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PubMed2005

Positive effect of posterior instrumentation after surgical posterior decompression for extensive cervicothoracic ossification of the posterior longitudinal ligament.

STUDY DESIGN: A case report of a 55-year-old patient with extensive cervicothoracic ossification of the posterior longitudinal ligament (OPLL) that was treated with posterior decompression and fusion. OBJECTIVE: To report the preventive effect of posterior instrumentation on postoperative paralysis in extensive cervicothoracic OPLL. SUMMARY OF BACKGROUND DATA: Thoracic myelopathy caused by OPLL in the thoracic spine was treated with operative decompression of the spinal cord via an anterior, posterior, or posterolateral approach. However, the lack of availability for some approaches in specific cases, as well as reports of some problems for each approach, indicates that a lack of consensus still remains regarding the choice of operative procedure. METHODS: A 55-year-old female with extensive cervicothoracic OPLL presented with progressive numbness in the both hands and a gate disturbance. Cervical laminoplasty, thoracic laminectomy, and posterior fusion were performed with electrophysiologic monitoring of the spinal cord evoked potential. RESULTS: After thoracic laminectomy, the amplitude of spinal cord evoked potential waveforms decreased but recovered after a posterior fusion by instrumentation. CONCLUSION: Prevention of postoperative paralysis from increasing by posterior instrumentation was shown using neurophysiologic monitoring.

Cervical Vertebrae↗
PubMed1998

The effects of foot position and load on tibial nerve tension.

Patients with tarsal tunnel syndrome of unknown etiology do poorly after surgical decompression. Although surgical decompression addresses the soft tissue constraints, it ignores the role of osseous support. Some authors have suggested that a pes planus deformity (i.e., valgus hindfoot and abducted forefoot) is an unrecognized cause of tarsal tunnel syndrome due to increased tibial nerve tension. An in vitro study was performed on nine cadaveric feet to determine the effects of foot position and load on tibial nerve tension. Tensile forces placed through the tibial nerve were measured when the foot was placed in dorsiflexion, eversion, combined dorsiflexion-eversion, and then under cyclical load and increasing internal rotation at 5 degrees increments from 0 degrees to 20 degrees. The nerve tension was reassessed after the creation of a pes planus deformity under the previous conditions. Tibial nerve tension in the stable and unstable foot was significantly increased by eversion, dorsiflexion, and combined dorsiflexion-eversion. Tibial nerve tension was significantly greater in an unstable foot when compared with a stable foot during eversion, dorsiflexion, and combined dorsiflexion-eversion. In the stable foot, tibial nerve tension was significantly increased during axial loading with increasing internal rotation when compared with 0 degrees rotation. The increased tibial nerve tension in the stable foot was significant with increasing internal rotation when 0 degrees was compared with 10 degrees, 15 degrees, and 20 degrees. In the unstable foot, the tibial nerve tension was significantly increased with increasing internal rotation compared with the nerve tension at 0 degrees of rotation. The increased tibial nerve tension in the unstable foot was significant with increasing internal rotation when 0 degrees was compared with 5 degrees, 10 degrees, 15 degrees, and 20 degrees. When stability of the foot and internal rotation were compared independently, each factor increased tibial nerve tension. However, these factors acting together did not significantly compound the increase in nerve tension. This study demonstrates that tibial nerve tension is increased in an unstable foot compared with a stable foot during eversion, dorsiflexion, combined dorsiflexion-eversion, and cyclical load with increasing internal rotation.

Biomechanical Phenomena↗
PubMed1992

Gliosis and ganglion cell death in the developing cat retina during hydrocephalus and after decompression.

