Postoperative Neurovascular Complications Research Articles

Carotid Body Tumor Presentation, Management, and Outcome an Institutional Experience – 12-Year Experience

Objective: This study aimed to analyze the presentation and treatment modalities of carotid body tumor (CBT) and evaluate the outcomes and complications of surgical treatment of CBT. Methodology: Twenty-seven CBT patients treated surgically from January 2012 to August 2022 were included in the study. Patient presentation, diagnostic modalities, surgical and radiological interventions, outcomes, and complications were analyzed. Results: (1) A total of 27 patients were studied, with an age ranging from 13 to 65 years (median age - 45 years), in which male preponderance was found (male: female = 2.5:1), (2) Local swelling was the most common symptom (n = 27), with other symptoms being hoarseness of voice, dysphagia, and ear/neck pain, (3) Left laterality was found in 76.2% of patients, whereas 17.3% of them were right sided with 6.5% of bilateral cases, (4) 15 patients (55.5%) out of the 27 total patients, were classified in Shamblin’s type II, 8 patients (29.6%) in Shamblin’s type I, and the remaining 4 patients (14.8%) as Shamblin’s type III CBTs, (5) Thirteen (48.1%) patients underwent preoperative angioembolization. All (100%) patients underwent complete excision (6) Operative site hematoma was the most common postoperative complication encountered. All patients are asymptomatic with the minimum of 6-month follow-up. Conclusion: Careful preoperative evaluation, which included appropriate modality for diagnosis, preoperative angioembolization for large tumors, meticulous dissection, and good postoperative care, resulted in complete excision of all the tumors and with less complications postoperatively. Shamblin III had a high risk of postoperative neurovascular complications. Therefore, early detection and prompt surgical resection of CBTs will decrease surgical morbidity.

Trends in the surgical management of parapharyngeal space tumors: A single-center retrospective analysis.

Surgery remains the mainstay treatment for parapharyngeal space (PPS) tumors. Given the rapid advance and increasing usage of endoscopic and robotic techniques, we aimed to investigate the surgical trends of PPS tumors in our institution and analyze their impact on patients' treatment outcomes. All patients who underwent surgical resection of PPS tumors from 2014 to 2021at the Eye, Ear, Nose, and Throat Hospital of Fudan University were retrospectively reviewed. Student's t-test, Chi-square test, and multinomial logistic regression analyses were used to compare the surgical outcomes between groups. Of the included 389 patients, the recipients of endoscopic surgery have largely increased in our center, with 17 of 134 cases (12.7%) in the group 2014-2017 and 187 of 255 cases (73.3%) in the group 2018-2021. The use of transoral and trans-nasal approaches increased in recent years (5.2% in 2014-2017 vs. 26.0% in 2018-2021), while that of trans-mandibular and lateral skull base approaches decreased (5.9% in 2014-2017 vs. 0.8% in 2018-2021). Decreased blood loss of operation and decreased risks of postoperative neurovascular complications were observed in the group 2018-2021. Similar findings were observed among patients receiving endoscopic surgery when compared with those receiving conventional surgery. In our institution, the overall trends in the surgical management of PPS tumors moved towards minimally invasive approaches with the assistance of endoscopy or surgical robots. The two surgical techniques were feasible and safe, and to a great extent, contributed to the improved surgical outcomes we observed in recent years.

Retrospective Mid-Term Follow-Up of Posttraumatic and Iatrogenic Neurovascular Complications in Surgically Treated Paediatric Patients with Distal Humerus Fracture

