Long-standing Compression Research Articles

Ocular neuromyotonia of the right third cranial nerve

Ocular neuromyotonia is a rare disorder of the oculomotor nerves caused by chronic damage to the nerve, usually secondary to previous irradiation or longstanding compression. We present the case of a 40-year-old man who had received proton beam therapyfor a right cavernous sinus chondrosarcoma 15 years earlier. He developed intermittent episodes of self-limited horizontal diplopia, which occurred over the course of 1 year. At its peak, the deviation reached 20Δ in primary gaze and 25Δ in right gaze. Signs included right upper lid retraction and right medial rectus muscle absence of relaxation after sustained left gaze, with mild deficit of elevation and depression but no pupillary involvement. Full recovery occurred after he closed his eyes. Ocular neuromyotonia of the right oculomotor nerve was diagnosed after recurrence of primary disease relapse was ruled out. Symptoms remitted completely under oxcarbazepine.

Prolonged endotracheal intubation: a feasible option for tracheomalacia after retrosternal goitre surgery.

Tracheomalacia may be caused by long-standing compression of retrosternal goitre because of destruction of support of tracheal cartilages. Life-threatening airway collapses may occur after surgical removal of goitre. However, available literature on management methods of tracheomalacia is sparse. Our study highlights prolonged endotracheal intubation as a feasible treatment method. This retrospective study analysed 106 thyroidectomies for retrosternal goitre performed between 1994 and 2019. We recorded each patient's clinical profile. Severe tracheomalacia was confirmed through the following: soft and floppy trachea on intra-operative palpation and the collapse of cross-sectional tracheal area measured in computed tomography (CT) images by >80%. We assessed the extent of airway stenosis of these cases. All severe cases were treated by prolonged endotracheal intubation. Surgical treatment was successfully performed in all 106 retrosternal goitre patients with no mortality. Seventeen severe tracheomalacia cases were confirmed. The extent of airway stenosis was assessed: the minimal tracheal diameter of compressed trachea was 0.2-0.4 [mean 0.31, standard deviation (SD) 0.06] cm, and the narrow tracheal length was 4-6.7 (mean 5.1, SD 0.6) cm. These patients underwent endotracheal intubation for 17-47 h after surgery. All patients were transferred to the general ward after extubation and successfully discharged. There were no cases of tracheal stenosis on follow-up. Tracheomalacia is a rare but serious complication of retrosternal goitre surgery. Based on our experience, prolonged endotracheal intubation is a feasible treatment for tracheomalacia after retrosternal goitre surgery.

Tracheomalacia due to trachea compression related to benign goiter

Tracheomalacia can result from long-standing compression by a large goiter. The cartilaginous rings of the trachea may be weakened or destroyed by long-standing compression, causing loss of structural support. Tracheomalacia after resectioning of benign goiter compressing trachea was an important issue. It has extended the time of mechanical ventilation, increased the risk of failure extubating and mortality. Descriptive and prospective study. From November 2014 to January 2017, we have collected 102 patients who had benign goiter compressing trachea and had thyroidectomy. Tracheomalacia was diagnosed and managed intra and postoperatively. Recognition of women accounted for the majority of 81.4%. The average age was 54.5 years old and the average duration of goiter was 5 years. The patients were hospitalized with the main symptom of dysphagia accounting for 21.6% and difficulty breathing when lying down was 16.7%. On CT scan, the average Goiter was 270g, the average narrow airway diameter was 8.4 mm, of which 12.7% of patients had narrow tracheal diameter <5mm. The rate of tracheomalacia was 4.9%. There were statistically significant differences between the 2 groups with and without tracheomalacia: elderly patients (p = 0.041); goiter long-standing time (p = 0.07); symptoms of positional dyspnea on lying (p = 0.003) and tracheal diameter compressed (p = 0.001). Tracheomalacia should be noted in patients older than 65 years old, goiter exist longer than 5 years and goiter is over 200g.

