75. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie

Dr. med.

Vorsitz

PD Dr. med.

Prof. Dr.

Presentation of the updated S3 guideline 'Treatment of peripheral nerve injuries'

Periphere Nerven

Vorstellung der aktualisierten S3-Leitlinie "Behandlung von peripheren Nervenverletzungen

Uncertainty about adequate diagnosis and treatment leads to a wide variation in the quality of care for patients with peripheral nerve injuries. The aim of the AWMF S3 guideline 'Treatment of peripheral nerve injuries' (first published June 20, 2013) is to provide reliable and generally accepted definitions of what is necessary and appropriate in prevention, diagnosis and treatment. The current update of the S3 guideline 'Treatment of peripheral nerve injuries' is being led by 5 specialist medical societies (DGNC, DGPRÄC, DGN, DGKOU and DGH) and coordinated by DGPRÄC and DGNC.By systematic literature review and consensus in an interdisciplinary panel of experts, seven PICO questions as well as statements and recommendations with explanatory background texts were developed.Six out of the seven PICO questions were addressed using quantitative systematic literature research. The working group agreed on six statements and 59 recommendations as part of the nominal group process and justified them on the basis of current studies. Significant innovations were implemented in the chapters on epidemiology in the area of war injuries, iatrogenic nerve damage and nerve injuries in children. Diagnostically, the relevance of MR neurography has been taken into account and in the area of therapy, reference has been made to the increasing availability of positive studies on the use of nerve transfers. The existing chapter on pain treatment has been expanded, particularly in the areas of 'neuromas' and "neuromodulation", based on current studies.The updated version was agreed by the working group, approved by the medical societies and submitted to the AWMF on time. To reduce uncertainties in the diagnosis and treatment of nerve injuries and improve the quality of treatment the guideline will be made publically available on the AWMF website.

Abstractvortrag | Abstract talk

The relevance of frailty in neurosurgically treatable diseases of peripheral nerves: A nationwide observational study from a large hospital network

Die Bedeutung der Gebrechlichkeit bei neurochirurgisch behandelbaren Erkrankungen der peripheren Nerven: eine landesweite Beobachtungsstudie aus einem großen Krankenhausverbund

In many neurosurgically treatable diseases, frailty is associated with pronounced disease progression and poorer treatment outcomes. The COVID-19 pandemic led to an increase in frailty among the general population. The impact of frailty on neurosurgically treatable diseases of peripheral nerves (PN) has never been studied before. Our study presents the first German-wide analysis of the impact of frailty on patients with four diseases of PN: Meralgia paresthetica (MP), benign nerve tumors (BNT), lesions of the brachial plexus (BP), and ulnar neuropathy (UN).Administrative Data from a German-wide network of 76 hospitals was retrospectively analyzed comparing the prepandemic (January 1, 2016 – December 31, 2019) vs. the pandemic phase (January 1, 2020 – December 31, 2022). Patients hospitalized for MP (G57.1), BNT (D36.1), lesions of BP (G54.0), and UN (G66.2) were included. Frailty was categorized according to the Hospital Frailty Risk Score (HFRS), as follows: low (HFRS <5 points), medium (5-15 points), and high (>15 points). Ethical approval was granted by the local ethics comittee (490/20-ek).A total of 8,992 patients were included in the study (prepandemic n=5,918, pandemic n=3,074). Daily admission rates decreased during the pandemic among all of the four entities: MP (0.6 to 0.3 [p<0.01], BNT (0.8 to 0.7, [p=0.05]), lesion of BP (0.9 to 0.7 [p<0.01]), and UN (1.9 to 1.2 [p<0.01], respectively. For MP, the rate of patients with medium frailty increased from 16.5 to 26.7% (p<0.01) during the pandemic phase compared with the prepandemic phase. Concordantly, the rates of patients with low frailty decreased from 82.2 to 71.0% (p=0.3). For BNT, lesion of BP, and UN, the overall rate of frail patients were lower and no change of HFRS between the pre- and pandemic phase were observed. Type of surgery did not change comparing the two phases. A reduction in length of hospital stay between pre- and pandemic phase was observed for BNT (4.6 ±4.7 vs. 3.7 ±3.4 days [p<0.01]), for lesions of BP (4.5 ±4.3 vs. 5.1 ±4.0 days [p>0.01], and for UN (2.4 ±2.3 vs. 1.9 ±3.4 days [p<0.01]).Daily admission rates of patients with PN diseases decreased during the COVID-19 pandemic in Germany. Among these, MP patients had the highest frailty scores with an increase during the pandemic phase. In all entities but MP, the pandemic led to a reduction in lenght of hospital stay. Our data shows for the first time, that frailty has an impact on patients treated for MP.

