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Open access

Phantom limb pain, traumatic neuroma, or nerve sheath tumor? Illustrative case

Patrick J Halloran, E. Antonio Chiocca, and Andres Santos

BACKGROUND

Phantom limb pain and traumatic neuromas are not commonly seen in neurosurgical practice. These conditions can present with similar symptoms; however, management of traumatic neuroma is often surgical, whereas phantom limb pain is treated with conservative measures.

OBSERVATIONS

A 77-year-old female patient with a long-standing history of an above-the-knee amputation experienced severe pain in her right posterior buttocks area for several years’ duration, attributed to phantom limb pain, which radiated down the stump of her leg and was treated with a variety of conservative measures. A recent exacerbation of her pain led to a prolonged hospitalization with magnetic resonance imaging of her leg stump, revealing a mass in the sciatic notch, at a relative distance from the stump. The anatomical location of the mass on the sciatic nerve in the notch led to a presumed radiological diagnosis of nerve sheath tumor, for which she underwent excision. At surgery, a neuroma of the proximal portion of the transected sciatic nerve that had retracted from the amputated stump to the notch was diagnosed.

LESSONS

Traumatic neuromas of transected major nerves after limb amputation should be considered in the differential diagnosis of phantom limb pain.

Open access

Minimally invasive resection of a prominent transverse process in neurogenic thoracic outlet syndrome: new application for a primarily spinal approach. Illustrative case

Marc Hohenhaus, Johann Lambeck, Nico Kremers, Jürgen Beck, Christoph Scholz, and Ulrich Hubbe

BACKGROUND

The optimal surgical approach to treat neurogenic thoracic outlet syndrome (nTOS) depends on the individual patient’s anatomy as well as the surgeon’s experience. The authors present a minimally invasive posterior approach for the resection of a prominent transverse process to reduce local muscular trauma.

OBSERVATIONS

A 19-year-old female presented with painful sensations in the right arm and severe fine-motor skill dysfunction in the right hand, each of which had been present for several years. Further examination confirmed affected C8 and T1 areas, and imaging showed an elongated C7 transverse process displacing the lower trunk of the brachial plexus. Decompression of the plexus structures by resection of the C7 transverse process was indicated, owing to persistent neurological effects. Surgery was performed using a minimally invasive posterior approach in which the nuchal soft tissue was bluntly dissected by dilatators and resection of the transverse process was done microscopically through a tubular retractor. The postoperative course showed a sufficient reduction of pain and paresthesia.

LESSONS

The authors describe a minimally invasive posterior approach for the treatment of nTOS with the aim of providing indirect relief of strain on brachial plexus structures. The advantages of this technique include a small skin incision and minor soft tissue damage.

Open access

“Winged” Eagle’s syndrome: neurophysiological findings in a rare cause of spinal accessory nerve palsy. Illustrative cases

Eric C Mitchell, Kitty Y Wu, Fawaz Siddiqi, John Yoo, Pavlo Ohorodnyk, Douglas Ross, and Thomas A Miller

BACKGROUND

Eagle’s syndrome (ES) classically describes dysphagia, globus sensation, and otalgia from an elongated and calcified styloid process or stylohyoid ligament. Compression of the spinal accessory nerve (SAN) has not been reported as an associated feature of ES or related variants.

OBSERVATIONS

The authors describe two cases of an atypical “winged” variant with SAN palsy resulting from compression by a posteriorly angulated or calcified styloid process. Both patients exhibited lateral scapular winging and atrophy of the trapezius and sternocleidomastoid muscles. Electrophysiological studies demonstrated motor unit preservation; therefore, surgical exploration, styloidectomy, and SAN decompression were performed through a transcervical approach. Postoperatively, both patients had improvements in pain and shoulder mobility, the return of muscle strength, and electrophysiological evidence of trapezius reinnervation.

LESSONS

Compression of the SAN, which can be identified both clinically and on electrodiagnostic testing, is an atypical finding that can result from a posteriorly angulated or calcified styloid process. This winged variant of ES should be included in the differential for SAN palsy, and a multidisciplinary approach is recommended for assessment and management.

