A new method of evaluating facial nerve function by using transcranial magnetic stimulation

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Peripheral Nerve s and Brachial Plexus

Tuesday, 8 July 1997

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Methods: We compared the effects of sciatic nerve axotomy = (N Neuroma P-4-S07 ! Does the age of the patientneglectthe otherfactors group. n= 6), with axotomy andeee (eee-group, n=6). We used various influencingoutcome of nervegrafting (= mAb.: EDt , OX18, OX6& anti-Substance-P(SP») to monoclonalantibodies Lukas Rasulic. Miroslav Samardzic, Danica GrujiCic, Miloje .loksimovlc, demonstrate microglial reaction in the spinal cord. SP-reactivity in the dorsal Ivan Piscevic.InstituteofNeurosurgery,Clinical Centerof Serbia,Belgrade, hom area and macrophage infiltration in the peripheral nerve. Yugoslavia Results: Macrophage infiltration in the peripheral nerve stump of the eeegroup was significantly reduced as compared to the N-group. In the N-groupThere are several factors influencing the final outcome following nerve repair, spinal cord a rapid and lasting increase of activated ED1-positive microglialespecially in nerve grafting. It has been generally accepted that age is the most cells was seen. In theeee-groupvery few EDt-positive microglial cells were critical factor with better results in children if all other factors are equal, due to regenerationand cerebral plasticity. The aim of present. Furthermore we observed a decrease in SP-reactivity in the dorsal the superior ability for neural hom of the N-group on the side of the peripheral lesion whereas SP-reactivitythis study is to analyse the influence of the patients' age in cases with proximal in theeee-groupdid not differ from normal control animals. nerve lesions, nerve defects over 5 cm, and timing of surgery more then 6 Conclusion:Infiltration of the proximal stump by macrophagesis reducedmonths following injury, each of these constituting prognostically unfavourable by theeee. The eee reduces the spinal cord reaction of microglial cells to factors. a peripheral nerve lesion. Possible mechanisms of the beneficial effects of the Study isbased on analysis of nerve grafting procedures performed in 78 children (aged up to t6 years) with 85 grafted nerves. Unfavourable factors eee are discussed. were present in 35(41.1 %) of 85 grafting procedures, one in 22 cases, two in 11 cases and all three in 2 cases. The results were available for 76 repaired nerves. Generally, the rate of P-4-sosl Interfascicularneurolysisor interfascicularnerve functional recoverywas 94.7% (72 of 76 nerves). eases with factors favourably graftsin the treatmentof old peripheral nerve i njury influencing outcome recovered with good results in 30 (83.3%) of 36 nerves. S. Rochkind, M. Alon, S. Dekel, N. Razon, G.E. Ouaknine. TeIAv;v-Sourasky In cases with factors unfavourably influencing outcome, the rate of functional MedicalCenter, Israel recoverywas 90% (36 of 40 nerves). Good recoveryin this group was registered We present the retrospective study of the functional recovery of 35 patientsin 18 (45%) of 40 cases. On the bases of this analysis we were able to draw several conclusions: sufferingfrom old peripheral nerves injuries (from 2.5 up to 60 after injury) years who underwent microsurgical management.Trauma mechanismsincludedgun1) The rate offunctionalrecoveryfollowinqnerve grafting in children is slightly lower if timing ofsurgery, the level of the lesion and length of nerve defect shot wounds, stab wounds, traction, and compressioninjuries. The patients were evaluated and surgically treated by extemal and interlascicular neurolysis are less favourable, 2) The failures are related to the length of nerve defects, 3) Quality of recovery is significantly lower if unfavourable factors are present, and/orinterlascicular autogenousnerve grafts(from 6 to 14).Intraoperativeelectrophysiologicalrecording was used during the operation to identify functionalespecially in proximal lesions with nerve defect over 8 cm. nervefascicles. During interlascicular neurolysis after direct nerve stimulation we received evoked responses from correspondingmuscles. Nineteen (54%)ol35 surgically treated patients showedgood and excellent P-4-S0S! Correlation between sensomotorrecovery, neurophysiological recovery andpatient'spersonal results in their motor function according to Individual Muscle Grade System of judgementabout theoutcomeafter peripheralnerve Center, This