Postoperative Numbness Research Articles

C2 nerve dysfunction associated with C1 lateral mass screw fixation.

The C1 lateral mass screw technique is widely used for atlantoaxial fixation. However, C2 nerve dysfunction may occur as a complication of this procedure, compromising the quality of life of affected patients. This is a review of the topic of C2 nerve dysfunction associated with C1 lateral mass screw fixation and related research developments. The C2 nerve root is located in the space bordered superiorly by the posterior arch of C1 , inferiorly by the C2 lamina, anteriorly by the lateral atlantoaxial joint capsule, and posteriorly by the anterior edge of the ligamentum flavum. Some surgeons suggest cutting the C2 nerve root during C1 lateral mass screw placement, whereas others prefer to preserve it. The incidence, clinical manifestations, causes, management, and prevention of C2 nerve dysfunction associated with C(1) lateral mass screw fixation are reviewed. Sacrifice of the C2 nerve root carries a high risk of postoperative numbness, whereas postoperative nerve dysfunction can occur when it has been preserved. Many surgeons have been working hard on minimizing the risk of postoperative C2 nerve dysfunction associated with C1 lateral mass screw fixation.

What should be the correct indications for laparoscopic inguinal hernia repair?

I appreciate the comments of Sabuncuoglu et al. [1] about my article [2]. They raised several important issues regarding indications for laparoscopic hernia repair, primary end points of hernia surgery, and the difficulties of urologic surgery after laparoscopic and endoscopic hernia repair. The historical studies on laparoscopic and open hernia repair techniques presented by Sabuncuoglu et al. do not analyze the different hernia types (e.g., medial and lateral inguinal hernias, scrotal hernias, incarcerated hernias, hernias after radical prostatectomy and recurrences following TAPP and TEP). Therefore, the statements of the Hernia Trialists Collaboration study are restricted [3]. Nevertheless, the data suggested less persistent postoperative pain and numbness following laparoscopic repair and the patients were able to return to their usual activities more quickly. According to the study, there was no apparent difference in recurrence rate between laparoscopic and open mesh methods of hernia repair. However, the transferability of the results is limited. The European Hernia Society (EHS) has recommended TAPP and TEP as standard procedures for repairing bilateral and recurrent hernias after anterior repair, and inguinal hernias in females [4]. In addition, the International Endohernia Society (IEHS) recommended TAPP and TEP as treatment options for complicated hernias (scrotal hernias, incarcerated hernias, hernias after radical prostatectomy, and recurrent hernias after TAPP and TEP procedures), if the repair is performed by a surgeon experienced in laparoscopic and endoscopic hernia repair [5]. Besides the recurrence rate, a high level of patient satisfaction with the outcome of their repair is an important primary end point in hernia surgery. According to my retrospective study, 96.9 % of all patients were satisfied with the result of their modified TAPP. Only 1.5 % was dissatisfied due to hernia recurrence, persistent pain, or postoperative complications. A radical prostatectomy after a bilateral laparoscopic or endoscopic hernia repair and a TAPP or TEP after a radical prostatectomy are challenging and time-consuming interventions. A modification of the surgical repair technique is necessary. There is necessarily a steep learning curve for these procedures. The repair should be done only by surgeons who have extensive experience in laparoscopic and endoscopic hernia repair [5]. According to single-case reports [6, 7], the fibrotic reaction of the implanted mesh after endoscopic and laparoscopic hernia repair makes urologic cancer surgery complicated. According to these reports, the preparation of the preperitoneal space should be nearly impossible [1]. In contrast, Stolzenburg et al. [8] presented a large series of 2,000 endoscopic extraperitoneal radical prostatectomy (EERPE) procedures, including 50 patients who had had a prior endoscopic/laparoscopic hernioplasty, with no conversions to an open procedure and the rates of intraand postoperative complications were not increased. We agree with these authors that EERPE after TAPP and TEP is a safe and effective procedure when port placement and the preparation of the retropubic space are modified. For this procedure, a surgeon experienced not only in laparoscopic hernia repair but also in laparoscopic radical prostatectomy is needed. Replying to the question of how to manage hernia repair in patients with risk factors for pelvic surgery, to our W. K. J. Peitsch (&) Klinik fur Allgemeinund Viszeralchirurgie, Katholisches Krankenhaus St. Josef, Kliniken Essen Sud, Propsteistr. 2, 45239 Essen, Germany e-mail: wkjpeitsch@t-online.de