Background: The purpose of the study was to investigate and describe neurovascular complications and mid-term clinical outcomes of operatively managed fractures of the distal humerus in a paediatric population. Neurovascular injuries are common in these fractures, but reports about their implications for mid-term clinical outcomes is sparse. Methods: A single-centre retrospective study was conducted at a university teaching hospital investigating paediatric patients who underwent operative management of a distal humerus fracture between 2014 and 2018. Patient demographics, fracture classification, pre-, peri- and postoperative neurovascular complications were investigated. Mid-term follow up clinical examination and functional scoring using QuickDASH, the Broberg and Morrey Score (BMS), the Mayo Elbow Performance Score (MEPS) and the Numeric Rating Scale were performed. Results: A total of 84 patients were identified, of which 34 met the inclusion criteria and were available for follow-up clinical examination. The average time to follow-up was 150 weeks (1049.44 days ± 448.54). Ten primary traumatic neurovascular complications were identified, the majority of which involved the median nerve. Primary traumatic dissection of the brachial artery was recorded in three patients. Secondary iatrogenic nerve injury was documented in five patients after previously normal clinical examination. At follow-up, the average QuickDASH score was 3.0 ± 4.3, BMS was 98.6 ± 3.4 and MEPS was 97.1 ± 3.3 points. Conclusions: The mid-term clinical outcome following surgical management of distal humerus fractures is excellent. There is, however, a considerable frequency of both primary and secondary neurovascular complications, which must be considered when opting to treat these injuries surgically.

Advances in Intraoperative Neurophysiological Monitoring Techniques in Transnasal Endoscopic Skull Base Surgery

Transnasal endoscopic skull base surgery has been increasing in volume in recent years and its indications are constantly expanding. The potential occurrence of intraoperative and postoperative neurovascular complications deserves special attention from neurosurgeons. Multimodal intraoperative neurophysiological monitoring technology allows neurosurgeons to monitor cerebral perfusion and the functional status of the associated cranial nerves in real time, thereby enabling surgeons to make prompt adjustments in surgical procedures and strategies and reduce the risks of postoperative neurological complications in patients. Based on available literature, we reviewed how appropriate monitoring strategies were optimized for different key components of transnasal endoscopic skull base procedures, intending to provide reference for clinicians.

Covering/Overstenting of the left subclavian artery (LSA) in thoracic endovascular repair (TEVAR) to treat various thoracic/thoracoabdominal aortic lesions: is revascularization of the left arm a must?(A retrospective cohort study with 12 years of experience to describe the real-world situation of daily clinical practice and the literature review)

<b> Introduction:</b> Pathologies of the descending thoracic aorta inwardly extended towards the aortic arch actually shorten the proximal landing zone for aortic prosthesis. This, in turn, worsens the accessibility of the aorta for endovascular therapeutic options of those pathologies. </br></br> <b> Aim:</b> This work considers the blockage of the left subclavian artery (LSA) through endovascular treatment of the pathologies of the descending aorta as the main work question, based on the hypothesis that there is no necessity for primary standard revascularization of the LSA in TEVAR with LSA covering. The researchers have 12 years of experience in the treatment of different thoracic aortic lesions. Their experience will also be reviewed in this paper. </br></br> <b> Materials and methods:</b> Retrospective unicenter cohort study in consecutive patients to describe the real-world situation of daily clinical practice. All patients who had undergone endovascular, hybrid, or open operative therapy of different pathologies of the descending aorta were included in this study. Various parameters were investigated, including therapeutic procedures such as 1) pure endovascular vs. hybrid; 2) year of therapy; 3) symptomatic vs. asymptomatic status of the patients; 4) different epidemiological factors (age, sex, risk factors, mortality, and follow-up); 5) overstenting/blocking of the LSA; 6) complications of applied therapies; 7) further operations/interventions to treat such complications; 8) radiological aortic measurements (such as lumen extensions, false lumen measurements, distance to the supra-aortic and visceral vessels); and 9) multiple other pathological features. Different statistical parameters were also examined. Survival was analysed with the Kaplan-Meier assessment in the group of whole patients vs. the group of over-stented patients. The analysis of variance was performed for independent parameters for the revascularized patients – not the revascularized patients – who had undergone LSA coverage. For statistical approval, the U-test was used. The P-value < 0.05 was considered significantly different. The literature review was performed by means of a search in PubMed, Google scholar, Research Gate, ScienceDirect, and Cochrane library, using the following terms: endovascular, TEVAR, revascularization, stroke, and left-subclavian-artery ischemia. The literature is classified accordingly in relation to the main topic. In fact, the literature underwent further analysis depending on the fact whether it went with or against our hypothesis. </br></br> <b> Results:</b> Overall, 112 patients were enrolled in the study. There was no significant difference comparing the non-revascularized vs.the revascularized group of patients, considering the consequences on cerebrovascular circulation (hemorrhagic, n = 1 case [4.8%] vs. 0 case [0%]; p = 0.32 and ischemic, n = 2 cases [9.6%] vs. 1 case [4.8%]; p = 0.56). There was no registered cases of spinal cord ischemia or left arm ischemia. As the main result, there was no case of left arm ischemia or death (mortality, 0). Survival was as follows for both groups: 22 [95% CI, 14.154–29.904] months vs. 43 [95% CI, 33.655–51.921] months, respectively, with no significant statistical difference (P > 0.05). The only statistically significant risk factor found was renal insufficiency (P, 0.028) but this too was considered a trend by the urgency of revascularization. Postoperatively, pneumonia showed a trend of higher frequency (P = 0.058) in the revascularized cases (n = 0 in the non-revascularized vs. n = 3 [21.4%] in the revascularized cases). There was no significant difference in the occurance of postoperative neurovascular complications (such as cerebrovascular accidents, spinal cord ischemia, or left arm ischemia) by comparing the groups of non-revascularized and revascularized patients. </br></br> <b> Conclusions: </b> The revascularization of the overstented LSA due to TEVAR should be limited to certain indications, including 1) inadequate intracerebral circle of Willis; 2) predominantly perfused left vertebral artery with inadequate blood perfusion via the right vertebral artery (e.g., by stenosis), 3) anatomic variance such as the left vertebral artery originating directly from the aortic arch (and must be blocked by TEVAR); 4) need of an adequate left internal thoracic artery for coronary artery bypass grafting (CABG); 5) need of a patent LSA for the dialysis shunt of the left arm. However, there is no appropriate evidence as yet based on sufficient study results achieved in trials with an advanced design (such as [double-]blind, multicenter randomized study) that appears to be urgently required.

