Peroneal Nerve Injury due to Hip Surgery Located at the Knee Level: A Case Report

Background: The hip surgery may be complicated with an iatrogenic peroneal nerve injury. The spontaneous recovery of these patients is usually poor, and majority of them require additional surgical treatment. In this paper, we presented a case of iatrogenic peroneal nerve injury following posttraumatic hip surgery, which was decompressed at the knee level, and achieved complete postoperative recovery. The case: A 32-year-old woman was admitted to our department due to EMNG-verified peroneal nerve lesion. Eight months before, the patient was injured in a traffic accident, followed by knee dislocation, hip dislocation, and acetabular fracture. After open reduction of the acetabular fracture performed by the orthopedic surgeons, the peroneal nerve palsy followed. At the admission, the clinical findings included left sided incomplete peroneal nerve palsy (MRC=2), pain in the lateral lower leg (VAS=3), and gait disturbances. Using EMNG, the nerve lesion was located at the knee level, while US indicated suspectable nerve compression, due to visible nerve thickening. The PNSQoL and SF-36 scores indicated a significant decline in patients' quality of life (QOL). Following GETA, the external neurolysis, decompression, and complete nerve deliberation were performed at the knee level, with preservation of all nerve branches. The patient reported immediate relief, while completely recovered 8 months following the surgery (MRC = 5, VAS = 0). In order to assess postoperative QOL, a prolonged follow-up is needed. Conclusion: The iatrogenic peroneal nerve injury following hip surgery may not always be located in the hip region. A proper anamnesis, physical examination, and diagnostic evaluation are necessary for proper treatment of these patients

Peroneal Nerve Injury due to Hip Surgery Located at the Knee Level: A Case Report

Background: A common peroneal nerve (CPN) injury located at the knee level, occurring as a consequence of hip surgery is described in the literature. However, there are only a few papers concerning their surgical management, while there are no thoroughly analyzed cases following open reduction and internal fixation (ORIF) of the acetabular fracture. This paper aimed to describe a such case and discuss current trends in the surgical management of these patients. The case: A 32-year-old woman was admitted to our department due to left-sided CPN palsy. The patient was injured in a traffic accident eight months earlier, followed by left hip dislocation and acetabular fracture. Following the acetabular fracture ORIF, a CPN palsy developed. The electromyoneurography (EMNG) and ultrasound (US) indicated a nerve lesion at the knee level. The surgical treatment included external neurolysis, decompression, and complete nerve deliberation, with the preservation of all nerve branches. The patient reported immediate relief, while completely recovered 8 months following the surgery (Medical Research Council (MRC) grade = 5, Visual Analogous Scale (VAS) = 0). Conclusion: The cause of CPN palsy following hip surgery may not always be located in the hip region. A detailed anamnesis, physical examination, and diagnostic evaluation are necessary for the proper surgical management of these patients. In addition to the EMNG, the US should be essential in preoperative planning and choosing the most effective surgical strategy

Etiology and mechanisms of ulnar and median forearm nerve injuries

© 2015, Institut za Vojnomedicinske Naucne Informacije/Documentaciju. All rights reserved. Bacgraund/Aim. Most often injuries of brachial plexus and its branches disable the injured from using their arms and/or hands. The aim of this study was to investigate the etiology and mechanisms of median and ulnar forearm nerves injuries. Methods. This retrospective cohort study included 99 patients surgically treated in the Clinic of Neurosurgery, Clinical Center of Serbia, from January 1st, 2000 to December 31st, 2010. All data are obtained from the patients' histories. Results. The majority of the injured patients were male, 81 (81.8%), while only 18 (18.2%) were females, both mainly with nerve injuries of the distal forearm – 75 (75.6%). Two injury mechanisms were present, transection in 85 patients and traction and contusion in 14 of the patients. The most frequent etiological factor of nerve injuries was cutting, in 61 of the patients. Nerve injuries are often associated with other injuries. In the studied patients there were 22 vascular injuries, 33 muscle and tendon injuries and 20 bone fractures. Conclusion. The majority of those patients with peripheral nerve injuries are represented in the working age population, which is a major socioeconomic problem. In our study 66 out of 99 patients were between 17 and 40 years old, in the most productive age. The fact that the majority of patients had nerve injuries of the distal forearm and that they are operated within the first 6 months after injury, promises them good functional prognosis

