Background. The increasing number of orphan (rare) diseases, most of which have a prevalence of less than 1 : 1,000,000, poses a serious challenge for modern medicine. In most cases, diagnosis is delayed leading to irreversible changes in the body. The Department of Psychoneurology at the State Institution “Ukrainian Center of Maternity and Childhood of the National Academy of Medical Sciences of Ukraine” has been involved in diagnosing and treating orphan diseases in children since 2012, with 80 % of cases accompanied by nervous system involvement. The purpose was to conduct a retrospective analysis of medical records of patients treated at the Department of Psychoneurology for Children with Perinatal Pathology and Orphan Diseases during the war in Ukraine. Materials and methods. During the full-scale invasion, 42 children with orphan diseases were hospitalized to the department. A retrospective analysis of the medical records of these inpatients was conducted to identify the specifics of diagnosis, clinical manifestations, and treatment. Results. In 90 % of cases, orphan diseases presented with clinical masks of neurological pathologies, complicating early diagnosis. The highest percentage of diagnoses (38 %) occurred in children aged 1 to 5 years. Male children were more susceptible to orphan diseases (ratio 1 : 2). An important aspect of care was treatment: 21 % of children were referred to the department for developing treatment strategies by a multidisciplinary team. Conclusions. Despite the challenges, the Department of Psychoneurology at the State Institution “Ukrainian Center of Maternity and Childhood of the National Academy of Medical Sciences of Ukraine” continues to successfully combat orphan diseases in children. Although the goal is to diagnose these diseases within the first year of life, it remains a challenge for the global medical community. The department also implements effective targeted treatment regimens through a multidisciplinary approach.

Background. Skin wound healing is a serious medical problem that is complicated by bacterial infections and requires appropriate care and treatment. Objective: to study the effect of a highly mineralized spray solution on the regenerative processes of the skin in a wound defect in an experiment. Materials and Methods. The study was conducted under laboratory conditions on 5 adult Chinchilla rabbits (weight 3.2-3.8 kg). A 10x10 cm area of skin on the back was shaved, and skin fragments measuring 2x2.5 cm were symmetrically excised on both sides of the spine at the level of X-XII ribs. A 0.5 ml solution of Staphylococcus aureus culture concentrate prepared in the laboratory of microbiology of the SI “Institute of Traumatology and Orthopedics of NAMS of Ukraine” was applied to the wounds. On the second and subsequent days of the experiment, a highly mineralized spray solution was applied to the experimental wound, while a physiological saline solution was applied to the control wound. On the 3rd and 7th days, a microbiological culture was taken from the wounds. After 7 days, the skin wound defect was taken for histological examination. Results. Macroscopically, there was a significant reduction in the area of the wound defect during the first three days of the experiment due to contraction, with a tendency to accelerate in the experimental defects. However, complete closure of the wound did not occur on the 7th day. The results of the cultures confirmed the growth of microbial colonies of Staphylococcus aureus, which visually (growth dynamics, number and size of colonies) did not differ from the biological samples obtained from control and experimental skin defects. Despite the contamination, purulent discharge from the wound was not observed. Conclusions. The experiment showed that the use of a highmineralized solution-based agent potentially contributes to regenerative processes in the skin, including angiogenesis and dermal restoration, but other effects, such as antiinflammatory and antibacterial, require further research.

Traction injury of the peripheral nerve (TIPN) is an injury that occurs as a result of stretching the nerve beyond its normal elastic properties. An analysis of the available literature has revealed the following. TIPN is the most common type of severe nerve injury in the setting of road traffic accidents, catatrauma, gunshot wounds, birth injuries, etc. The dynamics of TIPN during fast and slow stretching is the same and includes three phases: elastic, inelastic and tearing. The limits of elastic stretching of the nerve are determined by the degree of tortuosity of myelinated fibers and the elasticity of the connective tissue framework of the nerve. Stretching of the nerve beyond its elastic limits is characterized by rupture of axons and endoneurial sheaths, including at a considerable distance from the epicenter of pathomorphological changes, which determines the severity of the injury and the impossibility of effective nerve autoregeneration. The force of stretching and the direction of its application to the nerve trunk determine the severity of TIPN. The degree of nerve stretching varies along its length and reaches a maximum in the periarticular areas. A fairly moderate stretching of the nerve can lead to a noticeable change in the conductivity of electrical impulses. Unlike other localized types of nerve injury, the pattern of pathomorphological changes in TIPN includes various forms of damage to structural elements. Understanding the pathophysiology of TIPN is a prerequisite for the development of optimal treatment of this type of injury.