Even after surgical decompression, infantile hydrocephalus often results in permanent neurological symptoms, including visual deficits. However, little is known about the cellular changes that may be responsible for these effects. The present study was designed to analyze the retinae of normal, mildly hydrocephalic, severely hydrocephalic and surgically decompressed kittens to determine if changes occur in the density and size of retinal ganglion cells. Hydrocephalus was induced in 10 day old kittens by intra-cisternal injection of kaolin. Kittens were allowed to survive from 7 to 28 days after injection. Animals that were decompressed received ventriculoperitoneal shunts 10-15 days after the induction of hydrocephalus and were sacrificed 10-14 days after shunt placement. The density and area of neuronal and glial cells were determined within a sample area in peripheral nasal retina. Total cell density was significantly increased in mildly and severely hydrocephalic animals but returned to normal following decompression. This change represents a significant increase in the glial population. In addition, there was a significant loss of ganglion cells in both the severely hydrocephalic and the shunted groups. Based on these findings, we conclude that gliosis occurs as a result of cell death in the retina following severe hydrocephalus, and decompression is unable to reverse these effects. Furthermore, gliosis occurs in mild cases of hydrocephalus, and may be an early indication that cellular degeneration will follow.

Analysis of Variance↗
PubMed2006

Clinical outcome of peripheral nerve decompression in diabetic and nondiabetic peripheral neuropathy.

Surgical decompression of peripheral nerves in patients with diabetes was reported to restore sensation and improve function. In this study, a retrospective review of 12 diabetic and 20 nondiabetic patients with lower-extremity peripheral neuropathy who underwent surgical decompression was performed. Clinical evaluation by Tinel test, muscle power examination, and 2-point discrimination were performed preoperatively, at 6 months, and between 9 and 15 months postdecompression. Clinical outcomes were classified into excellent, good, or fair based on improvement in symptoms and return of function. Thirty-two patients underwent 36 surgeries, in which 99 lower-extremity nerves were decompressed. There was a statistically significant improvement in muscle function (P < 0.001) and 2-point discrimination for the small toe (P = 0.008) and big toe (P = 0.038). At a mean of 7.7 months, 90% of patients showed significant improvement in pain and function. It is concluded that surgical decompression was associated with significant improvement in clinical outcome in patients with diabetic and idiopathic neuropathy with evidence of superimposed compression.

Decompression, Surgical↗
PubMed2004

Sacral fractures with neurological injury: is early decompression beneficial?

During a 6-year period, 177 patients with a displaced sacral fracture were treated at our level-one trauma centre. At the initial presentation, 13 patients demonstrated a neurological deficit as a result of their sacral fracture. Six patients underwent surgical decompression, and seven patients were managed without surgical decompression. All patients were re-assessed at an average follow-up of 27.1 (range 12-84) months using the modified SOFCOT Index and the SF-36. Patients undergoing surgical decompression had a significantly better neurological improvement as measured by the modified SOFCOT Index (p=0.014). Moreover, patients undergoing surgical decompression had a significantly better physical function than the patients that were managed without surgical decompression, as measured by the SF-36 (p=0.044). We therefore believe that patients undergoing surgical decompression achieve better neurological improvement and better functional results.

Adolescent↗
PubMed2002

Treatment of patients with spinal metastases from head and neck neoplasms.

BACKGROUND: Spinal metastases are uncommon in patients with advanced head and neck cancer. Treatment strategies in this patient group have not been defined. Although it has been established that neurologic dysfunction in patients with spinal metastases and cord compression constitutes an oncologic emergency, the role of surgical treatment remains controversial. OBJECTIVE: To clarify the treatment options in patients with head and neck cancer who develop spinal metastases. METHODS: The clinical course of patients seen at our institution with head and neck neoplasms and spinal metastases from January 1992 to January 2000 was reviewed. RESULTS: Eleven patients were identified. Nine developed spinal metastases more than 3 months after the diagnosis of advanced head and neck cancer. The other 2 presented with synchronous spinal involvement and skull base neoplasms. Patients without neurologic symptoms were offered intravenous steroids and palliative radiation. Patients with neurologic symptoms were treated with either intravenous steroids and radiation or surgical decompression and spinal fusion. In 1 patient, no improvement occurred within the first 2 days of radiotherapy, and the patient underwent surgical decompression. Patients with an unstable spine underwent surgical decompression and spinal fusion. Patients with a life expectancy of more than 6 months and neurologic symptoms were offered surgical therapy. In the 9 patients with advanced cancer, the average survival time was 3 months. Two of these patients have survived longer than 6 months. CONCLUSIONS: We propose that surgical decompression is a viable, justifiable option for selected patients with advanced head and neck cancer and spinal cord compression. Furthermore, we recommend surgical decompression as a first option in patients with an unstable bony spine and/or in whom survival is expected to be longer than 6 months. Finally, we propose a patient management algorithm in these cases.