Kombinirano liječenje rupturirane aneurizme srednje moždane arterije praćene subarahnoidnim krvarenjem i akutnim subduralnim hematomom u višestrukoj aneurizmatskoj bolesti krvnih žila mozga: prikaz slučaja

Aneurysms of blood vessels at the base of the brain are pathological focal outpouchings, usually found at the branching points of the arteries. Aneurysm can remain silent for life. Clinical presentation is due to rupture and bleeding. In only 1.3% of cases it results in subdural hematoma, which is associated with direct interaction of the aneurysm with the basal arachnoid membrane. Multiple aneurysms are present in 15% to 33% of cases with subarachnoid hemorrhage. Assessment of these patients is more complicated, as there are no specific signs to pinpoint/detect the aneurysm that has ruptured. This report presents a 44-year-old female patient suffering from multiple cerebral aneurysm disease, who was urgently treated after rupture by both endovascular (for multiple aneurysms) and surgical (for acute subdural hematoma) approach in the same act under general anesthesia, which resulted in complete recovery of the patient.Aneurizme krvnih žila na bazi mozga su žarišna patološka proširenja koja se obično nalaze na račvanju arterija. Mogu ostati klinički nijeme cijelog života. Klinička slika nastaje zbog rupture i krvarenja. Samo u 1,3% slučajeva rezultira pojavom subduralnog hematoma, što je u vezi s izravnom interakcijom aneurizme i bazalne arahnoidne membrane. Višestruke aneurizme su prisutne u 15% do 33% bolesnika sa subarahnoidnim krvarenjem. Pristup ovakvim bolesnicima je složen, jer ne postoje specifični znaci koji bi ukazali na ili otkrili aneurizmu koja je rupturirala. Ovaj prikaz opisuje bolesnicu u dobi od 44 godine s višestrukom aneurizmatskom bolešću mozga koja je nakon rupture hitno podvrgnuta endovaskularnom (zbog višestrukih aneurizma) i kirurškom (zbog akutnog subduralnog hematoma) terapijskom zahvatu u istom aktu u općoj anesteziji, što je rezultiralo njezinim potpunim oporavkom

Miksopapilarni ependimom kralježnične moždine u odraslih: prikaz osobne serije i pregled literature

Myxopapillary ependymomas (MPE) of the spinal cord are slow-growing benign tumors most frequently found in adults between 30 and 50 years of age. They arise from the ependyma of the filum terminale and are located in the area of the medullary conus and cauda. The recommended treatment option is gross total resection, while patients undergoing subtotal resection usually require radiotherapy. Complete resection without capsular violation can be curative and is often accomplished by simple resection of the filum above and below the tumor mass. Nevertheless, dissemination and distant treatment failure may occur in approximately 30% of the cases. In this paper, we propose an original MPE classification, which is based upon our personal series report concerned with tumor location and its correlation with the extent of resection. We also provide literature review, discussing surgical technique, tumor recurrence rate and dissemination, and adjuvant treatment. In conclusion, our findings suggest that MPE management based on the proposed 5-type tumor classification is favorable when total surgical resection is performed in carefully selected patients. Yet, further studies on a much broader model is obligatory to confirm this.Miksopapilarni ependimomi (MPE) kralježnične moždine sporo su rastući, dobroćudni tumori najčešće zastupljeni u odraslih u dobi između 30 i 50 godina života. Nastaju iz ependima filuma terminale, a pretežito su smješteni u području medularnoga konusa i kaude. Kirurško uklanjanje tumora u cijelosti preporučena je metoda liječenja, dok u bolesnika u kojih to nije moguće učiniti u obzir dolazi subtotalna resekcija nakon koje je potrebno zračenje. Potpuno uklanjanje tumora uz očuvanje cjelovitosti tumorske kapsule postiže se jednostavnom resekcijom filuma terminale iznad i ispod tumorske mase, što može dovesti do izlječenja. Unatoč tomu, tumorska diseminacija uzduž neuralne osi može se javiti u oko 30% slučajeva. U ovom radu predlažemo originalnu klasifikaciju MPE koja prosuđuje smještaj tumora i obujam tumorske resekcije, a temeljena je na osobnoj seriji operiranih bolesnika. Također raspravljamo o kirurškoj tehnici, o mogućnostima recidiva i širenja ovakvih tumora, kao i o oblicima pomoćnog liječenja, koristeći se pregledom literature. Zaključujemo kako naši rezultati zagovaraju kirurško liječenje temeljeno na predloženoj originalnoj tumorskoj klasifikaciji, koje može biti uspješno u pažljivo odabranih bolesnika u kojih je tumor uklonjen u cijelosti. Naknadna istraživanja na znatno većem uzorku potrebna su za potvrdu naših rezultata

