Combat Injury of the Sciatic Nerve - An Institutional Experience.

INTRODUCTION: Combat injury of the sciatic nerve tends to be severe with variable but often profound consequences, is often associated with widespread soft tissue and bone injuries, significant neurologic impairment, severe neuropathic pain, and a prolonged recovery time. There is little contemporary data that describes the treatment and outcome of this significant military acquired peripheral nerve injury. We describe our institution's experience treating patients with combat-acquired sciatic nerve injury in the recent Iraq and Afghanistan wars. MATERIALS AND METHODS: IRB approval was obtained, and a retrospective review was performed of the records of 5,137 combat-related extremity injuries between June 2007 and June 2015 to identify patients with combat-acquired sciatic nerve injury without traumatic amputation of the injured leg. The most common mechanisms of injury were gunshot wound to the upper thigh or pelvis, followed by blast injury. Thirteen patients were identified that underwent sciatic nerve exploration and repair. Nine patients had nerve repair using long-length acellular cadaveric allografts. Five patients underwent nerve surgery within 30 d of injury and eight had surgery on a delayed basis. The postoperative follow-up period was at least 2 yr. RESULTS: Reduction of neuropathic pain was significant, 7/10 points on the 11-point pain intensity numerical rating scale. Eight patients displayed electrodiagnostic evidence of reinnervation distal to the injury zone; however, functional recovery was poor, as only 3 of 10 patients had detectable motor units distal to the knee, and recovery was only in tibial nerve innervated muscles. There were no serious surgical complications, in particular, wound infection or graft rejection associated with long-length cadaver allograft placement. CONCLUSION: Early surgery to repair sciatic nerve injury possibly promotes significant pain reduction, reduces narcotic usage and facilitates a long rehabilitation process. Allograft nerve placement is not associated with serious complications. A follow-up period longer than 3 yr would be required and is ongoing to assess the efficacy of our treatment of patients with combat-acquired sciatic nerve injury.

High-resolution ultrasound in combat-related peripheral nerve injuries.

INTRODUCTION: Peripheral nerve injuries (PNI) sustained in combat are typically severe and are frequently associated with marked soft tissue damage, anatomic distortion, and retained metallic fragments. These features complicate clinical and electrodiagnostic assessment and may preclude MRI. METHODS: We describe 4 cases of military personnel who sustained high-velocity gunshot wounds or blasts with metal fragment injuries in which high resolution peripheral nerve ultrasound (US) proved beneficial. RESULTS: In these cases, the clinical and electrodiagnostic exams provided inadequate localization and severity data of the nerve injuries, and MRI was either precluded or provided no additional information. In each case, US disclosed focal nerve segment abnormalities, including regions of focal enlargement and nerve discontinuity with end-bulb neuroma, which guided surgical planning for nerve repair. The findings on US were subsequently confirmed intra-operatively. CONCLUSIONS: High resolution peripheral nerve US is a useful modality in assessment of combat-related PNI. Muscle Nerve, 2016 Muscle Nerve 54: 1139-1144, 2016.

Neuralgic amyotrophy manifested by severe axillary mononeuropathy limited only to the anterior branch.

INTRODUCTION: In this study we describe a case demonstrating clinical, radiographic, electrophysiologic, and surgical evidence of a restricted but severe anterior branch axillary nerve mononeuropathy due to neuralgic amyotrophy (NA). METHODS: On each diagnostic modality there was severe involvement of the anterior and lateral deltoid muscle with sparing of the posterior deltoid and teres minor muscles and cutaneous innervation to the skin overlying the lateral shoulder. RESULTS: No structural etiologies were discovered during surgical exploration. CONCLUSIONS: This case provides another unique manifestation of NA and augments the theory of selective fascicular vulnerability.

Management of childhood neurotrauma.

A summary of some of the more important aspects of brain, spinal, peripheral nerve and sport injuries of childhood is presented. Guidelines for the treatment of severe brain injury have been developed for adults, are currently employed with success to treat children, but much information still needs to be acquired about childhood brain injury so that better age specific treatment modalities could be implemented. The unique anatomy of the spine during childhood predisposes to cervical spinal injury without radiographic abnormality; immobilization is the primary treatment and a minority of cases require surgery. Peripheral nerve injuries are uncommon, often missed, and require skillful evaluation and early treatment by physical therapy and oftentimes surgery. Appreciation of the sequelae of cerebral concussion, education on proper sport techniques, body conditioning, and equipment upkeep are the mainstay of vigilant sport injury treatment and prevention.

Recovery from Cruciate Paralysis Due to Axial Subluxation from Metastatic Breast Carcinoma: A Case Report.

Cruciate paralysis is an uncommon and potentially life-threatening myelopathy thought to arise from injury to the corticospinal tracts at a high cervical spinal level. The authors report on the case of a woman who developed cruciate paralysis secondary to axial subluxation of the cervical spine due to invasion by metastatic breast carcinoma. Correct bedside diagnosis, prompt spinal alignment via halo traction, and surgical spinal decompression with fusion stabilization reversed the paralysis completely. Postoperative antiestrogen medication, spinal radiation, and chemotherapy promoted local tumor control, allowing the patient longevity and good quality pain control. The prompt diagnosis and treatment of cruciate paralysis could effect a good prognosis in a seemingly terminal patient with metastatic spinal breast carcinoma by resolving life-threatening myelopathy, promoting longevity, and assisting with pain control.