Adult↗
PubMed1996

[The medical therapy of chronic pancreatitis. Problems, progress and outlook].

The aims of medical therapy in chronic pancreatitis are mainly to relieve the recurrent pain and to correct any malabsorption secondary to digestive insufficiency resulting from deficient exocrine pancreatic function. The treatment of the pain initially involves the use of dietary measures and analgesic drugs. The results of the use of pancreatic extracts and somatostatin reported in the literature are controversial, as are those of coeliac plexus block. Of unquestionable efficacy, at least in the short to medium term, are surgical decompression interventions in patients, with pain refractory to these measures and who present significant dilation of Wirsung's duct at ERCP. Endoscopic decompression constitutes an alternative to surgical decompression. In view of the transitory results of endoscopic decompression, which, in any event, should be implemented only by endoscopists possessing the necessary experience and expertise, the use of this technique may perhaps be targeted at carefully selected patients to be submitted to surgical decompression. As far as maldigestion is concerned, which occurs only when the pancreatic functional deficit reaches 90% or more, replacement therapy with pancreatic extracts must be resorted to. Multi-Unit Dose preparations are to be preferred, consisting in gastro-protected microspheres measuring not more than 2 mm in diameter and containing high doses of lipase, since at least 30,000 I.U. of lipase are required in the post-prandial phase for reasonably satisfactory correction of the steatorrhoea. Should this fail to prove effective, it is good policy to add antisecretory drugs (H2-antagonists, proton-pump inhibitors).

Chronic Disease↗
PubMed2003

Decompressive shunts and hepatic encephalopathy.

Encephalopathy is a major complication of all decompressive procedures done to reduce portal pressure. There are two major groups of decompressive procedures: surgical portosystemic shunts and transjugular intrahepatic portosystemic shunts (TIPS). Surgical decompressive shunts are of three types: total, partial and selective, depending on the amount of hepatopetal flow that is maintained in each of them. Encephalopathy with these shunts occurs because of reduction in hepatopetal flow. These shunts have failed to reduce mortality; in fact, some studies have shown an increase in mortality following shunts. TIPS has more or less replaced the need for surgical shunts, but their risk to cause encephalopathy is almost equivalent to that of selective shunts and in some series is even more. Lactulose, antibiotics and protein restriction can easily control severe encephalopathy as a consequence of decompressive shunts.

Decompression, Surgical↗
PubMed1994

Orbital decompression in Graves' disease.

OBJECTIVE: The authors' experience with surgical decompression of the orbits in patients with Graves' orbitopathy is reviewed. DESIGN: One hundred twenty-six consecutive primary orbital decompressions were retrospectively studied. SETTING: Tertiary care university hospitals. PATIENTS: All patients were referred by ophthalmologists for surgical decompression after failure of a trial of oral steroid therapy, and many had had orbital irradiation. INTERVENTION: Antral-ethmoidal or transconjunctival surgical decompression was accomplished in all. MAIN OUTCOMES: Measurements of visual acuity, ocular motility, and proptosis were accomplished preoperatively and a minimum of 3 months postoperatively. Surgical complications were tallied. RESULTS: Mean reduction of proptosis by antral-ethmoidal decompression was 5.3 mm, and 3.6 mm by the transconjunctival approach. Visual acuity improved in 34 orbits, was unchanged in 91 orbits, and decreased in one orbit. In a subgroup of 30 patients in whom ocular motility was quantified by prism cover test preoperatively, motility was unchanged or improved in 21 and was decreased in nine. Complications were infrequent. CONCLUSION: The antral-ethmoidal and transconjunctival approaches to orbital decompression are safe and effective.

