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[Peripheral nerve reconstruction - diagnostics as a basis for decision-making: report of the Consensus Workshop at the 35th Meeting of the DAM]. HANDCHIR MIKROCHIR P 2021; 53:168-174. [PMID: 33860493 DOI: 10.1055/a-1307-3963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
In the early stage of nerve lesions, the clinical differentiation between neurapraxia, axonotmesis and neurotmesis often presents a big challenge. Especially in the early stage, however, it is crucial to correctly classify the type of damage because this is what essentially determines the therapeutic concept, in particular the surgical approach and, therefore, the prognosis. A precise diagnosis not only requires detailed clinical assessment and medical history taking, but also the use of additional electrophysiological (functional) and/or imaging examinations. Electrophysiological diagnostic tests may provide information ion localization, severity, course, type of damage and incipient or past reinnervation. Preoperative functional diagnostic measures should include neurography, needle electromyography (EMG) and, if needed, evoked potentials (EP), while imaging procedures should include neural sonography and magnetic resonance imaging (MRI). As a complimentary procedure, EMG may also be performed during surgery.
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Chang KT, Lin YL, Lin CT, Hong CJ, Cheng YH, Tsai MJ, Huang WC, Shih YH, Lee YY, Cheng H, Huang MC. Neuroprotection in the Acute Stage Enables Functional Recovery Following Repair of Chronic Cervical Root Transection After a 3-Week Delay. Neurosurgery 2021; 87:823-832. [PMID: 31960049 DOI: 10.1093/neuros/nyz572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 12/01/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Preganglionic cervical root transection (PCRT) is the most severe type of brachial plexus injury. In some cases, surgical procedures must be postponed for ≥3 wk until electromyographic confirmation. However, research works have previously shown that treating PCRT after a 3-wk delay fails to result in functional recovery. OBJECTIVE To assess whether the immunosuppressive drug sirolimus, by promoting neuroprotection in the acute phase of PCRT, could enable functional recovery in cases of delayed repair. METHODS First, rats received a left 6th to 8th cervical root transection, after which half were administered sirolimus for 1 wk. Markers of microglia, astrocytes, neurons, and autophagy were assessed at days 7 and 21. Second, animals with the same injury received nerve grafts, along with acidic fibroblast growth factor and fibrin glue, 3 wk postinjury. Sirolimus was administered to half of them for the first week. Mechanical sensation, grasping power, spinal cord morphology, functional neuron survival, nerve fiber regeneration, and somatosensory-evoked potentials (SSEPs) were assessed 1 and 23 wk postinjury. RESULTS Sirolimus was shown to attenuate microglial and astrocytic proliferation and enhance neuronal autophagy and survival; only rats treated with sirolimus underwent significant sensory and motor function recovery. In addition, rats who achieved functional recovery were shown to have abundant nerve fibers and neurons in the dorsal root entry zone, dorsal root ganglion, and ventral horn, as well as to have SSEPs reappearance. CONCLUSION Sirolimus-induced neuroprotection in the acute stage of PCRT enables functional recovery, even if surgical repair is performed after a 3-wk delay.