Comparative Evaluation of Morphometry of Mental Foramen using Orthopantomogram and Dry Bones in North Indian Population

Introduction: Mental Foramen (MF) holds strategic importance in clinical dentistry and oral surgery. Its accurate identification determines the effectiveness of nerve blocks and prevention of postoperative neurovascular complications. Aim: To compare mental foramen on dry bones with their orthopantomogram and to find out if any difference and correlation exist between both modalities . Materials and Methods: This descriptive, cross-sectional study was conducted at Anatomy Department of Government Medical college Amritsar, Punjab, India, from January 2018 to December 2021. It comprised of 200 dry human mandibles belonging to either sex, ranging from dentulous to partial dentulous. Orthopantomagram (OPG) of same mandibles were taken. Study was conducted in two phases. Phase I was dry bone phase and Phase II was radiographic phase. Distance of mental foramen from symphysis menti, posterior border of ramus, alveolar crest, lower border of body of mandible and distance between depth of the socket and mental foramen were evaluated. Student’s t-test for comparison and Pearson’s correlation coefficient were applied to find any correlation between two modalities . Results: Distance of mental foramen from symphysis menti, posterior border of ramus of mandible, alveolar crest and depth of socket showed statistically significant difference (p-value <0.001) in between dry bone and orthopantomogram on both right and left sides. Actual bone length from mental foramen to symphysis menti,to posterior border of ramus and inferior border of body of mandible was more than it appeared on OPG. Distances obtained with OPG from MF to alveolar crest (dry bone: Right= 13.49±3.46 mm; Left= 13.42±3.49 mm and on OPG: Right= 16±4.15 mm; Left= 15.42±3.84 mm) and to depth of socket (dry bone: Right= 2.48±1.58 mm; Left= 2.70±1.68 mm and on OPG: Right= 3.69±2.08 mm; Left= 4.26±1.99 mm) were magnified. Conclusion: The results of the present study depicted that structures were not equally magnified. Knowledge about magnification at particular region is important before proceeding any surgery in that region.

