Riunione GdS
Neuropatie Traumatiche e Iatrogene
Proposte e aggiornamenti:
•
•
•
Protocolli operativi “interdisciplinari” per lo studio dei
nervi/plessi dopo lesione traumatica
Aggiornamento studi collaborativi
Prossima Riunione GdS (2012): candidati.
1) Protocolli operativi “interdisciplinari”
Accuratezza diagnostica e prognostica EMG
•
Gold standard: EMG
EMG +US/MR imaging: aumenta l’accuratezza
diagnostica
•
TIMING:
n. radiale-peroneale, PB:
T0: 1 mese
T1: 4-6 mesi
(PB prognosi migliore se chirurgia < 12 mesi)
ENG-EMG protocol
Sensory NCS
• Med-D1,Med-D2,Med-D3
• Uln-D5, (Uln-UC)
• Radial (base of thumb)
• LABC
• MABC
Motor NCS
• Axillary
• Musculocutaneous
• Radial
• Ulnar
• Median
• (Sovrascapular)
• (Long thoracic)
Muscles Needle Electrode Examination
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Supraspinatus
Infraspinatus
Deltoid
Biceps brachii
Triceps
Brachioradialis
Extensor carpi radialis
Extensor digitorum communis
Extensor indicis proprius
Flexor carpi radialis
Pronator teres
Flexor pollicis longus
Flexor carpi ulnaris
Flexor digitorum profundus IV-V
First dorsal interosseous
Abductor digiti minimi
Abductor pollicis brevis.
Controversies in Brachial
Plexus Surgery
•
•
•
WHEN?
WHETHER?
HOW?
Conservative management of 3-4 months
prior to operative exploration.
No spontaneous recovery
operative planning
Kim et al. J Neurosurg, 2003; 98:1005-1016
BP SURGERY: UP-TO-DATE
PRIMARY or EARLY REPAIR (>72 hours-2/3 weeks)
Neurotmesis (nerve sharply divided)
ASAP
Physical Therapy
Nerve contused, epineurium ragged
→ end-to-end suture, auto/allografts, tubulizations
SECUNDARY or DELAYED REPAIR (late<8-12 months,
very late> 12 months)
Closed injuries, partial nerve defects,
after time (≥ 4 months) for spontaneous recovery and
full clinical /neurophysiological evaluation of nerve functions.
→ surgical exploration (to determine the anatomic extent of the lesion):
neurolisys, end-to-end/endo-to-side repair, neurotizations, tubulizations,
auto/allografts, resection of neuroma in continuity, direct muscle neurotization
Kim et al. J Neurosurg. 2003; 98:1005-1016
Brachial Plexus:
SURGICAL OUTCOMES
•
1019 operative BPIs were managed at Lousiana
State Universisty Health Sciende Center in 30 years
•
Infraclavicular stretch injury (less frequent-28%,
than supraclavicular-72%) are technically more
difficult to treat and are associated with a higher
incidence of vascular and dislocation/fraction injuries.
Better PROGNOSIS: lateral/posterior
Poor PROGNOSIS:
Neurosurg Focus. 2004 May 15;16(5).
Kim et al.
medial cord.
•Increased incidence and indications for surgery
(>graft repair and neurotization) during recent years.
•Open injuries have better outcomes (78%) than
strech injuries (58%).
•Only 22% patients become totally and permanently
disabled.
•Conclusion: an aggressive surgical approach in
a specialized center remains appropriate.
Problemi aperti
• Mancanza di omogeneità di timing chirurgico
in PB (3-6 mesi; < 12 mesi, > 12 mesi).
• Follow up brevi per la valutazione del recupero
(outcome finale valutabile solo dopo 2-3 anni
dall’intervento/trauma).
• Imprecisa valutazione dei risultati (definiti
spesso “positivi” o “negativi” senza scelta di
outcome standardizzati e omogenei).
1) Protocolli operativi “interdisciplinari”
Chirurgia
•
PRIMARIA (0-20 gg): es. lesioni aperte.
•
SECONDARIA (lesioni chiuse):
in assenza di segni clinici e elettrofisiologici di
recupero dopo 6 - 8 mesi di osservazione →
esplorazione chirurgica
NB: importanti dati su follow up lunghi (> 1 anno).
2) Aggiornamento studi collaborativi:
STUDIO MARKERS ELETTROFISIOLOGICI PROGNOSTICI
DI RECUPERO NELLE NEUROPATIE TRAUMATICHE
• Stardardized AAN EMG protocol (Ferrante, Wilbourn, 2002)
• TIMING :
A and B groups
A) All suspected traumatic neuropathies (closed
injuries)
B) Primary surgery (open injuries).
2) Aggiornamento studi collaborativi:
STUDIO MARKERS ELETTROFISIOLOGICI PROGNOSTICI
DI RECUPERO NELLE NEUROPATIE TRAUMATICHE
14 centri
Centri aderenti
Comitato Etico
Torino-CTO
APPROVATO
Torino-Molinette
APPROVATO
Palermo-Villa Sofia
APPROVATO
Torino-Maria Vittoria
richiesto
Piacenza
richiesto
Padova
richiesto
Roma-Don Carlo Gnocchi
Genova-S. Martino
Verona
Rovigo
Trento- S. Chiara
APPROVATO
Siena-ASL 7, Clinica Neurologica, Le Scotte richiesto
Firenze- Careggi
Ancona-Osp. Riuniti-Torrette
3) Riunione GdS 2012: Candidati
Sono aperte le candidature
GRUPPO DI STUDIO “NEUROPATIE TRAUMATICHE E
IATROGENE”
Coordinatori: Palma Ciaramitaro [email protected]
Marcello Romano
[email protected];
[email protected]; [email protected]; <[email protected]>;
<[email protected]>;[email protected]; [email protected];
[email protected]; [email protected];
[email protected]; [email protected];
[email protected]; [email protected];
[email protected]; [email protected];
[email protected]; [email protected]; [email protected];
[email protected]; <[email protected]>;
[email protected]; [email protected];
[email protected]; [email protected];
[email protected]; [email protected];
[email protected]; [email protected]; [email protected];
[email protected],