Prognostic Significance of Preoperative Geometric Changes in the Internal Acoustic Canal for Hearing Preservation in Vestibular Schwannoma Surgery

This study focused on the changes in the internal acoustic canal (IAC) caused by vestibular schwannomas (VSs) and their prognostic significance for postoperative hearing outcome. A total of 125 consecutive cases of VS were included. We used a neuronavigation software to perform the following measurements on both the tumor side and healthy side: volume of the IAC (VIAC), maximal diameter of the IAC (DIAC), and length of the IAC (LIAC). A statistical analysis was realized using Spearman correlation to test the correlation of the morphometric measure of the IAC and postoperative hearing. Multivariate analysis was performed to test the impact of measurements of the IAC and preoperative hearing on postoperative hearing. The mean VIAC on the tumor side and on the healthy side was 0.271 and 0.169 cm3, respectively. The mean DIAC was 9.438 mm on the tumor side and 7.034 mm contralateral. The correlations tests showed significant correlations of both postoperative hearing deficit and degree of hearing loss with 1) VIAC on the tumor side, 2) difference between VIAC on the tumor side and healthy side, 3) DIAC on the tumor side, and 4) difference between the DIAC on the tumor side and healthy side. The multivariate analysis showed significant impact of the DIAC (P= 0.01) and preoperative hearing status (P= 0.02) on postoperative hearing. Enlargement of the VIAC and DIAC are negative prognostic factors for hearing preservation. Reasons may be long-standing compression of the auditory nerve and an increased vulnerability of the inner ear structures during the drilling of the IAC.

Isolated spontaneous posterior interosseous nerve palsy: a review of aetiology and management.

Isolated posterior interosseous nerve palsy is an uncommon condition and its management is controversial. Existing literature is sparse and a treatment algorithm based on existing best evidence is absent. A comprehensive review was undertaken to elucidate the causes of spontaneous posterior interosseous nerve palsy and suggest a management strategy based on the current evidence. Posterior interosseous nerve palsy can be broadly categorized as compressive and non-compressive, and the existing evidence supports surgical intervention for compressive palsy. For posterior interosseous nerve pathology with no compressive lesion on imaging, conservative management should be tried first. Surgery is therefore reserved for compressive lesions and for failure of conservative management. The commonly performed operative procedures include decompression and neurolysis, neurorrhaphy and nerve grafting, and tendon transfers with or without nerve grafting performed as a salvage procedure. The prognosis is poorer in patients aged > 50 years, those with a delay to surgery, and those who have had long-standing compression with severe fascicular thinning.

Is Preoperative Duration of Symptoms a Significant Predictor of Functional Status and Quality of Life Outcomes in Patients Undergoing Surgery for the Treatment of Degenerative Cervical Myelopathy?

Introduction Longstanding compression of the spinal cord in patients with degenerative cervical myelopathy (DCM) may result in irreversible neural tissue damage. This study aims to analyze whether a longer duration of symptoms is associated with poor surgical outcomes and to determine the optimal timing for decompressive surgery. Material and Methods Three hundred and fifty patients with symptomatic DCM were prospectively enrolled in either the CSM-North America or International study at 12 sites in North America. For each patient, extensive demographic information was collected, including age, co-morbidities, and a self-reported estimate of preoperative duration of symptoms. Postoperative functional status and quality of life were evaluated at 6-, 12- and 24-months using the modified Japanese Orthopaedic Association (mJOA), Nurick grade, Neck Disability Index (NDI) and Short-Form-36 (SF-36) Physical (PCS) and Mental (MCS) Component Scores. Change scores between baseline and 12-month follow-up were computed for each outcome measure. Duration of symptoms was dichotomized into a “short” and “long” group at several cut-offs. An iterative mixed model analytic approach procedure was used to evaluate differences in change scores on the mJOA, Nurick, SF-36 MCS and PCS and NDI between duration groups in 1-month increments. Two models were constructed: 1) an unadjusted model between duration of symptoms and surgical outcome and 2) a model adjusting for significant independent covariates identified through stepwise regression analysis. Results Our cohort consisted of 201 (57.43%) men and 149 (42.57%) women, with a mean age of 57.49 ± 11.77 years (range: 29–87 years). The mean duration of symptoms was 25.71 ± 36.68 months (range: 1–240 months). In unadjusted analysis, patients with a duration of symptoms shorter than 4 months had significantly better functional outcomes based on the mJOA ( p = 0.04) than patients with a longer duration of symptoms (>4 months). On average, patients with a shorter duration of symptom improved by 3.71 on the mJOA, whereas those with a duration 4 months or longer only exhibited a 2.96 mean gain. Twelve months was identified as the next important cut-off beyond which patients had a significantly worse outcomes on the mJOA; however, this difference was smaller. Following adjusted analysis, cut-offs of 4 and 12 months remained significant. Duration of symptoms was not associated with Nurick or SF-36 PCS or MCS in either the unadjusted or adjusted models. Conclusion Patients who are operated on within 4 months of symptom presentation have better mJOA outcomes. It is recommended that patients with DCM are diagnosed in a timely fashion and referred early for surgical consultation. Our study does not support the traditional conservative “watchful waiting” approach to symptomatic patients with DCM.