Adolescent↗
PubMed1999

Surgical management of Bell's palsy.

OBJECTIVES: Incomplete return of facial motor function and synkinesis continue to be long-term sequelae in some patients with Bell's palsy. The aim of this report is to describe a prospective study in which a well-defined surgical decompression of the facial nerve was performed in a population of patients with Bell's palsy who exhibit the electrophysiologic features associated with poor outcomes. In addition, management issues related to Bell's palsy including herpes simplex virus typel etiology, the natural history, electrodiagnostic testing, and efficacy of surgical strategies are reviewed. STUDY DESIGN AND METHODS: A multicenter prospective clinical trial was designed utilizing electroneurography (ENOG) and voluntary electromyography (EMG) to identify patients with Bell's palsy who would most likely develop poor return of facial function, as suggested by Fisch and Esslen. Patients who displayed electrodiagnostic features of poor outcome, >90% degeneration on ENOG testing and no voluntary motor unit EMG potentials within 14 days of onset of total paralysis, were offered a surgical decompression of the facial nerve through a middle cranial fossa surgical exposure, including the tympanic segment, geniculate ganglion, labyrinthine segment, and meatal foramen. Control subjects were those who displayed similar electrodiagnostic features and time course. RESULTS: Subjects who did not reach 90% degeneration on ENOG within 14 days of paralysis all returned to House-Brackmann grade I (n = 48) or II (n = 6) at 7 months after onset of the paralysis. Control subjects self-selecting not to undergo surgical decompression when >90% degeneration on ENOG and no motor unit potentials on EMG were identified had a 58% chance of developing a poor outcome at 7 months after onset of paralysis (House-Brackmann grade III or IV [n = 19]). A group with similar ENOG and EMG findings undergoing middle fossa facial nerve decompression exhibited House-Brackmann grade I (n = 14) or II (n = 17) in 91% of the cases. An exact permutation test confirmed that the surgical group had a significantly higher proportion of patients with a good outcome (House-Brackmann grade I or II) (P = .0002). CONCLUSION: Electroneurography in combination with voluntary EMG successfully identified patients who will most likely return to normal from those who had a greater chance of long-term sequelae from Bell's palsy. Surgical decompression medial to the geniculate ganglion significantly improves the chances of normal or near-normal return of facial function in the group that has a high probability of a poor result. Surgical decompression must be performed within 2 weeks of onset of total paralysis for it to be effective.

Adult↗
PubMed1988

[Surgical orbital decompression in Basedowian optic neuropathy. Apropos of 5 cases].

Surgical orbital decompression in 5 patients with basedowian optic neuropathy restored the visual acuity and visual field in all cases. The place of surgery among the different therapeutic options proposed for this serious complication of Basedow's disease is discussed, as well as the advantages over other decompression techniques of the procedure used : the cutaneous approach to a trans-ethmoidonasal decompression.

Adrenal Cortex Hormones↗
PubMed2005

Sex differences in carpal tunnel syndrome: comparison of surgical and non-surgical populations.