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Affiliation(s)
- Kai-Ting Chang
- Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Applied Chemistry, Chaoyang University of Technology, Wufeng, Taiwan
| | - Yi-Lo Lin
- Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Chi-Te Lin
- Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Nursing, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Chen-Jei Hong
- Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yung-Hsin Cheng
- Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - May-Jywan Tsai
- Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Cheng Huang
- Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Center for Neural Regeneration, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yang-Hsin Shih
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Central Clinic Hospital, Taipei, Taiwan
| | - Yi-Yen Lee
- Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Henrich Cheng
- Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Center for Neural Regeneration, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chao Huang
- Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Central Clinic Hospital, Taipei, Taiwan.,Division of Pediatric Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Basic Medical Education Center, Central Taiwan University of Science and Technology, Taichung, Taiwan.,School of Medicine, Taipei Medical University, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
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Meyer JS, Hessenauer FM, Reichel T, Pham M, Plumhoff P, Rueckl K. Isolated mononeuropathy of the suprascapular nerve: traumatic traction injury as an important differential diagnosis to the entrapment syndrome. JSES Int 2020; 4:499-502. [PMID: 32939475 PMCID: PMC7479038 DOI: 10.1016/j.jseint.2020.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Julian S Meyer
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Florian M Hessenauer
- Department of Diagnostic and Interventional Neuroradiology, University of Wuerzburg, Wuerzburg, Germany
| | - Thomas Reichel
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Mirko Pham
- Department of Diagnostic and Interventional Neuroradiology, University of Wuerzburg, Wuerzburg, Germany
| | - Piet Plumhoff
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Kilian Rueckl
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
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Heinen C, Dömer P, Schmidt T, Kewitz B, Janssen-Bienhold U, Kretschmer T. Fascicular Ratio Pilot Study: High-Resolution Neurosonography-A Possible Tool for Quantitative Assessment of Traumatic Peripheral Nerve Lesions Before and After Nerve Surgery. Neurosurgery 2020; 85:415-422. [PMID: 30107513 DOI: 10.1093/neuros/nyy355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/11/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Clinical and electrophysiological assessments prevail in evaluation of traumatic nerve lesions and their regeneration following nerve surgery in humans. Recently, high-resolution neurosonography (HRNS) and magnetic resonance neurography have gained significant importance in peripheral nerve imaging. The use of the grey-scale-based "fascicular ratio" (FR) was established using both modalities allowing for quantitative assessment. OBJECTIVE To find out whether FR using HRNS can assess nerve trauma and structural reorganization in correlation to postoperative clinical development. METHODS Retrospectively, 16 patients with operated traumatic peripheral nerve lesions were included. The control group consisted of 6 healthy volunteers. All imaging was performed with a 15 to 6 MHz ultrasound probe (SonoSite X-Porte; Fujifilm, Tokyo, Japan). FR was calculated using Fiji () on 8-bit-images ("MaxEntropy" using "Auto-Threshold" plug-in). RESULTS Thirteen of 16 patients required autologous nerve grafting and 3 of 16 extra-intraneural neurolysis. There was no statistical difference between the FR of nonaffected patients' nerve portion with 43.48% and controls with FR 48.12%. The neuromatous nerve portion in grafted patients differed significantly with 85.05%. Postoperatively, FR values returned to normal with a mean of 39.33%. In the neurolyzed patients, FR in the affected portion was 78.54%. After neurolysis, FR returned to healthy values (50.79%). Ten of 16 patients showed clinical reinnervation. CONCLUSION To our best knowledge, this is the first description of FR using HRNS for quantitative assessment of nerve damage and postoperative structural reorganization. Our results show a significant difference in healthy vs lesioned nerves and a change in recovering nerve portions towards a more "physiological" ratio. Further evaluation in larger patient groups is required.
