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Ricardo Segal, Usha Machiraju and Mark Larkins

✓ Segmental ulnar neuropathy has been reported as a result of ulnar nerve compression due to posttraumatic false aneurysms of the ulnar artery and, more infrequently, due to thrombosis or true aneurysms of the same vessel. The authors present a case of segmental sensory ulnar neuropathy in the wrist which intraoperatively demonstrated impingement on the ulnar nerve by a tortuous ulnar artery. The symptomatic relief and electrophysiological improvement that occurred immediately following neurovascular decompression confirm that the vascular anomaly was the cause of neuropathy. Pulsatile pressure applied to the nerve trunk may have triggered ectopic stimulation of sensory fibers manifested by a tingling and burning sensation. There was immediate resolution of paresthesia following mobilization of the impinging vessel from the nerve. Subsequent rapid electrophysiological recovery may be explained by improvement in focal nerve microcirculation following vascular decompression. Tortuosity (megadolichoectatic anomaly) of intracranial arteries has been related to cranial nerve or brain-stem dysfunction; however, this appears to be the first report in the literature of a case in which such association has been found to occur extracranially, involving a peripheral nerve.

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B. Fairburn and I. M. Larkin

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Randall R. McCafferty, Michael J. Harrison, Laszlo B. Tamas and Mark V. Larkins

✓ A retrospective review was conducted on the records and radiographs of six symptomatic patients and one asymptomatic patient with Forestier's disease. No other series of patients with this disease is found in the neurosurgical literature. Forestier's disease, also known as diffuse idiopathic skeletal hyperostosis (DISH), is an idiopathic rheumatological abnormality in which exuberant ossification occurs along ligaments throughout the body, but most notably the anterior longitudinal ligament of the spine. It affects older men predominantly; all of our patients were men older than 60 years of age. The disease is usually asymptomatic; however, dyspnea, dysphagia, spinal cord compression, and peripheral nerve entrapment have all been documented in association with the disorder. Five of the six symptomatic patients presented with dysphagia due to esophageal compression by calcified anterior longitudinal ligaments, and one patient developed recurrent spinal stenosis when scar tissue from a previous decompressive laminectomy became calcified. All patients responded well to surgery. Two of the four patients who underwent removal of cervical osteophytes required several months following surgery for the dysphagia to resolve. This would support the hypothesis that not all cases of dysphagia in Forestier's disease are due to mechanical compression. Dysphagia may result from inflammatory changes that accompany fibrosis in the wall of the esophagus or from esophageal denervation. Evaluation of dysphagia even in the presence of Forestier's disease must rule out occult malignancy. The authors' experience suggests that dysphagia in the setting of Forestier's disease is an underrecognized entity amenable to surgical intervention.

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Fred G. Barker II, Peter J. Jannetta, David J. Bissonette, Philip T. Shields, Mark V. Larkins and Hae Dong Jho

✓ The authors report the results of 782 microvascular decompression procedures for hemifacial spasm in 703 patients (705 sides), with follow-up study from 1 to 20 years (mean 8 years). Of 648 patients who had not undergone prior intracranial procedures for hemifacial spasm, 65% were women; their mean age was 52 years, and the mean preoperative duration of symptoms was 7 years. The onset of symptoms was typical in 92% and atypical in 8%. An additional 57 patients who had undergone prior microvascular decompression elsewhere were analyzed as a separate group. Patients were followed prospectively with annual questionnaires.

Kaplan-Meier methods showed that among patients without prior microvascular decompression elsewhere, 84% had excellent results and 7% had partial success 10 years postoperatively. Subgroup analyses (Cox proportional hazards model) showed that men had better results than women, and patients with typical onset of symptoms had better results than those with atypical onset. Nearly all failures occurred within 24 months of operation; 9% of patients underwent reoperation for recurrent symptoms. Second microvascular decompression procedures were less successful, whether the first procedure was performed at Presbyterian-University Hospital or elsewhere, unless the procedure was performed within 30 days after the first microvascular decompression. Patient age, side and preoperative duration of symptoms, history of Bell's palsy, preoperative presence of facial weakness or synkinesis, and implant material used had no influence on postoperative results.

