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PubMed2000

The management of cubital tunnel syndrome: a meta-analysis of clinical studies.

Despite extensive clinical experience in treating cubital tunnel syndrome, optimal surgical management remains controversial. A meta-analysis of 30 studies with accurate preoperative and postoperative staging was undertaken. Patients were staged preoperatively into minimum, moderate, and severe groups on the basis of clinical presentation. Treatment modalities included nonoperative management, surgical decompression, medial epicondylectomy, anterior subcutaneous transposition, and anterior submuscular transposition. Statistical analysis using a standard SAS database with analysis of variance and chi-square tests was used to assess the efficacy of each therapeutic modality. For minimum-staged patients, all modalities produced similar degrees of satisfaction. However, total relief occurred most after medial epicondylectomy and least after anterior subcutaneous transposition. Patients treated nonoperatively had the highest rate of recurrence. For moderate-staged patients, submuscular transposition was most efficacious, whereas patients with nonoperative management fared the worst. Finally, for severe-staged patients, current therapeutic modalities were not consistently effective, with medial epicondylectomy producing the poorest operative result. This article reveals statistically significant differences in outcomes among therapeutic modalities, which may assist in treatment planning; it introduces standardized methods to aid in determining, analyzing, and communicating treatment outcomes.

Cubital Tunnel Syndrome↗

PubMed2006

Radial optic neurotomy for central retinal vein occlusion: 117 consecutive cases.

PURPOSE: Venous occlusive disease is the second leading cause of permanent retinal vascular blindness. The anatomy of the optic disk including the cribriform plate and scleral ring may contribute to the development of retinal vasoocclusive diseases. Neurovascular compression within the confined space at this location (scleral outlet) may play a pathoetiologic role in central retinal vein occlusion (CRVO). We developed a surgical procedure (radial optic neurotomy [RON]) to open this space and relieve pressure on the central retinal vein. METHODS: Pars plana vitrectomy with RON was performed on 117 consecutive patients with CRVO and severe loss of vision (defined as 20/200 or worse). Patients were observed with serial fundus photography, fluorescein angiography, determination of Snellen visual acuity, and biomicroscopy for anterior segment neovascularization. RESULTS: There were no serious complications noted with this procedure. Anatomical and clinical improvement as determined by fundus examination, fundus photography, and fluorescein angiography was found in 95% of patients. Snellen visual acuity improved by an average of 2.5 lines (range, 1-12 lines) in 71% of patients. Two or more lines were gained in 53% of patients, and > or = 4 lines were gained in 25%. Anterior segment neovascularization was found in 6% of patients with CRVO. CONCLUSIONS: Surgical decompression of CRVO via RON is a technically feasible and safe procedure that was associated with anatomical resolution of CRVO in 95% patients and improved visual function in 71%.

Adult↗

PubMed2006

Radial optic neurotomy with adjunctive intraocular triamcinolone for central retinal vein occlusion: 63 consecutive cases.

PURPOSE: Central retinal vein occlusion (CRVO) is a leading cause of permanent retinal vascular blindness. In a previous communication the authors reported the results of radial optic neurotomy (RON) in 117 consecutive patients with severe CRVO. Persistent cystoid macular edema (CME) and macular pigmentation (MP) were observed and correlated with worse macular function. Intraocular triamcinolone (IOK) has been used to treat patients with CME and CRVO. The authors performed RON with simultaneous, adjunctive IOK (RON/IOK) in patients with CRVO to ascertain any anatomic or visual benefit of this combined approach. METHODS: Pars plana vitrectomy and RON were performed on a case-by-case basis on 63 consecutive patients with CRVO and visual acuity of 20/200 or worse. At the end of the case, 4 mg of triamcinolone was injected into the vitreous cavity (RON/IOK). Patients were observed with serial fundus photographs, fluorescein angiography (FA), Snellen visual acuity (VA), intraocular pressures (IOP), and biomicroscopy for anterior segment neovascularization (ANV). Anatomic and visual outcomes were compared to a previous series of 117 patients with severe CRVO undergoing RON alone. RESULTS: Clinical improvement as determined by fundus examination, photography, and FA was noted in 93% of patients following RON/IOK. Snellen VA improved by an average of three lines (range one to seven) in 68% of all patients. Two or more lines were gained in 44% of patients and four or more lines were gained in 20% of patients. ANV developed in 7% of patients following RON/IOK. Persistent CME and MP were noted in 17% and 28% of patients, respectively. These outcomes were similar to patients undergoing RON alone without IOK. Elevated IOP was noted in 25% of patients and one patient developed endophthalmitis following RON/IOK. CONCLUSIONS: Surgical decompression of CRVO via RON/IOK is a technically feasible procedure. Clinical resolution of the CRVO and improved visual function noted in RON/IOK paralleled outcomes following RON alone. RON/IOK was associated with a higher incidence of elevated IOP and endophthalmitis.

