The role of computed tomography and magnetic resonance imaging in surgical planning for thoracic outlet syndrome: the experience of a single third level reference center for peripheral nerve surgery.

OBJECTIVE: Anatomical abnormalities in the thoracic outlet syndrome are very frequent, but radiological images are not always reliable. Therefore, the different features and abilities of CT angiogram and brachial plexus MRI to detect anatomical abnormalities have been investigated. METHODS: All radiological and surgical records of patients operated for thoracic outlet syndrome between January 2011 and December 2018 were retrospectively analyzed. Considering the CT angiogram and/or brachial plexus MRI reports of the preoperative period, the performance of these investigations was evaluated by calculating the precision (P), sensitivity (Recall) and Hamming loss (L). RESULTS: From a total of 107 patients screened, 84 were eligible for study inclusion. Out of these, 46 had surgical abnormalities (group 1), while 38 did not (group 2). Among them, 30 patients have performed CT angiogram (subgroup A), 32 brachial plexus MRI (subgroup B) and 22 both (subgroup C). The best result is obtained when both diagnostic examinations are performed (subgroup C: P = 0.62; recall = 0.52; L = 0.038). CONCLUSIONS: Prescribing both investigations in selected patients increases the probability of finding anatomic anomalies and facilitates preoperative planning. However, as the radiological images are not completely exhaustive, the surgeon should always actively search and remove any potential source of compression on the nervous vascular bundle along the thoracic outlet.

Post-traumatic glomus tumor of the left anterior supraclavicular nerve: a case report.

OBJECTIVES: Peripheral nerve glomus tumors are extremely rare and occur with typical symptoms of peripheral neuropathic pain. Clinicians hardly consider this entity when faced with the swelling of a peripheral nerve and the diagnosis is reached only with histological examination. Nerves of limbs are usually affected and the solid glomus tumor is the most frequent histological variant. CASE DESCRIPTION: A 55-year-old man presented with a glomus tumor of the anterior supraclavicular nerve of the left cervical plexus, misdiagnosed clinically and radiologically as neuroma. Despite the preoperative suspicion and the intraoperative appearance, the histological examination revealed a glomus tumor with a prevalent muscular component, a glomangiomyoma. Once the tumor was removed, pain regressed completely. CONCLUSIONS: Because of its rarity, pre-operative diagnosis of glomus tumors is still a challenge, especially when arising from peripheral nerves. In the presence of chronic localized neuroma-type pain and sensitivity, glomus tumors should be considered in the pool of differential diagnosis, even if the imaging is not conclusive.

Monophasic synovial sarcoma mimicking schwannoma: a case report of a rare peripheral nerve tumor and literature review.

INTRODUCTION: Synovial sarcomas occurring as primary nerve tumors (SSPN) are rare and only 69 cases of SSPNs are reported in literature. Despite the little data available, SSPNs differ from other SSs in some distinctive aspects such as epidemiology, location, and early onset of symptoms. SSPN are consequently underdiagnosed and easily mistaken for benign or malignant peripheral nerve sheath tumors (PNST). Therefore, cytogenetic or molecular testing becomes essential in order to make a correct diagnosis. This article deals with an extremely rare case of monophasic SSPN of the posterior cords of the right brachial plexus. To our knowledge, this is only the tenth case of intraneural synovial sarcoma involving the brachial plexus. CASE PRESENTATION: We report the case of a 64-year-old man, who came to our attention due to a slow-growing painful right axillary neoformation, approximately 25 mm in size. The patient did not show any neurological impairments. Ultrasonography and constrast MRI showed a heterogeneous mass arising from the posterior cord of the right brachial plexus, resembling a schwannoma. The patient underwent total resection of tumor and capsule. Histologically, a diagnosis of monophasic synovial sarcoma was made based on histologic features and the immunohistochemical profile. CONCLUSIONS: We report a rare primary synovial sarcoma of the brachial plexus. Given its rarity, the diagnosis may be challenging and requires a core biopsy or the surgical specimen to permit immune-molecular analysis. Margin-free surgery is the mainstay of curative treatment, while chemo- or radiotherapy may have a role in advanced or margin-positive neoplasms.

Long-term functional recovery in C5-C6 avulsions treated with distal nerve transfers.

BACKGROUND: In patients suffering from traction lesions of the brachial plexus, complete C5 and/or C6 root avulsion patients with C7 root preservation are relatively uncommon occurrences, but represent excellent candidates for surgical treatment, with satisfactory results. Shoulder abduction and extra-rotation, elbow flexion and forearm supination are lost functions restorable with surgical treatment. METHODS: This single-center, prospective observational study involved a series of 27 young adults with C5 and/or C6 root complete avulsion and C7 preservation, which underwent surgical repair with double or triple nerve transfer. RESULTS: Patients recovered a useful elbow flexion. Electromyographic and clinical signs of biceps reinnervation were observed in each UN-MC nerve transfer. The abduction strength recovery was M5 in 10 patients, M4 in 14 patients and M3 in 3 patients. The external rotation strength recovery was M5 in 4 patients, M4 in 18 patients, M3 in 3 patients and M2 in 2 patients. The elbow flection strength was M5 in 5 patients, M4 in 15 patients and M3 in 7 patients. Elbow extension was preserved in all cases. CONCLUSIONS: The concept of 'peripheral rewiring procedures' represents an advance in the repair of the peripheral nerve injuries. Triple nerve transfer can be nowadays considered a standard treatment for isolated C5-C6 avulsions. We report our experience with the second-biggest casuistry in the literature on patients treated with this technique. We consider our outcome concerning functional recovery to be satisfying and comparable to data reported in the literature.

