[Epidural lipomatosis : management proposal]

Epidural lipomatosis is a rare condition characterized by excessive accumulation of normal fat in the epidural space. This paper presents the results of a retrospective study of the charts of 20 patients. The 20 patients - 17 men and 3 women - were on average 64 years old. They suffered from radiculopathy and/or neurogenic claudication. Lipomatosis was idiopathic in 6 patients and secondary in 14 patients. Lipomatosis was MRI grade 2 in 30 % of cases and grade 3 in 70 % of cases. The patients have all been improved thanks to decompressive surgery by laminectomy and resection of epidural fat. According to our experience and to the literature, surgical decompression is an effective and safe procedure for patients with symptomatic lumbar epidural lipomatosis in case of failure of conservative treatment or in case of neurological deficits. We present a decision tree that can help in the management of this disease.

[Which complementary examination does replace a bad clinical examination ? A good clinical examination ! A mood ticket...]

The writer rebels in a mood ticket on the dictatorship of the complementary examinations at the expense of the clinical approach. She comments on the multiple reasons, medical and medicolegal, which in the 21st century still encourages a good history taking and a good clinical examination.

Refractory neuropathic pain from a median nerve injury: spinal cord or peripheral nerve stimulation? A case report

Spinal cord stimulation (SCS) is the most frequently used neuromodulation technique even for neurogenic pain from a peripheral nerve injury although peripheral nerve stimulation (PNS) has been designed for this purpose. PNS appears less invasive than SCS or deep brain stimulation. It provides greater and specific target coverage and it could be more cost-effective than SCS because low electrical stimulation is exclusively delivered to the precise painful territory. We report a case of excellent result following median nerve stimulation at arm level after SCS failure and a 10-year history of intense pain. PNS would certainly have been considered much earlier if it was accepted and reimbursed by the Belgium National Insurance. PNS is a safe, simple, and efficient technique available for decades but it is still considered as experimental and underemployed. Belgian National Insurance fears an explosion of indications on neuromodulation if PNS was reimbursed. We consider that PNS aside SCS and other neuromodulation techniques should be made available in Belgium in case of peripheral chronic neuropathic pain.

[Bilateral peroneal neuropathy following bariatric surgery]

We report the case of bilateral peroneal neuropathy following massive weight loss after bariatric surgery. A few months after a gastric by-pass, the patient developed sequentially within 6 months a L2-L3 herniated disc that required surgery, a severe right peroneal nerve palsy that led to decompressive surgery and finally contralateral peroneal nerve palsy also operated. The electrophysiological analysis confirmed the clinical suspicion of peroneal nerve compression at the fibular head. Postoperative course was favorable. Literature reports peroneal nerve palsy after slimming, mostly when weight loss is fast and marked although the issue is rarely bilateral.

[Two post-traumatic "Gilliatt-Sumner hands" from decompensation of thoracic outlet syndrome]

The clinical picture of hand atrophy related to a cervical rib has been well described in 1970 by Gilliatt and Sumner. These authors reported a series of nine patients whose motor status was stabilized following decompressive surgery of the brachial plexus. We report two young patients decompensating a predisposed thoracic outlet (rudimentary cervical rib), following a scapular or cervical trauma. After several years of neck and arm painful complaints, the two patients progressively developed hand atrophy. One patient had been operated both at cervical (double discectomy and disc prosthesis) and elbow (ulnar nerve neurolysis) levels, before the diagnosis of thoracic outlet syndrome (TOS) was attained. Decompression of the brachial plexus by anterior approach has improved the painful symptoms and stabilized the motor status of our two patients. The diagnosis of plexus disease was reached in our two patients at the "true" neurogenic TOS stage (hand atrophy), evolving several years after a "disputed" neurogenic TOS (subjective complaints). These cases remind us to keep in mind the diagnosis of TOS in front of a cervicobrachialgia not or insufficiently explained by a cervical pathology.

[Clinical case of the month. Traumatic bilateral orbital encephalocele]

Acute traumatic orbital encephalocele is a rare entity, with less than 25 cases reported. We hereby describe the first bilateral orbital encephalocele through a blow-in orbital fracture after a blunt cranial traumatism. Early treatment of the orbital traumatic encephalocele is necessary in order to avoid the increase of the intra orbital pressure that might damage the optic nerve. Repairing the orbital roof has to be performed in a rigid manner in order to avoid the transmission of the intracranial pressure variation to the orbit. In the present case, the reconstruction of orbital roof was performed using a subfrontal approach supported by a titanium mesh fixed with screws and a mixture of bone powder mixed and fibrin glue.