Adult↗

PubMed1999

Spinal manifestation of metastasizing leiomyosarcoma.

STUDY DESIGN: Case report. OBJECTIVE: To provide additional information on possible relations between uterine and spinal manifestations of leiomyosarcoma. SUMMARY OF BACKGROUND DATA: Spinal metastases and primary spinal manifestation of leiomyosarcoma and other malignant smooth muscle tumors are rarely observed. METHODS: Clinical and radiologic follow-up of a patient with a spinal tumor. RESULTS: A 46-year-old women had rapidly progressive paraplegia caused by an extramedullary lesion in the extradural space at T2-T3, with spinal cord compression. After surgical decompression, the resected tumor was histologically classified as a leiomyosarcoma. Diagnostic work-up failed to detect the primary tumor site. Previous medical history had been uneventful except for hysterectomy 3 years earlier for a leiomyoma. Extended necroses and focal metaplasia were already described in the hysterectomy specimen indicating malignant disease; however, it was not definitely diagnosed. Multiple leiomyosarcoma metastases developed 22 months later. CONCLUSIONS: In retrospect, the origin of the leiomyosarcoma that manifested in the thoracic spine of the patient must be reconsidered. Rather than a primary dural leiomyosarcoma, this tumor represented the first evidence of recurrence of a missed diagnosis of early-stage uterine leiomyosarcoma.

Biomarkers, Tumor↗

PubMed2001

Cauda equina syndrome secondary to idiopathic spinal epidural lipomatosis.

STUDY DESIGN: Three cases of idiopathic epidural lipomatosis are reported. OBJECTIVES: Description of the relationship between spinal pathologic overgrowth of fat tissue and neurologic symptoms. SUMMARY OF BACKGROUND DATA: Idiopathic epidural lipomatosis is a very rare condition; it is usually secondary to chronic steroid therapy or endocrinopathic diseases. METHODS: Three men with a mean age of 58.5 years, who experienced intermittent claudication, bilateral radicular pain in both legs, and urinary dysfunction with hypoesthesia in the perineal region, were evaluated by plain radiography and magnetic resonance imaging, the results of which demonstrated a pathologic overgrowth of fat tissue in the spinal canal with a marked impingement of the dural sac. Obesity, endocrinopathic diseases, and chronic steroid therapy were excluded for all patients. Surgical treatment was performed by wide multilevel laminectomies, fat debulking, and instrumented posterolateral fusion. RESULTS: After surgery there was a gradual improvement in symptoms and signs so that 2 years later the patients returned to daily activities and were neurologically normal. CONCLUSIONS: Spinal epidural lipomatosis can be a cause of back pain but rarely radicular impingement. Magnetic resonance imaging is the procedure of choice. The treatment must be performed early by wide surgical decompression.

Aged↗

PubMed2004

Acute noncontiguous multiple-level thoracic disc herniations with myelopathy: a case report.

STUDY DESIGN: The case report of a 38-year-old man with a unique acute, triple-level, noncontiguous thoracic disc herniation (T6, T9-T10, and T11-T12), delayed onset of lower limb weakness, paresthesias below the T10 dermatome, and urinary dysfunction following minor trauma resulting from a motorcycle accident. OBJECTIVES: To present an unusual case of herniation that could involve ambiguous test results (imaging findings not necessarily correlated with severity of clinical manifestations). SUMMARY OF BACKGROUND DATA: Multiple-level symptomatic disc herniations of the thoracic spine are rare, and the reported cases are mostly of contiguous, two-level lesions with chronic clinical presentation. No case of acute three-level noncontiguous ruptured thoracic disc herniations with myelopathy has been reported. METHODS: Through the left transthoracic approach, partial corpectomy, complete discectomy, and interbody fusion of the T9-T10 vertebrae were performed. The less prominent lesions of the T6 and T12-L1 vertebrae were left untreated. RESULTS: Remarkable improvement of neurologic symptoms, including motor weakness and bladder dysfunction, was observed 1 week after operation. At 1-year follow-up, he could walk without aid and with a somewhat spastic gait. However, paresthesias below dermatome T12 persisted. The patient refused to accept the recommendation of further surgical decompression of the nerves at the T6 and T12-L1 vertebral lesions. CONCLUSION: Since the presentation of thoracic disc herniation is variable and difficult to correlate with imaging findings, decompression at all lesion levels in a patient with symptomatic multiple-level ruptured thoracic disc herniations may be necessary to achieve complete symptom relief and satisfactory results.

