Biomedical subjects
Publications and source records attributed to A Narakas.
Brachial plexus injuries effect hand function in different ways. Deficits may resemble those of a radial nerve palsy or those of an associated, high medioulnar paralysis. Analysis shows that active extension of the wrist is paramount in all procedures to gain quality results.
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39 implant replacement arthroplasties were reviewed with a mean follow-up of 13 years. The study includes nine cases of partial replacement of the proximal pole of the scaphoid, 16 cases of total replacement of the scaphoid and 14 cases of replacement of the lunate. In 33 cases the conventional silicone elastomer (CSE) was used and in six the high performance elastomer (HP). Subjective, clinical and radiological evaluations gave different results. Respectively the results were excellent in 41, 23 and 5%, satisfactory in 41, 49 and 39% and poor in 18, 28 and 56% of the cases. Lytic lesions in carpal and/or pericarpal bones were present in all except two cases. Study of the X-rays chronologically revealed that they increased in number and size. Six cases had their implant removed. All had histologically proven silicone synovitis. A major secondary operation has been performed or is foreseen in all cases except one. We do not recommend implant replacement arthroplasty for the scaphoid or the lunate bone.
The carpal tunnel syndrome is very frequent. The authors insist on some points of surgical technique. The results of a Swiss study on the problem of the recurrent carpal tunnel syndrome are described (96 cases); the etiology of the recurrency, the surgical technique and the results after operative revision are analysed.
Fractures of the clavicle, particularly those which are markedly displaced, may, in rare instances cause injury to the subclavian vessels and the brachial plexus which manifest progressively days or weeks after the initial trauma. More often than not, however, a costo-clavicular compression syndrome appears months or years after the clavicular fracture as a result of constriction by scar which invests the neuro-vascular bundle, by a secondary aneurysm or by hypertrophic callus. The authors report 16 such cases, one of which was treated conservatively, thirteen treated by surgical intervention while two cases are awaiting operation. These patients represent just over 1% of brachial plexus lesions seen over a period of twenty years in two surgical centres. Operative treatment consists of reduction of the clavicular deformity, possibly first rib resection, liberation of the plexus and correction of a vascular lesion as required. The outcome is usually good.
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Five patients were treated from May 1987 to April 1988 in CHUV, Lausanne, for a superior sulcus tumor (3 epidermoid, 2 undifferentiated carcinomas). Treatment consisted of preoperative radiotherapy (3000 cGy)-surgery-postoperative radiotherapy (1500-2500 cGy). Two patients died from metastases. Only one patient presented with a local recurrence. Surgical resection was carried out by combined cervical and thoracic exposure. The cervical approach allows separation of the tumor from the subclavian artery, brachial plexus and vertebrae. Then, by thoracotomy, the superior lobe with tumor and thoracic wall is removed. Technical aspects of the procedure are described.
Gluing of nerves with histocompatible and resorbable materials offers a distinct advantage on suturing alone because results in clinical surgery are similar and often better. This method, when applied properly, allows a considerable gain of operative time, which we estimate to be 3-fold (ie, instead of taking 1 hour for grafting one nerve trunk, it takes 20 minutes). It does not represent a breakthrough in peripheral nerve surgery because it does not guarantee that each nerve fiber will be aligned with its own stump. Gross evaluation shows that the percentage of good results is increased by approximately 15 per cent. It must be stressed, however, that a portion of this improvement, difficult to evaluate, may be caused not by the method but by the experience we have gained over the years practicing nerve repair. The commercial fibrin glue is not yet released in the United States by the Food and Drug Administration; however, it seems, at the time of this writing, that this will be done by the first months of 1988.
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The outcome of microsurgical reconstruction in 114 adult patients presenting with complete traumatic brachial plexus palsy was analyzed. The authors examined the effects of age, time since injury, operative findings, and the techniques of reconstruction on the level of muscle recovery. Statistical and analytic computer programs were used in an attempt to determine what factors most influenced recovery.
Surgical treatment of the thoracic outlet compression syndrome is being presently reconsidered. Until these last few years, there was the choice between two interventions only: scalenotomy, a simple operation entailing no complication, but with a 60% recurrence rate--or the resection of the first rib through an axillary approach, an efficacious intervention which caused, however, serious nervous complications in 14% of treated cases. The follow-up of 75 cases operated for a TOCS reveals to the authors that--all techniques taken into account--results are unsatisfactory in 33% of cases. These failures are due either to technical deficiencies, or to a complication arising in the course of the operation, or to an erroneous diagnosis. The authors resort to surgery only to treat serious vascular syndromes (absolute indication) or invalidating neurological compression syndromes, after failure of physical therapy (relative indication). They propose a cervical approach--the only one enabling a safe dissection of the brachial plexus--a partial scalenectomy, resection of all fibrous bands pressing on nervous trunks, or the resection of a cervical rib. Should the costo-clavicular space appear anatomically too narrow, the first rib, already partially freed by the cervical approach, will be resected through the axillary route.
240 patients out of 752 seen over a period of 21 years with traction lesions of the brachial plexus including a palsy of the intrinsic muscles of the hand have been studied by the authors. This study is biased by a high number of imprecisions. Nevertheless it shows that the fate of the intrinsic muscles depends essentially on the initial severity of injury whatever the type of conservative or operative treatment. There is no useful recovery when the lesions of these pathways are more severe than the 2nd degree of Sunderland. Palliative surgery is indicated in cases when all muscles of the forearm have reached a good function after conservative or operative treatment. Reconstructive surgery is however limited or prone to fail in 2/3 of cases because in the vast majority of patients with traction lesions of the brachial plexus there is no recovery of wrist and long finger extensors.
Neurotization with regional undamaged nerves is the principal method available for treating avulsive lesions of the brachial plexus, but the number of donor axons is low. If a patient presents traumatic brachial plexus roots avulsions associated with extraforaminal ruptures of brachial plexus roots the authors propose to use the latter stumps to reinnervate the brachial plexus below the site of the lesion (neuro-neural intra-plexal transfers). 15 patients with 28 neuro-neural intra-plexal transfers are studied; the average follow-up is 5 years and 6 months. The synkinesias are frequent (8 patients) and can cancel a positive motor result. Nevertheless, 15 of the 28 transfers gave a useful motor result at long term follow-up. The neuro-neural intra-plexal transfers are an alternative method in treating traumatic brachial plexus lesions with spinal root avulsions when plexus root stumps are available.
The brachial plexus roots were studied in 20 cadavers under magnification from their origin (division of the corresponding cervical spinal nerves) until their ending (origin of the corresponding trunks). Regional vascular injections were performed in 10 cases using colored latex. The means of fixation of each plexus root to the spine, as well as the collateral branches, the anastomoses and the vascular connections are described. The authors conclude by the description of a microsurgical posterior approach of C5-C6 and C7 up to their origin, with clinical applications.
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