study suggests that using the Lousiana State University Medical repair interlascicular neurolysis or interlascicular nerve grafts results functional in improvementof the patients suffering from old peripheral nerve injury. Z. Roganovic,M. Savic, B. Antic, R. Tadic,Military MedicalAcademy, Our intraoperative electrophysiologicalfindings after interfascicularneurolyDepartmentforNeurosurgery,Belgrade, Yugoslavia sis indicate that survival of nerve tissue occurs more than previously assumed. The analyzed series included 475 nerves, treated in our Department in two years period, who fulfilled the following criteria: complete nerve transection, reconstructionof nerve continuity by nerve graft and clinical and neurophysioP.4-S06 1Intraabdominalrepair of the N. obturatoriusby graft logical assessmentfor at least 18 months postoperatively. The end results were J. Benes. NeurosurgicalDepartment, Brno, CzechRepublic considered on the basis of restoration of sensation, retum of muscle power, neurophysiological statusand patient's personaljudgement about the outcome. Introduction:Repair of the defect of peripheral nerveby graftsfrom suratis n. is a contemporaryroutinely affair. Neverthelessthere are essentiallyless frequentFor each of these four parameters recovery was graded by 0 to 5 points. According to our results, patient's judgement about the outcome was alsituationsinneurosurgery,when the graft is possibleto use e.g.: Dottsoperation ways more sceptic, and neurophysiological recovery was always better than III.,n. of defect n,VII. in cerebellopontine angle or petrous bone, repairing of IV., Vi. and their defects by scull base surgery or defects of peripheral nervessensomotorrecovery,bU1 EMNG recovery correlated closely with sensory and intraabdominaly . Author presents a case report of a 28-year-old female with a patient's judge closely with motor recovery. Accordance between clinical and neurophysiologicalrecovery was the most obvious after radial, lesser after successful repair of the n. obturatoriusobt.) (n. by sural graft ingynaecological pereneal, and the lowermostafter ulnar,median and tibial nerve repair. operation. Methods: A 28-year-oldfemale underwenthysterectomy and lymphadenectomy sec. Wertheim owing to neoplasm during which a resection of the n. obt. occurred with a defect of 5 cm on the right side in cavum Douglassi. The P-4-S09 1 The anatomical andfunctionalprotectionof olfactorystructures:Technical problem consulted neurosurgeon decided to immediate sural grafting into the defect in accordance with gynaecologist. In the same position, when the right lower Jan Hemza. Opt.ofNeurosurgery, Hospifalabout Saint Ann, Brno, Czech extremity was completely elevated a 6 cm long graft was taken from two inciRepublic sions. Then the graft was sutured into the defect of n. obt, using microscope with monophil 9/0. The peritoneum was closed by several stitches and theThe author has a long time experiencewith the protectionof oltactory structures duringposttraumaticreconstructionof the anterior skull base. The problem both gynaecologistfinished the operation. Results: 6 months postoperatively the patient had clear signs of improve-anatomicalprotection, and functional. ment of sensation in the upper medial part of the right thigh, and EMG exami- The basic problemsduring preparation of the olfactory structures are traction and movement. The critical point is the connection between olfactory nerves nation showed rich reinervation signs. and olfactorybulb, which is very fragile with a traction power very(O.2--{).3 near Discussionand Conclusions:Duringgynaecologicaloperations intraab5 m. The elevation limit of the . 10- 5 Nm-l ) and a limit of elongation of 1 . 10dominal injury of the n. obt, very is rare. Even if theneurologicaldeficit is not so severe as an injury to e.g.: of the n. medianus or n, radialis, yet it is worth-olfactorytract is 10-15.10- 3 m. From personal experience, as well as anatomical and clinical studies the while to pay serious attention ofneurosurgeon a . Nevertheless the operation of this damage becomes a very rare one because 01 several conditions which principlesof the techniqueare formulated and very precisely described. The techniqueachieves 89-92 % anatomical and functional protection of the must be realisable: Immediate presence 01a skilledneurosurgeon, who is able to perlorm grafting in difficult anatomical conditions and necessity of using olfactory a nerves. microscope in gynaecological operating room.

