Nerve transfers for acute flaccid myelitis: a case series.

BACKGROUND: Acute flaccid myelitis (AFM) syndrome consists of loss of lower motor neurons following a viral infection, with preserved sensory function. It usually affects the upper limbs asymmetrically, with proximal more than distal muscle involvement. METHODS: Five cases were surgically treated with nerve transfers: spinal accessory to suprascapular nerve transfer (4 patients), branch of radial nerve to axillary nerve transfer (Somsak's procedure) (2 patients), and transfer of a fascicle of the ulnar nerve to the motor branch to the biceps (Oberlin's procedure) (1 patient). RESULTS: Motor improvement was seen in three cases. Widespread motor involvement was associated with poor outcome. CONCLUSION: This small series of cases reinforces that nerve transfers are a reliable option for treatment of selected children with AFM.

A practical approach to the lateral cutaneous nerve of the thigh: an anatomical study.

OBJECTIVES: To study the main anatomical landmarks related to the lateral cutaneous nerve of the thigh (LCN) in the infrainguinal region and to define reliable criteria for identifying the nerve during the surgery and electrophysiological study. METHODS: Bilateral dissections of 60 adult non-fixed cadavers were performed with measurements of the distance between the inferior border of the anterior superior iliac spine (ASIS) and the LCN (DAL) and the internal angle between the LCN and the inguinal ligament (IA). The number of nerves exiting the inguinal ligament, the position of the LCN relative to the ASIS and to inguinal ligament were observed and registered. A triangle was designed using the inguinal ligament, the ASIS and the direction of tendinous insertions of the tensor of fascia lata muscle as parameters and the nerves were tested according its localization inside the triangle in each dissection. RESULTS: In 80% of the dissections, the LCN passed under the inguinal ligament and was identified lateral to ASIS in only three dissections. A great variability was observed in the values of DAL and IA. The values of DAL ranged from 0 (immediately medial to ASIS) to 5 cm on either side with means of 1.31 and 1.22 cm on the right and left side, respectively. The values of IA ranged from 40° to 120°, with a mean of 66.08° on the right side and from 40° to 130° with a mean of 69.92° on the left side. No significant differences were identified between the two sides with respect to the relationship between the nerve and the inguinal ligament (Chi-square test, p=0.83); DAL (t test, p=0.37) or IA (t test, p=0.15). A single nerve was found in 70.83% of the dissections. The nerve was found inside the triangle in 95% of the dissections. CONCLUSIONS: Despite the symmetry found between the right and left sides, the values of the main anatomic parameters involved in the localization of the LCN presented a great degree of variability. Even so, dissection using the proposed anatomical triangle allows for the localization of the LCN in almost all cases.

Treatment of febrile seizures with intermittent clobazam.

Fifty children, 24 female and 26 male, with ages varying from 6 to 72 months (mean = 23.7 m.) that experienced at least one febrile seizure (FS) entered a prospective study of intermittent therapy with clobazam. Cases with severe neurological abnormalities, progressive neurological disease, afebrile seizures, symptomatic seizures of other nature, or seizures during a central nervous system infection were excluded. Seizures were of the simple type in 25 patients, complex in 20 and unclassified in 5. The mean follow-up period was 7.9 months (range = 1 to 23 m.), and the age at the first seizure varied from 5 to 42 months (mean = 16.8 m.). Clobazam was administered orally during the febrile episode according to the child's weight: up to 5 kg, 5 mg/day; from 5 to 10 kg, 10 mg/day; from 11 to 15 kg, 15 mg/day, and over 15 kg, 20 mg/day. There were 219 febrile episodes, with temperature above 37.8 degrees C, in 40 children during the study period. Twelve children never received clobazam and 28 received the drug at least once. Drug efficacy was measured by comparing FS recurrence in the febrile episodes that were treated with clobazam with those in which only antipyretic measures were taken. Ten children (20%) experienced a FS during the study period. Of the 171 febrile episodes treated with clobazam there were only 3 recurrences (1.7%), while of the 48 episodes treated only with antipyretic measures there were 11 recurrences (22.9%), a difference highly significant (p < 0.0001). Adverse effects occurred in 10/28 patients (35.7%), consisting mainly in vomiting, somnolence and hyperactivity. Only one patient had recurrent vomiting which lead to drug interruption. These effects did not necessarily occurred in every instance the drug was administered, being present in one febrile episode and not in the others. We conclude that clonazepam is safe and efficacious in preventing FS recurrence. It may be an alternative to diazepam in the intermittent treatment of FS recurrence.

Hepatic enzymes' level during chronic use of anticonvulsant drugs.

We studied retrospectively 894 adult epileptic patients treated during the period from 1983 to 1992. Hepatic enzymes abnormal values were seen in 49% (n = 438). In 22.3% (n = 200), at least 2 enzyme levels in different moments were altered. They were divided in three groups: GI with alterations at transaminases (3%, n = 6), GII with alterations at GGT and AP enzymes (72%, n = 144) and GIII with alterations in both groups (25%, n = 50). No patient developed clinical symptoms of liver disease. The increase of gamma-glutamil-transferase (GGT) and alkaline phosphatase (AP) levels is frequent and not necessarily pathological. Slight increase of transaminases can occur with no clinical correlation. The routine screening of hepatic enzymes level during the chronic use of anticonvulsivant drugs in adults has a questionable value.