Epidemiologija ozljeda živaca podlaktice – retrospektivna studija

The aim of this study was to investigate the mechanisms and etiologic factors of forearm nerve injuries. This retrospective survey included all patients treated surgically in Clinical Department of Neurosurgery, Clinical Center of Serbia, from January 1, 2000 to December 31, 2010. All relevant data were collected from medical records. Statistical procedures were done using the PASW 18 statistical package. Our study included 104 patients that underwent surgery after forearm nerve injury. The majority of admitted patients were male (n=84; 80.8%) and only 20 (19.2%) were female. Ulnar nerve injury predominated with 70 cases, followed by median nerve with 54 (51.9%) cases and radial nerve with only 5 cases. Transection was the dominant mechanism of injury and it occurred in 84.6% of cases. Injury by a sharp object was the most frequent etiologic factor and it occurred in 62 (59.6%) patients, while traffic accident and gunshot injuries were the least common etiologic factor of forearm nerve injury, occurring in 7 (6.7%) and 6 (5.8%) cases, respectively. Associated injuries of muscles and tendons, bones and blood vessels occurred in 20 (19.2%), 16 (15.4%) and 15 (14.4%) patients, respectively. The etiology and mechanism of peripheral nerve injury are of great importance when choosing the right course of treatment in each individual patient because timing and type of treatment are closely related to these factors.Cilj ovoga rada bio je procijeniti mehanizme i etiološke čimbenike ozljeda perifernih živaca podlaktice. Ova retrospektivna studija je obuhvatila sve bolesnike kirurški liječene u Klinici za neurokirurgiju Kliničkog centra Srbije u razdoblju od 1. siječnja 2000. do 31. prosinca 2010. godine. Svi relevantni podaci su dobiveni iz medicinske dokumentacije. Statistička obrada podataka je načinjena primjenom statističkog paketa PASW 18. U našoj studiji koja je uključivala 104 bolesnika operirana zbog povrede perifernog živca podlaktice većinu su činili muškarci (n=84; 80,8%), dok je bilo samo 20 (19,2%) žena. Najčešće ozlijeđeni živac bio je ulnarni živac u 70 slučajeva, potom medijani živac u 54 (51,9%) slučaja, dok je najrjeđe bio ozlijeđen radijalni živac i to u 5 slučajeva. Transekcija živca je bila dominantni mehanizam ozljede živca, a utvrđena je u 84,6% bolesnika. Lezija živca oštrim predmetom je bila najčešći etiološki čimbenik utvrđen kod 62 (59,6%) bolesnika, dok su prometni traumatizam i ozljeda vatrenim oružjem bili najrjeđi etiološki čimbenici ozljede perifernog živca podlaktice i javili su se u 7 (6,7%) odnosno 6 (5,8%) slučajeva. Udružene ozljede mišića i tetiva, kostiju i krvnih žila nađene su u 20 (19,2%), 16 (15,4%) odnosno 15 (14,4%) slučajeva. Etiologija i mehanizam ozljede perifernih živaca veoma su važni za odabir pravog načina liječenja kod svakog pojedinog bolesnika, jer su vrijeme i vrsta kirurške operacije usko vezani za ove čimbenike