Cutaneous hypoesthesia following plate fixation in clavicle fractures

Background:We report the functional impact and natural history of cutaneous hypoesthesia after plate internal fixation for mid shaft clavicle fractures with a horizontal skin incision from year 2009 to 2011.Materials and Methods:38 patients had complete followup data with an average followup period of 23.2 months (range 8-43 months). The impact of supraclavicular nerve injury was studied by assessment of the incidence, functional impact and natural history of numbness with detailed review of the case records and phone questionnaires.Results:The incidence of postoperative numbness was 55.3% (n = 21). Most patients reported the numbness to be at its worst within the first operative month. At the time of worst numbness, 28.6% (n = 6/21) of patients reported the numbness to be severe while 42.9% (n = 9/21) reported moderate numbness and 28.6% (n = 6/21) reported mild numbness. Fifteen of these patients described increased awareness of numbness during contact with straps or clothes. Two patients were significantly bothered by this numbness; 4 patients stated that it was a moderate bother while 7 patients considered it a mild bother. A total of 8 patients reported that they were not bothered at all by the numbness. An overwhelming majority of affected patients (90.5%, n = 19/21) reported an improvement in the severity of numbness felt over time. At the last followup, the incidence of numbness declined from 55.3% to 36.8% with 7 patients reporting complete resolution of numbness. The numbness however was found to persist in 66.7% of patients. Only 1 patient reported continued severe numbness. The awareness of numbness with straps and clothing was severe in 5 patients. None of the patients were significantly bothered by this numbness.Conclusions:Cutaneous sensory loss is a common occurrence following plate fixation of the clavicle and might have been under reported in the literature. The numbness improves in the vast majority, but commonly persists to some degree for up to 2 years and maybe permanent. However, only a small minority eventually considered the numbness a significant “bother” and to affect them while wearing clothing or when in contact with shoulder straps.

Postoperative numbness of the knee following total knee arthroplasty

The infrapatellar branch of the saphenous nerve is often injured during total knee arthroplasty (TKA), leading to numbness in its distribution distal to the incision. This is illustrated in a patient who suffered full-thickness burns to the lateral aspect of the knee from a hot water bottle. However, the proportion of patients who are informed of this phenomenon (as well as the effect of informing the patient of numbness) has not previously been studied according to the authors' knowledge. The aim of this study was to establish the proportion of patients with whom postoperative numbness was discussed during the consent procedure and whether this discussion was documented. A total of 73 patients (103 TKAs) agreed to take part in this study between 16 May and 9 July 2011. Patients were asked about their recollection of numbness being mentioned prior to the procedure as well as whether they experienced postoperative numbness. Statistical analysis was performed using SPSS®. Subjective numbness was noted in 27% of the patients in this study. The prevalence of numbness decreased with time. Patients whose consent process included a discussion of numbness were 3.3 times more likely to report numbness after TKA (p=0.003). Patient education regarding postoperative numbness increases the patient's awareness of any insensate skin that may develop. Numbness after TKA does improve with time but does not resolve completely. It is therefore recommended by the authors that numbness is discussed preoperatively with the patient and that this discussion is documented.

Postoperative numbness of the knee following total knee arthroplasty

The infrapatellar branch of the saphenous nerve is often injured during total knee arthroplasty (TKA), leading to numbness in its distribution distal to the incision. This is illustrated in a patient who suffered full-thickness burns to the lateral aspect of the knee from a hot water bottle. However, the proportion of patients who are informed of this phenomenon (as well as the effect of informing the patient of numbness) has not previously been studied according to the authors' knowledge. The aim of this study was to establish the proportion of patients with whom postoperative numbness was discussed during the consent procedure and whether this discussion was documented. A total of 73 patients (103 TKAs) agreed to take part in this study between 16 May and 9 July 2011. Patients were asked about their recollection of numbness being mentioned prior to the procedure as well as whether they experienced postoperative numbness. Statistical analysis was performed using SPSS®. Subjective numbness was noted in 27% of the patients in this study. The prevalence of numbness decreased with time. Patients whose consent process included a discussion of numbness were 3.3 times more likely to report numbness after TKA (p=0.003). Patient education regarding postoperative numbness increases the patient's awareness of any insensate skin that may develop. Numbness after TKA does improve with time but does not resolve completely. It is therefore recommended by the authors that numbness is discussed preoperatively with the patient and that this discussion is documented.

