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Amgad Hanna

OBJECTIVE

Meralgia paresthetica causes pain, burning, and loss of sensation in the anterolateral thigh. Surgical treatment traditionally involves neurolysis or neurectomy of the lateral femoral cutaneous nerve (LFCN). After studying and publishing data on the anatomical feasibility of LFCN transposition, the author presents here the first case series of patients who underwent LFCN transposition.

METHODS

Nineteen patients with meralgia paresthetica were treated in the Department of Neurological Surgery at University of Wisconsin between 2011 and 2016; 4 patients underwent simple decompression, 5 deep decompression, and 10 medial transposition. Data were collected prospectively and analyzed retrospectively. No randomization was performed. The groups were compared in terms of pain scores (based on a numeric rating scale) and reoperation rates.

RESULTS

The numeric rating scale scores dropped significantly in the deep-decompression (p = 0.148) and transposition (p < 0.0001) groups at both the 3- and 12-month follow-up. The reoperation rates were significantly lower in the deep-decompression and transposition groups (p = 0.0454) than in the medial transposition group.

CONCLUSIONS

Both deep decompression and transposition of the LFCN provide better results than simple decompression. Medial transposition confers the advantage of mobilizing the nerve away from the anterior superior iliac spine, giving it a straighter and more relaxed course in a softer muscle bed.

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Amgad Hanna

OBJECTIVE

Meralgia paresthetica causes dysesthesias and burning in the anterolateral thigh. Surgical treatment includes nerve transection or decompression. Finding the nerve in surgery is very challenging. The author conducted a cadaveric study to better understand the variations in the anatomy of the lateral femoral cutaneous nerve (LFCN).

METHODS

Twenty embalmed cadavers were used for this study. The author studied the LFCN's relationship to different fascial planes, and the distance from the anterior superior iliac spine (ASIS).

RESULTS

A complete fascial canal was found to surround the nerve completely in all specimens. The canal starts at the inguinal ligament proximally and follows the nerve beyond its terminal branches. The nerve could be anywhere from 6.5 cm medial to the ASIS to 6 cm lateral to the ASIS. In the latter case, the nerve may lodge in a groove in the iliac crest. Other anatomical variations found were the LFCN arising from the femoral nerve, and a duplicated nerve. A thick nerve was found in 1 case in which it was riding over the ASIS.

CONCLUSIONS

The variability in the course of the LFCN can create difficulty in surgical exposure. The newly defined LFCN canal renders exposure even more challenging. This calls for high-resolution pre- or intraoperative imaging for better localization of the nerve.

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Amgad Hanna

OBJECT

Brachial plexus (BP) diagrams in most textbooks and papers represent the branches and divisions of the upper trunk (UT) in the following sequence from cranial to caudal: suprascapular nerve, anterior division, and then posterior division. This concept contradicts what is seen in the operating room and is noticed by most peripheral nerve surgeons. This cadaveric study was conducted to look specifically at the exact pattern of branching of the upper trunk of the BP.

METHODS

Ten cadavers (20 BPs) were dissected. Both supra- and infraclavicular exposures were performed. The clavicle was retracted or resected to identify the divisions of the BP. A posterior approach was used in 2 cases.

RESULTS

In all dissections the origin of the posterior division was in a more cranial and dorsal plane in relation to the anterior division. In most dissections the supra scapular nerve branched off distally from the UT, giving it the appearance of a trifurcation, taking off just cranial and dorsal to the posterior division. The branching pattern of the UT consistently had the following sequential arrangement from cranial and posterior to caudal and anterior: suprascapular nerve (S), posterior division (P), and anterior division (A), hence the acronym SPA.

CONCLUSIONS

Supraclavicular exposure of the BP exposes only the trunks and divisions. Recognizing the “SPA” arrangement of the branches helps in identifying the correct targets for neurotization, especially given that these 3 branches are the most common targets for BP repair. Understanding the anatomy means better surgical planning and better patient outcomes.

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Amgad Hanna

OBJECTIVE

Meralgia paresthetica causes pain, burning, and loss of sensation in the anterolateral thigh. Surgical treatment traditionally involves neurolysis or neurectomy of the lateral femoral cutaneous nerve (LFCN). After studying and publishing data on the anatomical feasibility of LFCN transposition, the author presents here the first case series of patients who underwent LFCN transposition.

METHODS

Nineteen patients with meralgia paresthetica were treated in the Department of Neurological Surgery at University of Wisconsin between 2011 and 2016; 4 patients underwent simple decompression, 5 deep decompression, and 10 medial transposition. Data were collected prospectively and analyzed retrospectively. No randomization was performed. The groups were compared in terms of pain scores (based on a numeric rating scale) and reoperation rates.

RESULTS

The numeric rating scale scores dropped significantly in the deep-decompression (p = 0.148) and transposition (p < 0.0001) groups at both the 3- and 12-month follow-up. The reoperation rates were significantly lower in the deep-decompression and transposition groups (p = 0.0454) than in the medial transposition group.

CONCLUSIONS

Both deep decompression and transposition of the LFCN provide better results than simple decompression. Medial transposition confers the advantage of mobilizing the nerve away from the anterior superior iliac spine, giving it a straighter and more relaxed course in a softer muscle bed.