Development and validation of a novel artificial intelligence driven tool for accurate mandibular canal segmentation on CBCT

ObjectivesThe objective of this study is the development and validation of a novel artificial intelligence driven tool for fast and accurate mandibular canal segmentation on cone beam computed tomography (CBCT). MethodsA total of 235 CBCT scans from dentate subjects needing oral surgery were used in this study, allowing for development, training and validation of a deep learning algorithm for automated mandibular canal (MC) segmentation on CBCT. Shape, diameter and direction of the MC were adjusted on all CBCT slices using a voxel-wise approach. Validation was then performed on a random set of 30 CBCTs - previously unseen by the algorithm - where voxel-level annotations allowed for assessment of all MC segmentations. ResultsPrimary results show successful implementation of the AI algorithm for segmentation of the MC with a mean IoU of 0.636 (± 0.081), a median IoU of 0.639 (± 0.081), a mean Dice Similarity Coefficient of 0.774 (± 0.062). Precision, recall and accuracy had mean values of 0.782 (± 0.121), 0.792 (± 0.108) and 0.99 (± 7.64×10−05) respectively. The total time for automated AI segmentation was 21.26 s (±2.79), which is 107 times faster than accurate manual segmentation. ConclusionsThis study demonstrates a novel, fast and accurate AI-driven module for MC segmentation on CBCT. Clinical SignificanceGiven the importance of adequate pre-operative mandibular canal assessment, Artificial Intelligence could help relieve practitioners from the delicate and time-consuming task of manually tracing and segmenting this structure, helping prevent per- and post-operative neurovascular complications.

Three-dimensional (3D)-printed model reconstruction in pre-operative planning for wooden penetrating brain injury

ObjectiveThe advancements in technology have made the use of three-dimensional printed model reconstruction in neurosurgery receive special attention due to its role in the process of decision-making and pre-operative planning. Penetrating brain injuries (PBI) have a high risk of damage to the complex intracranial neurovascular structures. Due to its difficulty, 3D-printed model reconstruction could help neurosurgeons in the decision making of PBI surgery strategy. MethodsThe authors reported of an 18-year-old male carpenter who was referred to the hospital due to a wooden PBI. We performed computed tomography (CT) scan, CT angiography (CTA), magnetic resonance venography (MRV) and magnetic resonance angiography (MRA). We then performed segmentations and integrations of the digital imaging and communications in medicine (DICOM) data. The digital reconstruction was then used for 3D printing, and the printed model was used for the foreign object extraction simulation for pre-operative planning. ResultsThere were no intra- and post-operative neurovascular complications after the craniotomy and wooden foreign body extraction procedure. ConclusionThis method was beneficial since it enhances the anatomical visualization of the location and trajectory of the foreign body. Moreover, the printed model allows for a more direct and realistic simulation for the foreign body extraction procedure.

Subaxial Cervical Pedicular Screw Insertion via the Nonanatomic Axis: Technical Notes and Preliminary Clinical Report.

Retrospective study. To report the technical details of subaxial cervical pedicular screw insertion via the nonanatomic axis (nAA-CPS) and evaluate its clinical safety and accuracy. The nAA-CPS technique was performed in 21 patients. Preoperative and intraoperative management-related details are described, and a manipulation protocol is presented. Clinical outcomes were used to assess the safety and accuracy of screws was evaluated using postoperative computed tomography (CT) according to the pedicle perforation grading system, and the nonanatomic pedicle transverse angle (nPTA) and nonanatomic pedicle axis length (nPAL) were assessed based on pre- and postoperative CT images. According to "one constant entry point (EP) and two perpendicular trajectory angles" protocol, nAA-CPS was performed without much interference from the muscles. No intraoperative or postoperative neurovascular complications related to the technique were observed. Of the 112 inserted screws, 78 (69.64%) were assessed as grade 0, 24 (21.43%) as grade 1, 4 (3.57%) as grade 2 and 6 (5.36%) as grade 3. The overall rate of correct position (grades 0 and 1) was 91.07% (102/112), and the rate of malposition was 8.93% (10/112), including five screws implanted medially and the other five laterally. The nPTA was highly consistent on pre- and postoperative CT (P < .05), while postoperative nPAL was significantly shorter than preoperative nPAL (P > .05). Clinically, the accuracy and safety of nAA-CPS was similar to the traditional CPS technique. The protocol, derived from previous radiological studies and workshops, greatly helped standardize clinical manipulation; thus, nAA-CPS is a promising alternative to the traditional CPS.

