High Risk Of Nerve Injury Research Articles

A retrospective case-control study on the effectiveness of preoperative diffusion tensor imaging for mitigating nerve injury in extreme lateral interbody fusion surgery

Extreme Lateral Interbody Fusion (XLIF) has been established as an effective treatment for degenerative disorders of the lumbar spine. Nevertheless, there is a potential risk of lumbar plexus damage associated with XLIF, especially during surgeries at the L4-5 segment. Diffusion Tensor Imaging (DTI) evaluates the directional diffusion of water molecules in tissue, providing a more intricate depiction of internal tissue microstructure compared to conventional MRI techniques. The capability of DTI sequences to elucidate the 3-dimensional interplay between lumbar nerve pathways and adjacent musculoskeletal structures, potentially reducing the incidence of nerve injury complications related to XLIF, remains to be established. This study evaluates the effectiveness of preoperative Diffusion Tensor Imaging (DTI) in reducing neurological complications after Extreme Lateral Interbody Fusion (XLIF) surgeries at the L4-5 level, focusing on the interaction between lumbar nerves and the psoas major muscle. Retrospective case-control study. The study included 128 patients undergoing XLIF surgery for degenerative disorders at the L4-5 segment: 68 in the traditional group and 62 in the DTI group. The study assessed Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores, along with complication rates. It also documented psoas major muscle morphology and its correlation with nerve pathways. A retrospective analysis of 128 patients undergoing XLIF surgery for degenerative disorders at the L4-5 segment between February 2020 and August 2022 was conducted. The cohort was divided into a traditional group (68 patients) receiving presurgery MRI scans to identify surgical entry points at the intervertebral space midpoint (Zones II-III junction) and a DTI group (62 patients) who additionally underwent preoperative DTI to customize entry points. The study evaluated VAS and ODI scores, complication rates, psoas major muscle morphology, and its interaction with nerve pathways. The traditional group uniformly chose the Zone II-III junction for entry. In contrast, the DTI group's entry points varied. Postoperative follow-up revealed significant improvements in VAS and ODI scores in both groups. However, the DTI group experienced fewer immediate postoperative complications such as thigh pain, numbness, and motor disturbances. The study also noted a ventral shift in nerve positioning in patients with elevated psoas muscles. Preoperative DTI effectively maps the relationship between the psoas major muscle and lumbar nerves. Tailoring surgical entry points based on DTI results significantly reduces the risk of nerve damage in XLIF surgeries. The study underscores the importance of recognizing variability in lumbar nerve pathways due to differing psoas muscle morphologies, highlighting a higher risk of nerve injury in patients with elevated psoas muscles during XLIF procedures.

Electrochemically actuated microelectrodes for minimally invasive peripheral nerve interfaces.

Electrode arrays that interface with peripheral nerves are used in the diagnosis and treatment of neurological disorders; however, they require complex placement surgeries that carry a high risk of nerve injury. Here we leverage recent advances in soft robotic actuators and flexible electronics to develop highly conformable nerve cuffs that combine electrochemically driven conducting-polymer-based soft actuators with low-impedance microelectrodes. Driven with applied voltages as small as a few hundreds of millivolts, these cuffs allow active grasping or wrapping around delicate nerves. We validate this technology using in vivo rat models, showing that the cuffs form and maintain a self-closing and reliable bioelectronic interface with the sciatic nerve of rats without the use of surgical sutures or glues. This seamless integration of soft electrochemical actuators with neurotechnology offers a path towards minimally invasive intraoperative monitoring of nerve activity and high-quality bioelectronic interfaces.

Suprascapular nerve injury after reverse total shoulder arthroplasty. Correlation with screw out of vault penetration and functional situation. Prospective study.

