Ignazio G. Vetrano and Vittoria Nazzi
Vittoria Nazzi, Angelo Franzini, Giuseppe Messina and Giovanni Broggi
✓In the past few years, several different minimally invasive surgical techniques have been proposed to decompress the median nerve at the wrist. Use of these techniques has become widespread due to fewer local complications, faster functional recovery, and reduced surgical time. In this paper the authors compare 3 different minimally invasive surgical techniques used at their institution in the past 13 years. Between January 1994 and January 2007, 891 patients underwent 1272 surgeries at the authors' institution for carpal tunnel syndrome (CTS), for which a minimally invasive technique was used. In 473 cases (Group A), the transillumination technique with a single wrist incision and a “carpalotome” (a modified Paine retinaculotome) was used; in 216 cases (Group B), transillumination was abandoned and a single linear wrist incision for access with the carpalotome was performed; and in 583 cases (Group C), the techniques were further modified by making a second incision in the palm using the carpalotome. All 3 groups of patients were homogeneous for age, sex, and duration of the symptomatology. In 90% of the patients in Group A, in 88% of those in Group B, and 99.8% of patients in Group C, complete remission of symptoms was obtained. Due to persistence of symptoms, 44 patients in Group A, 24 in Group B, and only 1 in Group C underwent a repeated operation with the open technique. The only surgical complication requiring repeated operation of the 1272 operations was a lesion of the primitive median artery (1 patient in Group C).
The technique of median nerve decompression at the wrist that was used for patients in Group C represents a valid alternative for treatment of CTS.
Vittoria Nazzi, Giuseppe Messina, Ivano Dones, Paolo Ferroli and Giovanni Broggi
✓The authors report on the case of a 32-year-old woman with an intramuscular arteriovenous hemangioma (AVH) of the left forearm with burning pain and paresthesias diffused to the radial nerve–related territories. The patient underwent coil embolization of the AVH and surgical removal of the remnant and regrown AVH. This case demonstrates the safety and efficacy of surgery when interventional radiology fails to achieve complete occlusion. En bloc removal of the lesion was performed through a left elbow cleft incision, and intraoperative electrophysiological monitoring and angiography with indocyanine green (ICG) were performed. The pathological diagnosis was intramuscular AVH. Postoperative follow-up examinations demonstrated the permanent disappearance of the subcutaneous mass and of the patient's sensory disturbances. Complete excision of the AVH was confirmed on postoperative magnetic resonance angiography, and no surgery-related complications or new neurological symptoms were detected.
Intramuscular AVHs are rare lesions that can be successfully treated with both coil endovascular embolization and surgery; the latter is indicated when endovascular procedures fail to occlude the AVH completely. Intraoperative angiography with ICG can be helpful in confirming the success of the procedure.
Angelo Franzini, Giuseppe Messina, Vittoria Nazzi, Eliana Mea, Massimo Leone, Luisa Chiapparini, Giovanni Broggi and Gennaro Bussone
Spontaneous intracranial hypotension (SIH) is a potentially serious pathological syndrome consisting of specific symptoms and neuroradiological signs that can sometimes be used to assess the efficacy of the treatment. In this paper the authors report a series of 28 patients with this syndrome who were all treated with an epidural blood patch at the authors' institution. The authors propose a novel physiopathological theory of SIH based on some anatomical considerations about the spinal venous drainage system.
Between January 1993 and January 2007, the authors treated 28 patients in whom SIH had been diagnosed. Twenty-seven of the 28 patients presented with the typical findings of SIH on brain MR imaging (dural enhancement and thickening subdural collections, caudal displacement of cerebellar tonsils, and reduction in height of suprachiasmatic cisterns). The sites of the patients' neuroradiologically suspected CSF leakage were different, but the blood patch procedure was performed at the lumbar level in all patients. The patients were then assessed at 3-month and 1- and 3-year follow-up visits. At the last visit (although only available for 11 patients) 83.3% of patients were completely free from clinical symptoms and 8.3% complained of sporadic orthostatic headache.
The authors think that in the so-called SIH syndrome, the dural leak, even in those cases in which it can be clearly identified on neuroradiological examinations, is not the cause of the disease but the effect of the epidural hypotension maintained by the inferior cava vein outflow to the heart. The goal of their blood patch procedure (a sort of epidural block obtained using autologous blood and fibrin glue at the L1–2 level) is not to seal CSF leaks, but instead to help in reversing the CSF-blood gradient within the epidural space along the entire cord.
The authors' procedure seems to lead to good and long-lasting clinical results.
Ignazio G. Vetrano, Francesco Acerbi, Jacopo Falco, Grazia Devigili, Sara Rinaldo, Giuseppe Messina, Francesco Prada, Antonio D’Ammando and Vittoria Nazzi
Benign peripheral nerve sheath tumors (PNSTs) include mainly schwannomas—the most common tumors arising from peripheral nerves—and neurofibromas. Due to their origin, distinguishing between functional intact nerve and the fibers from whence the PNST arose may not always be easy to perform. The introduction of intraoperative tools to better visualize these tumors could be helpful in achieving a gross-total resection. In this study, the authors present a series of patients harboring PNST in which the surgery was performed under fluorescein guidance.
Between September 2018 and February 2019, 20 consecutive patients with a total of 25 suspected PNSTs underwent fluorescein-guided surgery performed under microscopic view with a dedicated filter integrated into the surgical microscope (YELLOW 560) and with intraoperative monitoring. All patients presented with a different degree of contrast enhancement at preoperative MRI. Fluorescein was intravenously injected after intubation at a dose of 1 mg/kg. Preoperative clinical and radiological data, intraoperative fluorescein characteristics, and postoperative neurological and radiological outcomes were collected and analyzed.
Six patients were affected by neurofibromatosis or schwannomatosis. There were 14 schwannomas, 8 neurofibromas, 1 myxoma, 1 reactive follicular hyperplasia, and 1 giant cell tumor of tendon sheath. No patient experienced worsening of neurological status after surgery. No side effects related to fluorescein injection were found in this series. Fluorescein allowed an optimal intraoperative distinction between tumor and surrounding nerves in 13 of 14 schwannomas and in all neurofibromas. In 6 neurofibromas and in 1 schwannoma, the final YELLOW 560 visualization showed the presence of small tumor remnants that were not visible under white-light illumination and that could be removed, obtaining a gross-total resection.
Fluorescein was demonstrated to be a feasible, safe, and helpful intraoperative adjunct to better identify and distinguish PNSTs from intact functional nerves, with a possible impact on tumor resection, particularly in diffuse neurofibromas.