Background. The incidence of pronator teres syndrome (PTS) is low. The misdiagnosis leads to delay in surgical treatment and irreversible changes not only within the median nerve (MN) itself, but within the sensory and muscular apparatus as well.Objective: to compare the outcomes of early and delayed surgical management of PTS; to compare the restoration of the pinch grip (PG) after decompression and reinnervation (nerve transfer, NT) of the anterior interosseous nerve (AIN) vs. decompression of MN alone in late terms of the disease (PTS).Materials and Methods. Six patients with verified PTS were included into the study. Three patients with the history of the disease (HoD) less than 3 mos. received surgical decompression (SD) of MN under standartized methodology alone. Another three patients with the HoD more than 3 mos. received SD of MN, with two of them received simultaneous NT of the branches of the radial or MN to AIN. In all patients sensory and motor deficit (function of "extrinsic"and "intrinsic"muscles), intensity of the neuropathic pain, both pre- and post-surgery have been evaluated according to MRC Scale and VAS, respectively. An ability to reproduce PG, or “OK” sign, with help of the thumb (flexor pollicis longus muscle – FPL) and index finger (deep flexor muscle – FDP2) were evaluated.Results. All patients showed complete relief of the neuropathic pain (VAS0) regardless of the terms of the disease. Three patients with HoD less than 3 mos. showed good recovery of FPL, FDP2 (M4-5) – all patients were able to reproduce "OK" sign. One patient with HoD more than 3 mos. after SD of MN alone showed no recovery of FPL, FDP2 (M0-1). Another two patients with the HoD more than 3 mos. showed good recovery of FPL and FDP2 (M3-4) after NT to AIN. No patient with HoD more than 3 mos. was able to reproduce "OK" sign.Conclusions. Early decompression of MN in PTS cases results in complete relief of the sensory and motor neurologic deficit; late decompression of MN in PTS cases does not lead to relief of the sensory deficit within NCP autonomous area, while the prognosis of the recovery of the median nerve innervated “extrinsic” and “intrinsic” muscles is rather unfavorable; In case of late PTS presentation, NT to AIN allows restoring only a single component ("extrinsics") of the motor functions of the hand which are required for the succesfull reproduction of the pinch grip; In case of late PTS presentation, poor recovery of OP should be expected, hence the succesfull reproduction of the pinch grip due to the thumb hyperadduction would be impossible; carefull interpretation of the clinical, radiological and electophysiological data on the pre-surgical stage could potentially help avoiding the misdiagnosis and improve the outcomes of the surgical treatment in all cases of a single or multilevel MN entrapment.

Damage to the major vessels in a retroperitoneal trauma belongs to the category of the most difficult, including damage to the inferior vena cava. The aim of the work is to demonstrate the features of clinical manifestations and tactical solutions of a gunshot fragment blind wound of the inferior vena cava with the migration of a foreign body along the blood stream. Materials and methods. A case of a gunshot fragment wound of the inferior vena cava with migration of the foreign body along the blood stream was studied. An injured person underwent sCT with and without contrast, FAST protocol, general blood test, biochemical blood test, CBV was determined using the formula of Moore, hourly diuresis was measured. Results. The patient was operated on for vital signs, the condition of the injured person was stabilized. During the revision of the abdominal cavity and paranephric tissue, no foreign body was identified. In the immediate postoperative period, the injured person underwent chest and abdominal CT, according to the data of that, a metal fragment was identified, which migrated along the inferior vena cava to the point of connection with the right atrium. The injured man was operated on at another specialized facility, where the foreign body was removed using a surgical magnetic tool. Conclusions. Fire damage to the inferior vena cava is classically accompanied by a severe general condition, massive blood loss, which requires urgent surgical interventions. Multi-component preoperative preparation, a clearly established diagnostic plan, a multidisciplinary approach based on the example of our clinical case allow saving life even in the most complex cases.

