Intracranial intradural variations of nerve roots.

BACKGROUND: The aim of this paper was to point out the intradural cranial nerve roots variations in their localization and number to establish the incidence and clinical importance of the cranial nerve root variations. METHODS: The anatomical study was performed on 120 sides in 60 cadavers. There were 51 male cadavers with the mean age 43.3 and 9 female cadavers with the mean age of 39.5 years. RESULTS: Abducens nerve variations were observed in 48 cases (80 %). They were more frequently on the left side, in 25 cases (41.66 %). Duplicated abducens nerve was observed in 25 cases (41.66 %). Double and triple abducens nerve variations were also observed. CONCLUSIONS: Cranial nerve variations are rare, but variations of abducens nerve and atypical exit of the hypoglossal nerve from the fossa cranium posterior is not a rare variation. Knowledge of this variation may be important to various fields of medicine (Tab. 3, Fig. 8, Ref. 34).

Low serum vitamin D levels are associated with a low percentage of TREM-2+ monocytes in low-grade gliomas and poorer overall survival in patients with high-grade gliomas.

INTRODUCTION: Anti-inflammatory effect of vitamin D (VD) could be beneficial in improving the survival of glioma patients. The aim of our study was to analyse the serum levels of vitamin D in glioma patients and to find an association with the prognosis of glioma patients and other investigated parameters. MATERIAL AND METHODS: The study included 63 patients with gliomas. Percentage of CD14+ monocytes, TREM-1+ and TREM-2+ monocytes were determined by flow cytometry, serum levels of 25(OH)D were evaluated by electrochemiluminescent binding test. RESULTS: Six patients out of 63 had normal levels of VD. A significant difference in the overall survival (OS) in the patients with severe VD deficiency, VD deficiency and insufficiency in grade IV was found. In grade II and III, the levels of vitamin D positively correlated with the percentage of TREM-2+ monocytes, and in grade II also a negative correlation of VD with TREM-1/TREM-2 ratio was observed. CONCLUSION: Levels of VD could influence the prognosis of patients with high-grade gliomas. Serum level of 25(OH)D in low-grade gliomas positively correlated with the percentage of anti-inflammatory acting TREM-2+ monocytes and negatively with TREM-1/TREM-2 ratio. This could be protective against the progression to high-grade glioma, because TREM-2 is associated with protective functions such as: tissue repair, control of local inflammation, or phagocytosis (Tab. 4, Fig. 4, Ref. 79).

TREM-1 and TREM-2 Expression on Blood Monocytes Could Help Predict Survival in High-Grade Glioma Patients.

OBJECTIVE: In recent years, the role of the modern inflammatory markers TREM-1 (triggering receptors expressed on myeloid cells) and HMGB1 (high mobility group box 1 protein) in tumorigenesis has begun to be studied. Their role in gliomas is not clear. The aim of our study was to find the role of inflammation in gliomas. Patients and Methods. In 63 adult patients with gliomas and 31 healthy controls, the expressions of TREM-1 and TREM-2 on CD14+ blood cells (method: flow cytometry) and the levels of soluble sTREM-1, HMGB1, IL-6, and IL-10 (Elisa tests) were analyzed. RESULTS: Cox proportional hazard analysis showed that a TREM-1/TREM-2 ratio was associated with reduced overall survival (HR = 1.001, P = 0.023). Patients with a TREM-1/TREM-2 ratio above 125 survived significantly shorter than patients with a TREM-1/TREM-2 ratio below 125. The percentage of CD14+ TREM-1+ cells was strongly associated with a plasma IL-6/IL-10 ratio (positively) and with IL-10 (negatively). Conversely, we found a higher percentage of CD14+ TREM-2+ monocytes in better surviving patients; these cells could downregulate the exaggerated inflammation and potentiate the phagocytosis in the tumor. The serum levels of HMGB1 negatively correlated with the percentage of CD14+ TREM-1+ cells and with the TREM-1/TREM-2 ratio. The positive correlation between the serum levels of a late proinflammatory cytokine HMGB1 with the percentage of TREM2+ CD14+ monocytes can be explained as an effort for suppression of systemic inflammation by anti-inflammatory acting CD14+ TREM-2+ cells. CONCLUSION: We showed that the TREM-1/TREM-2 ratio (expression on the surface of blood monocytes) could help predict prognosis in patients with gliomas, especially in high-grade gliomas, and that systemic inflammation has an impact on the patient's overall survival. This is the first study that showed that TREM expression on monocytes in peripheral blood could help predict prognosis in patients with gliomas.

