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1.
Acta Neurochir (Wien) ; 162(5): 1137-1146, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31897730

RESUMO

INTRODUCTION: Desmoid-type fibromatosis (DTF) frequently arises in patients with neuromuscular choristoma (NMC). We hypothesize that NMC-associated DTF occurs in soft tissues innervated by the NMC-affected nerve, and arises from CTNNB1-mutated (myo) fibroblasts within or directly adjacent to the NMC. MATERIALS AND METHODS: A retrospective review of patients treated at our institution was performed for patients with biopsy-confirmed diagnosis of NMC-DTF. Clinical presentation, physical examination, electrodiagnostic findings and radiological features (MR and FDG PET/CT images for each NMC-DTF) and pathologic re-review of available materials were analyzed. A literature review was also performed. RESULTS: Eight patients from our institution met the inclusion criteria. All patients presented with neuropathic symptoms and soft tissue or bone changes in the nerve territory innervated by the NMC. All MR images (N=8 cases) showed the characteristic features of NMC, and also showed direct contact between unifocal (N=5) or multifocal (N=3) DTF(s) and the NMC-affected nerve NMC. FDG PET/CT (N=2 cases) showed diffuse, increased FDG uptake along the entire affected nerve segment, contiguous with the FDG-avid DTF. In all cases, the DTFs arose in the soft tissues of the NMC-affected nerve's territory. No patient developed DTF at any other anatomic site. CONCLUSIONS: These data demonstrate that NMC-DTF arises solely within the NMC-affected nerve territory, and has direct contact with the NMC itself. Based on all these findings and the multifocality of NMC in several cases, we recommend imaging and surveillance of the entire NMC-affected nerve (from spine to distal extremity) to identify clinically-occult DTF in patients with NMC.

2.
Oper Neurosurg (Hagerstown) ; 18(2): 202-208, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31157396

RESUMO

BACKGROUND: The development of technical skills for a cervical laminectomy are traditionally acquired through intraoperative learning and cadaveric courses. These methods provide little objective assessment, involve financial and biohazard considerations, and may not incorporate desired pathology. OBJECTIVE: To develop an inexpensive cervical spine laminectomy simulator capable of measuring operative performance and to assess its face, content, and construct validity. METHODS: A virtual model was generated and 3D printed into negative molds. A multilayered surgical phantom was fabricating by filling molds with hydrogels, plaster, and fiberglass. A pressure transducer measured simulated spinal cord manipulation. Participants completed full-procedural laminectomy simulations. Post-simulation surveys assessed face and content validity. Construct validity was assessed by comparing expert and novice procedural metrics. RESULTS: Twelve surgeons participated. The simulator received median face and content validity ratings of 4/5. Differences between experts and novices were found in mean intrathecal pressure wave count (84 vs 153, P = .023), amplitude (4 vs 12% > 2SD above expert mean, P < .001), area under curve (4 vs 12% > 2SD above expert mean, P < .001), procedure time (35 vs 69 min P = .003), and complication rates (none vs 3 incorrect levels decompressed and 1 dural tear, P = .06). Insignificant differences were found in mean pressure wave slope and blood loss. CONCLUSION: This inexpensive cervical laminectomy simulator received favorable face and content validity ratings, and distinguished novice from expert participants. Further studies are needed to determine this simulator's role in the training and assessment of novice surgeons.

3.
Neurosurgery ; 86(3): 383-390, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-31215635

RESUMO

BACKGROUND: Intraneural ganglion cysts are joint-connected, with the primary pathology residing in the associated joint. For peroneal intraneural ganglion cysts, the surgical strategy can include resection of the synovial surface of the superior tibiofibular joint (STFJ). However, the rate of instability postoperatively is unclear. OBJECTIVE: To evaluate the rate of STFJ instability, following surgery for peroneal intraneural ganglion cysts. The second goal of the study was to assess the relationship between volume of resection of the STFJ and risk of extraneural recurrence. METHODS: We performed a retrospective analysis of a cohort of patients with peroneal intraneural ganglion cysts. We analyzed clinical factors, including recurrence, and assessed the rate of postoperative STFJ instability. We created 3-dimensional models of the STFJ pre- and postoperatively to compare the volume of resection in recurrent cases and nonrecurrent cases using a case-control design. RESULTS: The total cohort consisted of 65 subjects. No patient had evidence of radiological or clinical instability of the STFJ postoperatively. Extraneural radiological recurrence occurred in 6 (9%) patients. No intraneural recurrences were observed. The average volume of resection for patients with recurrence was 1349 mm3 (SD = 1027 mm3) vs 3018 mm3 (SD = 1433 mm3) in controls that did not have a recurrence (P = .018). CONCLUSION: This study supports performing an aggressive STFJ resection to minimize the risk of extraneural recurrence. Superior tibiofibular joint resection is not associated with postoperative joint instability. A smaller volume resection is correlated with recurrence risk.

