Multiyear experience in endoscopic thoracic sympathectomy

The results of endoscopic thoracic sympathectomy performed for 787 patients during a 30-year period are presented. Six hundred seventy three patients were operated on for upper limb arterial occlusion of distal and diffuse type, Raynaud's disease or syndrome, 7 patients - for causalgic pain in upper limbs and Sudeck's syndrome, 85 - for hyperhidrosis. Twelve patients underwent lower thoracic sympathectomy for painful chronic pancreatitis, 4 - total destruction of thoracic sympathetic trunk due to pernicious hypertension of unknown origin, and 6 - endoscopic thoracic sympathectomy for acute thrombosis of upper limb arteries with distal circulation impairment. Immediate positive effect of interventions was detected in all cases except for acute arterial thrombosis. One patient died postoperatively due to arrhythmia-related cardiac arrest. Postoperative complications - lung border damage and intercostal vascular hemorrhage - were detected in 0.2% of cases. Increased air effusion from pleural cavity and intercostal neuralgia were observed postoperatively in some cases but did not require any special management. Long-term outcomes were followed up for period of 5-10 years, 72.7% of monitored patients had stable positive outcomes. Our experience has demonstrated that endoscopic thoracic sympathectomy is a safe, minimally invasive and effective intervention for upper limb chronic arterial insufficiency of distal and diffuse type or for hyperhidrosis.

[Anesthetic management of a patient with oculopharyngodistal-myopathy]

Oculopharyngodistal-myopathy (OPDM) is an autosomal dominant, heredofamilial myopathy accompanied with slowly progressive ptosis and extraocular palsy, and weakness of the masseter, facial, and bulbar muscles, as well as distal involvement of the limbs starting around 40 years of age or later. A 54-year-old female with OPDM underwent resection of the uterus for uterus body cancer. We speculated the patient might be at the risk of aspiration pneumonia, prolonged respiratory depression, and malignant hyperthermia, and chose spinal and epidural anesthesia. The operation was performed successfully and the patient was discharged uneventfully.

[Propofol anesthesia for a patient in the terminal stage of Fukuyama type congenital muscular dystrophy]

A 31-year-old tracheostomized woman weighing 32.5 kg with Fukuyama type congenital muscular dystrophy in terminal stage was scheduled for dilatation of the tracheostoma, removal of the tracheal granulomas and reconstruction of gastrostoma. Anesthesia was induced and maintained with continuous propofol infusion and intermittent fentanyl. Muscle relaxant was not necessary because of generalized severe muscular atrophy. There was no hemodynamic derangement during the surgery and emergence from the anesthesia was rapid. There were no postoperative complications related to anesthesia and surgery.

Scapular fixation in muscular dystrophy

BACKGROUND

Winging of the scapula is caused by weakness of the thoracoscapular muscles, which allows the scapula to lift off the chest wall during shoulder movements. In facioscapulohumeral muscular dystrophy (and occasionally in other muscular dystrophies) there is selective weakness of the thoracoscapular muscles which may spare other shoulder muscles such as the deltoid muscle. This imbalance results in significant winging and loss of shoulder function. Historically, a number of different surgical and non-surgical interventions have been used to achieve scapular stability. This review examines the evidence available for the use of all scapular fixation techniques in muscular dystrophy, especially facioscapulohumeral muscular dystrophy.

OBJECTIVES

To examine the evidence for the relative efficacy of scapular fixation techniques in muscular dystrophy (especially fascioscapulohumeral muscular dystrophy) in improving upper limb function.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group trials register (search updated March 2003) for randomised trials and other reports, and made enquiries from authors of trials and other experts in the field.

SELECTION CRITERIA

All reports of scapular fixation for muscular dystrophy, including quasi-randomised or randomised controlled trials, comparing any form of scapular fixation (surgical and non-surgical) in people (of all ages and of all severity) with scapular winging due to muscular dystrophy. Our primary outcome measure was objective improvement in shoulder abduction. Our secondary outcome measures were: patient-perceived improvement in performance of activities of daily living, cosmetic results, subjective improvement in pain and proportion of patients with significant postoperative complications.

