Radioguided Occult Lesion Localization in Deep Schwannomas of the Peripheral Nerves: Results of a Preliminary Case Series.

BACKGROUND: The detection of small deep schwannomas of the peripheral nerves has been increasing since the the use of precise neuroimaging techniques has become more widespread; however, although nonpalpable lesions can be well defined by images, it is often difficult to identify them during the surgical procedure. The authors report seven cases of nonpalpable small deep schwannomas surgically treated after their identification using the radioguided occult lesion localization (ROLL) technique. METHODS: Seven men, whose ages ranged from 34 to 70 years (mean 52 years), presented with symptomatic nonpalpable peripheral nerve lesions; two cases involved the sciatic nerve, two the femoral nerve, two the radial nerve, and one the tibial nerve. Before the operation, all the patients were studied by ultrasonography and magnetic resonance imaging (MRI); 1 h before the surgery 3-5 MBq of 99mTc labeled with human albumin macroaggregates was injected into the lesion. A gamma detection probe permitted the preoperative and intraoperative detection of the nonpalpable schwannomas. CONCLUSIONS: The ROLL technique provides good support for identifying small lesions of the peripheral nerves both preoperatively and intraoperatively. This technique permits the use of minimally invasive approaches performed with local anesthesia, with good cosmetic results and acceptance by the patients.

Chronic post-traumatic neuropathic pain of brachial plexus and upper limb: a new technique of peripheral nerve stimulation.

The aim of the study was to evaluate the effect on pain relief in patients with peripheral neuropathic pain after brachial plexus injuries using an implanted peripheral nerve stimulator applied directly to the nerve branch involved into the axillary cavity. Seven patients with post-traumatic brachial plexus lesions or distal peripheral nerve complaining of severe intractable chronic pain were enrolled in a single-centre, open-label trial. Conventional drugs and traditional surgical treatment were not effective. Patients underwent careful neurological evaluation, pain questionnaires and quantitative sensory testing (QST). Surgical treatment consists of a new surgical technique: a quadripolar electrode lead was placed directly on the sensory peripheral branch of the main nerve involved, proximally to the site of lesion, into the axillary cavity. To assess the effect, we performed a complete neuroalgological evaluation and QST battery after 1 week and again after 1, 6 and 12 weeks. All patients at baseline experienced severe pain with severe positive phenomena in the median (5) and/or radial (2) territory. After turning on the neuro-stimulator system, all patients experienced pain relief within a few minutes (>75 % and >95 % in most), with long-lasting pain relief with a reduction in mean Numerical Rating Scale (NRS) of 76.2 % after 6 months and of 71.5 % after 12 months. No significant adverse events occurred. We recommend and encourage this surgical technique for safety reasons; complications such as dislocation of electrocatheters are avoided. The peripheral nerve stimulation is effective and in severe neuropathic pain after post-traumatic nerve injuries of the upper limbs.

Entrapment of the sciatic nerve at the linea aspera: A case report and literature review.

BACKGROUND: Nontraumatic, non-neoplastic sciatic nerve entrapment at the level of the thigh is extremely rare. In its course, in proximity of the linea aspera, the nerve is exposed to unexpected neuropathic syndromes associated with bone disorders. CASE DESCRIPTION: A 67-year-old woman presented with a painful, neuropathic syndrome of the sciatic nerve, not resulting from any trauma and persisting for approximately 2 years. Imaging studies of the thigh showed a delimited zone of hyperostosis in the proximal third of the femoral diaphysis. The symptoms dramatically resolved after the patient underwent neurolysis of the tract of the nerve adjoining to the linea aspera. At the clinical checkup 2 years later, the patient remained free of pain. CONCLUSION: The diagnosis of sciatic nerve entrapment at the linea aspera may present considerable difficulties. The clinical history and physical examination sometimes motivate the exploration and neurolysis of the nerve at this site.

SILENT DELTOID ATROPHY IN BEACH VOLLEYBALL PLAYERS: A REPORT OF TWO CASES AND LITERATURE REVIEW.

UNLABELLED: While examining the shoulders of 91 professional and semi-professional beach volleyball players, the authors observed two cases of grave atrophy of the deltoid muscle following painless axillary neuropathy, not resulting from any trauma. The causes, the clinical history and the untreated history of the entrapment of the axillary nerve in the quadrilateral space in sportsmen, are discussed on the basis of the presentation of the two cases illustrated and from existing literature. LEVEL OF EVIDENCE: 4.

[Thoracic outlet syndrome: clinical staging]. / Sindrome dello stretto toracico superiore: stadiazione clinica.

The clinical and instrumental manifestations of thoracic outlet syndrome are well known but the therapeutic choices frequently differ in relation to the physician's experience. Thus, there is no univocal opinion regarding the therapy of this complex syndrome. To solve this problem we have attempted to bring together the clinical and instrumental pictures in a single classification that includes the three fundamental aspects of the syndrome, namely nerve, artery and vein injury (NAV). Our goal was to achieve a universally accepted therapy-oriented staging system, as is the case with the TNM system for malignant tumours. From 1984 to 2002, in our institution 156 patients with thoracic outlet syndrome were evaluated. These were grouped in 4 stages depending on their NAV status. Subsequent therapy was in accordance with stage. Our results confirmed the accuracy of NAV. On the basis of our preliminary experience, the NAV staging system is useful for correct patient grouping. Now a prospective multicentre study is needed for universal scientific validation.

Nerve regeneration across cryopreserved allografts from cadaveric donors: a novel approach for peripheral nerve reconstruction.

OBJECT: The use of allografts from cadaveric donors has attracted renewed interest in recent years, and pretreatment with cryopreservation and immunosuppression methods has been investigated to maximize axonal regrowth and minimize allograft rejection. The authors wanted to assess the outcome of treatments of brachial plexus stretch injuries with cryopreserved allografts from cadaveric donors in nonimmunosuppressed patients. METHODS: Ten patients with brachial plexus lesions were submitted to electromyography (EMG) testing 1 and 3 months after a traumatic event and 1 week before surgery to localize and identify the type of lesion. Intraoperative EMG recordings were performed for intraoperative monitoring to select the best surgical strategy, and postoperative EMG was used to follow up patients and determine surgical outcomes. If nerve action potentials (NAPs) were present intraoperatively, neurolysis was performed, whereas muscular/nerve neurotization was performed if NAPs were absent. Cryopreserved allografts obtained from selected cadaveric donors and provided by the tissue bank of Treviso were used for nerve reconstruction in patients who were not treated with immunosuppressive drugs. RESULTS: The surgical strategy was selected according to the type and site of the nerve lesion and on the basis of IOM results: 14 cryopreserved allografts were used for 7 muscular neurotizations and for 7 nerve neurotizations, and 5 neurolysis procedures were performed. All of the patients had regained motor function at the 1- and 2-year follow-ups. CONCLUSIONS: Some variables may affect functional recovery after allograft surgery, and the outcome of peripheral nerve reconstruction is more favorable when patients are carefully evaluated and selected for the surgery. The authors demonstrated that using cryopreserved allografts from cadaveric donors is a valid surgical strategy to restore function of the damaged nerve without the need for any immunosuppressive treatments. This approach offers new perspectives on procedures for extensive reconstruction of brachial and lumbosacral plexuses.