Familial cavernous angiomatosis: case report of a family with multiple intracranial lesions

Kavernozni angiomi mozga pripadaju grupi okultnih vaskularnih malformacija središnjeg živčanog sustava, tj. promjenama koje se ne prikazuju na klasičnim angiografskim ispitivanjima. Intraoperativno ili na autopsiji predstavljaju vensko klupko slično malini. Dijagnostička metoda izbora je MR mozga na kojoj se kavernomi prikazuju najčešće kao zone mješovitog signala uslijed prisustva hemosiderina u okolnom moždanom parenhimu. Familijarni oblik kavernozne angiomatoze je autosomno-dominantno nasljedni poremećaj, koji se javlja kao posljedica mutacija na jednom od tri različita gena i najčešće je prisutan u hispanoameričkoj populaciji. Karakteristika familijarnog oblika oboljenja je prisustvo dvije ili više lezija u moždanom tkivu, kod dvije ili više osoba iz iste obitelji. Tijekom 2008. na Klinici za neurokirurgiju Niš je u kratkom vremenskom razdoblju hospitalizirano troje pacijenata u bliskom srodstvu kod kojih je dokazano postojanje multiplih kavernoznih angioma mozga realizacijom MR mozga uz patohistološku potvrdu kavernoma kod jednog operiranog bolesnika iz obitelji. Naknadno su ispitane još tri osobe iz obitelji pri čemu je pozitivan nalaz familijarne kavernozne angiomatoze potvrđen kod još dva člana koji su bili asimptomatski. MR mozga je realiziran uz upotrebu T1 i T2 SE kao i T2 GRE sekvence. Analiziran je broj lezija viđenih u T2 SE(60) i T2 GRE(406) sekvencama te je prikazana diskrepancija u nađenom broju kavernoma. Analiziran je broj kavernoma po regijama mozga, broj kavernoma kod asimptomatskih i simptomatskih pacijenata, kao i njihova distribucija. Dobiveni podaci prikazuju superiornost T2 GRE sekvence u senzitivnosti u odnosu na T2 SE sekvencu. Tip IV kavernoma po Zabramskom detektira se samo na T2 GRE snimkama. Postojanje tipa IV kavernoma je jedna od karakteristika familijarne kavernozne angiomatoze.Cavernous angiomas of the brain belong to a group of occult vascular malformations of the central nervous system, i.e. to changes not evident on conventional angiographic examinations. Intraoperatively or at autopsy, they represent raspberry-like clusters of veins. Magnetic resonance (MR) imaging of the brain is the diagnostic method of choice, where cavernomas typically appear as zones of mixed-signal intensity due to the presence of hemosiderin in the surrounding brain parenchyma. Familial form of cavernous angiomatosis is an autosomal dominant disorder which occurs as a result of the mutations in one of the three different genes, and is most often present in the Hyspanic-American population. Familial form of the disease is characterized by the presence of two or more lesions in the brain tissue, in two or more members of the same family. In 2008, three patients in close blood relation were hospitalized within a short period of time at the Neurosurgery Clinic Niš for multiple cavernous angiomas of the brain, as confirmed by MR imaging and a histopathologic finding in one surgically treated family member. Three other family members were subsequently examined and familial cavernous angiomatosis was confirmed in two additional members who were asymptomatic. MR imaging was performed using T1- and T2-weighted SE sequences and T2-weighted GRE sequence. The number of lesions seen in T2 SE (60) and T2 GRE (406) sequences was analyzed, and a discrepancy in the number of found cavernomas was displayed. The number of cavernomas by brain regions, the number of cavernomas in asymptomatic and symptomatic patients as well as their distribution, were also analyzed. The obtained data show superiority of the T2 GRE sequence over T2 SE sequence in terms of sensitivity. Type IV cavernoma is detected only on T2 GRE images, according to Zabramski. Type IV cavernoma is one of the features of familial cavernous angiomatosis