Baseplate screws have been suggested as a possible cause of suprascapular neuropathy after reverse total shoulder arthroplasty (RTSA). This study aims to investigate the association between screw penetration out of the vault, electromyographic study and the clinical outcomes. 31 patients who underwent RTSA for cuff tear arthropathy were prospectively enrolled. They were followed up for a minimum of 24 months. All underwent computed tomography 6 months postoperatively in order to determine the extraosseous position of the screws (perforation of the second bone cortex and protrusion into the supra or infraspinatus fossa). Electrodiagnostic evaluation was performed preoperatively and postoperatively to stablish any relation between cortex perforation of the screw and SSN injury. Clinical outcomes pre and postoperatively (Constant score, ranges of motion, and VAS) of patients with and without documented injury were recorded. 14 patients (45.2%) had abnormal preoperative SSN electrodiagnostic study (chronic or disuse injuries) and 6 patients (19.4%) abnormal postoperative study (acute injury. Of these last 6 patients: 2 cases appeared over the pre-existing lesion and 4 appeared over an intact preoperative nerve, all of them affecting the infraspinatus branch of the SSN. Perforation of the second cortex was detected for 60% of superior screws and 40% of posterior screws. The mean lengths of the superior and posterior screws were 30 and 18.2 mm, respectively. Patients with screw perforation of the second cortex were assessed as having a high risk of nerve injury (40% vs. 9.5%). Preoperative SSN injuries do not have a significant clinical impact and do not predispose to an acute postoperative SSN lesion. The Constant Score and VAS scale for patients with acute SSN injuries were not statistically different than those without SSN injury. Extraosseous position of the screw increases the probability of a SSN injury to 31%. This risk is higher with the posterior screw, which leads us to question whether it is really necessary to use it.

Factors Associated With Peripheral Nerve Injury After Pelvic Laparoscopy: The Importance of Surgical Positioning

Nerve damage after abdominal and pelvic surgery is rare but potentially serious. The incidence of peripheral nerve injury is difficult to assess, and rates of between 0.02% and 21% have been cited in the literature. Signs and symptoms of this type of injury may appear immediately after surgery or a few days later. This study was developed to assess the rate of peripheral nerve injury after pelvic laparoscopy and to identify associated risk factors. A pilot prospective cohort study was conducted between March 2018 and April 2019 on 101 patients with a 1-month follow-up using two semistructured clinical interviews. We carried out a descriptive analysis followed by univariable and multivariable logistic regression analyses. Thirteen patients were found to have peripheral nerve injuries, representing a rate of 12.9%. Overall, 14 injuries (five severe and nine mild) were detected. One patient had two mild injuries. In this study, the risk of injury was found to increase 1.77-fold (OR = 1.77, 95% CI [1.13, 2.76], p = .007) for each hour the patient was in the Trendelenburg position. The longer the patient is in the Trendelenburg position, the greater the risk of peripheral nerve damage. Patients aged 60 years or less also face a higher risk of nerve injury.

Gunshot-Related Upper Extremity Nerve Injuries at a Level 1 Trauma Center

Gunshot wounds can result in a spectrum of injuries to nerves, with little data to guide definitive treatment. We performed a retrospective evaluation of gunshot-related upper extremity injuries in an urban trauma center to analyze epidemiology, associated injuries, and short-term outcomes. We hypothesized that gunshot-related injuries would involve soft tissue cavitation, inducing axonotmesis and neuropraxia rather than neurotmesis injuries. All patients over the age of 16 with upper extremity gunshot trauma from May 2018 to May 2019 were identified through the University of Chicago orthopaedic and general surgery trauma databases. Initial nerve injuries were identified by physical examination. Patient demographic data, soft tissue and skeletal injury, treatment modality, and return of function were collected. Ballistic injuries in 1302 patients were treated over 12 months. We identified 126 upper extremity gunshot injuries in 117 patients. Thirty-eight upper extremities (38 patients) had a documented nerve deficit (38/126, 30%) with a follow-up rate of 94% (34/36) at a mean of 351 days after injury (median, 202 days; range, 13-929 days). One patient had a subacute transradial amputation, and 1 patient was deceased at final follow-up. The presence of vascular injury and fracture increased the rate of neurologic injury after gunshot injuries. At the most recent follow-up, 68% (23/34) of patients with upper extremity injury had improvement in nerve function as measured by objective clinical assessment, with 24% (8/34) experiencing full recovery at an average of 368 days (median, 261 days; range, 41-929 days). Nerve injury after ballistic trauma to the upper extremity is common. Vascular injury and fractures were associated with a higher risk of nerve injury. Short-term improvement in nerve function was seen in over half the cohort, suggesting a predominance of neuropraxic effects. Prognostic IV.