Current occurence of intraspinal intradural and extradural communicating branches in the spinal canal.

THE AIM of this work is to point out the intraspinal anatomical current occurrence interconnections between intradural and extradural nerve roots and their possible participation in radiculopathy. METHODS: The anatomical study was performed in 43 cadavers with a mean age of 53.7. All intradural and extradural rami communicantes between nerve roots were excised and examined histologically for the presence or absence of nervous tissue. RESULTS: Anatomical preparations revealed intradural and extradural rami communicantes in 9 cases (20.9 %), mostly in the cervical region in 5 cases and by plexus formation variations in 5 cases. Multiple extradural rami communicantes were observed in 6 cases (13.95 %), including the simultaneous occurrence of multiple intradural and extradural ones in 5 cases (11.6 %). CONCLUSIONS: This study allowed us to identify and describe unpublished intraspinal current occurrence intradural-extradural rami communicantes of nerve roots and their interrelationships throughout the spinal canal with their potential influence on the clinical picture (Tab. 1, Fig. 4, Ref. 25).

Surgical treatment of nervus pudendus.

An objective of our work was to clarify variations in pudendal nerve formation, as well as their possible impact on the clinical picture.Bilateral pudendal nerve course and formation was studied on 20 adult cadavers. Anterior approach was used in 15 of them, both posterior and anterior approaches were used in five of them. The prefixed type plexus formation was observed in eight cases (40 %). In these cases S1, S2 roots contributed to the formation of the pudendal nerve. In the postfixed type particularly the S3 root was dominant in two cases (66.7 %), and less the S4 root in one case (23.3 %) from three cases. Mostly the S2 root participated in its formation in 17 cases (85 %). The pudendal nerve branches run below the sacrospinous ligament on the level of the sacrospinous and sacrotuberous ligaments. The changes of the nerve and the branching therof were most evident from the anterior access below the sacrospinous ligament and in front of the sacrotuberous ligament. The inferior rectal nerve penetrating the sacrospinous ligament was seen in one case, it has risen from the pudendal nerve before entering the pudendal canal in four cases. The dorsal nerve of the penis has risen from the S1 root in two cases (10 %). We observed its branching before entering the pudendal canal in 15 cases (75 %). It has divided in the pudendal canal in other cases. This description may be useful particularly for the pudendal nerve block and the nerve saving surgeries directed on the relevant region (Fig. 8, Ref. 24).

Our experience with surgical treatment of lesions of nervus facialis.

OBJECTIVE: The study presents the results of reconstruction surgery of lesions on n. facialis with n. hypoglossus and n. accessorius performed in our clinic. PATIENT GROUP AND METHODS: 10 patients were treated by anastomosis of n. facialis with n. hypoglossus (HFA), 1 patient by anastomosis of n. facialis with n. accessorius (AFA). All operations were performed under the microscope; HFA and AFA anastomoses were sewed without tension at perineurium. The techique of suturation of facial nerves did not differ from the suturation of peripheral nerves in extremities. For the connection of n. VII-XII was not used plasma pasting. We did not use end to side anastomosis or reconstruction of n. VIIVII in pontocerebellar angle, in pyramid, or symetrical anastomoses of n. VII-VII, in any case. The results were objectivized by a VI grade Brudny's modification of House-Brackman classification introduced originally for scaling of the outcome of HFA anastomosis. In this study, this classification has been used for the objectivization of AFA anastomosis results. RESULTS: Reconstruction surgery by HFA and AFA resulted in all cases in grade III of the scale. Glossal hemiatrophy or atrophy of m. sternocleidomastoideus and m. trapesius were observed in patients treated by cross anastomosis with n. hypoglossus or n. accessorius. In patients treated by HFA and even more pronounced in patient with AFA anastomosis, minute synkineses in the region of labial angle, chin, also in the region of lower eyelid, occurred in the excited emotional state or during a long-lasting speech. Major diskincses were not observed in any of reported treatments. Recovery in older patients up to 60 years was coming more slowly, in one case after 6 months. CONCLUSION: Compared to AFA anastomosis, HFA anastomoses resulted in improved mimics and synkineses present here were finer. We prefer HFA anastomosis also because the discomfort caused by atrophy of ni. trapesius and ni. sternocleidomastoideus was apparently more perceived by patient treated by AFA than the negative effects of hemiatrophy reported by patients treated by FIFA.