DATA COLLECTION AND ANALYSIS

We collated and summarised studies on the treatment of scapular winging in muscular dystrophy.

MAIN RESULTS

No randomised trials were identified. We therefore present a review of the non-randomised literature available.

REVIEWER'S CONCLUSIONS

Operative interventions appear to produce significant benefits, though these have to be balanced against postoperative immobilisation, need for physiotherapy and potential complications. We conclude that a randomised trial would be difficult, but a register of cases and the use of a standardised assessment protocol would allow more accurate comparison of the disparate techniques.

[Umbilical cord blood--invaluable source of stem cells]

The aim of the study was to discuss the role of stem cells in the organism. The paper presents the significance of stem cells in the treatment of many diseases, such as hematopoietic system disorders, muscular dystrophies, Parkinson disease, and congenital immunodeficiency syndromes. The results of investigations on stem cells carried out in recent years allow to presume, that the usage of stem cells will turn out to be a breakthrough in the history of medicine. Umbilical cord blood can be the source of stem cells, which is now underestimated and very often removed.

Myogenic stem cells from the bone marrow: a therapeutic alternative for muscular dystrophy?

Differentiated muscle fibres can be formed by transplanted haematopoietic stem cells in models of acute or chronic muscle regeneration, including the dystrophin-deficient mdx mouse. Muscle-forming activity can be found in adult, foetal and embryonic haematopoietic tissues. The blood-to-muscle transition may be due to transdifferentiation of haematopoietic progenitors in response to local signals provided by the regenerating muscle. These signals are only poorly provided by the muscle of the mdx mouse, since transplantation into these mice of normal C57Bl/6 bone marrow gives rise only to a minimal number of muscle fibres expressing the normal dystrophin protein (<1%) throughout the animal life span. Expansion and active recruitment to myogenic differentiation of transplanted haematopoietic cells are therefore critical factors for a future use of bone marrow transplantation in cell/gene therapy of muscular dystrophy.

Management of myogenic ptosis

OBJECTIVE

To review the genetics, clinical features, and management of patients affected by myogenic ptosis.

DESIGN

Retrospective, noncomparative interventional case series.

PARTICIPANTS

Twenty-eight patients with myogenic ptosis.

METHODS

A review of all patients with myogenic ptosis between 1992 and 2000 was made in a tertiary oculoplastics practice.

MAIN OUTCOME MEASURES

Ocular and systemic findings associated with myogenic ptosis were examined. Patients were diagnosed clinically, and ancillary tests (including genetic tests and muscle biopsy histologic findings) were reviewed. Surgical management principles and complications are discussed.

RESULTS

Most of our ptosis patients had chronic progressive external ophthalmoplegia (43%), oculopharyngeal muscular dystrophy (OPMD; 18%), and myotonic dystrophy (18%). Fifty percent of myogenic ptosis patients in our series underwent frontalis suspensions. Twenty-one percent of patients who initially had operations at our institution had minor complications, most related to corneal exposure. The most common ocular finding other than ptosis and ophthalmoplegia was pigmentary retinopathy (25%). The most common systemic finding in our patients was dysphagia (43%). Genetic testing for OPMD was highly sensitive. Muscle biopsy results for mitochondrial myopathies were less accurate as adjunctive diagnostic tests.

CONCLUSIONS

Myogenic ptosis should be considered in the differential diagnosis of any atypical ptosis presentation. To avoid complications, surgery should be performed only when the visual axis is obscured. We recommend the use of silicone slings in any patient with severe ptosis and less than 8 mm of levator function. Genetic testing of patients with myogenic ptosis is important to allow accurate diagnosis and to permit appropriate counseling on potentially life-threatening health issues.