4.
Oper Neurosurg (Hagerstown) ; 18(1): 60-68, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30888029

RESUMO

BACKGROUND: Intraneural dissection is a useful technique for achieving gross total resection and preserving functional fascicles for peripheral nerve tumors. Finding the correct tissue plane is the critical step for safe successful enucleation. The authors hypothesized that the yellow color of benign nerve tumors can be used to identify surgical planes. OBJECTIVE: To describe a technique to find the correct intraneural dissection plane based on a quantified yellow appearance during resection of benign peripheral nerve sheath tumors. METHODS: Intraoperative photographs were reviewed to determine the percentage of yellow that tumors appeared at different phases of surgery. A technique was developed to quantitatively measure the amount of yellow using Photoshop. Previously published journal articles containing color images of peripheral nerve tumor resections were also analyzed for yellow tumor color. RESULTS: There were 24 patients with suitable images to permit measurement of color for 3 steps of the procedure. The average percentages of yellow for tumor exposure, tumor resection, and removed specimen were 36.5%, 59.1%, and 80.4%, respectively (P < .001). Three publications were found that contained high-quality images of at least 2 phases of the surgery with average yellow content of 47.4% and 84% (P < .01). CONCLUSION: The simple observation that a benign nerve sheath tumor is yellow in color can be used to guide surgical resection and achieve excellent outcomes. Intraneural dissection through the pseudocapsule should be pursued layer by layer until a yellow true capsule is found. By sparing functional nervous tissue within the pseudocapsule, this technique may lead to improved neurological outcomes.

5.
JBJS Essent Surg Tech ; 9(2): e18, 2019 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-31579536

RESUMO

Background: Interfascicular resection is a surgical technique used to safely treat benign peripheral nerve sheath tumors through careful dissection of functional neural elements off the tumor surface1,2. Description: Proper operative technique is essential to improving symptoms, preserving neurologic function, and minimizing the chance for recurrence. Accurate tumor localization, ideal patient positioning, and placement of a longitudinal incision permit adequate exposure. Prior to tumor resection, normal nerve should be identified proximally and distally and controlled with vessel loops. This allows functional fascicles streaming around the tumor in the pseudocapsule to be visualized during resection. A fascicle-free window is identified on the tumor surface through visual inspection and intraoperative neurophysiology monitoring if desired. The pseudocapsule layers are divided with a sharp instrument until a smooth and shiny true capsule layer is found. This plane should have minimal resistance and is developed circumferentially until the tumor can be enucleated in toto. At the poles of the tumor, a single nonfunctional nerve fascicle that courses into the tumor is typically found. If there is >1 fascicle running into the tumor, further pseudocapsule layers should be undermined to sweep fascicles off the true capsule surface. The entering-exiting fascicle can be tested for function and is cut sharply. The specimen should be sent to pathology for permanent sectioning. The sides of the pseudocapsule are spread in opposite directions to evaluate for residual tumor, and any remaining tumor is removed if it can be done safely. Meticulous hemostasis is achieved, and the surgical site is closed in anatomical layers. Alternatives: Pain is the most common presenting symptom, and neuroleptic medications should be used in escalating dosage prior to surgical intervention. Nonoperative medical therapy does not typically result in symptom freedom, and patients often opt for resection. For tumors that are suspected of being malignant, an image-guided percutaneous or open biopsy and staging (positron emission tomography and/or computed tomography scans of the chest, abdomen, and pelvis) are recommended prior to treatment planning. For symptomatic benign extremity lesions, surgical resection is the treatment of choice, and adjuvant therapies like radiation and/or chemotherapy are not recommended. For malignant lesions, more aggressive surgery (wide resection or amputation) and preoperative, intraoperative, or postoperative radiation with or without chemotherapy are often utilized. Rationale: The treatment approach depends on a variety of presenting features such as onset, progression, symptom severity, tumor size, location, imaging features, presence of a syndrome, and patient age. There is little benefit from the resection of an incidentally found, small, nongrowing lesion. The most common reasons for removal of extremity lesions are a painful mass and/or radiating "nerve" pain. There is a high likelihood of relieving the symptoms and minimizing the risk of recurrence, and a relatively low risk of causing neurologic injury. The procedure provides a definitive diagnosis. For patients with severe pain, progressive weakness, rapid tumor growth, or concerning imaging characteristics, biopsy should be considered to determine malignant potential.

