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Robert J. Spinner, John L. D. Atkinson and Robert L. Tiel

Object. Based on a large multicenter experience and a review of the literature, the authors propose a unifying theory to explain an articular origin of peroneal intraneural ganglia. They believe that this unifying theory explains certain intriguing, but poorly understood findings in the literature, including the proximity of the cyst to the joint, the unusual preferential deep peroneal nerve (DPN) deficit, the absence of a pure superficial peroneal nerve (SPN) involvement, the finding of a pedicle in 40% of cases, and the high (10–20%) recurrence rate.

Methods. The authors believe that peroneal intraneural lesions are derived from the superior tibiofibular joint and communicate from it via a one-way valve. Given access to the articular branch, the cyst typically dissects proximally by the path of least resistance within the epineurium and up the DPN and the DPN component of the common peroneal nerve (CPN) before compressing nearby SPN fascicles. The authors present objective evidence based on anatomical, clinical, imaging, operative, and histological data that support this unifying theory.

Conclusions. The predictable clinical presentation, electrical studies, imaging characteristics, operative observations, and histological findings regarding peroneal intraneural ganglia can be understood in terms of their origin from the superior tibiofibular joint, the anatomy of the articular branch, and the internal topography of the peroneal nerve that the cyst invades. Understanding the controversial pathogenesis of these cysts will enable surgeons to perform operations based on the pathoanatomy of the articular branch of the CPN and the superior tibiofibular joint, which will ultimately improve clinical results.

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Robert J. Spinner, Robert L. Tiel and David G. Kline

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Kimberly S. Harbaugh, Robert L. Tiel and David G. Kline

✓ Despite their benign histological appearance and the current literature composed primarily of case reports with favorable outcomes, ganglion cysts involving peripheral nerves (GCPNs) can cause permanent neurological deficits. The authors present a 27-year Louisiana State University Medical Center (LSUMC) experience with the surgical management of GCPNs. From 1968 to 1995, 27 patients were surgically treated for 27 cysts that involved nerves at nine locations. Cysts of the peroneal nerve were the most common, comprising 52% of the cases. Motor deficit, pain, and sensory changes were present in 83%, 78%, and 48% of cases, respectively. A history of acute trauma was noted in 22%. The mean follow-up duration in these cases was 61 months. Motor recovery was good in only 58% of cases and was related to the severity of the preoperative motor deficit. Pain resolved or was significantly improved in 89% of cases. Five patients underwent nine procedures before referral to LSUMC for treatment of recurrence of their ganglion cysts. None of these patients suffered recurrence after undergoing surgery at LSUMC. However, four additional patients (17%) experienced a total of six recurrences after undergoing their initial procedure. The mean time to recurrence for the patient group as a whole was 16 months. On the basis of their experience, the authors conclude that GCPNs can behave in an aggressive fashion. Patients should be counseled preoperatively about the potential for limited motor recovery and a significant chance for recurrence.

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Daniel H. Kim, Judith A. Murovic, Robert L. Tiel and David G. Kline

The authors review 118 operative brachial plexus gunshot wounds (GSWs), causing 293 element injuries that were managed over a 30-year period at Louisiana State University Health Sciences Center (LSUHSC). Retrospective chart reviews were performed. Using the LSUHSC grading system for motor sensory function, each element's grades were combined and averaged.

Most of the 293 injured elements were found to have gross continuity at operation and of 202 elements with complete neurological loss, only 16 (8%) exhibited total disruption. Of 293 injuries, 128 elements with complete or incomplete loss were not only in continuity when explored but also had positive intraoperative nerve action potentials (NAPs). After neurolysis, 120 of 128 elements in continuity (94%) improved to greater than or equal to Grade 3 function. Elements not regenerating early usually required repair. One hundred fifty-six of 202 completely or incompletely injured elements (77%) required resection and suture or graft repair based on intraoperative NAPs. Neurolysis achieved greater than or equal to Grade 3 results in 42 (91%) of 46 elements with complete loss. Suture repair resulted in good outcomes in 14 (67%) of 21 and in 73 (54%) of 135 undergoing graft repairs (1 to 3.5 cm length) and presenting with complete loss.

Of 91 incomplete elements, intraoperative NAPs were positive in 82 (90%) and 78 of 82 had good results. Nine had negative NAPs and six elements required suture repair. Three required grafts with results of greater than or equal to Grade 3 in five (83%) of six and two (67%) of three, respectively.

Based on 118 patient results with 293 injured elements, guidelines for the management of GSWs were established as described in this paper.

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Daniel H. Kim, Judith A. Murovic, Robert L. Tiel and David G. Kline

Object

The authors report the surgery-related results obtained in 143 patients with stretch-induced infraclavicular brachial plexus injuries (BPIs). The entire series comprised 1019 operative BPIs managed at the Louisiana State University Health Sciences Center between 1968 and 1998.