The effect of tourniquet use on operative performance and early postoperative results of anatomic double-bundle anterior cruciate ligament reconstruction

PurposeThe purpose of this study was to examine the effect of tourniquet use on operative performance and early postoperative results of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction. MethodsFifty-one patients who underwent scheduled ACL reconstruction for unilateral ACL deficiency from June 2010 to October 2011 were included in this study. The mean age at surgery was 26.3years (range 14–45years). An anatomic bundle reconstructive procedure with an autogenous hamstring tendon graft was performed in all cases. These patients were randomly divided into two groups: the tourniquet group (T group) and no tourniquet group (NT group). The reconstructive procedure was performed with the use of a tourniquet for 28 patients in the T group, while a tourniquet was inflated only during the graft harvest for 23 patients in the NT group. The surgical procedure and postoperative management were identical for both groups. Inter-group comparison was conducted for intra- and peri-operative clinical parameters as well as early postoperative results (functional recovery at 3months). ResultsThe arthroscopic visual field during the procedure was not compromised even without the use of a tourniquet. There was no significant difference in operative time between the groups (P=0.10). The amount of blood corrected through the intraarticular drain was significantly larger in the T group (P=0.02), while total blood loss calculated by the postoperative reduction of the hemoglobin value was not significantly different between the groups (P=0.74). Although the VAS value for postoperative numbness was significantly higher in the T group (P=0.0002), the VAS value for pain was not significantly different (P=0.30). Additionally, recovery of muscle strength at 3months was not significantly different between the groups. ConclusionThis comparative study showed that arthroscopic procedures could be uneventfully performed without the use of a tourniquet. The clinical parameters when not using a tourniquet were not significantly different, but the use of a tourniquet resulted in an increase in postoperative intraarticular bleeding and VAS for numbness. Level of evidenceProspective randomized study, Level II.

Treatment of Acute and Closed Achilles Tendon Ruptures by Minimally Invasive Tenocutaneous Suturing

Achilles tendon rupture is a common injury, and its complications can impair function. Numerous operations have been described for reconstructing the ruptured tendon, but these methods can compromise the microcirculation in the tendon and can seriously damage healing of the tendon. Suturing with a minimally invasive tenocutaneous technique soon after the rupture and systematic functional exercise can greatly reduce the possibility of complications. From June 1996 to February 2007, we treated 20 patients (14 males), who ranged in age from 21 to 66 years old, with this method. After follow-up period of 1 to 7 years, the mean American Orthopedic Foot and Ankle Society Ankle Hindfoot score was 95 (range 90 to 98), and the maximum length of postoperative scarring was 3 cm. One patient again ruptured his Achilles tendon 1 year after surgery in an accident; however, after 10 months, the repaired tendon was still intact. In another patient, the nervus suralis was damaged during surgery by piercing the tension suture at the near end, causing postoperative numbness and swelling. The tension suture was quickly removed, and the patient recovered well with conservative treatment. No large irregular scars, such as those sustained during immobilization, were present over the Achilles tendon. Minimally invasive percutaneous suturing can restore the original length and continuity of the Achilles tendon, is minimally invasive, and results in fewer postoperative complications than other methods.

