Case Studies - PNS Service

The Peripheral Nerve Surgery Service at Massachusetts General Hospital treats peripheral nerve injuries, tumors and other disorders affecting the network of nerves that link the brain and spinal cord to other parts of the body..

Femoral branch to obturator nerve transfer for restoration of thigh adduction following iatrogenic injury - Case report
Konstantinos Spiliopoulos, M.D., and Ziv Williams, M.D.
Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Obturator nerve injury is a rare complication of pelvic surgery. A variety of management strategies have been reported, with conservative measures being the preferred treatment in most cases. While nerve transfer has become more commonly used for restoring brachial plexus injuries, it has rarely been applied to the lower extremities. To the authors’ knowledge, this is the first report of an obturator nerve neurotization. A patient presented 7 months after an iatrogenic right obturator nerve palsy due to pelvic surgery for gynecological malignancy. She underwent a femoral branch to obturator nerve transfer to restore right thigh adduction. Ten months after the neurotization procedure, there was electromyographic evidence of almost complete obturator nerve reinnervation. At 1 year postoperatively, the patient had regained full muscle strength on thigh adduction and a normal gait. Nerve transfer could therefore be a good option in patients with obturator nerve injury whose symptoms fail to respond to conservative medical therapy.

KEY WORDS: Femoral Nerve, Neurotization, Obturator Nerve, Peripheral Nerve, Nerve Transfer. ( - PubMed Reference DOI: 10.3171/2011.1.JNS101239)

Brachial Plexus Reconstruction Following Resection of a Malignant Peripheral Nerve Sheath Tumor: - Case Report
Konstantinos Spiliopoulos, M.D., and Ziv Williams, M.D.
Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

BACKGROUND AND IMPORTANCE: The main therapeutic approach for malignant peripheral nerve sheath tumors (MPNSTs) of the brachial plexus is wide local excision. Sacrifice of some—occasionally all—elements of the brachial plexus often is required to obtain complete resection, and therefore can be associated with significant morbidity. While peripheral nerve repair is commonly used in the setting of traumatic nerve injury, little is known about its potential use in the treatment of MPNST.

CLINICAL PRESENTATION: We present a patient with an enlarging right neck mass who was diagnosed with MPNST of the brachial plexus. The patient underwent gross total resection of the tumor, requiring sectioning of the upper trunk of the brachial plexus, as well as associated divisions. Following resection, sural nerve grafts were used to connect the C5 nerve root to the anterior division of the upper trunk and the spinal accessory nerve to the suprascapular nerve, whereas a triceps branch of the radial nerve was coapted directly to the anterior division of the axillary nerve.

CONCLUSION: By 20 months after surgery, the patient had regained significant strength in her upper trunk distribution and demonstrated no evidence of tumor recurrence. Brachial plexus reconstruction offers a potentially valuable surgical adjunct to MPNST treatment.

KEY WORDS: Brachial, Malignancy, Nerve, Neurotization, Peripheral, Plexus, Transfer. ( - PubMed Reference DOI: 10.1227/NEU.0b013e31821867de

Role of resection of malignant peripheral nerve sheath tumors in patients with neurofibromatosis Type 1 - Clinical article
Gavin P. Dunn, M.D., Ph.D.,Konstantinos Spiliopoulos, M.D.,Scott R. Plotkin, M.D., Ph.D.,Francis J. Hornicek, M.D., Ph.D.,David C. Harm on, M.D.,Thomas F. Delaney, M.D., and Ziv Williams, M.D.
Departments of Neurosurgery, Neurology, Orthopedic Oncology, Cancer Center, and Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

OBJECT. Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive sarcomas that often arise from major peripheral nerves. Approximately half of MPNSTs arise in patients with neurofibromatosis Type 1 (NF1) who, in comparison with patients without NF1, present at younger ages and with larger tumors that are commonly associated with extensive plexiform neurofibromas. These tumors therefore pose a particularly difficult treatment challenge because of the morbidity often associated with attempted gross-total resection (GTR). Here, the authors aim to examine what role the extent of resection and other covariates play in the long-term survival of patients with NF1 in the setting of MPNST.

METHODS. The authors retrospectively reviewed the records of 23 adult patients with NF1 who underwent surgery for MPNSTs at their institution between 1991 and 2008. The primary end points of the study were mortality, local recurrence, and metastasis. Kaplan-Meier survival curves were evaluated for all patients. Differences for each of the primary end points were evaluated based on cause specific covariates, which included tiered tumor size, tumor location, grade, resection margin status, postoperative weakness, and use of chemotherapy and radiation therapy. Multivariate analysis was performed using Cox proportional hazards models.

RESULTS. Gross-total resection (p = 0.01) and surgical margin status (p = 0.034) had a statistically important role in prolonging overall survival in patients with NF1 by univariate analysis. When tumor size, location, grade, postoperative weakness, and radiation therapy were also taken into account using multivariate analysis, GTR continued to be a significant prognostic factor (p = 0.035).

CONCLUSIONS. These findings suggest that GTR offers significant long-term benefit on survival in patients with NF1. Benefit on survival occurred independently of all other covariates, suggesting that complete resection should be the principal goal of treatment in this patient population.

KEY WORDS: Malignancy, Peripheral Nerve, Neurofibromatosis, Peripheral Nerve Sheath Tumor. ( - PubMed Reference DOI: 10.3171/2012.9.JNS101610

Peripherial Nerve Service - MGH Neurosurgical Service - Wang Ambulatory Care Center - ACC 745 - Phone: 617-643-4102 - Fax: 617-643-4115 - Massachusetts General Hospital - 15 Parkman Street, Boston, Massachusetts 02114