Pediatric Parotidectomy: Do Surgical Indications Affect Outcomes?

Parotid gland pathologies requiring resection present with varying effects on surrounding tissue architecture, and we hypothesize that this spectrum of indications confers different risks of adverse events. The purpose of this study is to elucidate the complication profiles of parotidectomy in children across a spectrum of pathologies requiring parotid resection. The American College of Surgeons National Surgical Quality Improvement Program Pediatric data set was queried for parotidectomies performed from 2012 through 2017. Indications were subclassified based on International Classification of Diseases, Ninth Revision and Tenth Revision codes. Complications, readmissions, and reoperations were analyzed with appropriate statistics. Parotidectomies in children (n = 208) were mostly performed for neoplasms (47.6%), followed by inflammatory conditions (24.0%). Total parotidectomies took significantly longer (P < 0.001) and remained in the hospital significantly longer than superficial parotidectomies (P < 0.001). There was no significant difference (P = 0.417) between benign neoplasms (29.3%) and malignant neoplasms (37.9%) requiring total parotidectomy. However, there was a significant difference (P = 0.014) across various malformations, with 83.3% of lymphatic malformations requiring total parotidectomy. Although lymphatic malformations required more aggressive resection, these procedures had the lowest rate of adverse events (0%). Despite the unappreciable predilection toward total parotidectomy based on nature of neoplasms, parotidectomy performed for malignant neoplasms had a significantly increased risk of nerve injury (P < 0.001; odds ratio [OR], 3563) and medical complications (P < 0.001; OR, 67.2), whereas those performed for benign neoplasms did not have an increased risk of these complications (all P's > 0.209). Parotidectomy performed for vascular malformations had significantly increased risk of bleeding requiring transfusion (P < 0.001; OR, 14.9) and surgical complications (P < 0.001; OR, 9.2). Bleeding requiring transfusion was significantly related to longer surgical procedures (P < 0.001; 409 vs 191 minutes). Parotidectomy in pediatric patients for malignant neoplasms is associated with a significantly higher risk of nerve injury compared with parotidectomy for benign neoplasms. Parotidectomy for vascular malformations has a significantly higher risk of bleeding requiring transfusion, whereas parotidectomy for lymphatic malformations is associated with the lowest risk of medical and surgical complications.

Assessment of nerve stimulation during thyroidectomy for identification of the external branch of superior laryngeal nerve

Background The external branch of the superior laryngeal nerve (EBSLN) injury is an important and not uncommon, though frequently overlooked, complication of thyroid surgery. The rate of EBSLN injury has been reported to vary from 0 to 58%, depending on different postoperative assessment methods. Injury to the EBSLN during thyroid operation can paralyze ipsilateral cricothyroid muscle, and the clinical symptoms mainly include vocal fatigue and diminished vocal frequency range, especially with respect to raising pitch, which may result in decreased quality of life, particularly for voice professionals. Patients and methods This prospective study included 22 patients with goiter. They were divided into two groups: group 1 (G1) included all cases in whom nerve stimulator was used and group 2 (G2) included all cases in whom trial of visual identification of the EBSLN was done. Results It was found that patients with short obese neck, large gland size, large gland weight, and retrosternal extension showed difficulty in EBSLN identification and had high risk of nerve injury (P Conclusion It was concluded that routine use of nerve stimulator in surgical interventions on the thyroid gland will be beneficial for more secure identification and prevention of EBSLN injury and preservation of voice quality postoperatively.

Comparison of antegrade versus retrograde facial nerve dissection in cases of superficial parotidectomy for pleomorphic adenoma of parotid gland

Background: Pleomorphic adenoma being the most common benign tumor of the major salivary gland, parotid in particular, attracts attention. Facial nerve anatomically separates the superficial lobe from deeper lobe. Superficial Parotidectomy, commonly practiced surgical technique carries high risk of nerve injury causing long term functional and esthetic deficits. This prospective study was to designed to compare required time of surgery and facial nerve injury in antegrade versus retrograde dissection.Methods: Total of 32 patients who underwent superficial parotidectomy between June 2010 to June 2013 included in this study in which 18 patients were in retrograde dissection group and 14 subjects were in antegrade facial nerve dissection group. Time from the incision till closure is noted along with post operative facial nerve palsy for statistical analysis.Results: This study shows that retrograde facial nerve dissection in superficial parotidectomy requires statistically significant lesser time duration with no difference in facial nerve injury when compared to antegrade nerve dissection.Conclusions: This study approves retrograde facial nerve dissection over antegrade nerve dissection in cases of superficial parotidectomy for betterment of the patient.