Orthopedic management of the muscular dystrophies

Muscular dystrophy is a collective group of inherited, noninflammatory, progressive muscle wasting diseases. The initial pathologic feature is an abnormality in the genetic code for dystrophin or one of its associated glycoproteins, which leads to the various clinical syndromes. Despite minor variations between the different types, all muscular dystrophies have in common progressive muscle weakness, which is best typified by Duchenne muscular dystrophy. The weakness occurs in a proximal to distal direction and can compromise ambulatory status as well as cardiopulmonary function. Additionally, structural soft tissue contractures and spinal deformities may develop from poor posturing secondary to the progressive muscle weakness and imbalance. The rapidly developing scoliosis and its associated pelvic obliquity can even compromise sitting. Recent advances in molecular biology and gene therapy research raise the hope for a cure for muscular dystrophy in the near future. Until that time, however, the role of orthopedic surgeons in treating patients with muscular dystrophy is to preserve or prolong their functional status for as long as possible. This can be achieved by physical therapy, bracing, soft tissue releases for joint contractures, and early stabilization of the spine.

The treatment of scoliosis in muscular dystrophy using modified Luque and Harrington-Luque instrumentation

We have treated 101 patients with scoliosis secondary to muscular dystrophy over a 13-year period; 64 had Duchenne's muscular dystrophy, 33 spinal muscular atrophy and four congenital muscular dystrophy. The patients underwent a modified Luque (87) or Harrington-Luque instrumentation (14) combined with a limited Moe fusion in all except 27 cases. A mean of 13 levels was instrumented. The mean preoperative sitting Cobb angle was 84 degrees (10 to 150) and the mean postoperative angle 40 degrees (52% correction). Most patients (96%) were able to discard their braces and there was a high level of patient satisfaction (89.6%). Less correction was seen for severe curves, and there was a greater recurrence of postoperative pelvic tilt in those patients not instrumented to the sacrum. Although the incidence of minor or temporary complications was high, these occurred chiefly in the early high-risk patients with very severe curves and considerable pre-existing immobility.

Pressure-controlled ventilation via a mini-tracheostomy tube for patients with neuromuscular disease

The authors managed 10 patients with Duchenne muscular dystrophy (DMD) and five with MG with pressure-controlled ventilation (PCV) via mini-tracheostomy tube (MTT). The arterial partial pressure of CO2 (PaCO2) of the patients with DMD decreased after conversion to PCV via MTT from biphasic positive airway pressure (BIPAP) or a body ventilator. The MG patients could be converted from conventional volume-controlled ventilation to PCV via MTT. PCV via MTT achieves more effective ventilation than either BIPAP or a body ventilator and is as effective as ventilation via a conventional tracheal tube.

Blood loss in Duchenne muscular dystrophy: vascular smooth muscle dysfunction?

Patients with Duchenne muscular dystrophy (DMD) tend to bleed more during surgery than do patients with other conditions. A retrospective analysis of blood loss after spinal surgery for scoliosis was therefore undertaken in 102 patients undergoing surgery in the senior author's unit. These included 48 patients with DMD, 26 patients with spinal muscular atrophy, and a miscellaneous group of 28 other patients most of whom had idiopathic scoliosis. For each patient the age at surgery, estimated blood volume, duration of operation, Cobb angle, and number of vertebrae fused were recorded and compared. Expression of dystrophin in skeletal muscle and the underlying gene mutation were also determined. The estimated blood loss in patients with DMD was significantly higher than that in patients with spinal muscular atrophy undergoing the same or similar procedure (P < 0.005) and was also significantly greater than that of the third group, which consisted mostly of patients with idiopathic scoliosis (P < 0.0005). Blood loss in the patient group with DMD showed a significant relationship with duration of surgery (P < 0.05). As most patients expressed no dystrophin, this did not correlate with the estimated blood loss. There was also no correlation between the estimated blood loss and the type of gene mutation found causing DMD. The authors' previous observations confirm the increased blood loss in patients with DMD who undergo scoliosis surgery. Because children with DMD lack dystrophin in all muscle types, including smooth muscle, the excessive blood loss may be because of a poor vascular smooth muscle vaso-constrictive response due to a lack of dystrophin.