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I P-4-S10 I A new method of evaluating facial nerve functionby usingtranscranialmagneticstimulation

NobuyukiKobayashi,Seiya Kato, Souji Shinoda, Toshio Masuzawa. Departmentof SurgicalNeurology,Jichi MedicalSchool, Tochigi,Japan Introduction:Facial nerve function has been evaluated by the blink reflex evoked inelectrophysiologicalexamination. In this method, the evoked myo-

Tuesday, 8 July 1997

Peripheral Nerves and Brachial Plexus

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graphic waveform of the orbicularis oculi is recorded when Ihe first branch of Discussion: ADM injection into the peripheral facial nerve branches gave the trigeminal nerve is stimulated . However, no objective examination of the rise 10a satisfactory relief of involuntary movements and the effect was d early by cerevoluntary blink response exists . Since voluntary responses are initiated long-lasting. For Meige's syndromes, simple tran ssections of the nerve branches bral cortical excitation at the primary motor area, we attempted to record facialis inadequate in view of frequent recurrence and the current treatment with focal nerve output when the motor cortex was stimulated . We report a new method Botulinum toxin injection is effective oniy for a few months . Since the effects of of evaluating facial nerve funct ion by using transcranial magnetic stimulation. ADM were primarily due to the degeneration of target neurons, regeneration of Methods: Six subjects (4 normal volunteers , 2 patients with hemifacial the nerve would not occur. The present study indicates long lasting effects of spasms: HFS and Meige syndrome) were examined. Evoked myographic wave- ADM treatment and thus our novel approach may serve a useful adjunc t to the forms of the bilateral orbicula ris oculi muscie were recorded foliowin g stimulation treatment of this particular disorder. magnetic stimulation. We used the MAGST IM of the motor cortex ytranscranial b model 200 for stimulation, and recorded waveforms with a Neuropack 8 (Nihon P-4-513 I Postoperativeobliquesagittal MR imaging in Kohden). Results: Contractions of the orbicu laris oculi were evoked afte r magnetic microvasculardecompressionfor hemifacialspasm ± 1.2 msec on the contralateral side. Ipsilateral stimulation at a latency of 15.0 Y. Nagaseki, T. Omata ,T. Ueno, Y. Ohhashi, T. Horikoshi, H. Nukui. contraction was observed in only two of six subjects . The myographic waveforms Department ofNeurosurgery, Yamanashi Medical University, Yamanashi. Japan were monophas ic, and 72± 3% stimula tion intensity was needed in normal volunteers to evoke contraction. In patients with HFS and Meige syndrome , Introduction: To visualize vascular compres sion of nerves , the use of an oblique who appeared to have hyperacti ve facial nucleus, the latency tended to be sagittal gradient-echo (OS-GA ) magnetic resonance (MNA) imaging method has already been reported. The MA images after microvasculardecompression shorter. Discussion:Only large, single, monoph asic waveforms were observed with (MVD) for hemifacial spasm (HFS) have not been reported. We analyzed how facial motor cortex stimulation, resembling the A2 response of the blink re-the OS-GA images could visualize the post-MVD findings. flex. There was no ipsilateral rapid cont raction similar to the A1 oligosynaptic Methods:Our views were obtained along the nerve identified by the axial response . We consider that our new method will be useful to diagnose and view. The gradient-echoimaging sequences (TArTE= 200/20) could visualize evaluate theclinicallyhyperactive state of facial function. the compressivevessels as high intensity lines/spots and the facial and acoust ic nerves as isointensity lines on the same plane. Twenty-three patients with HFS (mean age: 57 years) underwent MVD and pre-and post-MVD OS-GR images. P-4-511 Hypoglossal-facialnerve side-to-end coaptation for Results: The post-MVD OS-GA images were divided into 3 groups. The MA images of A group showed a moderate size of low intensity area between preservationof hypoglossalfunction: Results of the verteb ral artery as the thick high intensity line and the root exit zone of the delayedtreatmentwith a new technique facial nerve (AEZ) in 9 cases, all with the vertebr al arteries transpositioned to Ju n-Ichi Murata, Yutaka Sawam ura. Hiroshi ADe. Department of Neurosurgery, the petrous bone, Group B showed a low inlensity spot betwee n PICA/A ICA University of Hokkaido. SChoolof Medicine, Sapporo, Japan as the thinner high intensity line and the REZ in 9, in whom the Teflon mesh Introduction:Conventional hypoglossal -facial nerve anastom osis for facial were interposed between the compress ive artery and the AEZ, and group C paralysis inevitably causeshemitongueatrophy and dysfunction. This paper with equivocal image in 5 nerves compre ssed by PICA or AICA . In 78.3% , the describesa new surgical technique which does not necess itate the use of nerve post-MVD conditions were clearly visualized using our OS-GA images. The grafts orhemihypoglossalnerve splitting in order to improve the results of this operative results were all excellent. Conclusion: The OS-GA MA images could visualize the post-MVD findings surgery. Method:The descending portion of the facial nerve in the mastoid cavity is as well as the pre-MVD