Donor Site Evaluation: Anterior Iliac Crest Following Secondary Alveolar Bone Grafting

The use of autogenous bone graft for Secondary alveolar bone grafting is well established in the treatment of cleft lip and palate patients. To evaluate post-operative morbidity of anterior iliac crest graft after secondary alveolar bone grafting in cleft patients. Forty patients during the period from July 2008 to March 2013, who underwent secondary alveolar bone grafting by harvesting graft from anterior iliac crest in Mamata Dental Hospital, Khammam, Andhra Pradesh, India are included in the present study. Unilateral and bilateral cleft patients who had undergone secondary alveolar bone grafting (SABG) with anterior iliac crest as their donor site have been selected and post- operative complications from the surgery were evaluated with the help of a questionnaire which included pain, gait disturbances, numbness and scar problems (infection, irritation). Patients who were operated gave maximum score for pain as 8 on visual analogue scale. No pain was observed in any of the cases after 8 days, gait disturbances were seen in all patients (limping) for 2-6 days, there was no post-operative numbness with all the patients returning to their routine in 6- 15 days and 90% of the patients gave a satisfied response towards scar. From the results in our study the morbidity after harvesting bone from iliac crest was found to be moderate to low, which had minimal complications and were well tolerated and greater acceptance from the patient.

Re-Adjustable Male Slings

Re-adjustable male slings are well established and should be offered to incontinent men with mild, moderate or severe incontinence. However, they should be able to interrupt their stream. Solely the slight increase of the urethral resistance (10 - 15 cmH20) supporting the smooth muscle component will provide continence for such patients. Argus, Remeex and Atoms allow exactly setting the urethral resistance to a level, which will provide continence thus avoiding obstructive voiding. Implantation may be carried out retropubically (Remeex), via a transobturator route (Atoms) or alternatively (Argus). The success rates after more than one-year follow-up come up to 84%. Intraoperative bladder perforations may occur in 6% - 11%, late complications are infections possibly leading to explantation in 8% - 12%. Postoperative perineal pain and/or numbness may be present.

Postoperative Lumbar Plexus Injury After Lumbar Retroperitoneal Transpsoas Minimally Invasive Lateral Interbody Fusion

Retrospective review. To evaluate the motor and sensory deficit rate after the lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion (MIS LIF) by reviewing a single surgeon's experience. The MIS LIF is an increasingly used alternative to traditional open anterior or posterior operations to treat a host of spinal disorders. It has many advantages, but the potential for immediate postoperative thigh numbness, pain, and potential motor weakness has been reported. Published rates range widely in part because previous studies have based patient outcomes on data from different surgeons using different techniques. An institutional review board-approved, retrospective review of a prospectively collected database was conducted. Seventy-one consecutive patients who underwent this procedure between L1 and L5 during a 3-year period met criteria and were included. Postoperative clinical examinations immediately after surgery and during routine follow-up intervals were examined. There was a 19.1% (14/71) rate of immediate postoperative ipsilateral thigh numbness during the study period. The annual rates of numbness progressively decreased annually. There was a 26.1% (6/23), 25% (5/20), and 10.7% (3/28) rate for 2008, 2009, and 2010, respectively. All patients with numbness had a fusion construct that involved L4-L5. More than half the patients, 54.9% (39/71), had immediate postoperative ipsilateral iliopsoas or quadriceps weakness. Of these, the vast majority had resolution by 3 months (92.3%), and all had complete resolution by 2 years. The lumbar retroperitoneal transpsoas MIS LIF is a safe alternative to traditional open operations for many spinal conditions. As with most minimally invasive techniques, there is a learning curve to be overcome to minimize the risk of iatrogenic nerve injuries. Our refined technique of the MIS LIF during a 3-year period has led to a significant reduction of the incidence of postoperative numbness of nearly 60% (from 26.1%-10.7%).

Randomized clinical trial comparing lightweight mesh with heavyweight mesh for primary inguinal hernia repair

The aim of the present randomized clinical trial was to compare feeling of a foreign body and the early and late outcomes after inguinal hernia repair with the heavyweight (HW) mesh and lightweight (LW) mesh during a 12-month follow-up at a single specialist center. One hundred and ten patients were randomized into HW and LW mesh groups, both of which underwent unilateral primary inguinal hernia via the Lichtenstein technique. At each postoperative visit, any complication, recurrence, feeling of a foreign body, quality of life, residual pain, and numbness were recorded. Complaint of feeling of a foreign body on the repaired side was more frequent in the HW mesh group than in the LW mesh group (P < 0.05). Fewer patients in the LW mesh group reported postoperative numbness around the groin or down the thigh than did those in the HW mesh group (P < 0.05). At 12-month follow-up, however, there was no difference between the LW and HW mesh groups as regards the incidence or severity of pain or discomfort and recurrence rate and nor was there any significant dissimilarity between the two study groups in any dimension of quality of life on the SF-36. There was no significant difference between our LW mesh and HW mesh groups in terms of chronic pain incidence, recurrence rate, and quality of life following inguinal hernia repair. However, fewer patients in the LW mesh group reported numbness around the groin or down the thigh postsurgery than did those in the HW mesh group and therein may lie in the superiority of LW mesh for inguinal hernia repair. Larger cohort studies with longer follow-up periods are required to elucidate in the future the benefits of the LW mesh.