Page kidney after botulinum toxin injection during chiropractic care

Page kidney refers to the phenomenon of hypertension secondary to long-standing compression of renal parenchyma caused by renal subcapsular collection. The most common cause of renal subcapsular collection is a hematoma which usually occurs after a history of blunt trauma. A 42-year-old female patient who received botulinum toxin injection in her back during chiropractic care was admitted to the emergency room with sudden bilateral flank pain and hypertension. The computed tomography (CT) images demonstrated the presence of bilateral subcapsular renal hematoma. The patient was treated conservatively and recovered well. The follow up CT images showed markedly resolved bilateral hematoma.

A Case of Fatal Iliac Vein Rupture Associated With May-Thurner Syndrome

May-Thurner syndrome results from long-standing compression of the left common iliac vein (LCIV) and is characterized by the formation of intraluminal spurs leading to obstruction of blood flow and deep vein thrombosis (DVT). Increased intraluminal pressures may occur as a consequence of venous obstruction, which when coupled with other factors thought to further weaken venous wall integrity (ie, inflammation or hormonal imbalances) may produce spontaneous (nontraumatic) and potential lethal venous rupture.We report a case of DVT in a woman with previously undiagnosed May-Thurner syndrome and heterozygosity for factor V Leiden mutation on exogenous hormone therapy, with subsequent spontaneous rupture of the LCIV leading to fatal hemoperitoneum. Autopsy revealed fibrous obliteration of the junction between the LCIV and inferior vena cava with associated DVT, transmural venous rupture, and thrombophlebitis.

Median Arcuate Ligament Syndrome - A Pain in the Differential Diagnosed by 3 Modalities

Purpose: Median Arcuate Ligament (MALS) is a condition that results from longstanding compression of the celiac artery and celiac ganglia by the Median Arcuate Ligament. The most common symptoms are post-prandial espigastric abdominal pain, nausea and weight loss secondary to anorexia. The pathophysiology is not fully understood, the compression of the celiac artery is thought to cause ischemia of the gastrointestinal tract. This disorder lacks strict definitive diagnostic criteria; making it difficult to maintain in the differential of abdominal pain. Therefore, the diagnosis of MALS is one of exclusion, requiring the dismissal of peptic ulcer disease, biliary pathology and pancreatic causes for such a presentation. We present a case series of three patients with MALS relieved by laparoscopic intervention. Methods: (1) A 36 year old female, H. pylori negative on EGD, with a six month history of post prandial abdominal pain not relieved by antacids or PPIs. Duplex ultrasonography showed elevated peak systolic velocities in the celiac artery. The patient underwent a laparoscopic decompression of her celiac artery which involved division of the median arcuate ligament fibers constricting the celiac artery. Subsequent to the procedure the patient is currently symptom free and doing well. (2) 27 year old Hispanic female was referred for evaluation of a nine year history of post-prandial abdominal pain accompanied by nausea and vomiting. CT angiography of the abdomen demonstrated stenosis of the proximal celiac artery. The patient was subsequently referred for surgical management and is currently doing well. Results: (3) 46 year old female was referred to her gastroenterologist for severe abdominal pain and nausea that would occur most acutely after meals lasting seven months. An MR angiogram was performed that showed post-stenotic dilation exaggerated on expiration. The patient was referred for laparascopic release of the MAL and is currently symptom free. Conclusion: Patients may experience different combinations of these symptoms making it less obvious that MALS is the cause; however, three options are available to gastroenterologists for diagnosis- MR or CT angiography and Duplex ultrasonograpy. We recommend that MALS be kept in the differential of long standing chronic abdominal pain especially when upper endoscopy has revealed no overt pathology.