Risk factors for acute nerve injury after total knee arthroplasty.

In this we study identified potential risk factors for post-total knee arthroplasty (TKA) nerve injury, a catastrophic complication with a reported incidence of 0.3%-1.3%. Patients who developed post-TKA nerve injury from 1998 to 2013 were identified, and each was matched with 2 controls. A multivariable logistic regression model was built to calculate odds ratios (ORs). Sixty-five nerve injury cases were identified in 39,990 TKAs (0.16%). Females (OR 3.28, P = 0.003) and patients with history of lumbar pathology (OR 6.12, P = 0.026) were associated with increased risk of nerve injury. Tourniquet pressure < 300 mm Hg and longer duration of anesthesia may also be risk factors. Surgical planning for females and patients with lumbar pathology should be modified to mitigate their higher risk of neurologic complications after TKA. Our finding that lower tourniquet pressure was associated with higher risk of nerve injury was unexpected and requires further investigation. Muscle Nerve 57: 946-950, 2018.

Continuous intraoperative vagus nerve stimulation for monitoring of recurrent laryngeal nerve during minimally invasive esophagectomy.

For squamous cell carcinoma of the esophagus, extended mediastinal lymphadenectomy especially around the bilateral recurrent laryngeal nerves (RLN) is associated with high risk of nerve injury. This does not only result in hoarseness of voice, increase the chance of pulmonary complications, but would also affect the quality of life of patients in the long term. Methods to improve safety of lymphadenectomy are desirable. Continuous intraoperative nerve monitoring (CIONM) based on a system using vagus nerve stimulation was tested. In thyroidectomy, this system has been shown to be useful. Our patient cohort was unselected, with the intent to perform bilateral RLN dissection undergoing video-assisted thoracoscopic (VATS) esophagectomy. Intermittent nerve stimulation for mapping and CIONM were employed to monitor left RLN nodal dissection, while only intermittent stimulation was used for the right RLN. CIONM has the potential to aid RLN dissection. The learning curves for the placement technique of CIONM, the threshold level and the interpretation of myographic amplitude and latency have been overcome. With the availability of nerve mapping and CIONM, more aggressive and thorough nodal dissection may be possible with less fear of RLN injury.

Association between sensory dysfunction and pain 1 week after breast cancer surgery: a psychophysical study.

Breast cancer patients treated with axillary lymph node dissection (ALND) have a higher risk of both acute and persistent pain than those treated with sentinel lymph node biopsy (SLNB). This could be attributed to a higher risk of nerve injury with ALND. We hypothesized that (1) pain patients have more pronounced sensory dysfunction than pain-free patients, (2) ALND have more sensory dysfunction and pain than SLNB patients and (3) patients with preserved intercostobrachial nerve (ICBN) preservation have less sensory dysfunction compared to a sectioned ICBN. Twenty-seven patients treated with ALND and 27 with SLNB examined with a standardized Quantitative Sensory Testing (QST) protocol, including sensory mapping, mechanical and thermal thresholds, as well as recording intraoperative ICBN handling and pain status 1 week post-operative. The area of cold hypoaesthesia was significantly associated with movement-related pain (P = 0.004), with a similar tendency for warmth (P = 0.018) and brush (P = 0.030) hypoaesthesia areas. 14 (26%) of the patients had moderate/severe pain at rest and 13 (24%) during movement without differences between ALND and SLNB, but ALND was associated with more sensory dysfunction than SLNB. Patients with sectioned ICBN reported lower pain intensity than those with preserved ICBN (P = 0.005), but without differences in sensory dysfunction. Pain was increased in patients having larger areas of hypoaesthesia and reduced in patients where ICBN-section was done. Sensory dysfunction was related to extent of axillary surgery, but not with ICBN handling. Our data suggest that acute pain after breast cancer surgery may be related to nerve injury.