Treatment of acute and closed Achilles tendon ruptures by minimally invasive tenocutaneous suturing

Achilles tendon rupture is a common injury, and its complications can impair function. Numerous operations have been described for reconstructing the ruptured tendon, but these methods can compromise microcirculation in the tendon and can seriously impair its healing. Suturing with a minimally invasive tenocutaneous technique soon after the rupture and systematic functional exercise can greatly reduce the possibility of complications. Between June 1996 and February 2009, we treated 88 patients (54 males; age range, 21-66 years) with this method. After follow-up ranging from 1-7 years, the mean American Orthopedic Foot and Ankle Society ankle-hind foot score was 95 (range, 90-98), and the maximum length of postoperative scarring was 3 cm. One patient re-ruptured his Achilles tendon one year after surgery in an accident, but after 10 months, the repaired tendon was still intact. In another patient, the nervus suralis was damaged during surgery by piercing the tension suture at the near end, causing postoperative numbness and swelling. The tension suture was quickly removed, and the patient recovered well with conservative treatment. No large irregular scars, such as those sustained during immobilization, were present over the Achilles tendon. Minimally invasive percutaneous suturing can restore the original length and continuity of the Achilles tendon, is minimally invasive, and has fewer postoperative complications than other methods.

Endoscopic maxillary sinus surgery through anterior or posterior nasolacrimal duct approach

To explore the feasibility and effectiveness of the approaches and methodology of the endoscopic surgery for maxillary sinus lesions through the medial wall of the maxillary sinus. From Jun. 2003 to Aug. 2010, endoscopic surgery through anterior or posterior nasolacrimal duct approaches to remove maxillary sinus lesions were conducted in 139 patients. Among them there were 43 cases with inverted papilloma, 63 cases with fungal maxillary sinusitis, 28 cases with maxillary sinus cyst, 3 cases with hemorrhagic necrotic polyps, and 2 cases with osteomas. All patients underwent preoperative CT scans, and patients with inverted papillomas also had MRI tests. Anterior-nasolacrimal canal paths included 3 ways: pyriform aperture, lacrimal bone recess (dissecting nasolacrimal duct or not were 2 subtypes), pyriform aperture-nasolacrimal duct approaches, and 97 patients were treated. Posterior-nasal lacrimal duct paths were also divided into 3 subtypes: the inferior turbinate flip flap, double pedicle inferior turbinate, single pedicle inferior turbinate, and 42 patients were treated. The postoperative effects were observed. All lesions were completely removed under endoscope, the nasolacrimal ducts and inferior turbinates were protected, no nasal lacrimal duct injury and inferior turbinate necrosis were found. Postoperative nasal congestion, headache, swelling discomfort, strange odor, dental pain and numbness and other symptoms gradually disappeared. Nine patients felt nasal dryness, and after nasal washing for about 1 month, the symptom gradually disappeared. Patients were followed up for 6 months to 79 months. In case of osteoma, and hemorrhagic and necrotic polyps, no recurrences were found. Apparent edema, hypertrophy of sinus mucosa could be seen during the surgery in all patients with fungal maxillary sinusitis, and the edema gradually disappeared after 3 months or so, with no relapse. Two cases of maxillary sinus cysts were found in other parts of the maxillary sinus 10 months and 18 months after the surgery, but the cysts were small and asymptomatic, so no further management needed, and they were still under follow-up. Three patients, recurred. In 1 case with inverted papilloma, a local lump on the opening were found 17 months after the surgery, and was removed in out-patient department and pathology showed papillary tumor recurrence, no relapse was found 1 year later; 1 patient had recurrence in anterior ethmoid sinus 15 months after operation, total ethmoidectomy was done and no relapse was found in 3 years. One patient had local recurrence in the posterolateral wall of the maxillary sinus 26 months after operation, and the secondary surgery was done via single pedicle inferior turbinate. The papilloma relapsed again after 1 year, an endoscopic Denker surgery was performed, with no recurrence after 18 months of follow-up. Three months after surgery, the maxillary sinus was scar-covered in all cases. Inferior turbinate maintained good shape, compared to those with inferior nasal meatus windowing surgery. Scars were significantly smaller, but no latch or obstruction of drainage were found. Endoscopic maxillary sinus surgery through anterior or posterior nasolacrimal duct approach can reduce the trauma, fully expose the sinuses, and facilitate postoperative treatment and review with a window. Retained inferior nasal turbinate is helpful to avoid dryness, crusting, headache and other complications due to too much removal of nasal exteral walls.