Objective: retrospective analysis of the outcomes of selective surgical reinnervation (SSR) of the axillary nerve (Ax) in patients with supraclavicular brachial plexus injury (SBPI). Materials and methods. Forty-two patients (mean age 31.2 years) received 25 SSR with extraplexus donor nerves (e-ND) – 9 cases of subtotal SBPI and 16 cases of complete SBPI. In 17 cases of subtotal SBPI exclusively intraplexus donor nerve (i-ND) were utilized. Twenty-nine (69%) patients received SSR in terms up to 6 months, 13 patients (31%) – in terms more than 6 months. All patients at the time of inclusion were examined neurologically, electophisilogically and in 6, 9, 15 and 17 months. Recovery of the deltoid (D) muscle was assessed on Medical Research Council Scale (MRC Scale) – effective power (Еp). Recovery of effective function (Ef) has been assessed on the basis of flexion angle in glenohumeral joint in sagittal plane. Results. Ер of D recovered in 12 patients (28%), in terms up to 6 months - in 31%, more than 6 months – in 23%. Ep of D recovered after SSR with i-ND in 9 patients (52%), in terms up to than 6 months - in 60%, more than 6 months – in 43%. Ep of D recovered after SSR with e-ND in 3 patients (12%), in terms up to 6 months- in 16%, no recovery of Ep has been observed in terms more than 6months.Ef of D recovered in 11 patients (26%), in terms up to 6months - in 31%, more than 6months – in 15%. Ef of D recovered after SSR with i-ND in 8 patients (53%), in terms up to 6 months - in 60%, more than 6 months – in 29%. Ep of D recovered after SSR with e-ND in 3 cases (12%), in terms up to 6months - in 16%, no recovery of Ep has been observed in terms more than 6months. Recovery of Ef of D at subtotal SBPI occurred in 10 cases (38%), regardless of whether i-ND or e-ND have been utilized. SSR with e-ND at subtotal SBPI allowed restoring Ef of D in 2 cases (22%). SSR with i-ND at subtotal SBPI allowed restoring Ef of D in 8 cases (47%). SSR at complete SBPI allowed restoring Ef of D in 1 case (6%). Conclusions. e-ND can be utilized at complete SBPI in order to provide stability to glenohumeral joint in terms up to 6 months; i-ND should be utilized in all cases of subtotal SBPI in order to provide Ef to D in terms up to 6 months.

The article shows the study results of the sciatic nerve pathomorphosis characteristics in gunshot wounds in experimental animals (pigs). Changes in the structure of nerve sheaths, its fascicles, features of nerve blood vessel injury were studied under optical magnification with digital recording of nerve histological sections. The ultrastructural changes of the sciatic nerve during the simulation of a gunshot wound of the peripheral nerve both with its anatomical section and with the preservation of anatomical integrity were studied. Histological examination of the sciatic nerve damaged by bullets of the 5.45 calibre showed significant morphological changes in the nerve structure both in case of anatomical section of the nerve and in case of its contusion. It has been proven that even if the anatomical integrity of the nerve is preserved, pronounced changes in the nervous tissue occur with a gunshot wound.