Process measures and patient/parent evaluation of surgical management of spinal deformities in patients with progressive flaccid neuromuscular scoliosis (Duchenne's muscular dystrophy and spinal muscular atrophy)

STUDY DESIGN

Fifty-four consecutive patients with flaccid neuromuscular scoliosis (33 with Duchenne's muscular dystrophy, 21 with spinal muscular atrophy) who had undergone surgery for their disorder between 1985 and 1995 were sent questionnaires to evaluate function, self-image, cosmesis, pain, pulmonary status, patient care, quality of life, and satisfaction. Forty-eight patients returned the questionnaires.

OBJECTIVE

To assess patient/parent satisfaction and clinical/functional ways in which spinal fusion helped or did not benefit these patients and to assess complications and the ultimate radiographic result.

SUMMARY OF BACKGROUND DATA

There are only a few reports of results of spinal fusion and segmental instrumentation for flaccid neuromuscular disorders. There are no published reports regarding patient/parent evaluation of the procedure.

METHODS

Results of the questionnaire were tallied, graded, and divided into eight categories. The questionnaire was validated by a Cronbach's alpha analysis, a test-retest, and a comparison with questionnaire answers from patients with idiopathic scoliosis. Radiographic data and complications also were accumulated. The follow-up periods after surgery ranged from 2 to 12.6 years (average, 7.8 years).

RESULTS

Except for two patients who died within 3 months of surgery, all patients seemed to have benefited from the surgery. Cosmesis, quality of life, and overall satisfaction rated the highest.

CONCLUSION

These data indicate that spinal fusion with segmental spinal instrumentation benefits most patients with Duchenne's muscular dystrophy or spinal muscular atrophy with spinal deformities in terms of all categories assessed, even though these diseases have a progressively deteriorating course.

Correlation of muscle fiber type measurements with clinical and molecular genetic data in Duchenne muscular dystrophy

Clinical improvement following surgery in patients with Duchenne muscular dystrophy (DMD) may be influenced by the severity of muscle fiber damage. This study correlates morphometric alterations of muscle fiber types, severity of fat tissue proliferation and fibrosis with Western blots, multiplex polymerase chain reaction (PCR), and postoperative state in DMD. The main results of this study show that the mean diameter of type 2 fibers is usually markedly larger than that of type I fibers in DMD although the number of type 2 fibers is severely reduced. The mean percentage of the remaining type 1 fibers was in the range of 57-82%. The morphometric and histopathological results were in agreement with the clinically estimated postoperative state, especially in the patients who presented a severe state or suggestive clinical improvement. It is concluded that combination of both quantitative and qualitative evaluation of muscle biopsies is suitable for better evaluation of the postoperative state in patients with DMD, whereas severity of exon deletions correlated poorly with morphometry and postoperative clinical state.

Lower limb surgery in Duchenne muscular dystrophy

Two hundred and thirteen of 428 patients with Duchenne muscular dystrophy (DMD) of a prospective and open study were operated on bilaterally with hip and knee release, aponeurectomy of the iliotibial band and Achilles tendon lengthening. In 87 patients the operation was carried out during early restrictions of the lower limb joint mobility at an average age of 6.56 years (4.02-8.26, SD 1.42). The follow-up was on average 5.4 years (0.25-9.01, SD 2.7). This group was compared to a control group (natural history) consisting of 100 non-operated DMD patients. A significant (P < 0.001) release of the contractures could be obtained. Loss of walking ability occurred in the control group at an average of 9.29 years (5.85-13.63, SD 1.98) and in the operated group at an average of 10.55 years (8.17-14.39, SD 1.76). This shows that early lower limb surgery leads to a prolongation of independent ambulation of 1.25 years on average. In contrast to the patients of the control group all treated patients between ages 6 and 8 years could walk independently. The positive influence of early lower limb surgery could also be shown by the development of Hammersmith motor ability score, CIDD (Council of Investigation of Duchenne Dystrophy) grading and Vignos scale. Nevertheless, in consideration of the well-known course of DMD not only the prolongation of ambulation but also the achieved prolongation of assisted standing ability with no or mild contractures are aims of lower limb surgery. Since no improvement of muscle strength could be observed after lower limb surgery, further studies have to investigate if additionally administered steroids can prolong ambulation after early lower limb surgery.

