Horner's syndrome after neck surgery.

Horner's syndrome (oculosympathetic paresis) is characterised by the classic triad of ipsilateral palpebral ptosis, pupillary miosis and facial anhidrosis. The syndrome arises from the interruption of sympathetic innervation to the eye and adnexa at varying levels. It is a rare complication of neck surgery.We describe 6 patients who presented with Horner's syndrome after a neck procedure in our department during the last 5 years and review the different neck procedures that can cause it.

Anterior exposure of the lumbar spine with and without an "access surgeon": morbidity analysis of 265 consecutive cases.

STUDY DESIGN: Retrospective review OBJECTIVE: To compare the incidence and type of exposure-related complications for anterior lumbar surgery performed with and without an "access" surgeon. SUMMARY OF BACKGROUND DATA: No data exist comparing the incidence and type of exposure-related complications for anterior lumbar surgery performed with and without a vascular surgeon's assistance. METHODS: A retrospective review was performed for 265 consecutive patients who underwent anterior lumbar spine surgery at our institution from 2003 to 2005. Each patient's records were reviewed for diagnosis, procedure, whether the surgical exposure was conducted by the spine surgeon (Spine) or with a vascular surgeon's assistance (Team), levels exposed, complications, and any lasting sequelae. RESULTS: The percentage of patients with at least 1 intraoperative complication was 8% and 12% for the Spine and Team cases, respectively. Two percent of the Spine patients experienced an intraoperative vascular complication compared with 7% of the Team cases. No intraoperative vascular complication occurred in the single-level Spine exposures. Four percent of the patients with single-level exposures with Team approaches sustained an intraoperative vascular complication. Eight percent of the multilevel Spine cases sustained an intraoperative vascular complication compared with 9% of the multilevel Team exposures. There were 14 vascular injuries appreciated intraoperatively in a total of 13 patients. These injuries were directly repaired in 10 patients without any residual sequelae. The rate of vascular complications was statistically higher for multiple-level exposures (9%) versus single-level exposure (3%; P = 0.0357). The rate of retrograde ejaculation was 6% in the Spine cases whereas it was 7% in the Team approach. CONCLUSIONS: Our results do not support the notion that the presence of an "access" surgeon will change the type and rate of complications. With adequate training and judgment, spine surgeons may safely perform such exposures, provided vascular surgical assistance is readily available.

Horner's syndrome: a complication of experimental carotid artery surgery in rats.

PURPOSE: To report on the occurrence of iatrogenic Horner's syndrome (HS) in epileptic rats after implantation of an electrode for vagus nerve stimulation and to describe the possible consequences of this new complication of carotid artery surgery in rats. METHODS: A bipolar circular electrode was placed around the left carotid artery and vagus nerve of 31 rats. The incidence of HS was evaluated by visual inspection within 24 h after surgery. RESULTS: 68% of rats suffered from HS immediately after surgery. This complication did not affect epileptogenesis. CONCLUSION: The occurrence of HS in the rat is a frequent complication of vagus nerve electrode implantation, which does not affect epileptogenesis in this study. However, rats affected by HS may suffer from damage to the sympathetic innervation of the gut, due to rat-specific neuroanatomy. Therefore, caution towards other research questions is warranted.

Reversible chest tube horner syndrome.

A 54-year-old woman who underwent chest tube placement after a lung biopsy was found on the first postoperative day to have ipsilateral ptosis and miosis, suggesting a Horner syndrome. A chest CT scan showed that the tip of the chest tube was apposed to the stellate ganglion. Repositioning of the chest tube later on the first postoperative day led to complete reversal of the Horner syndrome within 24 hours. We propose that the Horner syndrome arose as a result of pressure on the stellate ganglion, which interrupted neural conduction but did not sever the sympathetic pathway ("neurapraxia"). Whether prompt repositioning of the chest tube was critical in reversing the Horner syndrome is uncertain.

IL-1 alpha and TNF-alpha expression in rat periapical lesions and dental pulp after unilateral sympathectomy.