6.
World Neurosurg ; 129: e761-e766, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31203072

RESUMO

INTRODUCTION: The natural history of growth and radiologic progression of neuromuscular choristomas (NMCs) remain unknown. The purpose of this study was to describe the radiologic growth pattern of NMCs and to determine how the pattern of growth relates to clinical progression. METHODS: A retrospective review was performed for patients with a confirmed diagnosis of NMC and at least 2 years of radiologic (magnetic resonance imaging [MRI]) follow-up. Medical records, including physical examinations and radiologic studies, were reviewed in detail. The NMC length and transverse dimensions were compared between serial MRI examinations. RESULTS: Eleven patients with a mean radiologic follow-up time of 5.6 years (range 2-19 years) were identified. Motor deficits occurred in 10 patients (90%), sensory deficits in 5 patients (45%), and neuropathic pain in 4 (36%) patients. Eight patients (73%) presented with manifestations of limb undergrowth, 2 (18%) with congenital hip dysplasia, and 1 with a cavus foot deformity. Progression of motor and sensory deficits was observed in 5 (45%) and 1 (9%) patients, respectively. The maximal length and height of the NMC was significantly (P < 0.05) longer (initial 218 ± 118 mm vs. follow-up 270 ± 135 mm) and larger (20 ± 10 mm vs. 24 ± 14 mm) on the follow-up scan. MRI demonstrated abnormalities that were in continuity along the longitudinal extent of the NMC. CONCLUSIONS: According to this small but relatively long-term follow-up cohort, the growth pattern of this lesion is slow but progressive. We found a longitudinal continuity pattern of growth in all MRI scans, often spanning a great distance.


Assuntos
Plexo Braquial/diagnóstico por imagem , Coristoma/diagnóstico por imagem , Músculo Esquelético , Doenças do Sistema Nervoso Periférico/diagnóstico por imagem , Nervo Isquiático/diagnóstico por imagem , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
7.
Pain ; 160(5): 1029-1036, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30624344

RESUMO

Persistent pain after lumbar surgery (failed back surgery syndrome [FBSS]) remains a leading indication for chronic analgesia. However, no analgesics have proven efficacious for this condition. Although trials have evaluated gabapentinoids for chronic low back pain, none of these trials focused solely on FBSS. This randomized, double-blind cross-over trial evaluated the efficacy of gabapentin (1800 mg/day) for FBSS. Eligible patients had a diagnosis of FBBS, an average daily pain score of at least 4 of 10, a neuropathic pain component (indicated by the PainDetect), and reported at least half of their pain radiating in their lower extremity. Participants were randomized to 2, 7-week study periods separated by a 10-day washout. The primary outcome measure was a 0 to 10 numeric rating scale (NRS) of average pain. Secondary measures included the McGill Pain Questionnaire and Patient Global Impression of Change. The treatment effect was analyzed using a mixed effect analysis of covariance with fixed effects for treatment, period, and baseline 7-day mean NRS pain score and a random effect for the participant. The outcome of the model was the mean 7-day NRS score for the last 7 days of each treatment period. Thirty-two participants were randomized and included in the primary analysis; 25 completed both study periods. No difference was detected between treatments on any outcome measure, including the primary (least square mean difference in NRS: -0.01 confidence interval: [-0.22 to 0.20]). Given the escalating rate of complex lumbar surgery, future research to develop novel therapies for this prevalent syndrome is needed.