Multiformni glioblastom lokaliziran u motornom korteksu: specifičnosti u odnosu na gliome niskog stupnja iste lokalizacije - analiza serije od šezdeset bolesnika

The verified presence of a glioblastoma multiforme (GBM ) tumor in the motor area of the brain, in a patient lacking preoperative neurological deficit, offers no certainty that the tumor can be radically removed without the possibility of causing postoperative motor deficit. We present a series of 60 patients hospitalized at the Clinical Department of Neurosurgery, Clinical Center of Serbia in Belgrade between October 2011 and February 2015, harboring tumors located within and in the vicinity of the motor zone of the brain. By using Karnofsky‘s index (KI), the pre- and postoperative conditions of the patients were evaluated. Regarding electrical stimulation of the motor cortex, significantly lower values of the electrical current intensity, frequency, and pulse wave duration (p<0.01) were needed for triggering motor response in case of GBM tumor compared to a slowly growing tumor (low-grade). Patients with low-grade gliomas (LGG) had statistically significantly higher KI values pre- and postoperatively than patients with GBM (p<0.01). Using electrical stimulation of the cortex, a higher grade of resection of LGG could be achieved as compared with the group presenting with GBM (c2=5.281; df=1; p<0.05). Our findings and review of the results reported by other authors underline the necessity of routine application of electrical stimulation of the cerebral cortex in order to identify the primary motor field (M1).Jasna prezentacija tumora mozga u području motorne zone kod bolesnika koji prijeoperacijski nisu imali slabost ekstremiteta nije jamstvo da se on može radikalno odstraniti bez poslijeoperacijskog neurološkog deficita. Prikazujemo niz od 60 ispitanika sa supratentorijalnim tumorima lokaliziranim u i oko motorne zone mozga, koji su hospitalizirani na Institutu za neurokirurgiju KCS u Beogradu u razdoblju od listopada 2011. do veljače 2015. godine. Procjena prije- i poslijeoperacijskog stanja bolesnika je vrednovana ljestvicom Karnofski indeksa (KI). Iz serije su isključeni bolesnici s recidivom tumora i bolesnici čiji je KI kod prijma bio manji od 70. Tijekom procedure elektrostimulacije motornog korteksa potrebne su značajno manje vrijednosti jačine struje, frekvencije i pulsnog vala (p<0,01) za izazivanje motornog odgovora u slučaju postojanja tipa tumora multiformnog glioblastoma (glioblastoma multiforme, GBM ) u odnosu na spororastuće gliome (niskog stupnja) mozga. Nađena je statistički značajna razlika u prije- i poslijeoperacijskim vrijednostima KI (F=48,856; df=1; p<0,01; Eta2=0,457), naime, bolesnici s gliomima niskog stupnja imali su statistički značajno veću vrijednost KI prije- i poslijeoperacijski u odnosu na vrijednosti KI kod skupine bolesnika s GBM (p<0,01). Uporabom elektrostimulacije korteksa postignut je veći stupanj radikalnosti kirurške resekcije glioma niskog stupnja u odnosu na skupinu bolesnika s GBM (c2=5,281; df=1; p<0,05). Kirurgija tumora lokaliziranih u motornom korteksu predstavlja izazov zbog pratećeg rizika od de novo nastanka motornog deficita. Naši rezultati kao i rezultati drugih autora pokazuju neophodnost rutinske primjene direktne elektrostimulacije moždane kore radi identifikacije primarnog motornog polja (M1)

Standardna lumbalna diskektomija nasuprot mikrodiskektomiji – razlike u ishodu liječenja i stopi reoperacije

