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Open access

Unrecognized sciatic lipomatosis of the nerve diagnosed by telehealth: illustrative case

Tomas Marek, Noah D Spinner, and Robert J Spinner

BACKGROUND

Lipomatosis of the nerve (LN) is a rare congenital hamartoma in which abundant fibroadipose tissue is found within the epineurium of peripheral nerves. It is frequently associated with nerve territory overgrowth affecting bones or soft tissues. The clinicoradiological features are well known and pathognomonic.

OBSERVATIONS

A 38-year-old female was evaluated via telehealth for worsened sciatica after the resection of a sciatic notch lipoma, after having been evaluated over a decade for symptoms. Virtual physical examination revealed previously unrecognized subtle limb discrepancy (i.e., overgrowth). Although preoperative radiographs were unavailable during the initial evaluation, postoperative magnetic resonance imaging studies showed evidence of sciatic nerve LN. A diagnosis of LN and nerve territory overgrowth was established.

LESSONS

Despite its limitations, telehealth can be an effective alternative or adjunct to in-person evaluations in making complex diagnoses. Dedicated examination without clinical suspicion can miss subtle findings. An iterative process prompted by a focused history, knowledge of clinical associations, and pattern recognition can facilitate an accurate diagnosis without obvious face-to-face visual clues. In patients with rare disorders, asynchronous evaluation allows in-person visits to be supplemented by subsequent telehealth virtual physical exam findings. This case illustrates how examination via telehealth can be used to effectively diagnose a rare syndrome.

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Lateral pectoral nerve transfer for spinal accessory nerve injury

Andrés A. Maldonado and Robert J. Spinner

Spinal accessory nerve (SAN) injury results in loss of motor function of the trapezius muscle and leads to severe shoulder problems. Primary end-to-end or graft repair is usually the standard treatment. The authors present 2 patients who presented late (8 and 10 months) after their SAN injuries, in whom a lateral pectoral nerve transfer to the SAN was performed successfully using a supraclavicular approach.

Open access

Delayed motor weakness following peripheral nerve schwannoma resection: illustrative cases

Rohin Singh and Robert J. Spinner

BACKGROUND

Delayed facial palsy (DFP) after vestibular schwannoma resection is a well-documented, yet poorly understood condition. The exact pathophysiological mechanisms of DFP are unknown, although diminished intraoperative nerve response has been shown to be a prognostic factor. To date, no such condition has been described in regard to peripheral nerve schwannomas.

OBSERVATIONS

Here the authors present the first reported cases of delayed motor weakness (DMW) after peripheral schwannoma resection of the ulnar nerve at the elbow and peroneal nerve in the popliteal fossa. Both patients presented with a mass lesion and radiating paresthesias and had normal motor function preoperatively. Immediately after surgical resection, the patients had full strength. Within 24 hours, both patients exhibited marked weakness that gradually resolved over the course of several weeks.

LESSONS

DMW after peripheral schwannoma resection is a rare condition likely akin to delayed facial nerve palsy after VS resection. The mechanism of this phenomenon remains unknown, although symptoms appear to self-resolve with time. A better understanding of the processes driving this condition may allow for therapies that can expedite and improve long-term outcomes.

Restricted access

Major nerve injury after contraceptive implant removal: case illustration

Carlos E. Restrepo and Robert J. Spinner

Open access

Selective denervation for cervical dystonia

Megan M. J. Bauman, Nikita Lakomkin, and Robert J. Spinner

Cervical dystonia (spasmodic torticollis) is a condition that involves sustained, involuntary contraction of neck and shoulder muscles, leading to abnormal movements and head posture. The authors present the case of a 41-year-old man with severe right rotational torticollis for 1.5 years due to predominant right cervical paraspinal and left sternocleidomastoid muscle hyperactivity. Following failed medical management, the patient elected to undergo surgical treatment for his torticollis. In their video, the authors discuss the steps of selective denervation using a modified Bertrand procedure, highlighting the associated anatomy and surgical planes. At the 1.5-year follow-up, the patient had no pain and his head position remained straight.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.9.FOCVID2291

Free access

Targeted fascicular biopsy in a patient with prostate cancer

Jonathan J. Stone, Megan C. Kaszuba, and Robert J. Spinner

Patients who present with a history of cancer and the new onset of lumbosacral or peripheral neuropathy should be evaluated for the potential of metastasis. Targeted fascicular biopsy can be useful to diagnose atypical lesions within peripheral nerves in patients with major or progressive neurological deficits. In this video, the authors demonstrate the technique of targeted fascicular biopsy of the sciatic nerve in a 63-year-old man with a history of prostate cancer.

The video can be found here: https://youtu.be/PTOX9XxNBDU.

Open access

Occult lipomatosis of the nerve as part of macrodystrophia lipomatosa: illustrative case

Tomas Marek, Kimberly K. Amrami, and Robert J. Spinner

BACKGROUND

Macrodystrophia lipomatosa (MDL) is characterized by progressive overgrowth affecting soft tissues and bony structures and is part of lipomatous overgrowth syndromes. MDL has been associated with lipomatosis of the nerve (LN), an adipose lesion of nerve that has a pathognomonic magnetic resonance imaging (MRI) appearance as well as a mutation in the PIK3CA gene. The authors present a case of occult LN in the setting of MDL.