Assuntos
Analgésicos/administração & dosagem , Síndrome Pós-Laminectomia/tratamento farmacológico , Gabapentina/administração & dosagem , Resultado do Tratamento , Adulto , Idoso , Estudos Cross-Over , Método Duplo-Cego , Sistemas de Liberação de Medicamentos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor
8.
World Neurosurg ; 122: e1562-e1569, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30471442

RESUMO

BACKGROUND: Cervical and upper thoracic nerve root avulsions are preganglionic lesions that occur after extreme traction of the brachial plexus. The tearing of the roots from the spinal cord pia leads, not only to immediate and permanent deficits, but also to delayed neurologic complications. Symptomatic myelopathy can present in a late fashion owing to chronic sequelae from the inciting traumatic event. No unifying theory has yet been provided that can explain the causes of delayed spinal cord dysfunction after preganglionic brachial plexus injury. We have proposed a collective mechanism for the development of delayed spinal cord injury. METHODS: An institutional database search and a literature review were performed to find patients who had presented with delayed myelopathy after brachial plexus injury. RESULTS: We found 454 adult patients with traumatic brachial plexus injury and spinal cord injury from 1997 to 2018 in the institutional search. Of these patients, 74 had a delayed presentation of new myelopathic findings on physical examination that had developed ≥6 months after the initial presentation. In these 74 patients with delayed myelopathic symptoms, radiologic findings of spinal cord herniation, syringomyelia, superficial siderosis, or pathologic intradural or extradural cerebrospinal fluid collections from traumatic dural tears were present. Each of these pathologic entities was present in isolation or combination in our patient population. CONCLUSIONS: Four overlapping etiologies appeared to compose the primary foundation for delayed spinal cord dysfunction after brachial plexus injury. We have highlighted this continuum by providing institutional case examples and a review of the reported data.


Assuntos
Plexo Braquial/lesões , Doenças da Medula Espinal/etiologia , Adulto , Plexo Braquial/diagnóstico por imagem , Plexo Braquial/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Doenças da Medula Espinal/diagnóstico por imagem , Doenças da Medula Espinal/fisiopatologia
9.
World Neurosurg ; 122: e235-e240, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30312825

RESUMO

BACKGROUND: The perineural spread of prostate cancer into pelvic peripheral nerves is a rare, but increasingly recognized, entity. This form of metastasis invades the lumbosacral plexus via the splanchnic nerves innervating the prostate. The prevalence of perineural spread is likely underappreciated, and further imaging-based studies are needed to elucidate its true frequency. METHODS: A retrospective review was performed using an institutional radiology database. Medical reports from patients with prostate cancer who had undergone positron emission tomography (PET) imaging were queried for terms suggestive of perineural spread. PET and magnetic resonance imaging (MRI) from the identified patients were blindly reviewed for peripheral nerve involvement by 2 nuclear medicine and 2 musculoskeletal radiologists. RESULTS: A total of 22 patients were identified. After review by the radiologists, 16 patients had positive findings of perineural spread found on PET and 15 had abnormalities found on MRI involving lumbosacral plexus neural elements. All patients with biopsy-proven neoplastic perineural spread (including 1 patient with malignant peripheral nerve sheath tumor) had positive findings on both PET and MRI. All patients with biopsy-proven inflammatory lesions had negative PET and variable MRI findings. CONCLUSIONS: The perineural spread of prostate cancer might be more common than previously thought. The use of multimodal imaging for patients suspected of having perineural spread should be a part of the treatment algorithm. Targeted fascicular biopsy might be indicated for patients with progressive neurological deficit and an unclear diagnosis.


Assuntos
Imagem Multimodal , Neoplasias do Sistema Nervoso Periférico/diagnóstico por imagem , Neoplasias do Sistema Nervoso Periférico/secundário , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/patologia , Idoso , Idoso de 80 Anos ou mais , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Nervos Periféricos/diagnóstico por imagem , Tomografia por Emissão de Pósitrons , Estudos Retrospectivos
10.
Oper Neurosurg (Hagerstown) ; 16(3): E80, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30169700

RESUMO

Schwannomas are benign peripheral nerve sheath tumors that are typically round, smooth, and straightforward to resect. Occasionally they are more complicated to resect because of their size, location, degree of bony erosion, and vascular or neural compression. These complex lesions frequently require multidisciplinary surgical teams in order to decrease surgical morbidity. Historically, surgical planning consisted of imaging review and verbal communication among team members. 3-dimensional (3D) printing offers a new method for preoperative planning and is becoming more popular in Neurosurgery. This video demonstrates the use of 3D printing for complex paraspinal tumors in the cervical, thoracic, and sacral regions. The Institutional Review Board Office for Human Research Protection does not require approval for single participant case studies, or a case series with multiple participants. The subjects involved in this study were not identifiable and the general surgical consent form included permission for intraoperative photos.