Syringomyelia Due to Thoracic Spinal Stenosis With Ossified Ligamentum Flavum -Case Report-

A 50-year-old male presented with back pain and numbness of the lower extremities persisting for 10 years. He had played volleyball for a long period until recently. He had no history of meningitis or traumatic injury. Magnetic resonance imaging revealed a syringomyelia located in the region from T8 to T9 without contrast enhancement or Chiari malformations. Computed tomography showed T9-10 spinal stenosis caused by the right enlarged ossified yellow ligament. Decompressive laminectomy was performed and the ossified ligament removed. Due to the finding of arachnoid thickening and adhesions during the intradural operation, shunting was also performed. Postoperatively, the neuroimaging and clinical findings improved. Syringomyelia is often associated with Chiari malformations, trauma, spinal tumor, hemorrhaging, and meningitis. We suggest that repeated minor mechanical damage caused by physical exercise in addition to long-standing compression of the spinal cord due to spinal spondylosis could induce severe arachnoid fibrotic change similar to adhesive arachnoiditis, which may be one of the main triggers of syringomyelia. Extradural decompressive surgery is considered to be the initial treatment for syringomyelia associated with spinal spondylosis.

The role of optical coherence tomography in the detection of pituitary adenoma

To analyse retinal nerve fibre layer (RNFL) thickness in eyes with compression of the optic chiasm by a pituitary adenoma. RNFL thickness was analysed with optical coherence tomography (OCT) and compared to visual field measurements using high-pass resolution perimetry (HRP). Sixteen eyes from eight patients with pituitary adenoma were studied. All had bitemporal visual field depression caused by compression of the optic chiasm. Patients were submitted to an ophthalmic examination more than 14 months after surgery (seven patients had undergone trans-sphenoidal and one trans-cranial adenomectomy). The examination included HRP, fundus photography and measurement of the peripapillar RNFL thickness using OCT. In spite of temporal visual field depression, not all eyes showed reduced RNFL thickness by OCT. This was also true for some eyes in which RNFL was judged to be reduced on fundus photographs. Contrary to our expectations, RNFL thickness in the nasal quadrant was normal in nine of the 16 eyes. Corresponding figures for the superior, inferior and temporal quadrants were eight, six and five, respectively. The overall RNFL thickness, as measured by OCT, did not correlate well with neural capacity, which is an index of remaining retino-cortical neural channels in HRP. RNFL thickness as measured with OCT was reduced in most, but not all, eyes with temporal field depression caused by chiasmal compression. The pattern of RNFL loss did not correlate well with the visual field defect. Sensitivity of RNFL thickness measurement in OCT was low. The method has limited value in the diagnosis of pituitary tumour compression.

A review of factors predictive of surgical outcome for ossification of the ligamentum flavum of the thoracic spine

Ossification of the ligamentum flavum (OLF) is a pathological condition that affects the ligament and causes slowly progressive myeloradiculopathy in adults. Although OLF has been regarded as endemic to East Asian countries, studies from outside these areas have increasingly been reported. Because of long-standing compression of the spinal cord by OLF, a patient's functional prognosis may not always be favorable, and attempts have been made in recent studies to identify clinical factors that are predictive of the surgical outcome of patients with thoracic OLF. The authors conducted a review of the literature published in the English, Japanese, and Korean languages. They examined studies in which correlation between clinical factors and outcome was statistically evaluated. The clinical factors included sex, age, level of the ossified ligamentum flavum, number of segments affected by OLF, coexisting ossification of the posterior longitudinal ligament (OPLL) or other spinal disorders, preoperative duration of symptoms, preoperative neurological score, computed tomography (CT)-based classification, and the presence of intramedullary high signal intensity on T2-weighted magnetic resonance images. The clinical factors that are unlikely to be predictive of outcome include sex, age, level of the ossified lesion, number of OLF-affected segments, coexisting OPLL, CT classification, and the presence of high signal intensity. It is unclear whether the preoperative duration of symptoms or neurological score is predictive of outcome because the results have been inconsistent among the studies. Analysis of the more recent literature, however, suggests that these two factors are predictive of outcome. The use of a neurological score should be standardized so that compilation and comparison of data can be facilitated.