Cutaneous sensory deficit following post-auricular incision

Post-auricular incisions are performed for a range of otological procedures. Anecdotally, many patients suffer some numbness of the pinna or post-auricular skin post-operatively, but for most this appears to reduce with time. This study aimed to investigate this phenomenon. A single centre, questionnaire-based study was undertaken, assessing the presence of numbness beyond eight months post-surgery, its location, how it changed, and its impact on the patient. Patients whose numbness had resolved provided details of any temporary deficit. Data were acquired for 35 primary and 16 revision procedures. Sixty-nine per cent of patients undergoing primary surgery experienced post-operative numbness. Twenty-six per cent had continued numbness after at least eight months' recovery, but only 3 per cent were constantly aware of the deficit. Of those with an ongoing deficit, 78 per cent felt there had been a reduction in the severity, and 67 per cent in the area size, over time. Recovery appeared to be slightly worse in revision cases.

Factors That Influence Outcome of Percutaneous Balloon Compression in the Treatment of Trigeminal Neuralgia

Percutaneous balloon compression is an effective, low-cost, simple therapeutic modality with the special advantage of being the only percutaneous technique that can be simply performed with the patient under general anesthesia for the treatment of trigeminal neuralgia. To identify surgical and individual parameters that could influence outcome in patients with trigeminal neuralgia treated with percutaneous balloon compression. Within a 5-year period, 66 consecutive percutaneous balloon compressions were performed in 47 patients. The medical and surgical records of all patients were retrospectively reviewed and analyzed for a possible correlation between the following parameters and outcome: balloon shape, balloon volume, compression time, age, sex, type of pain, duration of disease, previous procedures, and trigeminal division affected. Univariate and multivariate analyses were used to test for statistical significance. The initial success rate was 85%, and 36% of the responders are still pain free with a mean follow-up of approximately 20 months, whereas in 33 patients, trigeminal pain recurred after a mean of approximately 17 months. Of the investigated parameters, significant correlations were obtained between balloon shape and all aspects of outcome, previous operations and complication rate, pain type and complication rate, and compression time and postoperative numbness. The balloon shape is a parameter with a very strong impact on outcome, and balloon volume should be adjusted to this parameter. Persistent elliptical balloon shapes should raise consideration of aborting the procedure. There were no differences in outcomes between 60 seconds and longer compression times. The number of previous operations did not correlate with pain relief, but seemed to increase the risk of complications. Patients with multiple sclerosis seemed to obtain similar benefit from the procedure as do patients with classic trigeminal neuralgia.