11.
Oper Neurosurg (Hagerstown) ; 16(1): E17, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29800277

RESUMO

Neuromuscular choristoma (NMC) is a rare congenital nerve lesion that is classified by the presence of heterotopic muscle fibers intercalated within nerve fascicles.1 The presence of NMC typically causes progressive neuropathy and bony/soft tissue undergrowth, often leading to a shortened atrophic limb.2,3 The typical appearance of NMC on magnetic resonance imaging is an enlarged fusiform nerve that exhibits minimal gadolinium enhancement.4 While there is increasing documentation of pathognomonic clinical and radiographic features for various diffuse fusiform peripheral nerve lesions, nerve biopsy is still occasionally required for some patients given the rarity of these diseases and progressive neuropathic features.The intraoperative appearance of NMC and its unique electrical stimulation properties are quite interesting. Intrafascicular replacement of nerve by skeletal muscle gives the nerve a red beefy color and causes the fascicles to contract with electrical stimulation.5 In this video, we demonstrate the intraoperative appearance and contractile properties of NMC in a 60-yr-old woman with progressive sciatic neuropathy. Histologic and immunohistochemical studies identified a gradient of intralesional mature skeletal muscle within the NMC, with substantially fewer desmin-positive skeletal muscle fibers in the distal aspect. A gradient of contractility with intraoperative stimulation seemed to correlate with this pathology. These findings suggest that the lesional extent of NMC may not be clinically or grossly evident, reflecting a varying distribution of skeletal muscle within the affected nerve.The Mayo Clinic Institutional Review Board Office for Human Research Protection does not require approval for single participant case studies. The subject involved in this study was not identifiable and the general surgical consent form included permission for intraoperative photos and video.

12.
J Neurosurg ; 131(1): 175-183, 2018 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-30168738

RESUMO

OBJECTIVE: Desmoid-type fibromatosis (DTF) presents a therapeutic dilemma. While lacking metastatic potential, it is a locally aggressive tumor with a strong propensity for occurrence near nerve(s) and recurrence following resection. In this study, the authors introduce the association of an occult neuromuscular choristoma (NMC) identified in patients with DTF. METHODS: After experiencing a case of DTF found to have an occult NMC, the authors performed a retrospective database review of all other cases of biopsy-proven DTF involving the extremities or limb girdles in patients with available MRI data. Two musculoskeletal radiologists with expertise in peripheral nerve imaging reviewed the MRI studies of the eligible cases for evidence of previously unrecognized NMC. RESULTS: The initial case of a patient with an occult sciatic NMC is described. The database review yielded 40 patients with DTF-18 (45%) in the upper limb and 22 (55%) in the lower limb. Two cases (5%) had MRI findings of NMC associated with the DTF, one in the proximal sciatic nerve and the other in the proximal tibial and sural nerves. CONCLUSIONS: The coexistence of NMC may be under-recognized in a subset of patients with extremity DTF. This finding poses implications for DTF treatment and the likelihood of recurrence after resection or biopsy. Further study may reveal crucial links between the pathogenesis of NMC and DTF and offer novel therapeutic strategies.

13.
World Neurosurg ; 119: e986-e990, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30114537

RESUMO

BACKGROUND: Using proper surgical technique, schwannomas can be resected safely, with a low recurrence rate and high likelihood of improvement in symptomatology. There are multiple peritumoral tissue layers, and finding the correct plane is critical to safe tumor enucleation. The contents of the pseudocapsule tissue surrounding a schwannoma are not well described, and the consequences of resecting or leaving pseudocapsules are unknown. METHODS: An institutional database was searched for any pathology reports that contained both of the words "schwannoma" and "capsule." Charts and histopathologic specimens were reviewed to determine the contents of various tissue layers and determine if there was any correlation between pseudocapsular contents and clinical outcomes. RESULTS: A pseudocapsule was separately sent for pathology in 36 patients during schwannoma resection. Ten pseudocapsule specimens contained microscopic foci of tumor. In a separate 6 patients, there was evidence of nerve fascicles. There were no correlations between the tumor or nerve in the pseudocapsule and postoperative neurologic deficits. After an average follow-up time of 3.1 years, no patients developed a recurrence either clinically or on follow-up imaging (imaging available in 52.7%). Histopathologically, the pseudocapsule was made of dense hypocellular collagen and occasionally contained arteries, veins, and nerve fascicles. CONCLUSIONS: The pseudocapsule surrounding a schwannoma occasionally contained nerve tissue and blood vessels. While a microscopic focus of tumor was often found in this tissue layer, recurrence is exceedingly rare and did not occur in this case series. The risk of undue pseudocapsule dissection likely outweighs any negligible benefit from microscopic cytoreduction.