Objective: the objective of this study was to retrospectively analyze the change in the surgical strategy (SS) of brachial plexus injuries (BPI), the outcomes of different SS and the factors that influenced the establishing process of a new SS in a single surgical centre in Kyiv, Ukraine. Materials and Methods. 148 patients (mean age 29.5) received 76 neurolysis (N), 14 grafting (G) and 58 nerve transfer (NT) surgeries after a mean 7.4 months following BPI. 29 patients received NT of n. phrenicus, 7 –ulnar nerve fascicles, 9 – lateral pectoral nerve, 7 – medial pectoral nerve to musculocutaneous nerve aimed to restore active elbow flexion. Six other patients received NT of ipsilateral extraplexal motor nerves. The follow-up period included neurological examination (MRC Scale), electromyographic examination and angular deviation in the elbow joint during recovered active elbow flexion. 148 patients were retrospectively divided into two groups A (102 patients, received surgeries from surgical team #1) and B (46 patients, received surgeries from surgical team #2). The SS used in each group and its change with time was analyzed during the 6-year span. Results. 41 patients (70.7%) showed recovery of effective power (Ep) (M4-5) of biceps brachii muscle (BB) after NT. 14 patients (18.4%) showed recovery of Ep of BB after N. 4 patients (28.6%) showed recovery of Ep of BB after G. Overall Group A patients received 55 NT, Group B – 3 NT. The number of NT among Group A patients increased in 2013-2019 from 31% to 100% with overall efficacy of NT increased from 50% to 83%. Conclusions. SS of BPI changed only for Group A patients – N was completely replaced by NT in 2019. For Group B patients N remained SS of choice. The establishing of new SS was influenced by four factors (time, anatomy of injury, donor nerves, radiological findings). The factors being processed, allowed us to define optimal time, effective donors and non-reliability of radiology at BPI. We state that it is only matter of own experience, based on the thorough analysis of the technique, that brings positive outcomes after new SS has been adopted.

Objective: The spinal accessory nerve (Acc) is susceptible to trauma in at least 6% of cases of brachial plexus injury (BPI). The impaired Acc function disables its utilization for transfer to the suprascapular nerve (SS). The selection of approach to SS is highly dependant on the anatomy of BPI. The purpose of this study was to determine the incidence of the anterior-posterior approach of Acc to SS transfer in BPI and associated functional outcomes. Methods. Twenty nine patients with BP/Acc associated injury were included. Ten patients underwent the transfer of Acc to SS by the anterior approach (AA), 19 patients – by the posterior approach (PA). Nine nerve transfers through AA and one nerve transfer through PA required the interposition of an autologous nerve graft. The functioning of the supra-/infraspinatus muscle was evaluated at 9 and 15mos. on the basis of the MRC and the external rotation (ER) range. ER more than +400 beyond the sagittal plane was regarded as effective recovery of function. Results. Impaired function (M3 or lower on MRC) of the lower trapezius muscle was associated with preserved anatomy of the SS in the supraclavicular region in 9 out of 10 cases. Eighteen patients (62%) recovered to M3 and higher (shoulder stability), 11of these (38%) showed recovery to M4-M5. Five of all patients recovered to M4-M5 and were able to produce ER within the effective ROM (+400-600 of ER). After the AA to the SS, shoulder stability was restored in 60% of cases (M4-M5 in 30%). After the PA to the SS, shoulder stability was restored in 74% of cases (M4-M5 in 42%). Only non-complete BPI showed effective recovery of power and function in terms of less than 6 mos. after injury. PA to SS with no graft provided shoulder stability in 72% of cases, AA to the SS and the graft interposition ensured shoulder stability in 50% of cases. Conclusions. The incidence of AA to the SS was 35%, PA – 65%; preserved anatomy of the SS in supraclavicular region was associated with an increased risk of trapezius muscle dysfunction; the PA to SS and consecutive direct end-to-end transfer of Acc showed better results compared to other combinations of nerve transfers in providing shoulder stability.