OBJECTIVES: Apical periodontitis is an inflammatory disease characterized by bone resorption, and sympathetic nerves are known to modulate bone resorption and bone remodeling. Higher numbers of osteoclasts and larger periapical lesions have been observed after sympathectomy in rats, but the mechanisms underlying the inhibitory effect of sympathetic nerves on osteoclasts are unknown. This study aimed to test the hypothesis that sympathetic nerves inhibit the production of the bone-resorbing pro-inflammatory cytokines IL-1 alpha and TNF-alpha in rat periapical lesions. METHODS: Rats were unilaterally sympathectomized and apical lesions were induced by exposing the dental pulp of molar teeth to the oral microflora. We quantified the cytokines IL-1 alpha and TNF-alpha by enzyme-linked immunosorbent assay, and immunohistochemical analysis was done for qualitative localization. Pulp from intact incisor teeth was tested as a control. RESULTS: We showed that IL-1 alpha was increased, but not TNF-alpha, in the periapical lesions on the sympathectomized side. Both IL-1 alpha and TNF-alpha were expressed in unexposed pulp. TNF-alpha was significantly decreased in the denervated incisor pulp, whereas the level of IL-1 alpha remained unchanged. CONCLUSIONS: This study suggests that sympathetic nerves have an inhibitory effect on IL-1 alpha in periapical lesions and a stimulatory effect on TNF-alpha in the intact rat pulp.

Nicotinic acetylcholine receptor subunit proteins alpha7 and beta4 decrease in the superior cervical ganglion after axotomy.

Synaptic transmission in the superior cervical ganglion (SCG) is mediated by nicotinic acetylcholine receptors (nAChR). After transection of the postganglionic nerves of the SCG in the adult rat, the transcript levels of four of the five nAChR subunits present in the ganglion, alpha3, alpha5, alpha7, and beta4, decrease dramatically. In the present study, the effect of axotomy on nAChR subunit expression was examined at the protein level, focusing on the alpha7 and beta4 subunits. Immunohistochemistry with monoclonal antibody mAb306 (for the alpha7 subunit) and polyclonal antibody 4886 (for the beta4 subunit) showed that immunoreactivities for both alpha7 and beta4 subunits were concentrated in neurons in the intact ganglion. Results from double staining with antibodies to these subunits and to tyrosine hydroxylase, the enzyme that catalyzes the rate-limiting step in the biosynthesis of the sympathetic neurotransmitter norepinephrine, demonstrated that most neurons in the SCG express both the alpha7 and beta4 subunits. Three days after axotomy, the number of immunolabeled neurons and the intensity of the immunostaining per labeled neuron were decreased for both subunits. Decreases in subunit levels were also observed by Western blot analysis. Observing changes in these subunits over time after surgery revealed that, while the protein level of the alpha7 subunit recovered substantially within 2 weeks after the lesion, that of the beta4 subunit stayed low. These data demonstrate that decreases in nicotinic receptor subunits are among the changes in proteins that occur in axotomized sympathetic neurons, and suggest that these decreases may contribute to the depression in ganglionic synaptic transmission observed in axotomized ganglia.

Monitoring of emission as direct intraoperative control for nerve sparing retroperitoneal lymphadenectomy.

An intraoperative test to identify emission relevant lumbar postganglionic nerves during nerve sparing retroperitoneal lymph node dissection is presented. The neurophysiological course of the ejaculation into the posterior urethra, the emission, is described. A retroperitoneal nerve sparing procedure was done for nonseminomatous testicular tumors bilaterally in 7 patients with pathological stage I disease and unilaterally in 4 with pathological stage IIa disease. While the isolated lumbar nerves were electrostimulated, the seminal vesicles and bladder neck were monitored by suprapubic transvesical sonography. Simultaneously, endoscopy of the posterior urethra was performed and time code was registered. Emission began with bladder neck closure, propulsive contraction of the seminal vesicles in the periphery and opening of the paracollicular region. Then, complete contraction of the seminal vesicles was associated with closure of the prostatic urethra and ended in the separate secretion from the ductuli prostatici and ejaculatorii. Descending from nerve L1 to L3, their importance for emission usually increased. For intraoperative monitoring of emission transvesical sonography alone is sufficient. In 2 patients this method allowed us to identify the relevant nerves within the retroperitoneal residual mass (fibrosis) after chemotherapy.