Neurofibroma of the vagus nerve in the cervical portion.

OBJECTIVE: Neurofibromas of the vagus nerve on the neck are very rare. They are asymptomatic, slowly growing. We have seen only one case of neurofibroma of the vagus nerve in the mentioned location during last 22 years. CLINICAL PRESENTATION: 33-year-old patient with negative family history. She has observed increasing swelling on the right side of the neck for about 2 years. She complained of the disorders of swallowing, expectoration, aspiration episodes, strider, intermittent palpitations, breathlessness, frequent airway infections. Magnetic resonance (MR) and angiography (AG) showed expansion in the mentioned location. CONCLUSION: We present our experiences with neurosurgical management of neurofibroma of the vagus nerve in the cervical portion using microscopic technique. We found only 9 described cases of surgical treatment of the neurofibroma of the vagus nerve in the neck location in available literature till 2007 (Fig. 6, Ref. 9).

Reconstruction of the skull base after injuries.

The aim of this study is presentation of 3 cases reconstructive surgery of the skull base after craniocerebral injury. INJURIES AND METHODS: Extensive injuries of the skull base result in communication with paranasal cavities. DIAGNOSTICS: The most serious part of the operation is the isolation of the liquor space from the external environment. Reconstruction surgeries of the skull base have significantly improved in recent years due to development of new methods in diagnostics and treatment. 3D CT reconstruction has proven to be particularly valuable for the verification of liquorea even in patients with inactive liquorea at the time of examination, as well as in patients with no CT defects or with normal MR finding. TREATMENT: The use of firm and shapeable materials extends the possibilities of reconstruction surgery, the spectrum of surgical methods and approaches for extensive injuries of the skull base (Fig. 9, Ref. 3) Full Text (Free, PDF) www.bmj.sk.

Surgery of the peripheral nerves.

OUTCOME: In contrast to the CNS, peripheral nerves have the ability to regenerate. This ability has been utilized for a long time in the therapy of injuries of peripheral nerves. The aim of the present research was to assess the achievements in reconstructive surgery including nerve grafting and peripheral nerve suture repair in our clinic. MATERIAL AND METHODS: During the 16-year period from 1986 to 2001 we surgically treated 116 patients with peripheral nerve lesions. The cases of lesions of the brachial plexus, partial peripheral nerve lesions and postoperative revision, as well as the attempts of reconstruction of cervical nerves and neurolysis are not included in this work. We analysed the results of surgery in our patients who where subjected to treatment of peripheral nerves in the arms (95 patients) and legs (21 patients). In 53 patients reconstructive surgery was performed by suture repair of peripheral nerve, which included treatment of 65 nerves, 10 patients were treated by suture repair of 2 nerves and repair of 3 nerves in one patient. In 42 patients we reconstructed 45 peripheral nerves of the hand by autograft. The total number of 42 patients compromised 37 males and five females. The average age was 36 years. Double nerve reconstruction (ulnar and median) was accomplished in three patients. In the remaining 21 patients (14 males and seven females) we performed 21 reconstruction operations of 24 injured nerves in the lower extremities, of which 8 operations of 9 nerves involved suture repair of peripheral nerves and 13 operations of 15 nerves were performed using a nerve graft. Their average age was 39.7 years. The average period between primary treatment and operation was 6.7 months. In five cases the interval exceeded 12 months. Operations were performed by microtechnique. All patients were subject to several postoperational tests aimed at the estimation of the degree of recovery in sensory and motor adaptation. The evaluation was performed according the Seddon classification (1975). Motor recovery was evaluated according to a five-point scale and the degree of sensory recovery according to a four-point scale. Recovery of grade M4 and S3 (or higher) was considered an excellent or very good result and grades M3 and S2 were considered a good result. Results corresponding to grades M0-M2 and S0-S1 were considered to be insufficient. RESULTS AND CONCLUSION: The results of reconstruction operations of peripheral nerves injuries were dependent on the patient's age, the period between the injury and operation, the length of the autograft, the location of the injury, the type of injured nerve and the character of the injury (Fig. 2, Tab. 7, Ref: 15).