Methods

Infraclavicular lesions represented 143 (28%) of the total of 509 stretch injuries involving both the infra-and supraclavicular brachial plexus, of which 366 (72%) were supraclavicular lesions. The operative approach is thoroughly outlined, and common patterns and combinations of involvement of nerves peculiar to the infraclavicular area are presented. Overall, the results of suture and graft repair were favorable for the lateral and posterior cord and their outflows. Repair of medial cord–median nerve also yielded acceptable results. The results of medial cord and medial cord–ulnar nerve, however, were poor. The incidence of associated injuries in the infraclavicular as opposed to the supraclavicular area, including shoulder dislocation and fracture and humeral fractures as well as vascular injuries including axillary artery injury was higher. Results of a literature search supported the finding that vascular injuries were increased due to the juxtaposition of vessels among the brachial plexus elements.

Conclusions

Thus, although less common than their supraclavicular counterpart, infraclavicular stretch injury lesions when they occur are technically more difficult to treat and are associated with a higher incidence of vascular and dislocation/fraction injuries. Favorable results were obtained for lateral and posterior cord lesions and their outflows, with acceptable outcome after medial cord–median nerve stretch injury repair. The results of medial cord and medial cord to ulnar nerve, however, were poor.

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Aruna Ganju, Norbert Roosen, David G. Kline and Robert L. Tiel

Object. The authors conducted a retrospective study of 107 consecutive patients with 111 brachial plexus tumors surgically treated at the Louisiana State University Health Sciences Center (LSUHSC).

Methods. During a 12-year period, from 1986 to 1998, 371 patients with lesions of the brachial plexus underwent surgery at LSUHSC. Among this group, 107 patients harbored 111 tumors of the brachial plexus. Neural sheath tumors were the most commonly found and included 33 neurofibromas (20 of which were associated with von Recklinghausen disease), 36 schwannomas, and 12 malignant neural sheath tumors. Of the non—neural sheath tumors, 13 were benign and 17 were malignant. Presenting symptoms included pain (59%), palpable mass (52%), paresthesias (30%), and paresis (29%).

Anterior supraclavicular (82%) or posterior subscapular (18%) approaches were used to achieve gross-total (79%) or subtotal (21%) resection of tumor. The average follow-up period was 38.3 months or 3.2 years.

Seventy percent of patients with benign neural sheath tumors became free from pain postoperatively or reported improvement in their preoperative pain status. Function remained intact or improved in 50% and remained stable postoperatively in another 20% of cases.

Preservation of function was more likely in patients who presented intact and in those who had not undergone a previous attempted biopsy procedure or resection than in those in whom such manipulation had occurred.

Conclusions. Resection of most plexal tumors is technically feasible and associated with acceptable morbidity and mortality rates.

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Daniel H. Kim, Judith A. Murovic, Robert L. Tiel and David G. Kline

Object

The authors focus on injury mechanisms involved in 1019 operative brachial plexus injuries (BPIs) managed between 1968 and 1998 at Louisiana State University Health Sciences Center (LSUHSC).

Methods

Data regarding these mechanisms of injury were obtained via retrospective chart reviews of patients who had undergone operations at LSUHSC.

Five main mechanisms of injury to the brachial plexus occurred in the series. These included 509 stretch/contusion injuries (49%) with four patterns of presentation in 366 patients: 208 C5–T1 nerve injuries; 75 C5–7, 55 C5–6 injuries; and 28 involving the C8–T1 or C7–T1 nerves. Stretch/contusion injury was followed in frequency by gunshot wound (GSW), resulting in 118 injuries (12%). Most of the 293 involved plexus elements had some gross continuity when surgically exposed. Seventy-one lacerations involved the brachial plexus (7%), including 83 sharp lacerations caused by knives or glass; 61 blunt transections due to automobile metal, fan, and motor blades, chain saws, or animal bites.

Nontraumatic BPIs included 160 cases of thoracic outlet syndrome or 16% of the total of 1019 BPIs. There were 161 tumors (16%) of neural sheath origin including 55 solitary neurofibromas (34%), 32 neurofibromas associated with von Recklinghausen disease (20%), 54 schwannomas (34%), and 20 malignant nerve sheath tumors (20%) removed. Obstetrical BPI was not included in the original series; however, the current literature is reviewed in this paper.

Conclusions

The conclusion of this study is that the brachial plexus can be injured by multiple mechanisms of which stretch/contusion injury is the most frequently encountered, followed by GSWs.

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Daniel H. Kim, Judith A. Murovic, Robert L. Tiel and David G. Kline

Object. The authors present a retrospective analysis of 119 surgically treated femoral nerve lesions at intrapelvic and thigh levels seen at the Louisiana State University Health Sciences Center.

