Postoperative complications of microvascular decompression for hemifacial spasm: lessons from experience of 2040 cases.

Microvascular decompression (MVD) is an effective and safe treatment option that offers the prospect of definitive cure for hemifacial spasm (HFS). However, there are potential risks of complications for MVD associated with retromastoid suboccipital craniectomy (RmSOC) and cranial nerves in particular. The purpose of this study was to identify clinical characteristics of possible complications after MVD for HFS and to establish appropriate management concept of these complications. We retrospectively reviewed medical records of 2040 patients who underwent RmSOC with MVD for HFS at Samsung medical center between January 1998 and March 2013. Of 2040 patients, 2027 were followed (99.4%). Of the 2027 patients, 1841 (90.8%) exhibited complete relief or minimal symptoms, and 113 (5.6%) reported improved spasm but had mild remnant symptoms. After operation, the most frequently developed complications were facial nerve palsy (8.19%), followed by middle ear effusion (4.90%) and hearing loss (3.63%). There were two cases of supratentorial subdural hemorrhage, three cases of infarction. MVD was found to be safe and effective treatment for HFS, in consistent with previous reports. Some of the complications such as facial nerve palsy, middle ear effusion, and hearing loss are relatively common. However, they have mild clinical courses that are usually transient.

Endoscope-assisted microsurgical resection of skull base meningiomas.

This study aims to determine the value of endoscope assistance in the microsurgical resection of skull base meningiomas. Fourty-six patients harboring a skull base meningioma underwent an endoscope-assisted microsurgical resection. In 30 patients (65%), tumor parts which could not be visualized under the microscope were detected with the endoscope. In 26 patients (56%), these tumor remnants were removed under endoscopic view. Gross total resection was achieved in 35 patients (76%) and near-total resection in 11 (24%). There was no surgical mortality. The major complication was new cranial nerve deficit. The application of endoscopes was most useful in the small supraorbital craniotomies to look under the ipsilateral optic nerve and internal carotid artery as well as to visualize the diaphragm sellae and olfactory groove. In the retrosigmoid craniotomies, the endoscope was beneficial to inspect the internal auditory canal, to look into Meckel's cave, or to inspect areas hidden behind the jugular tubercle and tentorial edge. There was no obvious complication related to the application of the endoscope. Endoscope assistance is particularly of value when skull base meningiomas are to be removed via small craniotomies to inspect blind corners which cannot be visualized in a straight line with the microscope. In addition, there is a benefit of using endoscopes with various angles of view in standard craniotomies and skull base approaches to look around bony and dural corners or to look behind neurovascular structures, by which the amount of skull base drilling and retraction to expose the tumor can be reduced.

Facial palsy after blunt trauma and without facial bone fracture.

A 14-year-old patient had a low-energy facial blunt trauma that evolved to right facial paralysis caused by parotid hematoma with parotid salivary gland lesion. Computed tomography and angiography demonstrated intraparotid collection without pseudoaneurysm and without radiologic signs of fracture in the face. The patient was treated with serial punctures for hematoma deflation, resolving with regression and complete remission of facial paralysis, with no late sequela. The authors discuss the relationship between facial nerve traumatic injuries associated or not with the presence of facial fractures, emphasizing the importance of early recognition and appropriate treatment of such cases.

Iatrogenic injury to the inferior alveolar nerve: etiology, signs and symptoms, and observations on recovery.

The purpose of this prospective, non-randomised, descriptive study is to characterise the neurosensory deficit and associated neurogenic discomfort in 52 patients with iatrogenic injury to the inferior alveolar nerve (IAN). All patients were examined and followed up according to a protocol assessing tactile, thermal, and positional perception as well as two-point discrimination and pain. In 48 patients with IAN injuries of differing etiologies who did not undergo surgery, 32 patients with injury associated with third molar surgery exhibited significant spontaneous improvement of sensory function. Recovery improvement of sensory function was insignificant in the patients with other etiologies. In most patients the level of sensory perception was such that microsurgical repair was only occasionally indicated. Four patients had microsurgical repair; the outcome was favourable in three. IAN injuries associated with third molar surgery, other dento-alveolar surgery or implant surgery occur sufficiently often to render prevention a key issue.