Carpal tunnel syndrome (CTS) patients are known to show gender-related differences in severity. The main aim of this cross-sectional study was to determine whether these differences between women and men may be related to age, education or body mass index (BMI) in two populations, one with idiopathic CTS not treated surgically and the other with idiopathic CTS treated by surgical decompression. A secondary aim was to check differences in surgical results between the genders in the surgical population. The non-surgical population consisted of 172 subjects (126 women and 46 men, mean age 55.1 years) whose data were obtained at electrophysiological examination. The surgical population consisted of 219 patients (177 women and 42 men, mean age 55.1 years) whose data were obtained before surgery. Age, education, BMI, duration of symptoms, electrophysiological and clinical severity of CTS (with ordinal scales), and the self-administered Boston Questionnaire (BQ) of symptoms and functional status of hands were considered. There were no differences in age or clinical and electrophysiological severity between women and men in either group, except for distal motor latency of the median nerve that was more delayed and duration of symptoms that was shorter in men than women in non-surgical sample. Men had a higher BMI than women. Women had higher BQ scores in the surgical and non-surgical samples. These differences remained when the results were analysed matching the men with an identical number of women of the same age, education and BMI. In the surgical population, the results of surgical decompression did not modify the gender-related differences in severity. As in many other syndromes and diseases, for a given clinical severity, women with CTS were more sensitive than men in reporting their symptoms. Risk factors of CTS, such as age, education and BMI, were not responsible for these differences. The results of surgical decompression were similar in men and women.

Age Factors↗
PubMed2006

Surgical removal of extravasated epidural and neuroforaminal polymethylmethacrylate after percutaneous vertebroplasty in the thoracic spine.

Although extravasations of polymethylmetharylate during percutaneous vertebroplasty are usually of little clinical consequence, surgical decompression is occasionally required if resultant neurologic deficits are severe. Surgical removal of epidural polymethylmetharylate is usually necessary to achieve good neurologic recovery. Because mobilizing the squeezed spinal cord in a compromised canal can cause further deterioration, attempts to remove epidural polymethylmetharylate in the thoracic region need special consideration. A 66-year-old man had incomplete paraparesis and radicular pain on the chest wall after percutaneous vertebroplasty for osteoporotic compression fracture of T7. Radiological studies revealed polymethylmetharylate extravasations into the right lateral aspect of spinal canal that caused marked encroachment of the thecal sac and right neuroforamina. Progressive neurologic deficit and poor responses to medical managements were observed; therefore, surgical decompression was performed 4 months later. After laminectomy and removal of facet joints and T7 pedicle on the affected side, extravasated polymethylmetharylate posterior and anterior to the thecal sac was completely removed without retracting the dura mater. Spinal stability was reconstructed by supplemental spinal instrumentation and intertransverse arthrodesis with banked cancellous allografts. Myelopathy and radicular pain gradually resolved after decompression surgery. The patient was free of sensory abnormality and regained satisfactory ambulation two years after surgical decompression.

Aged↗
PubMed2001

[Abdominal compartment syndrome].

Abdominal compartment syndrome (ACS) is defined by the deleterious effects of intraabdominal hypertension (IAH) on the pulmonary, cardiovascular, splanchnic, urinary and central nervous system. Abnormal and sudden increase in the volume of any component of the intraperitoneal or retroperitoneal space (occurRing postoperatively or subsequent to hemorrhagic trauma, referfusion edema, penumoperitoneum, intestinal distention, acute pancreatitis...) causes IAH. Sustained IAH leads to ACS which if left unrecognized or untreated is always fatal. Measurement of urinary bladder pressure is the best validated technique for diagnosis of IAH. It should be used routinely for minimally invasive surveillance of intra-abdominal pressure (IAP) in patients with severe thoraco-abdominal trauma or after major abdominal operations. Medical management of IAH is of limited efficacy making expedient surgical decompression the treatment of choice for ACS. Surgical decompression of the abdomen and temporary closure is generally recognized as effective in clinically patent ACS but the pressure threshold indicating the need for decompression remains controversial. No data are available from controlled randomized trials and current guidelines are based on the experience of large trauma centers. The few available prospective clinical series report survival rates in the 38 to 71% range after surgical decompression for ACS. These studies are difficult to compare due to methodological features but it would appear that centers using the lowest pressure threshold for decompensation (< 20 mmHg) have the highest survival rates. Despite the available physiological arguments, indications for prophylactic temporary abdominal coverage (TAC), e.g. in trauma patients or for early decompression in IAH patients without clinical ACS, have not been validated in clinical practice. The potential morbidity of decompression procedures, TAC, and subsequent abdominal wall reconstructions require comparative studies of these treatment options with available pharmacological and non-surgical means to lower IAP.