Scapulothoracic arthrodesis for patients with facioscapulohumeral muscular dystrophy

Ten scapulothoracic arthrodesis procedures were performed in six patients with facioscapulohumeral muscular dystrophy in order to improve considerably restricted activities of daily living. Four of these procedures were bilateral. The duration of follow-up ranged from 28 to 120 months. All patients reported improved function in activities of daily living. Active shoulder abduction was improved by an average of 44 degrees, and active flexion increased by 56 degrees. There was no deterioration in improved upper limb function with time. Complications included pneumothorax, atelectasis, pleural effusion and re-exploration for a segment of retained drain.

Management of the collapsing spine for patients with Duchenne muscular dystrophy

Instrumented fusion of the collapsing spine has gained widespread acceptance for patients with Duchenne Muscular Dystrophy but controversy still exists on the issue of extending the surgical fusion to sacrum in these patients. This retrospective study reviews the long-term outcome of a group of patients with spinal deformity associated with Duchenne Muscular Dystrophy who were managed with long spinal fusion to L5 and ongoing wheelchair seating attention. The clinical notes and radiographs of 19 consecutive patients were reviewed. Fifteen patients attended for clinical and radiological assessment at a mean of 28 months post operatively. The surgery for these patients involved a mean anaesthetic time of 3.5 h and a mean transfusion requirement of 5 units of red cell concentrate. At long-term follow-up 15 patients continued to sit in a well-balanced position. Surgical fusion of the spine to L5 combined with ongoing attention to seating is associated with good long-term functional results in these patients.

[Surgery of the spine in Duchenne's muscular dystrophy]

PURPOSE OF THE STUDY

The authors present a retrospective review of 27 patients presenting a Duchenne muscular dystrophy and who were operated for spinal deformity, with special reference to functional result and postoperative evolution of vital capacity.

MATERIAL AND METHODS

Age at surgery averaged 14. Mean scoliotic angulation was 42 degrees. A thoraco-lumbar kyphosis was present in 15 cases (kyphotic index less than 10 degrees). A pelvic obliquity averaging 17 degrees was associated in 19 cases. Mean pre-operative vital capacity was 56 per cent. Preoperative evolution of vital capacity was documented in 18 cases: annual rate of decrease was 4.3 per cent. Heart ejection fraction averaged 63 per cent in 23 cases, and was normal in 4 cases. Instrumentation was extended from D3, D4 or D5 to L5 (5 cases) or S1 (22 cases). Spinal fixation was done in all patients by subliminar wiring with Luque rods (5 cases) or Hartshill rectangle (22 cases). Sacral fixation was done with ilio-sacral screws linked to the rectangle by Cotrel Dubousset rods and dominos (15 cases).

RESULTS

Mean blood loss was 1750 cc. Postoperatively, 25 patients were extubated on the operative day, 1 patient at D + 1, and one patient underwent a tracheostomy after one month. Scoliosis was reduced to 10 degrees after surgery and 13 degrees after 30 months follow-up. Pelvic obliquity was reduced to 4 degrees after surgery and 7 degrees after 30 months. A good spinal balance was present after surgery in 20 patients; at follow-up, a coronal or sagittal imbalance averaging 40 mm was observed in 22 patients. Postoperative evolution of vital capacity was documented in 21 cases. The annual decrease rate was 6.4 per cent. Rate was higher in patients presenting a good preoperative vital capacity (over 70 per cent) and very low in patients presenting a preoperative vital capacity under 40 per cent. 10 patients were deceased at review after a mean 53 months survival, at a mean age of 19. 17 patients were alive with a 50 months follow-up.