Gunshot injuries to the colon are frequent in combat casualties, including the current invasion of Russia into Ukraine. Colon wounds are associated with high mortality and severe purulent-septic complications. In this translational study, we investigated gunshot wounds to the colon in 374 servicemen who were injured in East Ukraine. In the experimental part, a special certified ballistic gel 10 % FBI Ballistic Block was used for ballistic analyses of various bullets to confirm clinical data. Data analyses showed that the severity of colon injuries depended on the type of wounding projectile, which was confirmed in gel experiments. The action of the wounding projectile bullet "V-Max" 5.45x39 mm (with expansive properties) showed significant differences in relation to the colon injury as compared to the usual all-shell claw "PS" (p<0.05). Hollow-point bullet wounds require different surgical tactics as opposed to full-shell bullet wounds.

Background. Neuropathic pain is one of the principal secondary complications of spinal cord injury. The biological role of neuropathic pain has not been established yet. This type of pain is formed directly in the area of the spinal cord injury; therefore, it can be assumed that its intensity may characterize both degenerative and reparative processes. The aim of this work is to assess the possible relationship between the intensity of neuropathic pain in patients with spinal cord injury at cervical subaxial spine and the dynamics of neurological disorder regression. Materials and methods. We have performed a retrospective analysis of patients referred to outpatient department of the Romodanov Neurosurgery Institute of National Academy of Medical Sciences of Ukraine in the period from 2010 to 2020 after a surgical treatment of subaxial cervical spine traumatic injury. The extent of neurological disorders and the intensity of neuropathic pain were assessed within 5–7 and 11–13 months after surgery. Results. All 102 patients selected for analysis were divided into three groups depending on the intensity of the registered pain sensations: 1) absence of constant pain sensations — 19.6 % of subjects, 2)moderate pain— 56.9 %, 3) severe neuropathic pain — 23.5 %. In the first group, the regression of neurological disorders was 3.5 (95% confidence interval (CI) 2.15–6.15), in the second — 25.0 (95% CI 24.14–29.58), in the third — 13.0 (95% CI 10.87–16.55). The differences are statistically significant (χ2 = 60.4, df = 2, p < 0.0001). In patients with severe neurological disorders, the dynamics of recovery did not correlate with the pain intensity. With ASIA B, the dynamics of group 1 was 8.5 (95% CI 10.56–27.56), of group 2— 15.0 (95% CI 13.41–18.41), of group 3 — 10.5 (95% CI 7.45–14.89). With ASIA C functional class, the difference is even more pronounced: in group 1, the median was 8.0 (95% CI 0.83–20.83), in group 2 — 32.0 (95% CI 25.41–36.86), in group 3 — 15.5 (95% CI 10.27–27.4). With ASIA D, a similar trend was observed. Conclusions. The worst regression of neurological disorders is observed in patients without clinically significant pain, the best results of neurological dysfunction recovery are found in patients with mode rate neuropathic pain.

OBJECTIVE:The aim: Improving the effectiveness of patients' treatment with combat injuries of the peripheral nervous system, which consists in the application and development of new methods of reconstructive interventions, optimizing a set of therapeutic and diagnostic measures for the most effective management of this category of patients with peripheral nerve injury.PATIENTS AND METHODS:Materials and methods: The research is based on the results of surgical treatment of 138 patients with combat injuries of peripheral nerves for the period from 2014 to 2020. The mean age was 33.5 ± 2.1 years. Patients were treated for 1 to 11 months after injury (median - 8 months). Damage to the sciatic nerve was observed in 26.1%, ulnar - in 20.3%, median - in 18.8%, radial - in 15.9%, tibial - in 10.9%, common peroneal nerve - in 8% of cases.RESULTS:Results: It was shown that in all patients was significantly improved the recovery of all nerves. In the period from 9 to 12 months, the degree of recovery of motor function to M0-M2 was observed in 40.6%, to M3 - in 35.5%, to M4 - in 16.7%, to M5 - in 7,2%. The degree of recovery of sensitivity to S0-S2 was observed in 36.2%, to S3 - in 42.8%, to S4 - in 17.4%, to S5 - in 3.6%. Regression of pain syndrome after surgery was observed in 81.2% of patients.CONCLUSION:Conclusions: The results of surgical treatment of peripheral nerves gunshot injury are generally worse than other types of nerve injuries. The best results of surgical treatment of combat trauma of peripheral nerves are obtained in patients with sciatic nerve damage.