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Amgad Hanna

OBJECTIVE

Iatrogenic nerve injuries are devastating to both the patient and the surgeon. This study focuses on the anatomical relationship of the palmar recurrent branch with the parent median nerve in an attempt to identify higher risk types.

METHODS

The palmar recurrent branch was dissected in 75 embalmed cadavers. The median nerve was divided into 4 sections from lateral to medial, defined as zones 1–4. The angle to the axial plane of the median nerve was also measured and classified as 0°, 45°, 60°, and 90°.

RESULTS

Accessory recurrent branches were found in 36.2% of cases. The recurrent branch originated from zone 1 in 32.42%, zone 2 in 61.54%, zone 3 in 6.04%, and zone 4 in 0%. These are respectively classified as types I, II, III, and IV. The motor branch made an angle with the median nerve of 0° in 17% of cases, 45° in 37.4%, 60° in 26.4%, and 90° in 19.2%. These are respectively classified as types A, B, C, and D.

CONCLUSIONS

Close attention should be paid to the potential anatomical variabilities when performing nerve surgeries. For the palmar recurrent branch, the more medial the origin and the greater the angle it makes with the median nerve, the more dangerous it is. This classification is helpful in unifying the language and comparing results.

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Clayton Haldeman and Amgad Hanna

Neurofibromas are benign tumors composed of different cell types from the peripheral nervous system. Neurofibromas infiltrate between nerve fascicles and do not have a discrete capsule. On MRI, they are T1 hypointense or isointense, T2 hyperintense, often with a “target sign,” and contrast enhancing. The video shows gross-total resection of a peroneal nerve neurofibroma presenting as a painful mass in the popliteal fossa. Incisions across a skin crease can be either oblique or zigzag, but never perpendicular to it. It is also key to expose normal nerve proximal and distal to the tumor. The patient had a good functional outcome.

The video can be found here: https://youtu.be/G74Zoa1Y2JM.

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Amgad Saddik Hanna and Xavier Morandi

✓ Anterior sacral meningocele was first described in 1837. Most reported cases were associated with complications, including meningitis and death, because of misdiagnosis or inappropriate surgical approach. The authors present a case of anterior sacral meningocele accidentally discovered during pregnancy and provide unique magnetic resonance imaging documentation. The pathogenesis, management, and surgical technique are discussed.

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Mark Corriveau, Jacob D. Lescher and Amgad S. Hanna

Peroneal neuropathy is a common pathology encountered by neurosurgeons. Symptoms include pain, numbness, and foot drop. When secondary to compression of the nerve at the fibular head, peroneal (fibular) nerve release is a low-risk procedure that can provide excellent results with pain relief and return of function. In this video, the authors highlight key operative techniques to ensure adequate decompression of the nerve while protecting the 3 major branches, including the superficial peroneal nerve, deep peroneal nerve, and recurrent genicular (articular) branches. Key steps include positioning, circumferential nerve dissection, fascial opening, isolation of the major branches, and closure.

The video can be found here: https://youtu.be/0y9oE8w1FIU.

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Clayton L. Haldeman, Christopher D. Baggott and Amgad S. Hanna

Historically, peripheral nerve surgery has relied on landmarks and fairly extensive dissection for localization of both normal and pathological anatomy. High-resolution ultrasonography is a radiation-free imaging modality that can be used to directly visualize peripheral nerves and their associated pathologies prior to making an incision. It therefore helps in localization of normal and pathological anatomy, which can minimize the need for extensive exposures. The authors found intraoperative ultrasound (US) to be most useful in the management of peripheral nerve tumors and neuromas of nerve branches that are particularly small or have a deep location. This study presents the use of intraoperative US in 5 cases in an effort to illustrate some of the applications of this useful surgical adjunct.

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Shabbar F. Danish, Amer Samdani, Amgad Hanna, Phillip Storm and Leslie Sutton

Object

Posterior fossa decompression with duraplasty is routinely used for the treatment of Chiari malformations. It has been traditionally believed that this procedure requires a watertight seal with primary closure of the dura with either pericranium or allograft. In this study, the authors evaluated two synthetic dural substitutes in this patient population for feasibility of use and identification of perioperative morbidity.

Methods

The authors evaluated 56 patients who underwent duraplasty with a synthetic collagen matrix (Dura-Gen) after suboccipital craniectomy and C-1 laminectomy, and 45 patients in whom the dural closure involved acellular human dermis (AlloDerm). Patients in both groups were assessed for the presence of a pseudomeningocele, wound infection, cerebrospinal fluid (CSF) leak, and the need for repeated operation either for wound revision or the placement of a ventriculoperitoneal shunt. Operative times for which DuraGen duraplasty was used were compared with those for AlloDerm closure.

In the DuraGen group, complications included five pseudomeningoceles (8.9%), two wound infections (3.6%), one CSF leak (1.8%), and four repeated operations (three shunt revisions and one reexploration; 7.1%) in nine patients. In the AlloDerm group, there were five pseudomeningoceles (11.1%), one wound infection (2.2%), one CSF leak (2.2%), and two repeated operations (two shunt revisions; 4.4%) in seven patients. The operative time associated with DuraGen was significantly shorter than that of duraplasty that required closure with sutures (92 minutes compared with 128 minutes, p < 0.01).

Conclusions

The synthetic dural substitutes DuraGen and AlloDerm provide a suitable alternative duraplasty with comparable complication rates. DuraGen requires a significantly shorter operative time than AlloDerm.