Open access

Iatrogenic contralateral foraminal stenosis following lumbar spine fusion surgery: illustrative cases

Faisal Konbaz, Sahar Aldakhil, Fahad Alhelal, Majed Abalkhail, Anouar Bourghli, Khawlah Ateeq, and Sami Aleissa

BACKGROUND

Lumbar spine fusion is the mainstay treatment for degenerative spine disease. Multiple potential complications of spinal fusion have been found. Acute contralateral radiculopathy postoperatively has been reported in previous literature, with unclear underlying pathology. Few articles reported the incidence of contralateral iatrogenic foraminal stenosis after lumbar fusion surgery. The aim of current article is to explore the possible causes and prevention of this complication.

OBSERVATIONS

The authors present 4 cases in which patients developed acute postoperative contralateral radiculopathy requiring revision surgery. In addition, we present a fourth case in which preventive measures have been applied. The aim of this article was to explore the possible causes and prevention to this complication.

LESSONS

Iatrogenic foraminal stenosis of the lumbar spine is a common complication; preoperative evaluation and middle intervertebral cage positioning are needed to prevent this complication.

Open access

Anesthesia-induced Takotsubo cardiomyopathy in trigeminal neuralgia: illustrative case

Guido Mazzaglia, Giulio Bonomo, Emanuele Rubiu, Paolo Murabito, Alessia Amato, Paolo Ferroli, and Marco Gemma

BACKGROUND

Takotsubo syndrome (TS) represents a form of nonischemic cardiomyopathy characterized by sudden and temporary weakening of the myocardium. Many data suggest a primary role for sympathetic overstimulation in its pathogenesis. Nevertheless, these correlates are less easily identified during anesthesia.

OBSERVATIONS

A 50-year-old female patient with a 4-year history of drug-resistant left trigeminal neuralgia. She was scheduled for surgical microvascular decompression. In the operating room, after induction of general anesthesia and oral intubation, the electrocardiogram revealed a significant ST segment elevation along with a sudden decrease in systolic blood pressure and heart rate. Administration of atropine caused a conversion into ventricular tachycardia. The advanced cardiac life support protocols were applied with prompt defibrillation and rapid recovery at sinus rhythm. A transthoracic echocardiogram revealed apical akinesia with ballooning of the left ventricle with a reduction of systolic function. An emergency coronary arteriography was performed, showing normal epicardial coronary vessels. After 4 days, echocardiography revealed normalization of the left ventricular function with improvement of the ejection fraction.

LESSONS

In patients affected by trigeminal neuralgia, chronic pain can lead to a state of adrenergic hyperactivation, which can promote TS during the induction of general anesthesia, probably through the trigeminocardiac reflex.

Open access

Iatrogenic neurological injury after radiofrequency ablation and epidural steroid injections: illustrative cases

Lisa B. E. Shields, Vasudeva G. Iyer, Yi Ping Zhang, and Christopher B. Shields

BACKGROUND

Neck pain is often chronic and disabling. Cervical facet joint injections and epidural steroid injections are frequently used to manage chronic neck pain and cervicogenic headaches. While minimal side effects are commonly associated with these treatments, severe complications are exceedingly rare.

OBSERVATIONS

The authors report 4 cases of iatrogenic neurological injury after radiofrequency ablation (RFA) and epidural steroid injections. One patient experienced left shoulder, scapular, and arm pain with left arm and hand weakness that developed immediately after RFA for chronic neck pain. Electromyography/nerve conduction velocity (EMG/NCV) studies confirmed denervation changes in the left C8–T1 distribution. Three patients complained of numbness and weakness of the hands immediately after an interlaminar cervical epidural block. One of these patients underwent EMG/NCV that confirmed denervation changes occurring in the left C8–T1 distribution.

LESSONS

Spine surgeons and pain management specialists should be aware of neurological injuries that may occur after cervical RFA and epidural steroid injections, especially after a multilevel cervical procedure and with severe cervical spinal stenosis. EMG/NCV studies plays an important role in detecting and localizing neurological injury and in differentiating from conditions that mimic cervical root injuries, including brachial plexus trauma due to positioning and Parsonage-Turner syndrome.