Single-stage double motor nerve transfer for all finger flexion in iatrogenic C8-T1 spinal nerve injury: a case report and review of literature.

Restoration of hand function after C8-T1 spinal nerve injury is challenging. We report a case of a young patient who underwent single-stage transfer of extensor carpi radialis brevis (ECRB) branch of radial nerve to flexor digitorum superficialis (FDS) branch of median nerve and transfer of brachialis branch of musculocutaneous nerve to anterior interosseous nerve (AIN), aiming for restoration of all finger flexion in iatrogenic C8-T1 spinal nerve injury after the resection of a dumbbell-shaped C8 neurofibroma. At 18 months after the operation, the fingers and thumb functions were successfully restored. The operation might be useful for restoration of hand function in selected patients with C8, T1 brachial plexus injury. From the literature review, this is the first case that the technique of double motor nerve transfer and the transfer of ECRB branch to FDS branch were used to restore finger flexion in a patient with brachial plexus injury.

Filum Terminale Arteriovenous Fistula Coexisting with a Large L2-L3 Disc Sequestration and Associated Diffuse Lumbar Arachnoiditis.

The authors describe a case of filum terminale arteriovenous fistula (FTAVF) in association with a large L2-L3 disc sequestration and diffuse lumbar arachnoiditis. A 64-year-old male manifested with chronic back pain and gait difficulty. Magnetic resonance imaging (MRI) of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T9. There was a large disc sequestration came from L2-L3 disc herniation. In addition, thickening, clumping, and enhancement of the entire cauda equina were noted, probably representing arachnoiditis. MR angiography (MRA) and spinal angiography confirmed FTAVF at the level of L5. The patient underwent laminectomy with lysis adhesions and obliteration of the fistula. His postoperative course was uneventful. MRI and MRA of the thoracolumbar spine obtained 4 months after surgery revealed complete obliteration of the fistula and significant resolution of spinal cord congestion. Enhancement of the cauda equina roots was no longer visible. Interestingly, the significant resorption of the sequestrated disc was documented on MRI. The formation of the FTAVF in the present study may result from severe spinal canal stenosis caused by a large disc sequestration blocking the rostral venous drainage of the fistula, or chronic inflammation, and adhesions of the caudal nerve roots from lumbar arachnoiditis. It seems that FTAVF may be of acquired origin by this evidence.

Obturator Intraneural Ganglion Cysts: Joint Connected and Underdiagnosed.

BACKGROUND: Intraneural ganglion cysts of the obturator nerve are rare. Our aim is to review cases of obturator intraneural ganglion cysts at our institution and those reported in the literature. METHODS: We reviewed all cases evaluated by the senior author. A literature search was performed using the PubMed database and Google Scholar with the following terms: "obturator cyst," "obturator intraneural ganglion cyst," and "obturator intraneural ganglia." All cases underwent a retrospective review. Patient demographic data, including age, sex, and presenting signs and symptoms were recorded. Imaging studies were re-evaluated by 2 musculoskeletal radiologists experienced in the diagnosis of intraneural ganglion cysts. RESULTS: We identified 2 cases of obturator intraneural ganglia at our institution; both were connected to the hip joint. We found 4 cases that were clearly diagnosed as intraneural ganglia in the literature, of which only 1 was recognized by the original authors as being joint connected, but based on our reinterpretation, 3 of 4 were joint connected. An additional 9 cases identified in the literature did not definitely report the nerve-cyst relationship, but based on our reinterpretation, were believed to be intraneural; 8 were joint connected. CONCLUSIONS: We believe that obturator intraneural ganglion cysts adhere to the principles of the unifying articular theory. They arise from the anteromedial hip joint and extend into an articular branch and can reach the parent obturator nerve. Surgery should address the hip disease and/or the articular branch connection. Not appreciating the pathoanatomy of these cysts can lead to persistent or recurrent cysts.

Do Asians have Higher Carotid Bifurcation? A Computed Tomographic Angiogram Study of the Common Carotid Artery Bifurcation and External Carotid Artery Branching Patterns.

INTRODUCTION: Carotid endarterectomy is a major treatment modality for high-grade carotid stenosis. Preoperative identification of the level of the carotid bifurcation and its branching pattern is important in planning for adequate exposure and cross-clamping to achieve hemostasis during the procedure. Most of the previous studies on carotid arteries were performed in cadavers. METHODS: We studied levels of carotid bifurcation compared relatively with the level of the vertebral body and ipsilateral angle of the mandible and its branching pattern using computed tomographic angiogram (CTA) carotid with multiplanar reconstruction and three-dimensional imaging in 100 CTA studies. RESULTS: Most of the carotid bifurcations were located at the level of C3-C4 vertebral body and 12% were considered to be high bifurcation. Carotid bifurcations were located below the angle of the mandible in 83.5%. The superior thyroid, facial, and lingual arteries arose from separate branches of external carotid arteries in 67.7% of samples. Facial arteries arose in common trunk with lingual arteries in 29.2%, much more common than previous cadaveric studies. The lingual arteries arose with superior thyroid arteries in 2%, while occipital arteries had high variations in their branching patterns. CONCLUSIONS: CTA is an effective and reliable modality for preoperative evaluation of the carotid system in patients undergoing carotid endarterectomy and other carotid procedures. Higher percentage of high carotid bifurcation was found in our study, concordant with other Asian cadaveric studies. We assumed that carotid bifurcation of Asian tends to be located slightly higher than those of the Caucasian population.