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Affiliation(s)
- Christian Heinen
- Department of Neurosurgery, Evangelisches Krankenhaus, Campus Carl-von-Ossietzky University Oldenburg, Oldenburg, Germany
| | - Patrick Dömer
- Department of Neurosciences, Carl-von-Ossietzky University Oldenburg, Oldenburg, Germany.,Research Center Neurosensory Science, Carl-von-Ossietzky University Oldenburg, Oldenburg, Germany
| | - Thomas Schmidt
- Department of Neurosurgery, Evangelisches Krankenhaus, Campus Carl-von-Ossietzky University Oldenburg, Oldenburg, Germany
| | - Bettina Kewitz
- Department of Neurosciences, Carl-von-Ossietzky University Oldenburg, Oldenburg, Germany
| | - Ulrike Janssen-Bienhold
- Department of Neurosciences, Carl-von-Ossietzky University Oldenburg, Oldenburg, Germany.,Research Center Neurosensory Science, Carl-von-Ossietzky University Oldenburg, Oldenburg, Germany
| | - Thomas Kretschmer
- Department of Neurosurgery, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
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Incidence, diagnostics and treatment algorithm of nerve lesions after traumatic shoulder dislocations: a retrospective multicenter study. Arch Orthop Trauma Surg 2020; 140:1175-1180. [PMID: 31980880 PMCID: PMC7429521 DOI: 10.1007/s00402-020-03348-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND The shoulder is the joint most prone to dislocating in the human body and accounts for 45% of all dislocations. In addition to ruptures of the soft tissue and bony injuries, lesions to vascular structures as well as the brachial plexus and its corresponding nerves might occur. With an incidence of up to 65%, nerve lesions are frequently reported after shoulder dislocations. The aim of this study is to obtain information on epidemiology, diagnostics, treatment and duration until remission or late sequelae after shoulder dislocation and concomitant nerve injury in a large patient cohort. METHODS The patient cohort consisted of 15,739 patients from three centres who had sustained a shoulder dislocation. All patient files were searched for concomitant injury of the brachial plexus or its corresponding nerves. For epidemiological data analysis, demographic data, clinical follow-ups, electromyography and nerve conduction velocity were evaluated. RESULTS In total, 60 patients (32 males, 28 females) with a mean age of 60 years (range 19-88 years) met the inclusion criteria. In the majority of patients (n = 51), the trauma mechanism was a trivial fall on the outstretched arm. The most frequent dislocation direction was anterior-caudal in 61.6%, followed by strictly caudal in 16.6%. The brachial plexus was injured in 46 patients (76.6%) and isolated nerve damage was documented in 14 patients (23.3%). Electroneurographic examinations were performed in less than half of the patients (38.3%). CONCLUSION A combination injury of shoulder dislocation and plexus lesion may occur at any age and sometimes has a poor outcome. Electroneurographic examinations should be implemented when managing these patients as a cost-effective and supportive examination. LEVEL OF EVIDENCE Level IV, retrospective study.
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Martín Noguerol T, Barousse R, Socolovsky M, Luna A. Quantitative magnetic resonance (MR) neurography for evaluation of peripheral nerves and plexus injuries. Quant Imaging Med Surg 2017; 7:398-421. [PMID: 28932698 DOI: 10.21037/qims.2017.08.01] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Traumatic conditions of peripheral nerves and plexus have been classically evaluated by morphological imaging techniques and electrophysiological tests. New magnetic resonance imaging (MRI) studies based on 3D fat-suppressed techniques are providing high accuracy for peripheral nerve injury evaluation from a qualitative point of view. However, these techniques do not provide quantitative information. Diffusion weighted imaging (DWI) and diffusion tensor imaging (DTI) are functional MRI techniques that are able to evaluate and quantify the movement of water molecules within different biological structures. These techniques have been successfully applied in other anatomical areas, especially in the assessment of central nervous system, and now are being imported, with promising results for peripheral nerve and plexus evaluation. DWI and DTI allow performing a qualitative and quantitative peripheral nerve analysis, providing valuable pathophysiological information about functional integrity of these structures. In the field of trauma and peripheral nerve or plexus injury, several derived parameters from DWI and DTI studies such as apparent diffusion coefficient (ADC) or fractional anisotropy (FA) among others, can be used as potential biomarkers of neural damage providing information about fiber organization, axonal flow or myelin integrity. A proper knowledge of physical basis of these techniques and their limitations is important for an optimal interpretation of the imaging findings and derived data. In this paper, a comprehensive review of the potential applications of DWI and DTI neurographic studies is performed with a focus on traumatic conditions, including main nerve entrapment syndromes in both peripheral nerves and brachial or lumbar plexus.
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Affiliation(s)
| | - Rafael Barousse
- Peripheral Nerve and Plexus Department, Centro Rossi, Buenos Aires, Argentina
| | - Mariano Socolovsky
- Peripheral Nerve and Plexus Surgery Unit, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Antonio Luna
- MRI Unit, Neuroradiology Section, Clínica Las Nieves, SERCOSA, Health Time, Jaén, Spain.,Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA
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