[Cranial nerve damage after neuroaxial methods of anesthesia in puerperas].

The paper describes cranial nerve damage, a rare complication of neuroaxial anesthesia in obstetric care. In the literature, there are summarized data on 17 cases of neurological deficit developing after subarachnoidal or epidural anesthesia in puerperas. The etiological and pathogenetic factors of the above complications may be suggested to be the high disposition of a local anesthetic, arterial hypotension due to neuroaxial anesthetics, the outflow of cerebrospinal fluid after pachymeningeal puncture (including after unintended puncture during epidural anesthesia), and ischemic injury after the blood packing performed to relieve postpuncture headache. Closer consideration of these risk factors seems to reduce the incidence of cranial nerve damage in puerperas.

Isolated spinal accessory neuropathy in an adolescent: a case study.

We describe a case of dynamic scapular winging due to trapezius muscle paresis following a sport-related injury of the accessory nerve. The typical clinical findings related to the peripheral nerve involved, the importance of neurophysiologic work-up, and possibilities for treatment are discussed.

Nerve injuries after dental injection: a review of the literature.

Prolonged and possibly permanent change in sensation due to nerve damage can occur after dental injections. Although the condition is rare, many practitioners will see this form of nerve injury during their careers. The exact mechanism of the injury has yet to be determined, and little can be done to prevent its occurrence. This type of injury carries with it many functional and psychological implications, and referral to both dental and medical specialists may be necessary for continued follow-up and possible treatment.

Comparative analysis of the effectiveness of the mandibular angle fracture treatment methods.

425 patients with mandibular angle fractures were treated at the Hospital of Kaunas University of Medicine (HKUM) Clinic of Maxillo-Facial Surgery. Treatment included the application of closed fracture fragments fixation methods (wire splint fixation, and Kirschner wire osteosynthesis), and methods of open fixation--osteosynthesis using the supra-periosteal miniplate, and osteosynthesis using supra-osseous Zes Pol plate (the latter method was modified by the authors). Relative computerized densitometry showed that closed fixation methods result in a faster healing of fractures. The findings of the pain threshold testing showed that open fixation methods more severely damage the function of the lower alveolar nerve. Using closed fixation methods, osteomyelitis occurred in 5.3% of cases, while using open fixation methods--in 15.3% of cases. Thus, the authors of the article maintain that when mandibular angle fractures, in the presence of suitable conditions, closed fracture fragments fixation methods should be given a priority.

[Occipital condyle fracture associated with Jefferson's fracture and injury of lower cranial nerves: case report]. / Fratura de côndilo occipital associada a fratura de Jefferson e lesão dos nervos cranianos caudais: relato de caso.

Occipital condyle fracture(OCF) is rarely seen and can be missed during medical evaluation due to the variety of clinical presentations and the difficulty to be visualized radiographically. This fracture can be associated with cranial nerves injuries (31%), being the hipoglossal nerve the most frequently involved (67%). We report a 58 years old female patient who presented with OCF, injury of lower cranial nerves and Jefferson's fracture. The patient was treated with cervical traction for six weeks followed by halo immobilization for three months. There was bone consolidation recovery of the nervous injury after this period. This report emphazises the importance of investigating the skull-cervical transition in all patients with cervical trauma. Although Jefferson's fracture is rarely associated with OCF, it should be remembered and treated appropriately when diagnosed.

Inferior alveolar nerve paresthesia relieved by microscopic endodontic treatment.

We experienced two cases of inferior alveolar nerve paresthesia caused by root canal medicaments, which were successfully relieved by microscopic endodontic treatment. In the first case, the paresthesia might have been attributable to infiltration of calcium hydroxide into the mandibular canal through the root canals of the mandibular left second molar tooth. In the second case, the paresthesia might have been attributable to infiltration of paraformaldehyde through the root canals of the mandibular right second molar tooth. The paresthesia was relieved in both cases by repetitive microscopic endodontic irrigation using physiological saline solution in combination with oral vitamin B12 and adenosine triphosphate.

Characterizing liability for cranial nerve injuries: a detailed analysis of 209 malpractice trials.