Novel use of percutaneous cervical pedicle inlet screws for supplemental posterior fixation after anterior cervical deformity correction.

Introduction:Correction of cervical deformity can be achieved using anterior cervical fixation and fusion techniques. However, supplemental posterior fixation is a critical component for ensuring biomechanical longevity and favorable patient outcomes. We present a novel percutaneous technique for posterior cervical fixation in patients where cervical pedicle (CP) screws may not be feasible and midline muscle dissection is not needed.Methods:Three patients presented to our hospital with cervical pathology amendable to circumferential cervical fusion. After adequate deformity correction was performed through an anterior cervical decompression and fusion, staged posterior supplemental fixation was achieved using percutaneous CP inlet (CPI) screws using a percutaneous muscle-sparing approach.Results:All three patients underwent CPI screw placement without postoperative neurovascular complications. Postoperative radiographic follow-up showed the desired, proper screw placement, with continued maintained cervical alignment.Conclusions:CPI screw placement may be alternative hybrid screw that achieves a advantageous safety profile while also avoiding an open midline exposure.

Short-term effectiveness of arthroscopically capsular vertical mattress suturing for shoulder recurrent anterior dislocation combined with joint laxity

To evaluate the short-term effectiveness of arthroscopically capsular vertical mattress suturing for shoulder recurrent anterior dislocation combined with joint laxity. A retrospective analysis was performed on 6 shoulder recurrent anterior dislocation patients combined with joint laxity treated with arthroscopically capsular vertical mattress suturing between January 2017 and December 2018. There were 5 males and 1 female with an average age of 20.8 years (range, 19-24 years). The number of shoulder dislocation was 3-18 times, with an average of 9.5 times. The disease duration ranged from 2 to 60 months, with an average of 25.3 months. The preoperative Beighton score was 4-7, with an average of 5.8; the Instability Severity Index Score (ISIS) was 2-5, with an average of 3.5. There were 5 cases of simple Bankart injury and 1 case of bony Bankart injury. The range of motion of shoulder joint (including active flexion and lifting, external rotation, abduction and external rotation, and internal ratation) was recorded before operation and at last follow-up; Oxford shoulder instability score, Rowe shoulder instability score, and Simple Shoulder Test (SST) score were used to evaluate shoulder joint function before operation, at 6 months after operation, and at last follow-up, and complications were recorded. All patients were followed up 16-28 months (mean, 19.3 months). During the follow-up, all patients had satisfactory motor function, and no re-dislocation and postoperative neurovascular complications occurred. At last follow-up, the activities of active external rotation and abduction and external rotation were significantly improved when compared with those before operation ( P<0.05); the activities of active flexion and lifting and internal rotation were not limited before and after operation, and the difference was not significant ( P>0.05). The Oxford shoulder instability score, Rowe shoulder instability score, and SST score at 6 months after operation and at last follow-up were significantly improved when compared with those before operation ( P<0.05); there was no significant difference between at 6 months after operation and at last follow-up ( P>0.05). The treatment of shoulder recurrent anterior dislocation combined with joint laxity by arthroscopically vertical matress suturing can achieve good short-term effectiveness.

Neurovascular complications following carotid body paraganglioma resection

ObjectiveThe present consecutive case series reports our experience in the management of carotid body paraganglioma and aims to assess whether the Shamblin classification or tumor size are predictive of early and late postoperative neurovascular complications. Material and methodsA retrospective study included 54 carotid body tumor resections in 49 patients, between 1980 and 2011. Data comprised early (<1month) and late (18 months) postoperative neurovascular complications. ResultsEarly postoperative complications occurred in 31 cases, including 30 cases of cranial nerve deficit (56%). Cranial nerve deficit occurred in 83% of Shamblin III carotid body paragangliomas and was associated with significantly larger mean tumor size (4±1.4cm versus 2.9±1.3cm; P<0.01). Shamblin III tumor and tumor size>3.2cm emerged as predictive factors for early postoperative peripheral neurological complications. Eight patients (17%) showed no cranial nerve deficit recovery, even after 18 months’ follow-up; no predictive factors could be identified for this. ConclusionSurgical resection remains the only curative treatment in carotid body paraganglioma, with low vascular morbidity. However, early postoperative nerve deficit remains frequent (56%), although mostly temporary, with 17% definitive sequelae at 18 months. Tumor size and Shamblin classification are predictive of early neurovascular complications.