C1 Lateral Mass Screw Insertion With Protection of C1-C2 Venous Sinus

This is a technical note and review of the literature. We propose to describe a revised surgical technique of C1 lateral mass screw insertion with protection of C1-C2 venous sinus surrounding the C2 nerve root. During C1 lateral mass screw insertion and in posterior C1-C2 fixation, iatrogenic injury of C1-C2 venous sinus results in bleeding, which is troublesome. Appropriate management of the venous sinus in this region is critical to successful surgery in this complex anatomic region. We reviewed 48 patients who underwent posterior C1-C2 fixation at our institution between September 2001 and October 2008. Twenty-four atlas screws were inserted by the originally described C1 lateral mass screw technique (group A), and 28 through a revised posterior arch and lateral mass screw technique (C1 transpedicular screw) (group B). The final group of 44 atlas screws was placed with our newly revised technique (group C). Bleeding of venous sinus was encountered in 3 group A, 2 group B, and 1 group C atlas screw insertions. The incidence rate was 12.50% (A), 7.14% (B), and 2.27% (C). Statistical comparison showed no significant difference between the groups. All the cases were followed for a mean period of 28.1 month. Four patients in group A complained of postoperative numbness in occipitocervical region. No patients in group B or group C voiced this complaint. A high fusion rate was found in all 3 groups with no signs of implant failure. Bleeding of C1-C2 venous sinus is vigorous and frustrating. The revised technique we describe provides theoretical and practical protection of venous sinus. In addition, the firm bony purchase of screws afforded by this technique contributes to achieving stabilization of the upper cervical spine and a high fusion rate.

Computer-assisted surgical planning and simulation for condylar reconstruction in patients with osteochondroma

We describe the use of computer-assisted three-dimensional surgical planning in condylar reconstruction by vertical ramus osteotomy for patients with osteochondroma, and its clinical effects. Seventeen patients with osteochondroma of the mandibular condyle who were seen from March 2005 to March 2009 were divided into 2 groups treated by condylectomy and condylar reconstruction using vertical sliding osteotomy of the mandibular ramus with and without three-dimensional simulation using Surgicase CMF Materialise software. Clinical examination, radiographs, photographs, and details of operation and outcome were used postoperatively to evaluate the clinical effects of the technique. Satisfactory mouth opening was achieved in all cases. Mean (SD) osteotomy and fixation time, duration of intermaxillary fixation, and degree of postoperative numbness of the lower lip were considerably reduced among patients who had three-dimensional simulation. The combined use of computer-assisted three-dimensional surgical planning and simulation with vertical ramus osteotomy to reconstruct the condyle for patients with osteochondroma after excision of the tumour makes the operation more accurate and more convenient, and avoids damage to vital structures.

Post-operative numbness and patient satisfaction following plate fixation of clavicular fractures

Introduction and aim Numbness across the shoulder and upper chest wall is a frequent complication following plate fixation of clavicular shaft fractures. This is usually attributed to damage to branches of the supraclavicular nerve caused by the surgical approach. We investigate whether the use of an incision perpendicular to the long axis of the clavicle (vertical incision) rather than one parallel to it (horizontal incision) is associated with reduced post-operative numbness and improved patient satisfaction. Methods We retrospectively assessed a group of patients who underwent plate fixation of a fractured clavicle at our institution. Using a patient-completed questionnaire, we compared differences in numbness, scar satisfaction, pain, and overall satisfaction with the operation, between those who received a horizontal incision ( n = 21) versus those treated using a vertical incision ( n = 14). Results The likelihood of experiencing post-operative numbness was less in the vertical incision group. Those who had undergone vertical incisions also reported a significantly reduced degree of numbness and significantly less awareness of the numbness with clothing and shoulder straps. There was no statistically significant difference between the groups in terms of pain and scar satisfaction. Patients who reported being most bothered by their numbness also tended to report the highest dissatisfaction with the operation. Conclusion Vertical incisions for plate fixation of clavicular shaft fractures may be associated with reduced post-operative numbness and avoid some cases of patient dissatisfaction. Surgeons should consider using this approach in plate fixation of clavicle fractures.

Upper-limb somatosensory evoked potential monitoring in lumbosacral spine surgery: a prognostic marker for position-related ulnar nerve injury