[Thoracic outlet syndrome]

Thoracic outlet syndrome (TOS) is due to compression/irritation of brachial plexus elements ("neurogenic TOS") and/or subclavian vessels ("vascular TOS") in their passage from the cervical area toward the axilla. The usual site of entrapment is the interscalenic triangle. TOS is a highly controversial subject in regard to its incidence, diagnostic criteria and optimal treatment. Constitutional factors--osseous or more often fibromuscular--and external factors such as trauma predispose to the development of TOS. Various clinical pictures include pain in the cervical region and arm, paresthesias, aggravated by overhead positions of the arms, hand intrinsic muscle deficit/atrophy, easy fatiguability, paleness, coldness of hand. The clinical examination may be entirely normal or show cervical and scapular muscle spasm, tenderness of supraclavicular area, radial pulse attenuation upon positional maneuvers, sensory and/or motor deficit, usually of C8/T1 distribution. The diagnosis is based on clinical evaluation and absence of other relevant pathology. Sometimes TOS can enhance symptoms consecutive to cervical or supraclavicular lesions. Cervical spine and distal peripheral nerves are investigated by radiological and electrophysiological studies. Unless there is significant motor deficit or subclavian artery compression, the treatment should be kept conservative as long as possible, by adapted physical therapy. In case of neurological deficit or symptoms unresponsive to medical treatment, the patients will--like in other nerve entrapment syndromes--be helped by decompressive surgery, nowadays preferably performed via an anterior supraclavicular approach.

Sciatic nerve regeneration through venous or nervous grafts in the rat

This study analyses the interest of isologous venous grafts filled with saline or with Schwann cells versus nerve grafts as guides for regeneration of the sciatic nerve in 35 Wistar rats. Electrophysiological parameters (conduction velocities and distal latencies of motor responses) and the functional index of De Medinacelli were measured several times from 1 month to 1 year after surgery. An histological analysis was performed on 2 control rats and on 3 rats killed 6 or 12 months after surgery: the total number of fibers was counted on a montage photoprint of the whole nerve, and the diameters of axons and the thickness of the myelin sheath were measured on digitized images. With a portion of nerve as guide, the regeneration is faster than with a vein. However, regeneration after 6 months is at least as good with a venous graft filled with Schwann cells, as assessed by electrophysiological, functional, and histological analysis. The addition of Schwann cells in grafted veins allows the nerve to regenerate through longer gaps than previously described (25 vs 15 mm). In order to assess the quality of nerve regeneration, functional, electrophysiological, and histological analysis are complementary.

Soft cervical disc herniation: a retrospective study of 100 cases

During the period from January 1975 to January 1991, 100 patients with soft cervical disc herniation were operated on by either the anterior (84 patients) or posterior (16 patients) approach. There were 33 women and 67 men, aged from 25 to 67 years (average: 41.5%); 97% presented with radicular symptoms and/or signs while 15% presented with long tract symptoms and/or signs. The patients were evaluated by computed tomography and/or myelography. Thirty-six of the lesions occurred at the C 5/6 level and 54% at the C 6/7 level. Seventy-seven % reported total or partial relief of preoperative symptoms and signs postoperatively. Patients presenting with radiculopathy had better outcome than those presenting with combined radicular and spinal cord involvement.

Indications for peripheral nerve and brachial plexus surgery

Management of peripheral nerve injuries differs depending on the mechanism of injury. 1. If a nerve has been sharply and completely transected, it should be acutely repaired, especially if proximally located. 2. If a nerve has been bluntly divided and the stumps are found to be bruised, they should be tacked to adjacent planes. A secondary repair at 2 to 4 weeks is then recommended. 3. With closed injury in which the nerve is most likely still in continuity, the patient should be followed clinically and electrically for 2 to 5 months, depending on the nerve involved and the mechanism of injury. If there is no reversal of the proximal portion of the neurologic deficit by that time, surgical exploration should be done. Use of intraoperative NAP testing is important in this large category of injuries. 4. Injection and electrical injuries to a nerve are two special categories of lesions in continuity and require a highly specialized and individualized treatment dependent on the degree of deficit and severity of pain. 5. Pain unresponsive to medical treatment may also be an indication for surgery on a peripheral nerve, especially if the injured nerve needs to be repaired because of persistent neurologic loss. 6. Management of brachial plexus injuries is somewhat different. Function of each element of the plexus has to be analyzed separately. Several clinical, electrical, and radiologic findings may provide important information about how proximal the lesion is. 7. Missile wounds usually leave the nerve in continuity. Initial management is surgically conservative. Nonetheless, many of these lesions will subsequently require resection based on NAP recordings. 8. Management of obstetric brachial plexus palsy is controversial. We recommend initial conservative management, with observation much longer (9 to 12 months) than for other stretch injuries occurring in adults. With this approach, some but not many of such injuries will still need repair.