Accidents, Traffic↗

PubMed2004

Abdominal compartment syndrome secondary to ovarian mucinous cystadenoma.

BACKGROUND: Abdominal compartment syndrome secondary to a very large benign ovarian tumor has been rarely reported in gynecology. With the increase of intraabdominal pressure in abdominal compartment syndrome, all major organ systems are adversely affected, causing a potentially fatal condition. CASE: A 43-year-old woman presenting with a tensely distended abdomen developed hypotension, difficulty in ventilation, and anuria. An ovarian tumor complicated by abdominal compartment syndrome was diagnosed, along with hemodynamic decompensation. Prompt resuscitation with immediate surgical removal of the tumor reversed the life-threatening situation. CONCLUSION: Timely aggressive resuscitation, prompt surgical decompression, and intensive perioperative hemodynamic management are required for patients with ovarian mucinous cystadenoma complicated by abdominal compartment syndrome.

Abdomen↗

PubMed2003

Pathomechanism of myelopathy and surgical results of laminoplasty in elderly patients with cervical spondylosis.

STUDY DESIGN: Clinical and radiologic analyses in elderly patients with cervical myelopathy. OBJECTIVE: To investigate the pathomechanism of cervical myelopathy and the surgical results of laminoplasty in elderly patients older than 70 years old. SUMMARY OF BACKGROUND DATA: To date, there have been no reports on the pathomechanism of cervical myelopathy in elderly patients. Further, the surgical results and postoperative complications of laminoplasty have not been fully evaluated in elderly patients. METHODS: Eighty-nine patients who underwent cervical laminoplasty were reviewed. The patients were divided into 2 groups according to the age at the time of operation (the elderly patient group: 20 patients who were older than 70 years old, and the control group: 69 patients who were younger than 69 years old). Pre- and postoperative neurologic status (the Japanese Orthopedic Association score) and postoperative complications were compared between the two groups. Radiologic features were also examined. RESULTS: There was no statistical difference in the recovery rate of Japanese Orthopedic Association score between the elderly patient group and the control group. Activities of daily living improved in the elderly patients. Several complications, such as delirium and worsening hypertension, were found in the elderly patient group. In the preoperative radiographs, the incidence of either retrolisthesis or anterolisthesis in the elderly patient group was significantly higher than that in the control group. CONCLUSIONS: Retrolisthesis and anterolisthesis are often the cause of myelopathy in elderly patients. Surgical decompression for cervical myelopathy was beneficial even in elderly patients older than 70 years old. Laminoplasty achieves stability of the cervical spine, and this procedure is reasonable for the treatment.

Aged↗

PubMed2004

Congenital formation of an intraspinal osseous vertebral ring causing spinal cord compression.

STUDY DESIGN: A unique case of the congenital formation of an intraspinal osseous vertebral ring causing spinal cord compression is reported. OBJECTIVES: To our knowledge, such an osseous ring has not yet been described. The authors detail the clinical presentation, imaging, and treatment of the intraspinal osseous ring. SUMMARY OF BACKGROUND DATA: There are two traditional categories of congenital vertebral anomalies, that of failure of formation and of segmentation. The authors propose that this ring may not fit into either of these categories and may represent a new category of failure of migration. METHODS AND RESULTS: Surgical decompression using a costotransversectomy approach was performed. Adequate decompression the spinal cord was achieved. Anterior and posterior fusions with instrumentation were used to stabilize the spinal cord. CONCLUSIONS: An intraspinal osseous vertebral ring is a unique anomaly that, to our knowledge, has not been reported to date. The authors discuss the pathology, imaging, and treatment of this unique condition.

Child↗

PubMed2005

Cervical stenosis presenting with acute Brown-Séquard syndrome: case report.