Актуальність. Проблема відновлення фізіологічної симетрії обличчя є вкрай актуальною і важливою у пацієнтів з ураженнями лицевого нерва (ЛН). Неможливість повноцінно виражати емоції накладає надзвичайно сильний відбиток на психологічний стан хворих, а асиметрія обличчя обмежує комфортне перебування в соціумі та призводить навіть до виникнення депресивних розладів у такої категорії хворих. Мета дослідження: визначення чітких показань та протипоказань до проведення хірургічного лікування хворих із наслідками ураження лицевого нерва. Матеріали та методи. Проаналізовані ретроспективно результати лікування 178 хворих із наслідками ураження ЛН, яких було прооперовано в період з 1998 по 2018 рік. Вікові межі хворих — 3–73 роки, серед них 67,9 % осіб були віком до 44 років. Статевий розподіл такий: переважна більшість осіб жіночої статі — 117 (65,7 %); чоловіків — 61 (34,3 %). Діагностичний комплекс включав клінічну оцінку тяжкості ураження ЛН і електронейроміографічне дослідження. Хворим проводили такі види хірургічного лікування: невротизація ЛН різними нервами-донорами, невроліз ЛН, зокрема зі встановленням пристроїв для тривалої електростимуляції (електростимулюючих систем — ЕСС), шов ЛН, автопластика ЛН, статичні методи корекції обличчя, транспозиція м’язів тощо. ­Результати. Згідно з результатами хірургічного лікування усіма методами, ефективність лікування була такою: у 144 хворих (80,9 %) досягнуто відновлення функції ЛН за шкалою House-Brackmann до ІІ–ІІІ позиції, у 34 хворих (19,1 %) — до IV–V позиції. Окремо відображено показники добрих результатів (до ІІ–ІІІ позиції за шкалою House-Brackmann) по кожному методу лікування: невроліз ЛН — у 66,6 %; нев-роліз ЛН + імплантація ЕСС — 93,3 %; невротизація ЛН + імплантація ЕСС — 100 %; шов ЛН — 50 %; автопластика ЛН — 100 %; транспозиція м’язів (скроневого м’яза) — 100 %; статичні методи корекції обличчя — у 87,5 % хворих. Висновки. Хірургічне лікування, спрямоване на відновлення функції лицевого нерва та мімічних м’язів, слід проводити лише за наявності чітких до цього показань та за умови вичерпаних ресурсів консервативного лікування. Кращі результати відновлення функції ЛН спостерігаються у хворих, прооперованих у терміни до 12 місяців від моменту його ураження.

Институт травматологии и ортопедии НАМН

Abstract Introduction. When considering the array of biomedical problems associated with facial nerve palsy (FNP), it is apparent that the problem of choosing an effective type of facial nerve transfer is of paramount relevance. Hence, it is to the pursuit of a solution to the above stated problem that our study is devoted. Materials and methods. We analyzed the data obtained as a result of assessing the outcome of 149 patients with trauma-caused FNP who had undergone surgical treatments in the period between 2001-2018. The FN nerve transfer techniques utilized were as such: for group 1 – the use as a donor nerve the branch of the accessory nerve innervating the sternocleidomastoid muscle (n=87); group 2 – the descending branch of the hypoglossal and the branch of the accessory nerve (n=62). Results. In groups 1–2, the FN nerve transfer significantly improved FN function (p <0.01; Wilcoxon Matched Pairs Test), and most patients (n=135; 90.6%) noted an improvement in the clinical status up to degree II-III on the House-Brackmann scale (good result). Conclusion. The use of the accessory nerve branches to the sternocleidomastoid muscle, as donated, ensures restoration of FN function to levels II-III on the House-Brackmann scale in 89.7% of all operated patients, and the results it achieves do not differ from those of the technically more complex nerve transfer of FN by descending branch of the hypoglossal nerve with combination of branches of the accessory nerve.