[Rare compression syndromes of the peripheral nerves of the forearm and distal leg]. / Zriedkavé uzinové syndrómy periférnych nervov na predlaktí a predkolení.

OBJECTIVES: The study presents results of rare operations of the peripheral nerves compartment syndromes of the forearm and distal leg, completed in our clinic during a 14-year period (1990-2004). SUBJECTS AND METHODS: We completed 25 procedures for 25 compartment syndromes in 25 patients. All patients sufferred from unilateral compartment syndromes. The patients were operated for the first time in our clinic. None of them needed to be re-operated. The clinical pictures of the compartment syndromes were classified (three degrees) according to the Dellon's intensity classification: None of the patients sufferred from the Ist degree compression. The IInd degree occured in 4 patients (16%). The IIIrd degree occured in 21 patients (84%). The surgical procedure's effectiveness was analyzed, taking into consideration the degree of the compression, its duration and the symptoms duration. RESULTS: Excellent and good results were observed in all cases of the IInd degree compression and the symptoms duration up to 12 months. Worse results were recorded in the IIIrd degree compression cases, where excellent and good results were observed in 19 cases (76%). In cases, where the symptoms lasted for over 12 months, no excellent or good results were recorded. CONCLUSION: The decisive factor affecting the procedure's outcome, is the degree of the compression and its duration. The main factors improving the outcome of the procedure are the following: the patient's age up to 30 years of age and the duration of the symptoms up to 1 year, when the defect is not irreversible.

[Our experience with surgical management of injuries to peripheral nerves of the upper extremities]. / Nase skúsenosti s chirurgickým liecením poranení periférnych nervov horných koncatín.

OBJECTIVES: The authors present their results of 44 microsurgical procedures of 47 nerves in 44 patients subjects over a period of 19 years, from 1985 to 2003. STUDY GROUP SUBJECTS AND METHODS: 44 patients with injuries to peripheral nerves of the upper extremities underwent reconstructions of 47 nerves using autotransplants. The procedures effectivity results were analysed using the following indicators: the injury to the procedure time, the patient's age, the autotransplant length, the injury type, the injury site, the injured nerve type. RESULTS: The best results were reached: in young patients up to the age of 20, in cases of early operations up to 3 months, in cases when grafts up to 5 cm were used. Clean, for instance incision injury, has much better prospects for successful nerve graft autotransplantation than others, more complicated injuries (e.g. lacerated injury or contusion).

Atypical course of nervus axillaris.

OBJECTIVES: Aberrations observed during surgical therapy has inspired us to investigate the variations of nervus axillaris formation. MATERIAL: 100 brachial plexuses in 50 cadavers were examined for the incidence the variations of nervus axillaris. RESULTS: In 1 case (2%) we observed the aberration of nervus axillaris formation. CONCLUSION: This study identifies and describes an exceptional anatomical variation--beginning n. axillaris as the continuance of the posterior branch of the upper trunk (Fig. 1, Ref. 2).

Variations of nerve roots of the brachial plexus.