STUDY DESIGN: An unusual case report of cervical stenosis presenting with the Brown-Séquard syndrome. Technical considerations and a literature review are discussed. OBJECTIVE: To evaluate cervical stenosis as an etiology of the Brown-Séquard syndrome and whether surgical decompression is effective for improving neurologic outcome. SUMMARY OF BACKGROUND DATA: Of the causes of the Brown-Séquard syndrome, intrinsic cervical spine pathology has rarely been reported in the literature. We report the first case of a chronic cervical stenosis presenting with an acute Brown-Séquard syndrome after a severe coughing episode. METHODS: A 75-year-old woman with a previous history of cervical stenosis had sudden onset of weakness develop in the right upper and lower extremities, and disruption of pain and temperature sensation on the left side of her body after an episode of severe coughing associated with pneumonia. Magnetic resonance imaging of the cervical spine revealed severe canal stenosis from C3 through C7, with diffuse intramedullary hyperintensity consistent with myelomalacia of the cervical cord. A decompressive cervical laminectomy with fusion was performed. RESULTS: The patient improved neurologically, with near complete resolution of the right hemiparesis at 6-month follow-up. CONCLUSION: Multilevel chronic cervical stenosis can present with an acute Brown-Séquard syndrome. Cervical laminectomy and decompression are effective treatments for cervical stenosis with an acute Brown-Séquard syndrome.

Acute Disease↗

PubMed2005

Longitudinal incision in surgical release of De Quervain disease.

The objective of this paper is to contrast the use of a longitudinal incision in surgical decompression of De Quervain disease with a transverse incision. The advantages are ease in recognition of compartment variations and superficial branches of radial nerve and prevention of palmar tendon subluxation by permitting a more dorsal release of the compartment sheath. Since 2002, we have used a longitudinal skin incision instead of the classic transverse incision to release the first dorsal compartment.

Decompression, Surgical↗

PubMed2006

Immediate lamina papyracea reconstruction during endoscopic sinus surgery for surgically managed subperiosteal abscess in children.

The sinonasal area of a child's face is the keystone of facial architecture, and any trauma to this area may result in facial dysplasia. Animal studies have proven facial skeletal growth retardation following functional endoscopic sinus surgery. The effect of sinus surgery on facial skeletal growth in humans still needs to be established. Therefore, very conservative surgical resection during functional endoscopic sinus surgery in children is advocated. We present a surgical technique of immediate lamina papyracea reconstruction during endoscopic sinus surgery in children. We have used this technique in endoscopic surgical decompression of subperiosteal abscess secondary to sinusitis in children. We present two cases in which this technique was used in children aged 33 months and 8 years old. The postoperative computed tomography scans showed an intact lamina papyracea.

Abscess↗

PubMed2004

Proximal radial compression neuropathy.

Proximal radial nerve compression occurs infrequently and is diagnosed successfully even less frequently. A large clinical series of patients with proximal radial nerve compression neuropathy was reviewed to determine better the common symptoms, physical findings, and electrodiagnostic findings, and to identify the predictors of better or worse outcome after surgical decompression. Seventy-nine proximal radial compression neuropathies were treated in 71 patients by the same surgeon between 1991 and 2000. The most consistent symptoms were deep aching pain in the forearm, pain radiation to the neck and shoulder, and a "heavy" sensation of the affected arm. The most common physical findings were tenderness over the radial nerve at the supinator muscle level, pain on resisted supination, and the presence of a Tinel sign over the radial forearm. Electrophysiologic studies were of limited value in diagnosis, with 90% of patients having normal findings. On operation, prominent pathology of the posterior interosseous nerve was observed in 36 of 79 limbs (46%). Follow-up ranged from 12 to 86 months (mean, 21 months) with no significant complications or recurrence of symptoms. Of the 79 nerve decompressions, 77% had excellent recovery and 20% were judged to be good. Of 69 patients employed when treated, 60 resumed gainful employment, including 53 who returned to their regular jobs. Proximal radial compression neuropathies are uncommon but present with a basic constellation of symptoms and physical findings, and decompression can provide excellent relief of symptoms.

Adult↗

PubMed2005

Acute progressive bilateral carpal tunnel syndrome after upper respiratory tract infection.

