[Brachial plexus lesions from the neurosurgical view].

Neurosurgery does not claim to have improved surgery of the brachial plexus. But achievements in microsurgery have advanced surgical possibilities in several faculties. Neurosurgery for example has introduced considerable improvements concerning the assessment of intraforaminal or intraspinal root injuries.

[Potential limitations and risks in the treatment of painful neuropathies].

Introduction: Neuropathic pains often cause social disintegration of the patients, encouraging us to apply microsurgical techniques to peripheral nerve lesions, but there are limitations and risks to take into account when handling scarred nerve tissue.

Facts And Theoretical Considerations: The historical development of our microanatomical knowledge of grading of nerve lesions as well as facts on different fibrotic intraneural reactions are pointed out and additionally compared to today's theories of the origin of neuropathic pains.

Methods: The microsurgical methods applied to entrapment syndromes, pseudoneuroma and neuroma formations consist of either external and interfascicular neurolysis or nerve grafting depending on the estimated grade of nerve lesion.

In vivo visualization of the neuromuscular junction before and after autologous nerve transfer in the rat.

In vivo visualization of the neuromuscular junction with epifluorescence imaging techniques has become a successful method of observing the ongoing process of re-occupation by regenerating motor axons of former post-synaptic sites after nerve injury. By using a light-integrating video camera for digital documentation, all parts of the neuromuscular junction can be visualized, as detailed as when documented with high-speed film, but with a minimum light intensity to prevent damage of neural or muscular structures. Results from comparisons of pre- and post-synaptic staining indicate a non-reoccupation rate up to 37 percent at a 55-day interval after nerve transfer, and up to 34 percent at a 66-day postoperative interval.

Diagnosis and surgery of brachial plexus injuries.

The surgical outcome of traumatic injuries of the brachial plexus (BP) depends on the following parameters: 1) accurate preoperative diagnosis of cervical root avulsion; 2) time interval between injury and surgery; 3) delicate handling of the nerve tissue; and 4) postoperative physiologic training. This report is based on a 15-year experience in brachial plexus surgery and is supported on the grounds of two major studies. In a prospective study, the authors controlled for the reliability of preoperative radiologic diagnosis by myelo-CT and MRI scans for 40 patients, to evaluate the integrity of the intraspinal cervical roots after brachial plexus injury.

Surgical reconstruction of the musculocutaneous nerve in traumatic brachial plexus injuries.

Over the last 16 years, 345 surgical reconstructions of the brachial plexus were performed using nerve grafting or neurotization techniques in the Neurosurgical Department at the Nordstadt Hospital, Hannover, Germany. Sixty-five patients underwent graft placement between the C-5 and C-6 root and the musculocutaneous nerve to restore the flexion of the arm. A retrospective study was conducted, including statistical evaluation of the following pre- and intraoperative parameters in 54 patients: 1) time interval between injury and surgery; 2) choice of the donor nerve (C-5 or C-6 root); and 3) length of the grafts used for repairs between the C-5 or C-6 root and the musculocutaneous nerve.

Diagnosis of root avulsions in traumatic brachial plexus injuries: value of computerized tomography myelography and magnetic resonance imaging.

Surgical management and prognosis of traction injuries of the brachial plexus depend on the accurate diagnosis of root avulsion from the spinal cord. Myelography, computerized tomography (CT) myelography, and recently magnetic resonance (MR) imaging have become the main radiological methods for preoperative diagnosis of cervical root avulsions. Most of the previous studies on the accuracy of CT myelography and MR imaging studies have correlated the radiological findings with the extraspinal surgical findings at brachial plexus surgery.

[Peripheral nerve injuries--current treatment standard].

A review of our century's efforts to overcome nerve defects reveals the conclusion that today microsurgical techniques and interfascicular nerve grafting offer the best chances to get success in peripheral nerve repair. There exists a theoretical grading system of Sunderland, which enables us to understand the very different factors which might influence the sprouting of nerve fibers within the damaged or repaired nerve segments. But in practice, the indication to operate always depends on our own decision.

[Ganglia of peripheral nerves].