Predictive parameters of patients' relevant outcome following surgery for carpal tunnel syndrome

Varia klinische Neurochirurgie

Prediktive Parameter für ein Patienten relevantes Outcome nach Operation bei Karpaltunnel-Syndrom

The most common nerve entrapment syndrome is carpal tunnel syndrome (CTS). Clinical and instrumental findings are necessary to diagnose CTS. Decompression of the median nerve is recommended when conservative treatments fail. Although surgery is most beneficial, it may not lead to a favorable outcome for some patients. Therefore, a prospective study was conducted to examine prognostic factors for outcome following decompression surgery.102 wrists were prospectively observed. Clinical, electrophysiologic, and neuro sonographic findings and self-reported scores were compiled 2 months before and 3 months after decompression. Parameters were compared to assess general changes. Two groups were identified with good and poor outcome based on self-reported symptom severity (SSS) and functional status scores (FSS). Data were analyzed using either student's t-test or Mann-Whitney U-test. To identify predictive parameters regression analyses were performed. Significant parameters were evaluated to determine cut-off values using ROC-curves.The follow-up revealed improved SSS and FSS. Examinations demonstrate improvement in nerve conduction and swelling of the median nerve. Multivariate regression indicated that diabetes mellitus, SSS and positive Phalen's sign were predictors of relative decrease in symptom severity. Whereas the age group and FSS have an impact on relative improvement of functional status. Logistic regression showed a good outcome for patients younger than 50 years, without diabetes mellitus and with high preoperative SSS. For a SSS of 3.2 or higher, surgery could be recommended. When considering functional status, only a high preoperative FSS predicted a good outcome. Therefore, a cut-off value of at least 2.6 is recommended.Analyses demonstrated that decompression resulted in physiological benefits. However, the study was unable to identify multiple predictive parameters. Results indicated that patients over 50 years and those with diabetes mellitus had a higher risk of receiving inadequate benefit from surgery. However, self-reported SSS and FSS are necessary to provide professional consultations.

Prof. Dr. med.

Surgical treatment of inflammatory peripheral nerve entwinement – Results after (intraneural) neurolysis without nerve transplantation

Chirurgische Therapie entzündlicher peripherer Nervenkonstriktionen – Ergebnisse nach (intraneuraler) Neurolyse ohne Transplantation