DISCUSSION

Spinal surgery in Duchenne muscular dystrophy has a low morbidity. It allows to keep sitting position to the child and to preserve quality of life. Surgery should be considered as soon as frontal or sagittal collapse of the spine is observed. However surgery does not result in respiratory improvement nor in life duration lengthening.

Pharyngeal dysphagia caused by isolated myogen dystrophy of musculus cricopharyngeus

Five patients suffering from idiopathic cricopharyngeal dysfunction (without Zenker's diverticulum) were treated surgically. Together with cricopharyngeomyotomy biopsies were taken at the level of the cricopharyngeus. Histological, enzyme hystochemical and electronmicroscopic examinations were performed on all patients. In two cases the histology revealed myogen dystrophy (presence of necrosis, myophagocytosis, abnormal fiber structure, basophilic fibers, fibrosis, mild cellular reaction and predominancy of fiber type I). Since the complete patient evaluation (clinical features, electromyography, serum creatinin phosphokinase level, etc.) could rule out any general, muscle disorders, the cause of the idiopathic pharyngeal dysfunction must have been in these two cases an isolated myogen dystrophy of the cricopharyngeus.

Rigid internal fixation of the jaws in an adult patient with facio-scapulo-humeral muscular dystrophy: report of a case

This study shows the advantages of rigid internal fixation in the surgical management of a facial deformity in a 29-year-old patient with facio-scapulo-humeral dystrophy (FSHD). After presurgical orthodontic treatment, surgery consisted of a Le Fort I maxillary osteotomy, with 5 mm of anterior movement, and fixation with miniplates. After mandibular sagittal split set-back osteotomy, internal fixation was applied on each side using two bicortical screws; no postoperative intermaxillary fixation was utilized. At the 2-year follow-up, the patient was satisfied with the surgical results; lip competence and occlusion were good. The advantages of using internal rigid fixation are: immediate osseous stability which does not require intermaxillary fixation, improved perioperative airway management (no preoperative tracheostomy) and earlier functional recovery.

Troponin I as a specific marker for heart damage after heart transplantation in a patient with becker type muscular dystrophy

In a patient with Becker type muscular dystrophy, the development of cardiomyopathy may require heart transplantation, and during both the perioperative period and later it is useful to determine whether myocardial cell damage is occurring; however, the measurement of serum levels of creatine kinase (CK), MB isoenzyme, is not useful because that isoenzyme is released by the dystrophic skeletal muscle, as well as damaged myocardium. Because cardiac troponin I (cTn I) seems to be quite specific for myocardial cells, we reasoned that measurement of serum levels of this protein could distinguish between myocardial damage and skeletal muscle disease in this patient during and after transplantation. During the immediate postoperative period, the time course of the release of total CK (tCK), CK MB mass, myoglobin, and cTn I were different, yielding a peak within 4 hours for CK MB, 24 hours for myoglobin and 36 hours for tCK and cTn I. During the first postoperative year, the patient displayed a release of tCK, CK MB, and myoglobin; cTn I was constantly lower than the reference value for cardiac myocyte necrosis, suggesting the presence of a continuous muscular damage without any myocardial involvement and an accurate specificity of cTn I to differentiate between myocardial and muscular cell damage in patients with neuromuscular disorders.

Use of gold weights to correct lagophthalmos in neuromuscular disease

Upper eyelid gold-weight implants are widely used in the correction of lagophthalmos in many neuromuscular conditions, most commonly facial palsy. The paralytic lagophthalmos that occurs in facioscapulohumeral muscular dystrophy (FSHD) is common and can cause severe ocular complications. It is not usually considered for surgical correction. Upper lid loading with 24K gold implants and reconstructive lower lid surgery in a 64-year-old woman with FSHD corrected eyelid deformity and exposure keratitis. Surgical treatment also markedly improved facial appearance. This treatment may merit wider use in FSHD.