Intrauterine hemodynamics of tricuspid valve dysplasia in a growth-restricted infant

We present a case of fetal tricuspid valve dysplasia, which was diagnosed at 22 weeks of gestation during a routine obstetrical examination. Serial fetal echocardiographic evaluation revealed progressive right ventricular outflow tract obstruction and persistent cardiomegaly. A female infant weighing 1,916 g was delivered by elective cesarean section at 38 weeks of gestation. Longstanding compression of the fetal lungs secondary to the persistent cardiomegaly resulted in severe respiratory distress and cyanosis immediately after birth. Although, mechanical ventilation and continuous infusion of prostaglandin were instituted, the infant died of respiratory failure at 21 days of age. During the pregnancy, the fetus exhibited intrauterine growth restriction, but hydrops did not occur. In regard to the fetal hemodynamics in this cardiac anomaly, transatrial communication is essential for fetal survival. The diameter of the fossa ovalis, which is a marker of transtrial blood flow, was adequate in this case. However, marked enlargement of the right heart associated with regurgitation interfered with left ventricular filling and output, which resulted in restriction of the combined ventricular output and intrauterine fetal growth restriction.

Spontaneous Resolution of Epidural Hematoma after Continuous Epidural Analgesia in a Patient without Bleeding Tendency

Spontaneous Resolution of Epidural Hematoma after Continuous Epidural Analgesia in a Patient without Bleeding Tendency

A Case of Postpneumonectomy Syndrome Treated with Endobronchial Stent

Postpneumonectomy syndrome is a rare complication that usually occurs in younger patients within the first year after a right total lung resection. Its clinical presentations are stridor, dyspnea, and recurrent pulmonary infections. An airway obstruction secondary to the extreme mediastinal shift and ratation after a pneumonectomy is the main mechanism. It is commonly complicated with tracheobronchomalacia due to longstanding airway compression. The management modalities involve a repositioning of the mediastinum with volume expansion of the pneumonectomy site by a expandable prosthesis. however, other methods including an endobronchial stent insertion should be considered in the presence of a tracheobronchomalacia or in poor surgical candidates. Here we describe a case of postpneumonectomy syndrome complicated by a bronchomalacia, which was successfully treated with a self-expandable endobronchal stent.

Lymph node compression causes stenotic kinking of the internal carotid artery

A 34-year-old woman presented with recurrent transient ischemic attack (TIA) of the left hemiparesis. Carotid angiography disclosed a stenotic kinking of the right internal carotid artery (ICA). The patient underwent exploration of the right ICA for a planned endarterectomy. An enlarged lymph node was found to have compressed and kinked the artery. The lymph node was removed, and segmental resection of the kinked, stenosed, and atrophic ICA, followed by end-to-end reanastomosis, was performed with successful result. Histologically, the lymph node was calcified, and the atrophy of the ICA, the lumen of which was smooth without atheroma, was localized at the site of compression. Based on the findings of the stenotic kinking of the ICA, long-standing compression by the lymph node was the most probable cause of the kinking, rather than the atherosclerotic change of the ICA.

Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome.

Thirty patients were treated surgically for spinal epidural hematoma (SEH). Twelve of these cases resulted from spinal surgery, seven from epidural catheters, four from vascular lesions, three from anticoagulation medications, two from trauma, and two from spontaneous causes. Pain was the predominant initial symptom, and all patients developed neurological deficits. Eight patients had complete motor and sensory loss (Frankel Grade A); six had complete motor loss but some sensation preserved (Frankel Grade B); and 16 had incomplete loss of motor function (10 patients Frankel Grade C and six patients Frankel Grade D). The average interval from onset of initial symptom to maximum neurological deficit was 13 hours, and the average interval from onset of symptom to surgery was 23 hours. Surgical evacuation of the hematoma was performed in all patients; 26 of these improved; four remained unchanged, and no patients worsened (mean follow up 11 months). Complete recovery (Frankel Grade E) was observed in 43% of the patients and functional recovery (Frankel Grades D or E) was observed in 87%. One postoperative death occurred from a pulmonary embolus (surgical mortality 3%). Preoperative neurological status correlated with outcome; 83% of Frankel Grade D patients recovered completely compared to 25% of Frankel Grade A patients. The rapidity of surgical intervention also correlated with outcome; greater neurological recovery occurred as the interval from symptom onset to surgery decreased. Patients taken to surgery within 12 hours had better neurological outcomes than patients with identical preoperative Frankel grades whose surgery was delayed beyond 12 hours. This large series of SEH demonstrates that rapid diagnosis and emergency surgical treatment maximize neurological recovery. However, patients with complete neurological lesions or long-standing compression can improve substantially with surgery.