findings. It might be very useful in the recurrent cases exposed by drilling and its most proximal portion is sectioned. The hypoglossalin which the prosthesis would slip off or with vertebral artery reposition . nerve is exposed at the level of the axis and dissected as proximally as possible. One-half of the hypoglossal nerve is transected: less than one-half of this nerve is adequate for appro ximation to the distal stump of the atroph ic facial nerve. P-4-514I Treatment ofobstetric brachialplexuslesions. A multidisciplinary approach The proximally cut end of theypoglossalnerve h and the distal stump of the facial nerve are approximated and anastom osed without tens ion. W.J.R. van Ouwer kerk, W.B.M.s iocn , A.C.J. Slooff.Dept. of Neurosurgery, Results:This techn ique was used in 4 patients with facial paralysis of more FreeUniversity Hospital, Amsterdam, The Netherlands than 24 months duration. Good recovery of facial movement was accomp lished of l plexus injuries in 3 out of 4 patients. No patients experienced hemitongue atrophy or dysfunc-In The Netherlands experience in the treatment obstetrica goes back a very long way, mainly due to the pioneering work of one of the tion. neurosurgicalcenter s. Discussionand Conclusions:Because it completely preserves glossa l co-authors (A.C.J.S.). Treatment is concentrated in three multidiscipl a inary function , thehemihypoglossal-facialnerve anastomosis described here consti- As treatment of these lesions is complex it always involves approach. In this presentation we discuss how treatment of these childre n is tutes a successful approach in patients with ong-standingfacial l paralysis who organized. In the Free University Hospital in Amsterdam the pediatric neurodo not wantcompromisedtongue funct ion. surgeon (W.J.R. v.0.) coordinates the treatment, which is adm iniste red by a multimember plexus team. The reqular team members are a pediatr ic neurosurgeon, a neurosurgeo n, a plastic surgeon. a rehabilitation specialist, a neuP-4-512I Selective facialneuronotomyby way of the rophysiologist and a pediatric neurologist. Early presentation to the ped iatric retrogradeaxoplasmictransportof adriamycin: neuro surgeon or neurologist is stressed to [assess the severity of the lesion, Surgicalexperience in idiopathic blepharospasm give parents information, coordi nate early conservative treatment measures] . Mamoru Ohta1• Jun Sakuma 1. Hiroshi ltokawa2 , Namio Kodama2 , [obtain a careful history] and start the monitoring of the natural history. Early Teiji Yamamoto3. 1 Department of Neurosurgery, Masu MemorialHospite), follow up is at 4-week intervals. At the age of 4 months a decision is made as 3 Departmentof Neurology. Nihonmatsu,2 Department of Neurosurgery, to whether or not a plexus exploration and reconstruction should be perform ed. Fukushima Medical School, Fukushima. Japan The decision made by the multimember team is based on criteria for recovery Introduction:Idiopathicblepharospasm , an involuntary movement disorder of of the child (to be mentioned in the presenta tion). Follow up of conse rvatively or central origin, has been subjected to a variety of treatments , however, withoutsurgically treated children is done if indicated by different plexus team members. long-term satisfactoryrelief. The targeted destruction of motor neurons that give Patients are monitored at regular intervals by the assembled plexus team. In rise toinvoluntarymovementscan theoretically abolish the movements. Based the presentation we discuss our approach to newborns with obstetrical plexus on this concept . here. we report the intraneural injection of Adriamycin (ADM),injuries, timing and methods of evaluation, advant ages and value of diagno stic a retrogradel y transportedneurotoxin via axoplasmic flow, controls involuntary tools,assessmentof surgical outcome and timing, and indications for and value of secondary plastic reconstructive surgery. movements. Materials and Methods: The peripheral facial nerves of 7 patients were exposed at the periauricular portion under general anesthesia. Orbital branches of the facial nerve were selected by the electrical stimulation to the nerves and P.4-515 ! Evaluation ofaccessory-suprascapular nerve 1-'1of 5- 10% ADM was slowly injected into freed from adjace nt soft tissue. Ten transferin obstetric brachial plexusparesis the nerve subepineurially with a microsyr inge. G, Blaauw 1, A.C.J. SloolI1, W.B.M. Slooll 2.1 Department of Neurosurgery, ReSUlts: The long-term stud ies of up to 2 and a half years revealed excellent 2 Department of UniversityHospitalMaastricht, The Netherlands. relief of blepharospasmin 5 patient s (totally abolished blepharospasm ) and Neurosurgery,Free UniversityHospital, Amsterdam. The Netherlands functionally sat isfactoryrelief was obtained in 2 patients. Four of them, however, the the revealed excess crease formation in upper eyelid due to long-term involuntary Abduction and particularly, external rotation defici encies ofshoulderare movement s. Eyelid plasty added to ADM treatment brought about satisfactory main problems in the treatment of obstetric brachial plexus lesions. Extern al results for three patients . Systemic side effects were not observed. rotation often returns only partially and with an endorotation cont ractur e. de-

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