Microdiscectomy (MD) is accepted nowadays as the operative method of choice for lumbar disc herniation, but it is not rare for neurosurgeons to opt for standard discectomy (SD), which does not entail the use of operating microscope. In our study, differences in disc herniation recurrence and clinical outcome of surgical treatment of lumbar disc herniation with and without the use of operating microscope were assessed. Our study included 167 patients undergoing lumbar disc surgery during a three-year period (SD, n=111 and MD, n=56). Clinical outcome assessments were recorded by patients via questionnaire forms filled out by patients at three time points. Operation duration, length of hospital stay and revision surgeries were also recorded. According to study results, after one-year follow up there was no statistically significant difference between the SD and MD groups in functional outcome. However, we recorded a statistically significant difference in leg pain reduction in favor of the MD group. According to the frequency of reoperations with the mean follow up period of 33.4 months, there was a statistically significant difference in favor of the MD group (SD 6.3% vs. MD 3.2%). There appears to be no particular advantage of either technique in terms of functional outcome since both result in good overall outcome. However, we choose MD over SD because it includes significantly lower recurrent disc herniation rate and higher reduction of leg pain.Mikrodiskektomija (MD) je danas prihvaćena kao operativna metoda izbora u liječenju lumbalne diskus hernije, ali se neurokirurzi nerijetko odlučuju za standardnu diskektomiju (SD) koja ne podrazumijeva upotrebu operativnog mikroskopa. U našoj studiji smo nastojali uočiti razlike vezano za rekurentnu diskus herniju i funkcionalni ishod kirurškog liječenja lumbalne diskus hernije uz uporabu operativnog mikroskopa i bez nje. Naša studija je uključila 167 bolesnika koji su podvrgnuti operaciji lumbalne diskus hernije tijekom trogodišnjeg razdoblja (SD, n=111 i MD, n=56). Ishod liječenja procjenjivao se pomoću upitnika koji su bolesnici ispunjavali u tri vremenske točke. Vrijeme trajanja operacije, dužina hospitalizacije i reoperacije su također bilježeni. Nakon godinu dana praćenja prema našim rezultatima nije bilo statistički značajne razlike između skupina SD i MD u funkcionalnom ishodu liječenja, ali je zabilježena statistički značajna razlika u smanjenju boli u nozi u korist skupine MD. Prema učestalosti reoperacija s prosječnim razdobljem praćenja od 33,4 mjeseca, utvrđena je statistički značajna razlika u korist skupine MD (SD, 6,3% i MD, 3,2%). Nijednoj operativnoj tehnici ne može se dati prednost u smislu funkcionalnog ishoda liječenja, jer obje daju odlične rezultate. Ipak, naš izbor je mikrodiskektomija zbog niže stope rekurentne diskus hernije i višeg stupnja smanjenja boli u nozi

Razvojna venska anomalija kao drenažna vena arteriovenske malformacije mozga

Developmental venous anomalies are cerebral vascular malformations that present normal venous drainage of cerebral tissue. With increased and accessible usage of modern diagnostic tools, they are now one of the most commonly diagnosed cerebral vascular malformations. Although developmental venous anomalies are considered to be benign lesions, association with arteriovenous malformation renders malignant potential to this combined pathology. In the case presented, these malformations were clinically silent and diagnosed accidentally, so they were not treated either with surgery, endovascular surgery or radiosurgery, considering the possible complications such as venous infarction of the brain, and because there was no obvious neurologic deficit related to this pathology. The patient presents for regular neurosurgical follow up examinations and has been free from symptoms that were present on admission.Razvojne venske anomalije predstavljaju cerebrovaskularne malformacije koje čine vensku drenažu moždanog tkiva. S povećanom i dostupnijom upotrebom modernih dijagnostičkih postupaka one su sada među najčešće dijagnosticiranim cerebrovaskularnim malformacijama. Iako se razvojne venske anomalije smatraju benignim lezijama, udruženost s arteriovenskom malformacijom daje ovoj mješovitoj patologiji maligni potencijal. U slučaju koji predstavljamo ove malformacije bile su klinički nijeme i dijagnosticirane su slučajno, tako da nisu liječene kirurški, endovaskularno niti radioterapijom, imajući u vidu moguće komplikacije kao što su venski infarkti, kao i zato što nije bilo očitog neurološkog defi cita povezanog s ovom patologijom. Naš bolesnik redovito dolazi na neurokirurške kontrole i sada nema simptoma koji su bili prisutni kod prijma