Abdomen↗
PubMed2004

[Spinal epidural hematomas. Prognostic factors in a series of 22 cases and a proposal for management].

INTRODUCTION: Spontaneous and non-spontaneous spinal epidural hematoma (SEH) is a rare condition in neurosurgical practice. It presents as an acute spinal cord compression and usually requires emergent surgical decompression. Recently non-surgical treatment (corticoid therapy) has been proposed in selected cases of SEH with good neurological recovery. OBJECTIVES: To identify the prognostic factors of this condition. A treatment management based upon our results is proposed. MATERIAL AND METHODS: Between 1985 and 2001, 22 patients suffering SEH were treated at our Department. Age, sex, initial neurological condition (evaluated using the Frankel grading scale), surgical timing, radiological data such as location, extension and degree of radiological cord compression, anticoagulation or antiplatelet therapy, epidural anesthesia and previous spinal surgery were analyzed in order to find prognostic factors. Finally, conservative or surgical treatment as well as final neurological condition were also considered for the analysis. RESULTS: The average age was 69 years with a male preponderance (72.7%). Surgical decompression was done in 17 cases, most of them (11 cases) presenting with high neurological deficit (Frankel A-B). Conservative treatment was used on 5 patients. Operated patients showed a larger degree of neurological recovery. The incidence of post-operative complications was of 13%. CONCLUSIONS: This study shows the efficiency of SEH surgical evacuation performed within the first 24 hours, particularly when the patient presents a severe neurological deficit (Frankel A-B). Patients presenting minimal neurological involvement (Frankel D-E) can be managed successfully with conservative treatment.

Adult↗
PubMed2006

Anomaly of the supraclavicular nerve: case report and review of the literature.

We report a male cadaver found to have his right intermediate branch of the supraclavicular nerve piercing the clavicle. No other anomalies were found in this specimen. Following a review of the literature, it appears that symptoms related to this finding are rare but do occur most commonly involving the intermediate branch of the supraclavicular nerve. Symptoms may be alleviated with surgical decompression of the entrapped nerve. Although rare, the clinician should include entrapment of the supraclavicular nerve within the clavicle in their differential diagnosis of shoulder pain.

Aged, 80 and over↗
PubMed1999

Results of pudendal nerve neurolysis-transposition in twelve patients suffering from pudendal neuralgia.

PURPOSE: Pudendal neuralgia caused by nerve compression may be improved by surgical decompression of the pudendal nerve. This study was undertaken to determine if clinical symptoms, electrophysiological investigations, and the efficacy of preoperative pudendal nerve blocks could be used to predict the efficacy of surgery. METHODS: Twelve consecutive patients complaining of anal pain, genital pain, or both, exacerbated in the sitting position and unsuccessfully treated by analgesic drugs before referral were studied. In these 12 patients decompression of the pudendal nerve was performed after unsuccessful CT-guided injection of corticosteroids in the pudendal nerve at the ischial spine or after pain relapse following successful injections. Nineteen nerves were decompressed by surgery, and the compressed area was located between the sacrospinal and sacrotuberal ligaments for 18 nerves. RESULTS: Three months after surgery, four patients were totally relieved, and three were only partially improved. After 21 months of follow-up, three patients were cured, one was slightly improved, and eight remained in pain. In the three patients cured by surgery, pain completely disappeared for at least two weeks after a nerve block repeated twice before surgery, whereas pain relief was observed in only one of the nine other patients (P = 0.018). None of the three patients cured by surgery were being treated for depression, whereas six of the nine remaining patients were receiving antidepressants or were followed by a psychiatrist (P = 0.09). Results of surgery did not depend on other preoperative clinical or electrophysiological data. CONCLUSIONS: This preliminary study suggests that complete disappearance of pain for at least two weeks after a nerve block repeated twice before surgery may be the best criterion to predict success. Based on this criterion, surgery would have been performed in four patients in this study, of whom three would have been cured.

Aged↗