Evidence in peroneal nerve entrapment: A scoping review

peer reviewedBackground and purpose: Daily management of patients with foot drop due to peroneal nerve entrapment varies between a purely conservative treatment and early surgery, with no high-quality evidence to guide current practice. Electrodiagnostic (EDX) prognostic features and the value of imaging in establishing and supplementing the diagnosis have not been clearly established. Methods: We performed a literature search in the online databases MEDLINE, Embase, and the Cochrane Library. Of the 42 unique articles meeting the eligibility criteria, 10 discussed diagnostic performance of imaging, 11 reported EDX limits for abnormal values and/or the value of EDX in prognostication, and 26 focused on treatment outcome. Results: Studies report high sensitivity and specificity of both ultrasound (varying respectively from 47.1% to 91% and from 53% to 100%) and magnetic resonance imaging (MRI; varying respectively from 31% to 100% and from 73% to 100%). One comparative trial favoured ultrasound over MRI. Variable criteria for a conduction block (>20%–≥50) were reported. A motor conduction block and any baseline compound motor action potential response were identified as predictors of good outcome. Based predominantly on case series, the percentage of patients with good outcome ranged 0%–100% after conservative treatment and 40%−100% after neurolysis. No study compared both treatments. Conclusions: Ultrasound and MRI have good accuracy, and introducing imaging in the standard diagnostic workup should be considered. Further research should focus on the role of EDX in prognostication. No recommendation on the optimal treatment strategy of peroneal nerve entrapment can be made, warranting future randomized controlled trials. © 2021 European Academy of Neurolog

Thoracic Outlet Syndrome Part II: Consensus on the Management of Neurogenic Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery

peer reviewedBACKGROUND: In the first part of this report, the European Association of Neurosurgical Societies' section of peripheral nerve surgery presented a systematic literature review and consensus statements on anatomy, classification, and diagnosis of thoracic outlet syndrome (TOS) along with a subclassification system of neurogenic TOS (nTOS). Because of the lack of level 1 evidence, especially regarding the management of nTOS, we now add a consensus statement on nTOS treatment among experienced neurosurgeons. OBJECTIVE: To document consensus and controversy on nTOS management, with emphasis on timing and types of surgical and nonsurgical nTOS treatment, and to support patient counseling and clinical decision-making within the neurosurgical community. METHODS: The literature available on PubMed/MEDLINE was systematically searched on February 13, 2021, and yielded 2853 results. Screening and classification of abstracts was performed. In an online meeting that was held on December 16, 2021, 14 recommendations on nTOS management were developed and refined in a group process according to the Delphi consensus method. RESULTS: Five RCTs reported on management strategies in nTOS. Three prospective observational studies present outcomes after therapeutic interventions. Fourteen statements on nonsurgical nTOS treatment, timing, and type of surgical therapy were developed. Within our expert group, the agreement rate was high with a mean of 97.8% (± 0.04) for each statement, ranging between 86.7% and 100%. CONCLUSION: Our work may help to improve clinical decision-making among the neurosurgical community and may guide nonspecialized or inexperienced neurosurgeons with initial patient management before patient referral to a specialized center. Copyright © Congress of Neurological Surgeons 2022. All rights reserved

Classical pituitary tumour apoplexy: clinical features, management and outcomes in a series of 24 patients.

We retrospectively analysed the incidence, clinical presentation, endocrinological and radiological findings, medical and surgical management of pituitary apoplexy in our department (single-centre study), having a large experience in pituitary surgery. Among 1540 pituitary lesions, 24 patients presented with pituitary apoplexy. Their charts were retrospectively reviewed. The symptoms included headache (92%), nausea and vomiting (54%), visual deficit (50%), oculomotor paresis (54%) and/or an altered mental state (42%). Skull X-rays (n = 14) demonstrated an enlarged sella turcica in all cases; CT-scan and/or MRI always revealed a sellar and suprasellar expanding lesion. Panhypopituitarism was present on admission in 70% of the patients. Urgent therapeutic management included high-dose cortisone treatment in all but one patients and CSF drainage in three. Three patients were treated conservatively. Nine patients were operated on rapidly, within hours or a few days because of severe visual deficit and/or altered level of consciousness. Nineteen patients were operated by the trans-sphenoidal approach; one of them required a second operation by craniotomy. There were two deaths related to the illness and one to an ill-defined reason at 4 months. Among the other patients 95% made a good recovery. All but two patients required a substitutive treatment with adrenal (83%), thyroid (68%), gonadal (42%) and/or growth (16%) hormones. The preoperative visual deficits recovered in all but one patients (92%) whereas the oculomotor pareses improved in all but two patients (85%). In conclusion, pituitary tumour apoplexy is a rare event, complicating in our series 1.6% of 1540 pituitary adenomas. Even in severe cases, complete recovery is possible if the diagnosis is rapidly obtained and adequate management is initiated in time. Surgical results after trans-sphenoidal approach are in the majority of cases very satisfactory