OUTCOME: Aberrations observed during surgical treatments inspired us to initiate the investigation of variations in the formation of brachial plexus. MATERIAL AND METHODS: 100 brachial plexuses in 50 cadavers were examined for the incidence of neural variations. We examined the involvement of the C4 root and eventually of that of Th2 root, as well as various deviations in the exit of individual roots and their branches from the backbone. We have focused also on their paths, anastomoses, on their thickness or on their eventual absence. In addition to the anatomical complexity and variability, the specifics of motor innervation related to diagnostics are also emphasized. The attention is paid to the mechanisms and morphological reasons of the occurrence of specific types of injuries. RESULTS: Prefixed type was present in 24 cases (48 %), postfixed type was present just in one case. Aberrations have been observed in 14 cases (28 %). They occurred more frequently on the left side (9 cases) followed by two-sided aberrations (4 cases). CONCLUSION: This study enabled to identify and describe exceptional and hitherto undescribed anatomical variations in the formation of nerve roots of brachial plexus.

Diagnosis and treatment of brachial plexus injuries.

In the reconstruction of the nerves in traction injuries of brachial plexus, the main role is the correction of the function of upper extremity. This article is aimed at establishing a diagnosis, indications for intervention and surgical treatment. Operation results are influenced by a degree of injury, type of surgical therapy, patient's age, and by the time delay between the injury and the intervention (Ref. 6).

[Neurolyses of peripheral nerves of the lower extremities]. / Neurolýzy periférnych nervov dolných koncatín.

AIM: This study presents our results of 34 operations in 33 patients undergoing treatment of nerves of the lower extremities, using the method of neurolysis, during an eighteen-year-period, from 1985 to 2003. METHODOLOGY: Thirty three patients underwent superficial neurolysis, five patients underwent both, superficial and internal neurolysis. The surgical procedures were conducted on patients, who suffered from complete or persisting neurological deficits. The cases, which required resection of the fascicles and reconstruction using autografts, as well as the cases, which had already had reconstructional procedures done, were not included in this study. The surgical procedure's efficacy was analysed considering the time delay of the operation after the injury, the patient's age and the type of the injured nerve. RESULTS AND CONCLUSION: Good and excellent results were reported in patients up to the age of 20 and in operations within 3 months after the injury. In all cases of the tibial nerve neurolyses excellent results were reported.

Follow-up evaluation of neurolysis of brachial plexus and peripheral nerves of upper extremities.

BACKGROUND: The work presents the results of neurolysis of brachial plexus and peripheral nerves of upper extremities performed in the Neurosurgical clinic of the Faculty Hospital Bratislava during the 18-year period from 1985 to 2003. PATIENTS AND METHODS: 59 patients were subject to surgical therapy by neurolysis, including 10 treatments of brachial plexus and 49 treatments of the upper limb nerves. The average age in the patient group was 35 years. The average period between the injury and surgical treatment was 6.9 months. Extremely long period over 12 months occurred in 3 cases. The treatment was performed in patients with complete or persisting neurological deficit. The external neurolysis was performed in 59 patients and this treatment was supplemented also by internal neurolysis in two cases. Cases requiring resection of fascicles and reconstruction with autotransplants and cases where reconstruction surgery has been already performed in the past have not been included into the study. The analysis of results was performed with respect to the period between the injury and operation, patient age, the type of injured nerve and the degree of fibrotic changes that have been identified peroperationally. RESULTS: The evaluation of results has been performed according to Seddon classification (1975). The complete recovery of mobility, strength and BMG findings (classification grade M5) was observed in 25 patients. The functional grade M3 and more was present in 52 patients. The best results were observed in the youngest patient group aged below 20 years, in cases of early therapy onset, in patients with distal traumatic lesions and for neurolyses of n. radialis. CONCLUSION: Based on our experience we believe that the early surgical revision is the critical factor determining the outcome of the operations in indicated cases. (Tab. 6, Ref. 3.)

[Neurolyses of the brachial plexus and peripheral nerves of the extremities]. / Neurolýzy brachiálneho plexu a periférnych nervov koncatín.