Posterior C1-C2 transarticular screw fixation for atlantoaxial instability assisted by intraoperative 3-dimensional fluoroscopy-based navigation

To assess the feasibility, efficacy and indication of posterior C1-C2 transarticular screw fixation for atlantoaxial instability assisted by intraoperative 3-dimensional fluoroscopy-based navigation. From November 2005 to October 2012, 58 patients with atlantoaxial instability underwent posterior C1-C2 transarticular screw fixation assisted by intraoperative 3-dimensional fluoroscopy-based navigation. Those with excellent atlantoaxial reduction and no need for decompression underwent percutaneously minimally invasive procedures. Operative duration, blood loss volume, reduction of atlantoaxial joints and postoperative neurovascular complications were recorded. Screw positions were studied by postoperative computed tomography (CT) and divided into 3 categories. The follow-up period was at least 3 months. Local symptoms (assessed by visual analogue scale (VAS) score), neurological conditions (Nurick classification) and bone graft fusion were evaluated. Among them, the procedure was either open surgery (n = 51) or percutaneously minimally invasive surgery (n = 7). A total of 111 screws were placed satisfactorily. Five patients underwent only unilateral C1-C2 transarticular screw fixation. No severe complications were encountered. The mean operative duration was 202.2 ± 54.2 minutes and the average volume of blood loss 412.6 ± 281.2 ml. And the values were comparable to those for the traditional fluoroscopy-guided free-hand procedures. No statistical significance existed between open and percutaneously minimally invasive procedures in operative duration, blood loss volume and precision of screw placement. The patients with incompletely reduced C1-C2 dislocation had comparable clinical outcomes with those with complete reduction. After a 3-month follow-up, all of them showed significant improvements of local symptoms. VAS score decreased from 4.5 ± 1.3 preoperatively to 0.7 ± 0.8 postoperatively while the Nurick classification improved from 2.4 ± 1.1 to 0.6 ± 1.0. And bone graft fusion was satisfactory. Posterior C1-C2 transarticular screw fixation for atlantoaxial instability assisted by intraoperative 3-dimensional fluoroscopy-based navigation is both feasible and safe. Combined with minimally invasive techniques, this procedure may achieve greater precision and minimal invasion.

Medial Approach for Hindfoot Arthrodesis with a Valgus Deformity

Surgical correction of valgus deformity of the hindfoot has traditionally been via a lateral incision, often complicated by wound healing problems and sural nerve damage. Potential advantages of a medial approach especially for a valgus deformity include excellent wound healing, no risk of damage to the sural nerve and extensibility of the approach to include additional procedures such as navicular fusion or tendon transfer if indicated. We present a retrospective review of 18 consecutive patients with valgus deformity of the hindfoot, all undergoing arthrodesis via a medial approach. Indications included osteoarthritis, tibialis posterior dysfucntion, post-traumatic arthritis and rheumatoid arthritis. All wounds healed by primary intention and there were no postoperative neurovascular complications. The mean preoperative subtalar valgus deformity was 32 (range, 12 to 49) degrees, which was improved to mean postoperative valgus deformity of 17 (range, 10 to 25) degrees. Fusion following the primary surgery was achieved in all but one of the patients (a heavy smoker and post-traumatic arthritis), with the mean time to fusion being 5.6 months. We provide further evidence to support previous documentation in the literature that the medial approach for the correction of hindfoot valgus deformity can be successfully used to achieve excellent exposure of the subtalar joint in order to correct the valgus deformity, avoiding the risks of wound healing and nerve damage associated with a lateral approach.