Methods. Femoral nerve lesions treated between 1967 and 2000, (89 traumatic injuries and 30 tumors and cystic lesions) were evaluated for injury mechanisms, resulting lesions, surgical management, and postoperative functional outcomes by using retrospective chart reviews.

The most common injury mechanism was iatrogenic (52 cases), which occurred after hernia and hip operations (10 each), followed by arterial bypass and gynecological procedures (eight each), angiography (seven), abdominal surgery (five), appendectomy (two), a laparoscopy, and a lumbar sympathectomy. Other injury mechanisms included hip or pelvic fractures (19), gunshot wounds (10), and lacerations (eight). The 30 femoral nerve tumors and cystic lesions consisted of neurofibromas (16), schwannomas (nine), ganglionic cysts (two), neurogenic sarcomas (two), and a leiomyosarcoma.

Forty-four patients underwent neurolysis. Some had recordable nerve action potentials (NAPs) across their lesions in continuity, despite severe distal loss. Others with recordable NAPs had mild loss, but also experienced a pain problem, which was helped in some by neurolysis. In 36 patients, in whom repairs were performed using long sural grafts for mostly proximal pelvic-level injuries, recovery of useful function occurred. Eight of nine thigh-level suture repairs led to improvement to good functional levels. Most of the tumors and cystic lesions were resected, with preservation of preoperative function.

Conclusions. The majority of femoral nerve injuries resulted in lesions in continuity, and intraoperative NAP recordings were essential in evaluating axonal regeneration across these lesions. Despite severe and frequently proximal injury levels requiring repairs with long grafts, femoral nerve lesion repairs resulted in good functional recovery.

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Daniel H. Kim, Yong-Jun Cho, Robert L. Tiel and David G. Kline

Object. Outcomes of 1019 brachial plexus lesions in patients who underwent surgery at Louisiana State University Health Sciences Center during a 30-year period are reviewed in this paper to provide management guidelines.

Methods. Causes of brachial plexus lesions included 509 stretches/contusions (50%), 161 plexus tumors (16%), 160 thoracic outlet syndromes (TOSs, 16%), 118 gunshot wounds (12%), and 71 lacerations (7%). Many features of clinical presentation, including prior treatment, patient's neurological status, results of electrophysiological studies, intraoperative findings, and postoperative level of function, were studied. The minimum follow-up period was 18 months and the mean follow-up period was 42 months. Repairs were best for injuries located at the C-5, C-6, and C-7 levels, the upper and middle trunk, the lateral cord to the musculocutaneous nerve, and the median and posterior cords to the axillary and radial nerves. Conversely, results were poor for injuries at the C-8 and T-1 levels, and for lower trunk and medial cord lesions, with the exception of injuries of the medial cord to the median nerve. Outcomes were most favorable when patients were carefully evaluated and selected for surgery, although variables such as lesion type, location, and severity, as well as time since injury also affected outcome. This was true also of TOSs and tumors arising from the plexus, especially if they had not been surgically treated previously.

Conclusions. Surgical exploration and repair of brachial plexus lesions is technically feasible and favorable outcomes can be achieved if patients are thoroughly evaluated and appropriately selected.

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Daniel H. Kim, Kisoo Han, Robert L. Tiel, Judith A. Murovic and David G. Kline

Object. In this article the authors present a retrospective analysis of 654 surgical outcomes in patients with ulnar nerve entrapments, injuries, and tumors during a 30-year period.

Methods. Data were gathered between 1968 and 1998 at Louisiana State University Health Sciences Center. Mechanisms of injuries or lesions included 460 entrapments at the elbow level (70%), 76 lacerations (12%), 52 stretches/contusions (8%), 34 fractures/dislocations (5%), 12 gunshot wounds (2%), two injection-induced injuries (0.3%), and 13 nerve sheath tumors (2%).

In cases of entrapment, direct operative recordings uniformly demonstrated a slowing of conduction at the elbow, even in cases in which preoperative noninvasive studies had been nondiagnostic. Intraoperative electrical “inching” studies also demonstrated significant conduction abnormalities that lie just proximal to and through the olecranon notch rather than distal, beneath the flexor carpi ulnaris muscle. There were only eight exceptions to this. Lesions not in continuity due to the injury required primary or secondary end-to-end sutures or graft repair. Aided by intraoperative nerve action potential recording, lesions in continuity received either external or internal neurolysis and split repair or resection followed by end-to-end suture or graft repair. Functional recoveries of Grade 3 or better were seen in 81 (92%) of 88 patients who underwent neurolysis, 42 (72%) of 58 patients who received suture repair, and 24 (67%) of 36 patients who received graft repair. Nevertheless, fewer Grade 4 or 5 recoveries were reached than those seen in patients with radial or median nerve injuries. Nerve sheath tumors were resected with preservation of preoperative function in five of seven patients.

Conclusions. Although difficult to obtain, useful functional recovery can be achieved with proper surgical management of ulnar nerve entrapments and injuries.