This report describes the case of a 32-year-old male presenting with acute progressive bilateral carpal tunnel syndrome after a benign upper respiratory tract infection. Serial nerve conduction studies confirmed progressive entrapment of the median nerves in the carpal tunnel to the point of axonal damage. Surgical decompression relieved the entrapment, and nerve conduction studies improved.

Acute Disease↗

PubMed2004

Primary leiomyosarcoma of the vertebra: Case report and review of the literature.

A case of primary leiomyosarcoma of a thoracic vertebra associated with a compression fracture in a 75-year-old woman was preoperatively thought to be granulation tissue. Surgical decompression was performed and the histological and immunohistochemical studies established the diagnosis of leiomyosarcoma. Based on the clinical and radiological examinations, metastases were ruled out. Primary leiomyosarcoma of the vertebra is extremely rare and in that site it is considered to have a relatively poor prognosis.

Aged↗

PubMed1998

Persistent infra-orbital nerve hyperaesthesia after blunt orbital trauma.

BACKGROUND: Hyperaesthesia involving the infra-orbital nerve is rarely associated with orbital floor fracture. METHODS: An 11-year-old boy and a 34-year-old man had persistent and severe hyperaesthesia in the distribution of the infra-orbital nerve 12 and 26 months, respectively, after blunt orbital trauma. RESULTS: Surgical decompression of the infra-orbital nerve resulted in rapid and complete resolution of the hyperaesthesia in both cases. CONCLUSION: Persistent hyperaesthesia of the infra-orbital nerve is another indication for exploration of the orbital floor following blunt orbital trauma.

Adult↗

PubMed1998

Association of obesity, gender, age and occupation with carpal tunnel syndrome.

BACKGROUND: The present study determines the association of obesity, gender, age and occupation in patients with carpal tunnel syndrome (CTS) in a New Zealand population. METHODS: Analysis of questionnaires and clinical review of patients who had undergone surgical decompression of the median nerve in the carpal tunnel. RESULTS: The age and gender distribution of 655 hands (512 patients) that had undergone carpal tunnel release (CTR) were compared with the age and gender distribution of the New Zealand population. The results indicate that the 3-year-period prevalence of CTS in females is more than double that in males. Proportionally there were more patients over age 55 than in the general population. The findings also indicate that, proportionally, six times the number of females who worked in moderate manual work underwent CTR compared with the general female population and proportionally twice the number of males who worked in heavy office/clerical work underwent CTR compared with the general male population. It was also found that CTR patients are twice as likely to be overweight (body mass index [BMI] > 25) than the general population and female patients are twice as likely to be obese (BMI > 30) than the general population. CONCLUSIONS: Carpal tunnel syndrome is more than twice as common in females as it is in males, and patients aged more than 55 years are more likely to suffer from CTS. Females with CTS are more likely to work in moderate manual work and males with CTS are more likely to work in heavy office/clerical work. Obesity and CTS are related statistically.

Adult↗

PubMed2006

Intracystic pressure in patients with temporal arachnoid cysts: a prospective study of preoperative complaints and postoperative outcome.

BACKGROUND: Arachnoid cysts (AC) can cause a wide spectrum of clinical symptoms. Only a limited number of studies have investigated intracranial pressure in patients with AC. We wished to investigate the relationship between intracystic pressure, preoperative complaints and postoperative symptom relief in adult patients operated on for a unilateral temporal AC. MATERIAL AND METHODS: This was a prospective, population based study involving 38 adult (>18 years) patients (mean age 43 years; range 18-69) with a previously untreated unilateral temporal AC. RESULTS: For all cyst types, mean pressure was 131 mm H2O. The main preoperative complaints were headache and dizziness/nausea. By median split, patients were divided into a low pressure (<130 mm H2O) and a high pressure (>130 mm H2O) group. Patients with high intracystic pressure had a significantly higher preoperative visual analogue scale (VAS) score (54.7) than that found in patients with low intracystic pressure (39.4). Both pressure groups had a significant fall in VAS score after surgical decompression of the cyst. Intracystic pressure correlated significantly with arterial pCO2 and mean arterial pressure. CONCLUSION: There was a significant correlation between intracystic pressure and the preoperative level of complaints. Mean intracystic pressure in adult patients with unilateral temporal AC seems to lie within the limits of normal intracranial pressure. We therefore hypothesise that factors other than absolute pressure, such as altered compliance and impedance of the brain, may be involved in the pathophysiology of intracranial AC.

Adolescent↗