Background context Somatosensory evoked potential (SSEP) is used to monitor integrity of the brain, spinal cord, and nerve roots during spinal surgery. It records the electrical potentials from the scalp after electrical stimulation of the peripheral nerves of the upper or lower limbs. The standard monitoring modality in lumbosacral spine surgery includes lower-limb SSEP and electromyography (EMG). Upper-limb SSEP monitoring has also been used to detect and prevent brachial plexopathy and peripheral nerve injury in thoracic and lumbosacral spine surgeries. We routinely monitor lower-limb SSEP and EMG in lumbosacral spine procedures at our institution. However, a few patients experienced postoperative numbness and/or pain in their ulnar distribution with uneventful lower-limb SSEP and EMG. Purpose We hypothesized that the postoperative upper extremity paresis in lumbosacral surgeries may result from compression and/or stretch of the brachial plexus and/or ulnar nerve while the patients were in prone position. Using upper-limb SSEP, we investigated whether we observe any significant change in the SSEP, and if so, whether we can prevent or reduce frequency of postoperative upper extremity deficits. Study design/setting In this prospective study, we monitored upper-limb SSEP, in addition to lower-limb SSEP and EMG, in 230 elective, posterior lumbosacral spinal procedures. All operations were performed by a group of four neurosurgeons. Patient sample One hundred and thirty-one female and 99 male with an age range of 28 to 86 years between January 2004 and December 2005 were studied. Outcome measures Amplitude and latency of upper-limb or ulnar SSEP were continuously compared with those of the baseline. A greater than or equal to 50% decrease in SSEPs amplitude and/or a greater than or equal to 10% increase in latency were considered to be significant. Methods After intubation, patients were positioned prone on Jackson or Andrews spinal table. Anesthesia was maintained with inhalant gas (desflurane or sevoflurane) and propofol infusion with and without minimal infusion of narcotics (fentanyl, sufentanyl, or remifentanil). Intraoperative neurophysiologic monitoring of upper-limb or ulnar SSEP was achieved by continuously recording cortical and subcortical responses after alternate stimulation of the ulnar nerve at the wrist. In our institutional protocol, a greater than or equal to 50% decrease in SSEPs amplitude and/or a greater than or equal to 10% increase in latency were considered to be significant to alert the operating surgeons. When significant changes occurred, the surgeon was immediately notified. Also, reevaluation of vital signs, depth of anesthesia, and patient's position, and technical troubleshootings were subsequently followed. Results We observed a greater than or equal to 50% decrease in amplitude of ulnar SSEP in 10 patients without significant changes in lower-limb SSEP (peroneal or posterior tibial nerve SSEP) or EMG during surgery. Eight patients had changes in unilateral limbs, and two patients had changes in bilateral limbs. Two patients with significant changes in unilateral limbs showed changes twice. The mean SSEP amplitude for the 14 changes was 29.2±3.1% (mean±SEM, standard error of mean) of the baseline value at the average surgical time of 60±1.5 minutes. With repositioning of the arms, the amplitudes were immediately restored with the average of 70.2±7.1% (n=14) of the baseline value. The mean amplitude of upper-limb SSEP was 73.4±8.7% (n=12) of the baseline at wound closure. The average surgical time was 154±29.2 minutes per case for the 10 patients. There was no documented postoperative upper extremity paresis in all 230 patients. Conclusions The present study demonstrates that upper-limb SSEP monitoring could detect position-related ulnar neuropathy in 5.2% of the patients undergoing lumbosacral spine surgery.

Anterior Palate Sensory Impairment after Septal Surgery

This study was performed to present a series of patients who experienced anterior palatal sensory impairment after nasal septal surgery. This phenomenon has not been reported in the English literature to date. We reviewed 107 septal surgeries done by the same surgeon over a 3-year period. One hundred one surgeries were septoplasty by technique of submucous resection, three surgeries were septal perforation repairs using a mucosal advancement flap from the nasal floor, two surgeries were excisions of benign septal neoplasms, and one surgery was a closed reduction of a nasal septal fracture. Overall, 3/107 patients (2.8%) experienced postoperative numbness of the anterior palate. Two of these patients underwent septoplasty, and the third patients underwent repair of septal perforation. A chisel was used to resect a portion of the maxillary crest posterior to the nasal spine in 11 patients, including the 3 patients who reported postoperative numbness. Suction cautery was also used in one of the 3 patients to address bleeding of the nasopalatine artery. Two patients reported concomitant palatal paresthesias with numbness, and both had recovery of normal sensation at 3 months follow-up. The third patient, in whom cautery was used, continued to experience numbness 1 year postoperatively. Sensory impairment of the anterior palate may result from surgery of the nasal septum and appears to be associated with chisel of the maxillary crest. Cautery should be avoided near the nasopalatine foramen. The relevant surgical anatomy of the nasopalatine nerve is reviewed and discussed in the context of these cases.