Comparison of abdominal wall morbidity between medial and lateral row-based deep inferior epigastric perforator flap

Although deep inferior epigastric perforator (DIEP) flap is associated with decreased abdominal morbidity, motor nerve damage during flap elevation cannot be ignored. We compared abdominal morbidity after elevation of DIEP flap with lateral row perforators (L-DIEP) and medial row perforators (M-DIEP) to determine the perforators associated with less abdominal morbidity. Women who underwent breast reconstruction with DIEP flaps (n = 49) were included in this study. Among them, M-DIEP and L-DIEP were harvested in 27 and 22 patients, respectively. Pre- and postoperative trunk flexor muscle ability (at 3 and 6 months after surgery) was measured prospectively in all patients using an isokinetic dynamometer. The patients were also investigated for postoperative pain, stiffness, activity, bulging, and lumbago. At 3 months after surgery, a significant decrease in trunk flexor muscle ability was observed in the patients of the L-DIEP group, but they recovered well after further 3 months. However, the recovery tended to be weak. Similar results were obtained with respect to pain, stiffness, activity, bulging, and lumbago between the two groups at 6 months after surgery. Dominant perforators for DIEP flap elevation should be chosen by considering flap viability. However, surgeons should be aware that elevation with L-DIEP is associated with a high risk of nerve injury, and may in turn result in short-term decreases in trunk flexor muscle ability. Therefore, precautionary methods should be taken by the surgeons to preserve the motor nerve with atraumatic dissection, especially during elevation with L-DIEP.

Coronectomy may be a way of managing impacted third molars

TPubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) and the grey literature database SIGLE. Randomised controlled trials (RCTs) and non-randomised controlled trials (CCTs) that compared coronectomy with total removal for third molar extractions with high risk of nerve injury were included. Data were extracted independently and in duplicate by two reviewers. Risk of bias was assessed according to the Cochrane Reviewers' Handbook. Meta-analysis and sensitivity analysis were performed. Four studies (two RCTs and two CCTs) involving 699 patients and 940 third molars were included. Pooled risk ratios for coronectomy compared with total removal are shown in table 1.Coronectomy was changed to total removal during surgery due to root loosening or mobilisation in 2.3% to 38.3% of cases. In 0% to 4.9% of cases reoperation was required in the coronectomy group due to persistent pain, root exposure or persistent apical infections. Root migration was only reported in three studies and ranged from 13.2% to 85.9%. We suggest that coronectomy can protect inferior alveolar nerves in the extraction of third molars with high risk of nerve injury as compared with total removal, and that the risk ratios of post-operative infections were similar between the two surgical modalities.

Minimally Invasive Reconstruction of Lateral Ligaments of the Ankle Using Semitendinosus Autograft

Multiple techniques have been described for reconstruction of the lateral ligaments of the ankle. Most require extensive exposure and dissection, which may lead to potential problems with wound healing, higher risk of nerve injury, fibrosis, and stiffness. This study reports on the results of a minimally invasive method to reconstruct the ligaments using a semitendinosus tendon autograft and achieve a stable ankle while avoiding these problems. From September 2006 to May 2010, 25 patients (14 males, 11 females) with chronic ankle instability underwent lateral ligament reconstruction. The average age was 32.4 (range, 17 to 62) years old. A semitendinosus autograft was harvested through 2 small knee incisions. For the ankle reconstruction, 4 small incisions of 5 mm each were made at the medial and lateral side of the fibular tip, the talar neck, and the middle of the calcaneus. Anatomical reconstruction of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) was then performed through these small incisions. The mean final follow-up was 32.3 (range, 12 to 56) months. AOFAS questionnaires were used to measure clinical outcomes and donor site morbidity and patient satisfaction are also reported. Preoperative and postoperative stress tests were performed and radiographic parameters were measured. The mean AOFAS score increased on average from 71.1 to 95.1 (P < .001). Two patients reported residual instability on uneven ground. No patient reported weakness or disability from the donor site. The satisfaction level was excellent in 20 patients and good in 5 patients. Significant improvement in stress radiographic parameters was noted for the talar tilt angle, with reduction from a mean of 14.0 to 3.8 degrees (P < .001); anterior talar displacement reduced from a mean of 12.3 to 4.6 mm (P < .001). Reconstruction of the lateral ankle ligaments using a semitendinosus tendon autograft and a minimally invasive approach can achieve a stable ankle while avoiding extensive exposure and risk of nerve injury. Level IV, retrospective case series.