Inflammatory processes with subsequent stricture formation may be responsible for poor clinical outcome of motor function following peripheral nerve inflammation such as neuralgic amyotrophy. The aim of this study was to investigate clinical and intraoperative findings in patients with surgically treated peripheral nerve entwinement.In a retrospective analysis from 2015-2023, 17 nerve constrictions in 14 patients were surgically treated after sonographic diagnosis and included in this analysis. Clinical and diagnostic findings before and after surgery were assessed and the type of surgical procedure was evaluated.All patients underwent preoperative high-resolution neurosonography, which revealed the presence of a nerve stricture/entwinement. The mean patient age was 53 (±10.5) years. 64.3% of the patients were male, 35.7% were female. The stricture was located in 35.3% (n=6) each at the median and radial nerve, in 17.6% (n=3) at the musculocutaneous nerve and in 11.8% (n=2) at the suprascapular nerve. Neurolysis with epi- and perineurectomy was performed in 53.0% (n=9), epineurectomy in 23.5% (n=4) and neurolysis in 23.5% (n=4). No patient underwent transplantation. In 2 cases no clear constriction was identified intraoperatively. A high-grade paresis (M0-3) was present preoperatively in 88.2% (n=15), postoperatively in 23.5% (n=4); 11.8% (n=2) showed no clinical improvement. Surgery was performed M=6.5 months after symptom onset, the last follow-up was held M=5.5 months postoperatively. There was a significant correlation between type of surgical procedure and degree of postoperative paresis with better results after more aggressive procedures (epi-&perineurectomy > epineurectomy > neurolysis, r=0.73, p=0.007), but not between preoperative clinical status and type of surgery. There was no correlation between the extent of paresis and the location of the lesion.A reliable diagnosis of peripheral nerve entwinement has only been possible since the establishment of high-resolution neurosonography. Our data show that sonography-guided intraneural neurolysis of the entwinement leads to good clinical results. Perineural neurolysis, on the other hand, often appears to be insufficient. The outcome results shown are comparable with literature reports, which have always included cases undergoing nerve transplantation. Transplantation might not be required if intraneural neurolysis with epi- and perineurectomy is performed.

PD. Dr.

Improving facial palsy-specific quality of life: FACE-Q® evaluation of peripheral nerve reconstruction and facial re-symmetization in 66 patients

Tumor

Verbesserung der Lebensqualität von Fazialisparese Patienten: FACE-Q® Evaluation der funktionellen Reanimation und Resymmetrisierung des gelähmten Gesichts von 66 Patienten.

Facial palsy – idiopathic, infectious or iatrogenic due to neurosurgical or ENT procedures – is the most frequent of cranial nerve lesion. Associated functional and aesthetic deficits impair the quality of life of patients. To determine treatment and outcome in our tertiary multidisciplinary facial nerve center, a retrospective observational study was performed of all patients treated between 2019 to 2023.Observer-based analysis of facial function according to the House-Brackmann score (H&B) was compared to facial palsy-specific patient reported outcome measures (PROM) of the FACE-Q scale. Descriptive statistics for all measures were analyzed and correlations were calculated to compare facial palsy-specific instruments, as well as observer-based grading.In total, 66 patients (80% female, median age 50 years) with acute and chronic facial palsy were included. A severe palsy (H&B °V-VI) was recorded in 51% while moderate palsy (H&B °III-IV) was treated in 29%. Etiology of palsy was iatrogenic (i.e., after vestibular schwannoma resection) in 68% of cases, further etiologies were neurofibromatosis, idiopathic palsy, cavernomas and meningeomas. Twenty-six peripheral nerve transfers were conducted and 25 cases combined with ancillary symmetrizing static procedures. Reconstructing the motor unit by functional muscle transfer was required in seven cases. Revisions of three cases were due to unfavorable lid chains. Patient satisfaction was highest in patients receiving invasive treatment for mild palsy (H&B ° I-II), followed by patients with severe impairment (H&B °V-VI). PROM of social function and satisfaction was lowest in the moderate palsy group despite improvements in smiling and eating distress functional scores.Peripheral facial nerve surgery alongside adjacent symmetrizing procedures prove to be enhancing muscular, social and psychological function, highly influencing quality of life for patients with all severities of paralysis. To fully assess the burden of disease of facial palsy patients, validated disease-specific assessment should be applied in addition to standardized observer-based ratings. Patients treated for mild paralysis achieved highest satisfaction scores by supercharging end-to-side nerve transfer and aesthetic eyelid procedures. All functions need to be considered in reconstructing, reanimating and re-symmetrizing the paralyzed face.

Seltene und ungewöhnliche periphere Nervenläsionen – chirurgische Herausforderungen

Session 27
Periphere Nerven

Termin

Vorsitz

Thema

Programm

Session 27Periphere Nerven

Termin

Vorsitz

Thema

Programm

Session 27
Periphere Nerven