OBSERVATIONS

A 2-year-old boy with progressive soft tissue overgrowth of his proximal right lower extremity was initially diagnosed with neurofibromatosis type 1 (NF1). At our institution, NF1 as well as other overgrowth syndromes including PTEN hamartoma tumor syndrome were excluded. He was diagnosed as having so-called MDL. Upon reinterpretation of the patient’s MRI studies, short-segment LN involving the proximal sciatic nerve and part of lumbosacral plexus was identified. He underwent 2 debulking/liposuction procedures for soft tissue overgrowth. Genetic testing of tissue revealed a mutation in PIK3CA.

LESSONS

Thorough clinical examination (for signs of overgrowth) as well as an MRI study of the entire neural pathway is a critical part of the diagnostic workup to evaluate for LN. The authors believe that an increasing association of LN, even when occult, will emerge that will explain many cases with marked nerve-territory overgrowth.

Open access

Selective upper trunk posterior division fascicular nerve transfer for proximal spinal accessory neuropathy: illustrative case

Kitty Y Wu and Robert J Spinner

BACKGROUND

Spinal accessory nerve palsy can lead to severe shoulder pain and weakness, lateral scapular winging, and limitations in overhead activity. It most often occurs because of iatrogenic injury from procedures within the posterior triangle of the neck.

OBSERVATIONS

The authors present the case of a 39-year-old male with symptoms of right shoulder weakness and neck pain after a total thyroidectomy and right neck dissection. With ultrasound findings of a neuroma-in-continuity but no clinical or electromyographic signs of reinnervation at 6 months, surgical intervention was indicated. Operative exploration confirmed a very proximal injury and nonconducting neuroma-in-continuity of the spinal accessory nerve. A selective distal nerve transfer from the posterior division of the upper trunk was performed. At the 2.5-year follow-up, the patient demonstrated excellent recovery of full active shoulder abduction and forward flexion, return to full-time employment, and mild residual scapular winging.

LESSONS

Distal nerve transfers should be considered in cases of late presentation when primary repair is not possible or long interpositional grafts are required. Selective fascicular transfer from the posterior division of the upper trunk provides the advantages of a single incision, short reinnervation time, and synergistic donor function to facilitate motor reeducation.

Restricted access

Posterior interosseous nerve discontinuity due to compression by lipoma: report of 2 cases

Andrés A. Maldonado, Benjamin M. Howe, and Robert J. Spinner

Paralysis of the posterior interosseous nerve (PIN) secondary to compression is a rare clinical condition. Entrapment neuropathy may occur at fibrous bands at the proximal, middle, or distal edge of the supinator. Tumors are a relatively rare but well-known potential cause. The authors present 2 cases of PIN lesions in which compression by a benign lipoma at the level of the elbow resulted in near transection (discontinuity) of the nerve. They hypothesize a mechanism—a “sandwich effect”—by which compression was produced from below by the mass and from above by a fibrous band in the supinator muscle (i.e., the leading edge of the proximal supinator muscle [arcade of Fröhse] in one patient and the distal edge of the supinator muscle in the other). A Grade V Sunderland nerve lesion resulted from the advanced, chronic compression. The authors are unaware of a similar case with such an advanced pathoanatomical finding.

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Falls and peripheral nerve injuries: an age-dependent relationship

Kimon Bekelis, Symeon Missios, and Robert J. Spinner

OBJECT

Despite the growing epidemic of falls, the true incidence of peripheral nerve injuries (PNIs) in this patient population remains largely unknown.

METHODS

The authors performed a retrospective cohort study of 839,210 fall-injured patients who were registered in the National Trauma Data Bank (NTDB) between 2009 and 2011 and fulfilled the inclusion criteria. Regression techniques were used to investigate the association of demographic and socioeconomic factors with the rate of PNIs in this patient population. The association of age with the incidence of PNIs was also investigated.

RESULTS

Overall, 3151 fall-injured patients (mean age 39.1 years, 33.3% females) sustained a PNI (0.4% of all falls). The respective incidence of PNIs was 2.7 per 1000 patients for ground-level falls, 4.9 per 1000 patients for multilevel falls, and 4.5 per 1000 patients for falls involving force. This demonstrated a rapid increase in the first 2 decades of life, with a maximum rate of 1.1% of all falls in the 3rd decade, followed by a slower decline and eventual plateau in the 7th decade. In a multivariable analysis, the association of PNIs with age followed a similar pattern with patients 20–29 years of age, demonstrating the highest association (OR 2.34 [95% CI 2.0–2.74] in comparison with the first decade of life). Falls involving force (OR 1.25 [95% CI 1.14–1.37] in comparison with multilevel falls) were associated with a higher incidence of PNIs. On the contrary, female sex (OR 0.87 [95% CI 0.80–0.84]) and ground-level falls (OR 0.79 [95% CI 0.72–0.86]) were associated with a lower rate of PNIs.

CONCLUSIONS

Utilizing a comprehensive national database, the authors demonstrated that PNIs are more common than previously described in fall-injured patients and identified their age distribution. These injuries are associated with young adults and falls of high kinetic energy.