Assuntos
Neurilemoma/patologia , Neoplasias do Sistema Nervoso Periférico/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neurilemoma/diagnóstico por imagem , Neurilemoma/cirurgia , Neoplasias do Sistema Nervoso Periférico/diagnóstico por imagem , Neoplasias do Sistema Nervoso Periférico/cirurgia , Estudos Retrospectivos , Adulto Jovem
14.
Acta Neurochir (Wien) ; 160(9): 1833-1836, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29974241

RESUMO

Perineural spread has been described in multiple neoplasms of neural and non-neural origin. The peripheral nervous system may represent a highway by which tumors can spread throughout the body. Malignant peripheral nerve sheath tumor (MPNST) is a neoplasm arising from peripheral nerves with high rates of local recurrence and distant metastases, leading to a poor 5-year overall survival. In many cases, the optimal treatment involves wide en bloc excision with negative margins as well as chemotherapy and radiation. Even in cases of negative surgical margins, recurrence rates are high, suggesting possible skip lesions or very distant infiltration along the involved nerve. We report a case of high-grade MPNST of the sciatic nerve with post-mortem dissection and histopathologic characterization of perineural spread of microscopic disease to sites significantly proximal and distal to areas with evidence of gross disease, which may help to explain the high rates of local and distal recurrence in MPNST.


Assuntos
Neurofibrossarcoma/patologia , Pelve/patologia , Nervo Isquiático/patologia , Feminino , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia
16.
Neurosurg Focus ; 44(VideoSuppl1): V7, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29291291

RESUMO

Patients who present with a history of cancer and the new onset of lumbosacral or peripheral neuropathy should be evaluated for the potential of metastasis. Targeted fascicular biopsy can be useful to diagnose atypical lesions within peripheral nerves in patients with major or progressive neurological deficits. In this video, the authors demonstrate the technique of targeted fascicular biopsy of the sciatic nerve in a 63-year-old man with a history of prostate cancer. The video can be found here: https://youtu.be/PTOX9XxNBDU .


Assuntos
Doenças do Sistema Nervoso Periférico/cirurgia , Neoplasias do Sistema Nervoso Periférico/secundário , Neoplasias do Sistema Nervoso Periférico/cirurgia , Neoplasias da Próstata/cirurgia , Nervo Isquiático/cirurgia , Biópsia , Humanos , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso Periférico/diagnóstico por imagem , Doenças do Sistema Nervoso Periférico/etiologia , Neoplasias do Sistema Nervoso Periférico/complicações , Neoplasias do Sistema Nervoso Periférico/diagnóstico por imagem , Neoplasias da Próstata/diagnóstico por imagem , Nervo Isquiático/diagnóstico por imagem
17.
Acta Neurochir (Wien) ; 160(3): 651-654, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29372402

RESUMO

The intraoperative use of intravenous fluorescein is presented in a case of peroneal intraneural ganglion cyst. When illuminated with the operative microscope and yellow filter, this fluorophore provided excellent visualization of the abnormal cystic peroneal nerve and its articular branch connection. The articular (synovial) theory for the pathogenesis of intraneural cysts is further supported by this pattern of fluorescence. Further, our report presents a novel use of fluorescein in peripheral nerve surgery.


Assuntos
Cistos Glanglionares/cirurgia , Articulação do Joelho/cirurgia , Nervo Fibular/cirurgia , Fluoresceína , Corantes Fluorescentes , Cistos Glanglionares/patologia , Humanos , Cuidados Intraoperatórios , Articulação do Joelho/patologia , Masculino , Microscopia de Fluorescência , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Nervo Fibular/patologia
18.
Clin Anat ; 31(3): 417-421, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29193420