Function of the sphincter of Oddi in patients with juxtapapillary duodenal diverticula: evaluation by intraoperative biliary manometry under a duodenal pressure load.

The purpose of this study was to elucidate the function of the sphincter of Oddi (SO) in patients with juxtapapillary duodenal diverticula (JDDs). The SO function was evaluated by intraoperative biliary manometry in three groups of patients. Group 1 consisted of nine patients with JDDs and a dilated common bile duct (CBD) (diameter > 10 mm). Group 2 consisted of six patients with JDDs and a normal-sized CBD (diameter < 10 mm). Group 3 consisted of 26 patients without JDDs and with normal-sized CBDs. In the absence of a duodenal pressure load, the patients in group 1 demonstrated a lower baseline SO pressure and lower resistance of the biliary outflow than patients in group 3. They also demonstrated a lower baseline SO pressure and shorter decay time (which represented terminal biliary ductal resistance) than patients in group 2. In the presence of a duodenal pressure load of 300 mm H2O, the patients in group 1 demonstrated a lower incidence of phasic SO contractions, a higher baseline SO pressure, and a higher resistance of the biliary outflow than group 2 and group 3 patients. The decay time in group 1 and group 2 patients was higher than that of group 3 patients. Based on these findings, we conclude that the SO function in patients with JDDs is impaired owing in part to long-standing compression of the terminal biliary ductal system by a distended JDD associated with a rise in intraduodenal pressure in daily life.

Differential involvement of brainstem pathways due to fourth ventricular epidermoid cyst: a case study

A 66-year-old man presented with progressive dysfunction of bilateral cerebellar hemispheres or its connections, corticospinal tracts and medial longitudinal fasciculus (MLF) due to a 4th ventricular epidermoid cyst for the past 47 years. Sensory, auditory and blink reflex pathways were clinically and electrophysiologically normal as indicated by clinical examination and normal median nerve somatosensory evoked responses (SER), brainstem auditory evoked responses (BAER) and bunk reflex (BR) studies. These findings were unchanged fifteen months after removal of the lesion. Our findings suggest that 1. (1) in extraaxial brainstem compression, MLF dysfunction can occur, 2. (2) MLF, corticospinal tracts and possibly cerebellum and its connections appear to be mare susceptible to longstanding compression and can be selectively and irreversibly damaged whereas pathways located in their vicinity, subserving SER, BAER and BR are spared, and 3. (3) normal clinical and electrophysiological examination of sensory, auditory and BR pathways in presence of abnormal MLF, corticospinal and cerebellar functions should raise a clinical suspicion of an extraaxial brainstem compressive lesion.

A CASE REPORT OF SPONTANEOUS FRACTURE IN A CATHETER OF A TOTALLY IMPLANTABLE VENOUS ACCESS PORT

A case of spontaneous fracture of a catheter of a totally implantable venous access port is described. A totally implantable venous access port was placed in a 62-year-old male patient with short bowel syndrome for home parenteral nutrition. Thirteen months after implantation it was noted on chest X-ray that the catheter had fractured and the distal fragment embolized to the right atrium. The embolized catheter fragment was retrieved viaa percutaneous femoral vein approach using a basket catheter. The catheter inserted using the percutaneous subclavian puncture technique has been broken due to the long-standing compression at the narrow space between the clavicle and first rib. Catheter fracture is a relatively rare, but avoidable complication by introducing the catheter lateral to the midclavicular point.