Functional outcome after transfer of brachialis on anterior interosseous and supinator on posterior interosseous nerves: A preliminary report.

OBJECTIVE: Traumatic spinal cord injury (SCI) resulting in tetraplegia is a leading cause of morbidity among young adults worldwide and its management remains challenging. Restoring hand function in these patients must be considered a top priority with great impact on their quality of life (QOL); although nerve and tendon transfer have been extensively described, type of procedure to be chosen is not standardized and few studies have determined the functional outcome of those procedure and their impact on QOL is still poorly assessed. We report a preliminary retrospective study regarding feasibility and functional outcomes of nerve transfer procedures including bilateral brachialis nerve on anterior interosseous nerve (AIN) and supinator branch on posterior interosseous nerve (PIN) for hand reanimation following SCI focusing on the impact of these procedures on QOL. METHODS: We performed a retrospective study involving patient sustained SCI and underwent nerve transfer of brachialis branch from musculocutaneous nerve on AIN and supinator branch from the trunk of the radial nerve on the PIN. We included 11 patients (14 limbs) with traumatic SCI resulting in C4 level tetraplegia in five patients, C5 in four and C6 and C7 in one case each, with a median age of 31.5 years underwent surgery at a median of 10 months after injury; including both transfers in 10 cases and AIN reanimation only in one. Functional assessment including medical research council (MCR) grade, graded redefined assessment of strength sensation and prehension (GRASSP) and spinal cord independence measure (SCIM) were performed at least 12 months follow up. RESULTS: Thirteen PIN innervated muscles achieved an MRC score ≥3/5 whereas AIN supplied muscles in 5 out of 15. GRASSP qualitative measure improved from a baseline value of 1 to 2, while quantitative measure passed from 1 to 3 after 12 months; the difference was statistically significant (p = .005 and p = .008, respectively). SCIM self-care sub-score also statistically significant improved from 3 to 4 at 12 months (p = .016). No complication or donor morbidity occurred. CONCLUSIONS: Functional performance has been significantly improved by nerve transfer procedures 1 year after surgery. Nerve transfers may represent a valuable option for the restoration of the hand function in patients with tetraplegia with minor or no morbidity.

Targeted Muscle Reinnervation and Osseointegration for Pain Relief and Prosthetic Arm Control in a Woman with Bilateral Proximal Upper Limb Amputation.

BACKGROUND: Bilateral proximal upper limb loss is a dramatic life-changing event. Replacement of the lost function with prosthetic arms, including multiple mechatronic joints, has remained a challenge from the control, comfort, and pain management perspectives. Targeted muscle reinnervation (TMR) is a peripheral nerve surgical procedure proposed to improve the intuitive control of the prosthetic arm and for neuroma and phantom pain management. Moreover, osseointegrated percutaneous implants (OPIs) allow for direct skeletal attachment of the prosthetic arm, ensuring freedom of movement to the patient's residual articulations. CASE DESCRIPTION: We have reported the first combined application of TMR and an OPI to treat a 24-year-old woman with a bilateral amputation at the shoulder level on the right side and at the very proximal transhumeral level on the left side. TMR was performed bilaterally in a single day, accounting for the peculiar patient's anatomy, as preparatory stage to placement of the OPI, and considering the future availability of implantable electromyographic sensors. The 2 OPI surgeries on the left side were completed after 8.5 months, and prosthetic treatment was completed 17 months after TMR. CONCLUSIONS: The use of TMR resolved the phantom pain bilaterally and the right-side neuroma pain. It had also substantially reduced the left side neuroma pain. The actual prosthetic control result was intuitive, although partially different from expectations. At 2 years after TMR, the patient reported improvement in essential activities of daily living, with a remarkable preference for the OPI prosthesis. Only 1 suspected case of superficial infection was noted, which had resolved. Overall, this combined treatment required a highly competent multidisciplinary team and exceptional commitment by the patient and her family.

Synovial cysts of the hip.