RESUMO

Inflammatory etiologies are becoming increasingly recognized as explanations of some neuropathies, especially those occurring in the perioperative period. Although "brachial neuritis" is known to affect extraplexal nerves, accessory nerve palsy following median sternotomy has been attributed to stretch on the nerve. To better elucidate stretch as a potential cause, a cadaveric study was performed. Two patients who developed accessory nerve palsy following median sternotomy are presented to illustrate features consistent with the diagnosis of a perioperative inflammatory neuropathy. Five adult unembalmed cadavers underwent exposure of the bilateral accessory nerves in the posterior cervical triangle. A median sternotomy was performed and self-retaining retractors positioned. With the head in neutral, left rotation and right rotation, retractors were opened as during surgery while observing and recording any accessory nerve movements. The self-retaining sternal retractors were fully opened to a mean inter-blade distance of 13 cm. Regardless of head position, from the initial retractor click to maximal opening there was no gross movement of the accessory nerve on the left or right sides. Opening self-retaining sternal retractors does not appear to stretch the accessory nerve in the posterior cervical triangle. Based on our clinical experience and cadaveric results, we believe that inflammatory conditions, (i.e., idiopathic brachial plexitis) can involve the accessory nerve, and might be triggered by surgical procedures. Clin. Anat. 31:417-421, 2018. © 2017 Wiley Periodicals, Inc.


Assuntos
Traumatismos do Nervo Acessório/etiologia , Esternotomia/efeitos adversos , Idoso , Feminino , Humanos , Inflamação/complicações , Masculino , Pessoa de Meia-Idade
19.
J Neurosurg ; 129(4): 1063-1066, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29192861

RESUMO

The authors report the case of a 52-year-old man who presented with rapid-onset lancinating facial pain consistent with trigeminal neuralgia. Magnetic resonance imaging revealed a nonenhancing small lesion on the right trigeminal nerve concerning for an atypical schwannoma or neuroma. The patient underwent resection of the mass via a right retrosigmoid approach. His facial pain completely resolved immediately postoperatively and had not recurred at 6 months after surgery. The mass was consistent with normal brain tissue (neurons and glial cells) without evidence of mitoses. A final histopathological diagnosis of ectopic brain tissue with neural tissue demonstrating focal, chronic T-cell inflammation was made. The partial rhizotomy during resection was curative for the facial pain. To the authors' knowledge, this is the first report of neuroglial ectopia causing trigeminal neuralgia.


Assuntos
Encéfalo , Coristoma/complicações , Neuralgia do Trigêmeo/etiologia , Coristoma/diagnóstico , Coristoma/patologia , Coristoma/cirurgia , Craniotomia/métodos , Diagnóstico Diferencial , Seguimentos , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Nervo Trigêmeo/patologia , Nervo Trigêmeo/cirurgia , Neuralgia do Trigêmeo/patologia , Neuralgia do Trigêmeo/cirurgia
20.
Oper Neurosurg (Hagerstown) ; 14(6): 697-704, 2018 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-29029228

RESUMO

BACKGROUND: Surgical education relies on operative exposure with live patients. Carotid endarterectomy (CEA) demands an experienced surgeon with a very low complication rate. The high-risk nature of this procedure and the decline in number of CEAs performed annually has created a gap in residency training. OBJECTIVE: To develop a high-fidelity whole-task simulation for CEA that demonstrates content, construct, and face validity. METHODS: Anatomically accurate models of the human neck were created using multilayered poly-vinyl alcohol hydrogels. Graded polymerization of the hydrogel was achieved by inducing crosslinks during freeze/thaw cycles, stiffening the simulated tissues to achieve realistic tactile properties. Venous bleeding was simulated using pressure bags and a ventricular assistive device created pulsatile flow in the carotid. Ten surgeons performed the simulation under operating room conditions, and metrics were compared among experience levels to determine construct validity. Participants completed surveys about realism and usefulness to evaluate face validity. RESULTS: A significant difference was found in operative measures between attending and resident physicians. The mean operative time for the expert group was 63.6 min vs 138.8 for the resident group (P = .002). There was a difference in mean internal carotid artery clamp time of 43.4 vs 83.2 min (P = .04). There were only 2 hypoglossal nerve injuries, both in the resident group (P = .009). CONCLUSION: The whole-task CEA simulator is a realistic, inexpensive model that offers comprehensive training and allows residents to master skills prior to operating on live patients. Overall, the model demonstrated face and construct validity among neurosurgery and vascular surgeons.


Assuntos
Simulação por Computador , Endarterectomia das Carótidas/educação , Internato e Residência , Modelos Anatômicos , Neurocirurgia/educação , Treinamento por Simulação/métodos , Adulto , Perda Sanguínea Cirúrgica , Artéria Carótida Interna/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Humanos , Traumatismos do Nervo Hipoglosso/etiologia , Complicações Intraoperatórias/etiologia , Pessoa de Meia-Idade
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