Complications after the first microvascular decompression for hemifacial spasm included ipsilateral deaf ear in 2.6% and ipsilateral permanent, severe facial weakness in 0.9% of patients. Complications were more frequent in reoperated patients. In all, one operative death (0.1%) and two brainstem infarctions (0.3%) occurred. Microvascular decompression is a safe and definitive treatment for hemifacial spasm with proven long-term efficacy.

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M. Benjamin Larkin, Erin K. M. Graves, Jason H. Boulter, Nicholas S. Szuflita, R. Michael Meyer, Michael E. Porambo, John J. Delaney and Randy S. Bell

OBJECTIVE

There are limited data concerning the long-term functional outcomes of patients with penetrating brain injury. Reports from civilian cohorts are small because of the high reported mortality rates (as high as 90%). Data from military populations suggest a better prognosis for penetrating brain injury, but previous reports are hampered by analyses that exclude the point of injury. The purpose of this study was to provide a description of the long-term functional outcomes of those who sustain a combat-related penetrating brain injury (from the initial point of injury to 24 months afterward).

METHODS

This study is a retrospective review of cases of penetrating brain injury in patients who presented to the Role 3 Multinational Medical Unit at Kandahar Airfield, Afghanistan, from January 2010 to March 2013. The primary outcome of interest was Glasgow Outcome Scale (GOS) score at 6, 12, and 24 months from date of injury.

RESULTS

A total of 908 cases required neurosurgical consultation during the study period, and 80 of these cases involved US service members with penetrating brain injury. The mean admission Glasgow Coma Scale (GCS) score was 8.5 (SD 5.56), and the mean admission Injury Severity Score (ISS) was 26.6 (SD 10.2). The GOS score for the cohort trended toward improvement at each time point (3.6 at 6 months, 3.96 at 24 months, p > 0.05). In subgroup analysis, admission GCS score ≤ 5, gunshot wound as the injury mechanism, admission ISS ≥ 26, and brain herniation on admission CT head were all associated with worse GOS scores at all time points. Excluding those who died, functional improvement occurred regardless of admission GCS score (p < 0.05). The overall mortality rate for the cohort was 21%.

CONCLUSIONS

Good functional outcomes were achieved in this population of severe penetrating brain injury in those who survived their initial resuscitation. The mortality rate was lower than observed in civilian cohorts.

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R. Michael Meyer, M. Benjamin Larkin, Nicholas S. Szuflita, Chris J. Neal, Jeffrey M. Tomlin, Rocco A. Armonda, Jeffrey A. Bailey and Randy S. Bell

OBJECTIVE

Traumatic brain injury (TBI) is independently associated with deep vein thrombosis (DVT) and pulmonary embolism (PE). Given the numerous studies of civilian closed-head injury, the Brain Trauma Foundation recommends venous thromboembolism chemoprophylaxis (VTC) after severe TBI. No studies have specifically examined this practice in penetrating brain injury (PBI). Therefore, the authors examined the safety and effectiveness of early VTC after PBI with respect to worsening intracranial hemorrhage and DVT or PE.

METHODS

The Kandahar Airfield neurosurgery service managed 908 consults between January 2010 and March 2013. Eighty of these were US active duty members with PBI, 13 of whom were excluded from analysis because they presented with frankly nonsurvivable CNS injury or they died during initial resuscitation. This is a retrospective analysis of the remaining 67 patients.

RESULTS

Thirty-two patients received early VTC and 35 did not. Mean time to the first dose was 24 hours. Fifty-two patients had blast-related PBI and 15 had gunshot wounds (GSWs) to the head. The incidence of worsened intracranial hemorrhage was 16% after early VTC and 17% when it was not given, with the relative risk approaching 1 (RR = 0.91). The incidence of DVT or PE was 12% after early VTC and 17% when it was not given (RR = 0.73), though this difference was not statistically significant.

CONCLUSIONS

Early VTC was safe with regard to the progression of intracranial hemorrhage in this cohort of combat-related PBI patients. Data in this study suggest that this intervention may have been effective for the prevention of DVT or PE but not statistically significantly so. More research is needed to clarify the safety and efficacy of this practice.