Coronectomy vs. Total Removal for Third Molar Extraction

The objective of this systematic review was to compare the outcomes between coronectomy and total removal for third molar extractions with high risk of nerve injury and to help practitioners make prudent decisions on whether and how third molars should be removed. PubMed, Embase, Web of Science, CENTRAL, and SIGLE were searched from January 1990 to October 2011 for randomized or non-randomized controlled trials. Four studies met our inclusion criteria. The pooled risk ratio (coronectomy vs. total removal) was 0.11 (95% CI = 0.03-0.36), 1.03 (95% CI = 0.54-1.98), 0.55 (95% CI = 0.28-1.05), and 1.14 (95% CI = 0.57-2.30) for inferior alveolar nerve injury, post-operative infection, dry socket, and pain at 1 wk after surgery, respectively. A relatively high rate of failed coronectomy in one study (38.3%, compared with 2.3%-9.4% in others) may be attributed to a higher proportion of narrowing roots and vertical impactions. Although root migration rate was high (13.2%-85.29%), the migration distances were short (3.06 ± 1.67 mm), and the directions were away from the nerves. Moreover, the rates of re-operation and root exposure were low. Therefore, coronectomy appears superior to total removal for reducing inferior alveolar nerve damage and could be used in clinical practice for third molar extractions with high risk of nerve injury.

Anterior interosseous nerve compression syndrome: Is there a role for endoscopy?

Anterior interosseous nerve syndrome is characterized by paralysis of the flexor digitorum profundus, the flexor pollicis longus and the pronator quadratus muscles without sensory loss. Extended exploration of the anterior interosseous nerve is the surgical treatment of choice. The present study evaluates the feasibility of an endoscopic approach for nerve decompression. Preparation of the anterior interosseous nerve was performed in ten human cadaver arms. Subsequently, one female patient suffering from anterior interosseous nerve syndrome was endoscopically operated on. A skin incision of 3-4 cm in the proximal direction was made at the forearm, and the median nerve was visualized between the pronator teres muscle and the flexor digitorum superficialis. Subsequently, the anterior interosseus nerve branch was identified, followed distally and decompressed under endoscopic view. The procedure could be accomplished in all cases under endoscopic view. Due to the very steep surgical angle, a branch of the anterior interosseus nerve was injured in one cadaver case. In all other cases, no adverse effects were observed. In the clinical case, the anterior interosseus nerve was endoscopically identified and decompressed, but a skin incision of 5 cm was required. The results demonstrate that an endoscopic decompression of the anterior interosseus nerve is possible. Several difficulties occurred: Due to the depth of the surgical approach, especially in case of bulky muscles and very small skin incisions, the view is limited, harboring a higher risk of nerve injury. With more experience and specially designed endoscopes, application of this technique in anterior interosseus nerve compression syndrome might become more feasible.

Forced Needle Advancement During Needle-Nerve Contact in a Porcine Model

In this study, we determined whether needle advancement during needle-nerve contact (forced needle-nerve contact) is associated with a higher risk of nerve injury compared with needle-nerve contact without needle advancement (nonforced needle-nerve contact). In 8 anesthetized pigs, the brachial plexus nerves underwent forced (0.15 Newton) or nonforced (0.0 Newton) needle-nerve contact without nerve penetration. The grade of nerve injury was histologically assessed using an objective score ranging from 0 (no injury) to 4 (severe injury). Sixty-nine nerves, including controls, were examined. Histology revealed a significant difference between forced and nonforced needle-nerve contact (median [interquartile range] 3 [2-4] vs 2 [1-2]; P = 0.004). Myelin damage and intraneural hematoma occurred only after forced needle-nerve contact. The severity of structural nerve injury after needle-nerve contact was directly related to force exposure via needle advancement.