AIM: This study presents the results of the brachial plexus and the peripheral extremities nerves neurolyses conducted in our clinic for 18 years from 1985 to 2003. SUBJECTS AND METHODOLOGY: 92 patients were treated surgically using neurolyses. Out of this number, 10 of them concerned brachial plexi, 49 nerves of the upper extremities and 33 nerves of the lower extremities. Out of the total patient number, 67 were males and 25 females, aged 30 years on average. The average time gap between the injury and the surgical procedure was 6.9 months. An extremely long time gap (over 12 months) was recorded in 5 cases. The operations were conducted in patients who suffered from a complete or persisting neurological deficits. In 92 patients, external neurolysis was conducted, out of them in 7 cases also internal neurolysis was conducted. Cases which required resection of the fascicles and reconstruction using autotransplants, as well as cases which had already undergone reconstruction procedures, have not been included in this study. The results analysis has been conducted with respect to the time gap between the surgical procedure and the injury, to the patient's age, to the type of the injured nerve and to the peroperatively detected degree of fibrotic changes. RESULTS: The best results were observed in patients under 20 years of age, in cases of early treatment, in distal injuries and in neurolyses of the tibial and radial nerves. CONCLUSION: When indicated, the early surgical treatment is the main factor determining the results of the surgical procedures.

[Aanalysis of the brachial plexus traumatic lesions reconstructive procedures unfavourable results]. / Analýza nepriaznivých výsledkov rekonstrukcných operáicií traumatických lézií brachiáilneho plexu.

AIM: The aim of this study is to analyze unfavourable results of nerve transfers to the musculocutaneous nerve, using upper intercostal nerves. METHODOLOGY: The trial group included 7 patients with traction injuries of the brachial plexus, who were treated surgically, using intercostal nerves as nerve transfers. The follow-up period was at least 3 years. The analysis of the motor function recovery depended on the respective patient's age and the operation time. RESULTS: In not a single case a functional recovery of the musculocutaneous nerve was achieved. CONCLUSION: The time gap between the injury and the operation, the level and the extent of the nerve injury and the type of the reconstructive procedure, all the above are the main prognostic factors for the functional recovery of the paralyzed muscles, resulting from its traction injury.

[Anatomic deviations in the origin of the median nerve]. / Anatomická odchýlka vo formovaní n. medianus.

OBJECTIVE: Deviations detected during the operation triggered our interest to start work dealing with variations in the formation of n. medianus GROUP: One hundred brachial plexuses were examined in order to detect variations of n. medianus. Attention was paid to the course and anastomoses. RESULTS: In 32 cases (64%) the authors observed 40 deviations. The deviations occurred more frequently on the left in 16 cases. They were most frequently of anastomosis character. CONCLUSION: The study made it possible to detect and describe deviations in the formation of n. medianus up to the lower third of shoulder.

[Anatomic variations in the brachial plexus trunks and nerve roots]. / Anatomické varianty nervových korenov a trunkov brachiálneho plexu.

BACKGROUND: Deviations observed during operations triggered our effort to initiate an investigation concerning variations in the formation of brachial plexus. MATERIAL AND METHODS: In 50 cadavers of adult subjects the authors examined 100 brachial plexuses in order to detect incidence of neural variations. The participation of the C4 radix or Th2 radix as well as various variants from outlets of individual radices and their branches from the vertebral column to the variants in the formation of nerve trunks was investigated. The attention was devoted to their course, anastomoses, thickness and occasional absence. In addition to anatomical complexity and variability, attention is paid to motor innervation peculiarities in relation to diagnosis. The attention is paid to the mechanisms and morphological reasons in the origin of certain type of injuries. RESULTS: The prefixed type occurred in 24 cases (48%), the postfixed one in a singe case. In 25 cases (50%) 32 deviations were observed. The deviations were more frequent on the left side in 11 cases. CONCLUSION: The study made it possible to find out and describe exceptional, so far unpublished, anatomical deviations in the formation of nerve radices and trunks of brachial plexus.