Surgical Treatment of Carotid Body Paragangliomas: Outcomes and Complications According to the Shamblin Classification

ObjectivesThe objective of this study was to review our experience in the surgical management of carotid body paragangliomas and evaluate the outcomes and complications according to the Shamblin classification.MethodsThirteen patients who had been diagnosed and surgically treated for carotid body tumors (CBTs) were enrolled in this study. We reviewed patient demographics, radiographic findings, and surgical outcomes collected from medical records.ResultsFifteen CBTs were found in 13 patients and 13 tumors were resected. Selective preoperative tumor embolization was performed on six patients. The median blood loss, operation time, and hospital stay for these patients were not significantly reduced compared to those without embolization. The median tumor size was 2.3 cm in Shamblin I and II and 4 cm in Shamblin III. The median intraoperative blood loss was 280 mL and 700 mL, respectively (P<0.05). Internal carotid artery ligation with reconstruction was accomplished on three patients (23%), and they all belonged to Shamblin III (38%). One Shamblin III patient (8%) developed transient cerebral ischemia, and postoperative stroke with death occurred in another Shamblin III patient. Postoperative permanent cranial nerve deficit occurred in three patients (23%) who were all in Shamblin III (P=0.03). There were no recurrences or delayed complications at the median follow up of 29 months.ConclusionShamblin III had a high risk of postoperative neurovascular complications. Therefore, early detection and prompt surgical resection of CBTs will decrease surgical morbidity.

Management of the Internal Carotid Artery in Tumors of the Lateral Skull Base: Preoperative Permanent Balloon Occlusion without Reconstruction

To present our experience with permanent preoperative balloon occlusion of the internal carotid artery while dealing with different abnormalities of the lateral skull base and a comparison with the results mentioned in the literature. Retrospective case review. Private neurotologic and skull base tertiary referral center. Fifteen patients who underwent preoperative balloon occlusion of the internal carotid artery and surgery subsequently for various abnormalities of the lateral skull base between 1989 and 2002. Each patient was subjected to four-vessel angiography along with the manual cross-compression test and balloon test occlusion to assess the efficacy of the collateral circulation. After angiography, each patient underwent a preoperative balloon occlusion, after which a lateral skull base procedure was performed for removal of the abnormality. Only those patients showing evidence of adequate collateral cerebral circulation and a less than 1-second delay between the angiographic phases of the two cerebral hemispheres on angiography were considered fit for preoperative balloon occlusion. While under going the preoperative balloon occlusion, the patients were clinically assessed for the development of any neurologic symptoms and signs. Long-term follow-up after surgery was also based on the development of symptoms and signs of neurovascular compromise. A major complication in the form of long-lasting hemiplegia occurred in one patient (6.7%). This complication was the result of technical factors rather than an effect of cerebral ischemia, because it was caused by an intimal dissection produced by the catheter. A defect in the visual field occurred in one patient (6.7%) that resolved partially after antiplatelet therapy. There was no mortality in our series related to preoperative balloon occlusion of the internal carotid artery. Preoperative balloon occlusion of the internal carotid artery can still be considered a viable option for the management of the internal carotid artery during lateral skull base surgery. Proper preoperative evaluation of the adequacy and efficacy of the collateral cerebral circulation reduces the chances of postoperative neurovascular complications.

The use of a volar ulnar portal in wrist arthroscopy

Purpose The purpose of this study was to quantitatively describe the neurovascular relationships of a volar ulnar (VU) wrist arthroscopy portal. A second purpose was to evaluate whether the use of a VU portal identified additional pathology of the lunotriquetral ligament and ulnar sling mechanism that was not seen through the dorsal portals. Type of study This study was an anatomic study and retrospective chart review. Methods Cadaver dissections established the neurovascular anatomy of the VU portal. Measurements were taken from the portal to the ulnar nerve and artery, the palmar cutaneous branch of the ulnar nerve, and the pronator quadratus. A dorsal capsulotomy was performed to assess the ligamentous interval. A chart review was performed of 23 patients in whom a volar ulnar portal was used. Intraoperative pathology that was identified through the VU portal but was not visible through a dorsal portal was recorded. Postoperative neurovascular complications were noted. Results The portal was generally > 5 mm radial to the ulnar neurovascular bundle, but no true internervous plane was seen. Tears of the palmar aspect of the lunotriquetral ligament were seen in 7 patients. One patient had a triangular fibrocartilage tear that extended into the dorsal radioulnar ligament. Conclusions This study provides a safe, standardized approach to the volar ulnar aspects of the radiocarpal joint, which is useful for evaluation of the ulnar sling mechanism and the dorsal radioulnar ligament. The VU portal aids in the diagnosis and debridement of tears involving the palmar aspect of the lunotriquetral ligament. The VU portal should be considered for inclusion in the arthroscopic examination of any patient with ulnar sided wrist pain. Level of evidence Level IV.