Tratamento endovascular da reestenose carotídea: resultados em curto prazo

CONTEXTO: O tratamento cirúrgico da reestenose carotídea apresenta alta taxa de lesão neurológica. Contrariamente, o tratamento endovascular da doença obstrutiva carotídea extracraniana tem se tornado mais factível e gradualmente menores taxas de risco cirúrgico vêm sendo reportadas, tornando-se uma opção em situações especiais, e provavelmente poderá ser considerado o tratamento padrão para reestenose carotídea. OBJETIVOS: Avaliar a aplicabilidade, a segurança e a eficácia da angioplastia com o uso do stent (ACS) no tratamento da reestenose carotídea (REC) no intraoperatório e no pós-operatório recente (&lt;30 dias). MÉTODOS: Análise retrospectiva dos pacientes portadores de reestenose carotídea submetidos à angioplastia com stent no período de março 2000 a junho de 2004. RESULTADOS: Foram analisados 19 pacientes com reestenose carotídea. Quatorze pacientes (74%) eram do sexo masculino, com média de idade de 74 anos. Quinze (79%) eram assintomáticos com estenose &gt;80%, enquanto quatro (21%) eram sintomáticos com estenose &gt;70%. Apenas em um paciente não foi utilizado sistema de proteção cerebral. O sucesso técnico foi obtido em todos os casos. Não houve morte ou acidente vascular encefálico no intra ou no pós-operatório recente (30 dias). CONCLUSÃO: O tratamento endovascular da reestenose carotídea mostrou-se uma abordagem factível e segura em curto prazo

Detecting and identifying nonrecurrent laryngeal nerve with the application of intraoperative neuromonitoring during thyroid and parathyroid operation

PurposeThe nonrecurrent laryngeal nerve (NRLN) is a rare anatomical variant but associated with high risk of nerve injury during thyroid and parathyroid operations. Therefore, intraoperative detection and verification of NRLN are necessary. MethodA total of 390 consecutive patients who underwent thyroid and parathyroid operations (310 RLNs dissected on the right side and 293 nerves on the left side) were enrolled. Electrically evoked electromyography was recorded from the vocalis muscles via an endotracheal tube with glottis surface recording electrodes. At an early stage of operation, vagal nerve was routinely stimulated at the level of inferior thyroid pole to ensure normal path of RLN. If there is a negative response from lower position but positive response from upper vagal stimulation, it indicates the occurrence of a NRLN, and we localize its separation point and path. ResultsFour right NRLNs (1.3%) without preoperative recognition were successfully detected at an early stage of operation. Three patients were operated on for thyroid disease, one for parathyroid adenoma and all were associated with right aberrant subclavian artery. All NRLNs were localized and identified precisely with intraoperative neuromonitoring. Functional integrity of all nerves was confirmed by the intraoperative neuromonitoring and postoperative laryngeal examination. ConclusionsVagal stimulation at the early stage of operation is a simple, useful, and reliable procedure to detect and identify the NRLN.

A Novel Surgical Approach to Impacted Mandibular Third Molars to Reduce the Risk of Paresthesia: A Case Series

Extraction of impacted mandibular third molars (M3s) may cause temporary or permanent neurosensorial disturbances of the inferior alveolar nerve (IAN). Although the incidence of this complication is low, a great range of variability has been reported in the literature. Several methods to reduce or eliminate this complication have been proposed, such as orthodontic-assisted extraction, extraction of the second molar, or intentional odontoectomy. The purpose of this series of cases is to present a novel approach for a riskless extraction of impacted mandibular M3s in contact with the IAN. Nine consecutive patients (4 male and 5 female; mean age 24.9 years, range 18-43 years) required the extraction of 10 horizontally or mesioangular impacted mandibular M3s. In all cases the M3 was in contact with the IAN with a high risk of nerve injury. A staged approached was proposed and accepted by the patients. This approach consisted in the surgical removal of the mesial portion of the anatomic crown to create adequate space for mesial M3 migration. After the migration of the M3 had taken place, the extraction could then be accomplished in a second surgical session minimizing neurological risks. All M3s moved mesially within 6 months (mean 174.1 days, range 92-354 days) and could be successfully removed without any neurological consequences. This technique may be considered as an alternative approach to the extraction of horizontally or mesioangular impacted M3s in proximity to the IAN.