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 bypass, 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.Nous rapportons le cas d’une neuropathie fibulaire bilatérale suite à une perte de poids massive après chirurgie bariatrique. Quelques mois après le by-pass gastrique, le patient a développé, successivement en l’espace de 6 mois, une hernie discale L2-L3 gauche nécessitant intervention chirurgicale, une atteinte fibulaire déficitaire sévère droite menant à une chirurgie décompressive et enfin l’atteinte fibulaire controlatérale également paralysante et opérée. L’étude électrophysiologique a confirmé la suspicion clinique d’atteinte fibulaire au niveau de la tête du péroné. L’évolution postopératoire a été favorable. La littérature rapporte l’atteinte du nerf fibulaire sur amaigrissement, rarement bilatérale, surtout lorsque la perte de poids est rapide et importante

Development of a reconstituted nerve in a three-dimensional collagen gel under tension populated with fibroblasts and Schwann cells.

Our aim is to devise an artificially reconstituted nerve segment made of a three-dimensional collagen gel populated with aligned fibroblasts and Schwann cells. Collagen lattices were prepared by mixing concentrated medium, a type I collagen solution and rat Schwann cells (SC), rat neural fibroblasts (nF) or human dermal fibroblasts (dF) and allowed to polymerize at 37 degrees C. In these free-floating lattices, nF and dF retracted the gel more than SC. All cells appeared to be elongated and oriented at random. Rat cells obtained by enzymatic digestion of nerves undergoing wallerian degeneration retracted the gel at a larger extent than cells from intact nerves. Rectangular lattices restrained at each extremity acquired a paraboloid shape upon retraction by neural or dermal F reflecting the mechanical tension developed by these cells on their support. Adult SC alone produced a faint paraboloid even at high cell density while SC associated with nF developed a paraboloid similar to that obtained with nF alone. The mechanical force developed by dermal F and SC in the restrained lattice was measured by strain gauges and found much higher for F than for SC. In restrained lattices, both types of F were elongated and aligned to the long axis of the gel while SC elongated but not necessarily in a parallel fashion. The central portion of a mixed nF-SC collagen restrained lattice produces a flattened cylindric segment made of longitudinally oriented col-lagen fibrils, F and SC, which could represent a promising material for preparation of nerve grafts. An original plastic mould was devised to allow the preparation of cylindrical segments of free or restrained collagen lattices in view of in vitro and in vivo regeneration studies

Intrasellar arachnoid cysts.

OBJECTIVE: To evaluate the clinical, endocrinological, and radiological presentation of nine cases of surgically verified intrasellar arachnoid cysts and to discuss the physiopathological mechanisms of formation of these cysts. METHODS: Among 1540 patients presenting with pituitary lesions, nine presented with an intrasellar arachnoid cyst. Their charts were retrospectively reviewed. RESULTS: Presenting symptoms included headache (n = 2), visual symptoms (n = 3), menstrual irregularities (n = 2), rapid weight gain (n = 1), vertigo (n = 1), and/or confusion (n = 1). Two cysts were discovered incidentally. T1-weighted magnetic resonance imaging scans showed an intrasellar cystic lesion in all cases, with a huge suprasellar extension in six cases. The cyst was of the same intensity as the cerebrospinal fluid (CSF) in only two patients. A transsphenoidal approach allowed the transdural aspiration of fluid and injection of a water-soluble contrast agent under mild pressure. In three patients, the contrast infiltrated along the pituitary stalk toward the subarachnoid spaces; in the other patients, it remained in the intrasellar compartment. Cyst membranes were removed as completely as possible with fenestration toward the subarachnoid spaces in communicating cysts. In spite of tight packing of the sella and sphenoid sinus, CSF fistulae requiring reoperation developed in two patients. CONCLUSION: The clinical picture of an intrasellar arachnoid cyst resembles that of a nonfunctional pituitary adenoma. Magnetic resonance imaging scans typically show a cystic intrasellar lesion with suprasellar extension, containing isointense or, more often, hyperintense fluid on T1-weighted sequences. In spite of the risk of CSF fistulae, the preferred surgical approach is transsphenoidal. A physiopathological mechanism is proposed according to anatomic variations of the sellar diaphragma allowing penetration of subarachnoid spaces into the sellar compartment and their enlargement by a ball-valve mechanism