Wrist arthroscopy through a volar radial portal

Purpose: To quantitatively describe the neurovascular relationships of a volar radial wrist arthroscopy portal and to evaluate whether volar wrist arthroscopy identified additional pathology of the dorsal capsular structures and the palmar region of the scapholunate interosseous ligament that was not seen through the dorsal portals. Type of Study: This study was an anatomic study and retrospective chart review. Methods: Cadaver dissections established the neurovascular anatomy of the volar radial portal. Measurements were taken from the portal to the radial artery and its superficial palmar branch; the superficial radial nerve, the median nerve, and its palmar cutaneous branch; and the pronator quadratus. A dorsal capsulotomy was performed to assess the ligamentous interval. A chart review of 30 patients in whom a volar radial portal was used was performed. Intraoperative pathology identified through volar wrist arthroscopy that was not visible through a dorsal portal was recorded. Postoperative neurovascular complications were noted. Results: There was a greater than 3 mm safe zone surrounding the portal that was free of any neurovascular structures. There were no complications from the use of the portal. Additional pathology that was not visible from a dorsal portal was identified in 10 cases. This included 1 case of hypertrophic synovitis of the dorsal capsule, 1 patient with an avulsion of the radioscapholunate ligament, 1 patient with a tear restricted to the palmar region of the scapholunate interosseous ligament, and 7 patients with tears of the dorsal radiocarpal ligament. Conclusions: This study provides a safe, standardized approach to the volar radial aspects of the radiocarpal and midcarpal joints. Volar wrist arthroscopy identified additional pathology of the palmar scapholunate interosseous ligament and dorsal capsular structures in 30% of the patients. The volar radial portal should be considered for inclusion in the arthroscopic examination of any patient with radial-sided wrist pain.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 6 (July-August), 2002: pp 624–630

Premiers résultats du clou Polarus dans le traitement des fractures proximales de l'humérus

The Polarus nail has recently been popularised to fix proximal humeral fractures. In the current pilot study we reviewed the early results obtained using this nail.Ten patients with proximal humeral fracture (four pathological, 5 traumatic and one non-union) were fixed using a Polarus nail. The fractures were classified according to Neer (7 two-parts and 3 three-part fractures). The mean followup was 22 months (6–39) months. The following criteria were assessed: pain, range of shoulder movement and function. Seven patients were satisfied with their operation, their fractures healed in a mean period of 3 months (2–4 months). No postoperative neurovascular complications were encountered; the re-operation rate, was however 30%.Conclusion: in the authors' brief pilot study in 10 patients, and despite the heterogenous fracture types, we came in to conclusion that the indications for using Polarus nail is limited due to the high complications rate associated with the procedure when used for displaced three or four part surgical neck fracture of humerus.

Neurovascular morbidity from the lithotomy position

The lithotomy position is used in pediatric surgery when it is necessary to have simultaneous access to the abdomen and perineum. At the authors' institution, after a prolonged period in the lithotomy position, significant lower limb complications developed in four patients. Two patients with Hirschsprung's disease underwent a redo Duhamel procedure, one had an anorectal leiomyoma excised, and one had an ileoanal anastomosis for ulcerative colitis. Sciatic nerve injury developed in two patients and deep venous thrombosis and bilateral compartment syndrome resulting in myonecrosis developed in one each. There is an association between operations that require prolonged lithotomy position and the development of postoperative neurovascular complications. By placing the child in the lithotomy position only when access to the perineum is required, these significant injuries may be avoided.