BACKGROUND: Synovial cysts of the hip are relatively rare lesions comparing to other joints. Patients are usually asymptomatic, but in some cases symptoms such as pain and/or compression of vessels or nerve could be present. Purpose of the study was to define clinical features and optimal management of synovial cyst of the hip joint through an accurate review of the literature. METHODS: We present three consecutive cases treated with three different therapeutic strategies: surgical excision, wait-and-see and needle aspiration. An accurate review of the literature has been performed to identify patients who had been treated for synovial cyst of the hip. RESULTS: Due to the rarity of the disease, there are no significant data in literature supporting the gold standard of treatment. Treatment of the synovial cyst depends on their size, symptoms and comorbidities. CONCLUSIONS: Most of the Authors recommend surgical treatment for symptomatic synovial cysts and needle aspiration as an option treatment in asymptomatic patients without vessel or nerve compression. In patients that referred symptoms in correspondence with the hip joint, not strictly related with radiograph findings, a CT or MRI examinations should be performed to exclude possible differential diagnosis.

Transhiatal Approach to Filum Terminale Externum Sectioning in Adult Patient With Tethered Cord Syndrome: Case Report.

BACKGROUND AND IMPORTANCE: An adult patient was referred to our department for tethered cord syndrome. A lumbar magnetic resonance imaging showed a conus medullaris at the S2 level and the caudal part of the dural sac at the S3 level. We present a minimally invasive spine surgery procedure at the hiatus level for the treatment of tethered cord syndrome by the surgical section of the filum terminale externum, which avoids bone demolition. CLINICAL PRESENTATION: A 65-yr-old Caucasian man was referred for dysesthesia and a burning sensation in his lower limbs, which was both spontaneous and triggered by contact with his clothes. He had been unable to walk for 5 mo due to severe pain and stiffness in his legs. He suffered from minimal, occasional urinary incontinence and complained about muscle cramps in the supine position that prevented him from sleeping; he was only able to sleep when sitting in a wheelchair. Informed patient consent was obtained for the procedure; no opinion was requested from the Ethics Committee. A minimally invasive transhiatal approach with the sectioning of the superficial dorsal sacrococcygeal ligament without the removal of bone tissue allows access to the sacral canal, after which it is possible to section the filum terminale externum using a microsurgical technique. CONCLUSION: After a 6-mo follow-up period, the patient no longer had dysesthesia and pain in his legs, and was able to walk, albeit just a few meters. This surgical technique has the advantage of minimally invasive spine surgery, has few complications, and avoids risk of retethering.

Custom made bioceramic implants in complex and large cranial reconstruction: a two-year follow-up.

INTRODUCTION: Large cranial defects still represent a challenge in neurosurgery. Currently different biomaterials are available for cranial reconstruction including titanium, acrylic mesh and different types of calcium phosphate-based bone grafts. The goal of surgery is a perfect fit of the implant without infection and absorption, and a good aesthetic result. This paper describes a surgical method for cranioplasty, using a customised porous hydroxyapatite (HA) prosthesis. MATERIALS AND METHODS: Sixty patients treated surgically with a customised porous-HA prosthesis for large cranial defects, were followed retrospectively. A two-year follow-up was carried out with periodic visits and CT scans. Safety (the incidence of adverse events and fractures of the implant) and clinical performance (biological and cosmetic results) were evaluated. RESULTS: Fifty one patients were followed-up, no rejection occurred and only one case of infection was recorded. Five patients had minor surgery-related complications, and no spontaneous implant fractures or mobilisation were reported. Three patients exhibited implant fractures as a result of trauma and all healed spontaneously. All patients showed a satisfactory clinical outcome with good cosmetic appearance in the early postoperative period and after a long-term follow-up. CONCLUSIONS: Cranioplasty performed with a customised porous-HA prosthesis gave a positive outcome, showing it to be an appropriate technique for use in large and complex cranial reconstruction.

Long-term results following cranial hydroxyapatite prosthesis implantation in a large skull defect model.

BACKGROUND: A large skull defect may occur after different events such as trauma, tumor resection, and vascular injuries. There is still some doubt about the best material to use for reconstruction. Hydroxyapatite ceramic is one of the materials in use, and its biocompatibility and osteoconductivity are well established. This study evaluated the interaction of a commercial hydroxyapatite custom-made prosthesis implanted in a large skull defect, to assess its osteointegration and its habitability with newly formed bone over time. METHODS: Ten sheep underwent craniectomy and reconstruction of the skull defect with a porous hydroxyapatite cranial prosthesis. The animals were divided into two groups: animals in group A were euthanized after 6 months and animals in group B were euthanized after 12 months. At the end of the experimental periods, each implant was evaluated macroscopically and radiologically, and analyzed by micro-computed tomography, histology, histomorphometry, and microhardness techniques. RESULTS: During the study, no adverse events occurred, and there was no evidence of inflammation or negative tissue reactions. Histology and histomorphometry showed new bone formation inside the implant in both experimental periods; newly formed bone had increased significantly (p < 0.05) by over 300 percent between 6 and 12 months. Three-dimensional micro-computed tomographic analysis showed new bone formation and material remodeling. Microhardness analysis indicated that the mineralization process and the mechanical properties of newly formed bone were not altered. CONCLUSIONS: The hydroxyapatite prosthesis showed its osteoconductivity and good biocompatibility. A low rate of fibrous tissue formation and a high rate of bony regeneration were found.