OBJECTIVES/HYPOTHESIS: The potential for adverse events with lasting functional effects makes cranial nerve (CN) injury a target for litigation. Our objective was to comprehensively examine records of malpractice trials and detail issues influencing outcomes. STUDY DESIGN: Retrospective analysis. METHODS: The Westlaw database (Thomson Reuters, New York, NY) was searched for jury verdict reports related to medical malpractice and CN injury. After excluding nonrelevant cases, we examined 209 trials for characteristics including nerve(s) injured, alleged causes of malpractice, demographic information, specialty, and outcome. RESULTS: The most commonly litigated CNs were VII (24.4%) and II (19.6%). Sixty-nine (33.0%) trials resulted in damages awarded. Outcomes varied, ranging from a 29.2% plaintiff success rate for CN XI injury to 48.4% for CN II injury. Plaintiffs had less success with increasing age. Average damages awarded were $1.7 million. The most commonly named defendants were otolaryngologists and general surgeons. Individual considerations varied but commonly included alleged deficits in informed consent (25.4%), unnecessary procedures (14.8%), undergoing additional surgery (25.8%), and untimely recognition of complications (23.9%). CONCLUSIONS: Malpractice trials were resolved in the defendant's favor the majority of the time. In cases where plaintiffs were successful, however, awards were considerable, averaging nearly $2 million. Factors influencing case outcome included age, location, perceived deficits in informed consent, allegedly unnecessary surgery, requiring additional surgery to repair a complication, and untimely recognition of complications. Although specific factors should be taken into consideration with each procedure, providing detailed informed consent and communicating with patients regarding expectations may minimize liability.

Traumatic superior orbital fissure syndrome: assessment of cranial nerve recovery in 33 cases.

BACKGROUND: Superior orbital fissure syndrome is a rare complication that occurs in association with craniofacial trauma. The characteristics of superior orbital fissure syndrome are attributable to a constellation of cranial nerve III, IV, and VI palsies. This is the largest series describing traumatic superior orbital fissure syndrome that assesses the recovery of individual cranial nerve function after treatment. METHODS: In a review from 1988 to 2002, 33 patients with superior orbital fissure syndrome were identified from 11,284 patients (0.3 percent) with skull and facial fractures. Severity of cranial nerve injury and functional recovery were evaluated by extraocular muscle movement. Patients were evaluated on average 6 days after initial injury, and average follow-up was 11.8 months. RESULTS: There were 23 male patients. The average age was 31 years. The major mechanism of injury was motorcycle accident (67 percent). Twenty-two received conservative treatment, five were treated with steroids, and six patients underwent surgical decompression of the superior orbital fissure. After initial injury, cranial nerve VI suffered the most damage, whereas cranial nerve IV sustained the least. In the first 3 months, recovery was greatest in cranial nerve VI. At 9 months, function was lowest in cranial nerve VI and highest in cranial nerve IV. Eight patients (24 percent) had complete recovery of all cranial nerves. Functional recovery of all cranial nerves reached a plateau at 6 months after trauma. CONCLUSIONS: Cranial nerve IV suffered the least injury, whereas cranial nerve VI experienced the most neurologic deficits. Cranial nerve palsies improved to their final recovery endpoints by 6 months. Surgical decompression is considered when there is evidence of bony compression of the superior orbital fissure.

Craniofacial and skull base trauma.

BACKGROUND: Traumatic craniofacial and skull base injuries require a multidisciplinary team approach. Trauma physicians must evaluate carefully, triage properly, and maintain a high index of suspicion to improve survival and enhance functional recovery. Frequently, craniofacial and skull base injuries are overlooked while treating more life-threatening injuries. Unnoticed complex craniofacial and skull base fractures, cerebrospinal fluid fistulae, and cranial nerve injuries can result in blindness, diplopia, deafness, facial paralysis, or meningitis. Early recognition of specific craniofacial and skull base injury patterns can lead to identification of associated injuries and allow for more rapid and appropriate management. CONCLUSION: Early detection and treatment of craniofacial and skull base traumatic injuries should lead to decreased morbidity and mortality. This review discusses the most common of these injuries, their possible complications, and treatment.