocol within two follow-up periods: 3 to 6 and 12 to 18 months after discharge from the hospital. RESULTS: Dysfunction of recurrent laryngeal nerve and hypoglossal nerve were registered 12 to 18 months after CEA with similar incidence of 1.4%. There was no sign of residual damage to other cranial nerves. Sensory disturbances in the area supplied by cervical plexus, mainly transverse cervical and greater auricular nerve, were diagnosed in 26% of patients. There were no statistically significant differences in local neurological complication rates between patients operated on according to standard and eversion procedures. CONCLUSIONS: 1. Permanent damage of cranial nerves refers to small group of patients after carotid endarterectomy and concern predominantly recurrent laryngeal nerve and hypoglossal nerve. 2. Majority of local neurological complications are injuries to cervical plexus branches. 3. Eversion carotid endarterectomy is not related to higher incidence of local neurological deficits compared to standard procedure.

Pourfour du Petit syndrome: a case following a traffic accident with severe cranioencephalic trauma.

Poufour du Petit syndrome is an extraordinarily unusual clinical condition produced by hyperactivity of the sympathetic cervical chain as a consequence of irritation of these nerves. It causes an ipsilateral mydriasis, which, in patients suffering a head injury as in the case reported here, can confuse the diagnosis and disconcert physicians.

Risk of persistent cranial nerve injury after carotid endarterectomy.

OBJECT: Cranial nerve injuries, particularly motor nerve injuries, following carotid endarterectomy (CEA) can be disabling and therefore patients should be given reliable information about the risks of sustaining such injuries. The reported frequency of cranial nerve injury in the published literature ranges from 3 to 23%, and there have been few series in which patients were routinely examined before and after surgery by a neurologist. METHODS: The authors investigated the risk of cranial nerve injuries in patients who underwent CEA in the European Carotid Surgery Trial (ECST), the largest series of patients undergoing CEA in which neurological assessment was performed before and after surgery. Cranial nerve injury was assessed and recorded in every patient and persisting deficits were identified on follow-up examination at 4 months and 1 year after randomization. Risk factors for cranial nerve injury were examined by performing univariate and multivariate analyses. There were 88 motor cranial nerve injuries among the 1739 patients undergoing CEA (5.1% of patients; 95% confidence interval [CI] 4.1-6.2). In 23 patients, the deficit had resolved by hospital discharge, leaving 3.7% of patients (95% CI 2.9-4.7) with a residual cranial nerve injury: 27 hypoglossal, 17 marginal mandibular, 17 recurrent laryngeal, one accessory nerve, and three Homer syndrome. In only nine patients (0.5%; 95% CI 0.24-0.98) the deficit was still present at the 4-month follow-up examination; however, none of the persisting deficits resolved during the subsequent follow up. Only duration of operation longer than 2 hours was independently associated with an increased risk of cranial nerve injury (hazard ratio 1.56, p < 0.0001). CONCLUSIONS: The risk of motor cranial nerve injury persisting beyond hospital discharge after CEA is approximately 4%. The vast majority of neurological deficits resolve over the next few months, however, and permanent deficits are rare. Nevertheless, the risk of cranial nerve injury should be communicated to patients before they undergo surgery.

Brachial-plexus palsy in the newborn.

Twenty-one patients who had twenty-three brachial-plexus palsies resulting from trauma at birth were studied over a three and one-half year period, between July 1983 and December 1986. The incidence of this group of injuries was 2.5 per 1,000 live births. There were fourteen palsies of the fifth and sixth cervical nerves; eight of the fifth, sixth, and seventh cervical nerves; and one of the entire brachial plexus. Two patients were lost to follow-up shortly after birth. Of the remaining nineteen patients (twenty-one palsies), fifteen (seventeen palsies) had full recovery at an average of three months (range, two weeks to twelve months), and four (four palsies) had residual paralysis of the upper extremity at more than twenty-six months. We concluded that the newborn who has a brachial-plexus palsy has a favorable prognosis for complete recovery.

Tritiated thymidine autoradiographic study on the influence of sensory and sympathetic innervation on periodontal wound healing in the rat.

Understanding of wound healing mechanisms is important in designing preventive and therapeutic approaches to inflammatory periodontal diseases, which are a major cause of dental morbidity. In this study, cell proliferation was assessed after an experimental gingival wound; this was preceded by either resection of 3 mm of the inferior alveolar nerve, total extirpation of the superior cervical ganglion, trauma to those structures or sham operations. At different times, animals were pulsed with 0.5 microCi/g body weight of tritiated thymidine; histological sections were processed for quantitative autoradiography of different compartments of the periodontium. Wounding led to a significant increase in cell proliferation in the epithelial layer, the fibroblast compartment and the periodontal ligament, but not in the alveolar crest compartment. Sympathetic denervation significantly enhanced this response in the epithelial layer, the fibroblast compartment and the alveolar crest, whereas sensory denervation only modified the response in the fibroblast layer. Thus it appears that sympathetic innervation plays an important role in the regulation of cell proliferation in the periodontium and that pharmacological modulation of sympathetic activity should be further studied as a therapeutic approach in periodontal disease.