The authors present two different types of ganglion affecting the peripheral nerves: extraneural and intraneural ganglion. Compression of peripheral nerves by articular ganglions is well known. The surgical management involves the complete removal of the lesion with preservation of most nerve fascicles.

[An epidural spinal abscess with caudal symptoms as a complication of Crohn's disease].

Progressive symptoms of caudal compression (flaccid paraparesis, sensory disorders), accompanied by severe pain and fever, developed over a few days in a 26-year-old man with Crohn's disease for 11 years. Spinal computed tomography, performed under the diagnosis of herniated disc, revealed intraspinal soft tissue, as well as gas in the spinal canal (L2-S3) and the paravertebral muscles. This led to the diagnosis of acute epidural abscess and a laminectomy was performed (at L4-S2).

Vascular lesions of the internal auditory canal.

We report here two cases of vascular tumors arising within the internal auditory canal, both of which presented with cerebellopontine angle symptoms and simulated acoustic neurinomas. The first case was an arteriovenous malformation that caused moderate sensorineural hearing loss, tinnitus, vertigo with lateropulsion, facial weakness, and trigeminal hypoesthesia on the same side. The second case was a venous angioma, to our knowledge the first ever reported in this location, which presented with sudden complete deafness and progressive hemifacial spasm.

Surgical treatment of myeloradiculopathy in cervical spondylosis. A report on 438 operations.

In the past eleven years we have performed 438 microsurgical ventral discectomies with bilateral foraminotomy followed by fusion with palacos in the cervical spine in our clinic. An analysis of the preoperative symptoms shows a great variability and overlapping of the various segments. To determine the right level for the operation it is crucial that the results of the clinical and the radiological examinations be evaluated.

Revascularization of nerve grafts: an experimental study.

The time course of revascularization of grafted nerves, and the possible dependence of this revascularization on the length of the graft are two related questions that are addressed. Survival of Schwann cells in the nerve graft and a timely revascularization must be seen as a precondition for an optimal regeneration process. The revascularization process after different postoperative intervals is demonstrated in the sciatic nerve of rabbits by the use of microangiography, with Roentgen-positive water-soluble contrast medium.

[Intermedius neuralgia].

We report 2 cases of microvascular decompression of the nervus intermedius. The current views of aetiology of neuralgia and spasm of the cranial nerves are discussed based on intraoperative observations and electro-optical investigation reported in the literature. The complex anatomy within the sensory system of the facial nerve, and the intersection of its area of supply with that of the glossopharyngeal and vagus nerves are discussed.

[Angiomatous malformation of the inner auditory canal with the leading symptoms of vertigo and tinnitus].

A case of a rare arteriovenous malformation in the internal auditory canal is reported. It caused unilateral tinnitus, facial weakness, trigeminal hypesthesia, and vertigo with lateropulsion. The audiological and otoneurological findings together with air-cisternography a CT scan had indicated an intrameatal tumor.

Management of seventh and eighth nerve involvement by cerebellopontine angle tumors.

Microsurgical techniques have made a significant contribution in the advancement of surgery. Since then, the field of neurosurgery has made great and rapid strides. Neurosurgeons now venture through the deep and delicate regions of the brain where they dared not venture only a few years ago.

[Results of 110 microsurgical acoustic neuroma operations].

We report our experiences in 110 cases of microsurgical removal of acoustic neurinomas. The historic development, the chances of preservation of the facial nerve and hearing function and the mortality risks are described in detail, hereby stressing the advantages of the lateral suboccipital approach in microneurosurgery.

[100 microsurgical tumor excisions in the cerebellopontile angle with special reference to the preservation of hearing function].

A report is given on the experience gained in the microsurgical treatment of 100 tumours of the cerebellopontine angle - among them 78 neurinomas - under special consideration of the preservation of the audition. The advantages of the lateral suboccipital access in connection with the possibility to open the internal auditory meatus are pointed out. The problems regarding the treatment of bilateral neurinomas of the acusticus in Morbus Recklinghausen are discussed under a theoretical and a practical angle.

[Anterior interosseous nerve syndrome].

Two cases of Kiloh-Nevin syndrome are reported and the operative possibilities discussed. The difficulties in predicting nerve regeneration complicate the choice of treatment.