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Alshehri T, Alhassan MA, Muharraq AA, Pasha AA. Brachial Plexus Neuropraxia Post Open Reduction and Internal Fixation of Left Acetabulum Fracture. J Orthop Case Rep 2025; 15:43-49. [PMID: 40351609 PMCID: PMC12064220 DOI: 10.13107/jocr.2025.v15.i05.5550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2025] [Revised: 03/25/2025] [Indexed: 05/14/2025] Open
Abstract
Introduction Acetabular fractures are often sustained injuries linked to high-energy trauma, such as falls from a considerable height or road traffic incidents. The modified Stoppa technique is currently used approach to treat acetabular fractures. The brachial plexus injury following open reduction and internal fixation (ORIF) of the left acetabulum fracture wasn't reported before. Case Report Herein we presented a case of a 16-years-old male with a history of road traffic accident sustained an isolated close left acetabulum fracture. X-ray shows associated both column acetabulum fracture with central subluxation. He was managed with open reduction and internal fixation through a modified Stoppa approach with a lateral window. The patient underwent ORIF on the 6th day of the trauma. Fixation was done with plates and screws. At recovery room he could not move whole left upper limb and no sensation while the operated limb DNV was intact. After 15 min of recovery, sensation returned, but motor deficit persisted, indicating brachial plexus neuropraxia. The brain CT scan of was performed and unremarkable finding. After 6 months, the patient restores his sensation on his own, and improved power 5/5 of the left upper limb. Conclusion Long stays under general anesthesia and patient position are considerable causes of BPI. Early diagnosis (clinical/imaging) and management typically involve conservative measures, with most patients achieving full recovery. Prevention procedures are essential, including monitoring the patient and proper intraoperative positioning to avoid such nerve injury.
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Affiliation(s)
- Turki Alshehri
- Department of Trauma and Orthopedic Surgery, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
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Windmueller RA, Gbayisomore OO, Mead RL, Desai MJ, Bowman EN. Brachial plexus injuries in the contact athlete: a narrative review. ANNALS OF JOINT 2025; 10:18. [PMID: 40385690 PMCID: PMC12082188 DOI: 10.21037/aoj-24-67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Accepted: 03/05/2025] [Indexed: 05/20/2025]
Abstract
Background and Objective Brachial plexus injuries (BPIs) are a rare but potentially devastating injury among contact athletes. More common injuries, such as "burners" or "stingers", indicate a temporary and less severe insult to either the nerve roots or plexus. The aim of this review is to discuss this spectrum of injuries in their epidemiology, mechanism in contact sports, diagnosis, and treatment. Methods This literature review utilized key terms to search manuscripts available in English from inception to October 2024 within three research databases. Key Content and Findings BPIs among contact athletes occur on a spectrum from neuropraxia to neurotmesis. Neuropraxia is very common among contact athletes with approximately a 49-65% incidence among career football players with the most common mechanism being a traction injury. Most of these resolve within minutes to hours. Axonotmesis and neurotmesis can be far more severe injuries and require further investigation if not resolved by 2-3 weeks. The majority of athletes who suffer neuropraxic injuries will return to sport with minimal to no time missed, however, more severe injuries portend variable outcomes. Conclusions BPIs are common among contact athletes and involve a spectrum of nerve damage, of which most are self-limiting. However, further evaluation is warranted when symptoms last beyond 2-3 weeks. Future studies should focus on treatment algorithms and long-term outcomes, including return to sport.
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Affiliation(s)
- Rachel A. Windmueller
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Reagan L. Mead
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mihir J. Desai
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric N. Bowman
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Sane ES, Huo R, Brogan DM, Harris MJ, Dy CJ. Creating a Reachable Workspace Model With 3D Motion Capture to Track Adult Brachial Plexus Injury Recovery: A Representative Case Report. HSS J 2025:15563316251324165. [PMID: 40190803 PMCID: PMC11969488 DOI: 10.1177/15563316251324165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2024] [Accepted: 01/22/2025] [Indexed: 04/09/2025]
Abstract
We describe the treatment of a patient recovering after reconstruction surgery for brachial plexus injury (BPI), which causes damage to the nerves of the arm. We used 3D motion capture to create a 3D "map" of the patient's reachable workspace-that is, how far the patient could reach within his own environment as a measure of how well his arm functioned-and tracked changes over a 2-year period. We also describe the patient's self-reported outcomes and compare them to the workspace measurement.
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Affiliation(s)
- Eshan S. Sane
- Department of Orthopaedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Rannon Huo
- Program in Physical Therapy, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - David M. Brogan
- Department of Orthopaedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Michael J. Harris
- Program in Physical Therapy, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Christopher J. Dy
- Department of Orthopaedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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Eldaly AS, Avila FR, Torres-Guzman RA, Maita KC, Garcia JP, Serrano LP, Emam OS, Forte AJ. Virtual and Augmented Reality in Management of Phantom Limb Pain: A Systematic Review. Hand (N Y) 2024; 19:545-554. [PMID: 36341580 PMCID: PMC11141420 DOI: 10.1177/15589447221130093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Upper and lower limb amputations are frequently associated with phantom limb pain (PLP). Recently, virtual reality (VR) and augmented reality (AR) have been reported as a potential therapy of PLP. We have conducted a systematic review of literature to evaluate the efficacy of VR and AR in managing PLP. Four databases were searched: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for our organization. The initial search resulted in 164 results. After title, abstract, and full-text screening, 9 studies were included. One study was of good quality and 8 studies were of fair to poor quality. Seven studies utilized VR and 2 studies utilized AR. The number of treatment sessions ranged from 1 to 28 and the duration ranged from 10 minutes to 2 hours. Several pain scales were used to evaluate PLP pre- and postintervention including Numeric Rating Scale, Pain Rating Index, McGill Pain Questionnaire, and Visual Analog Scale. All the studies reported improvement of PLP on one or more of pain scales after one or more sessions of VR or AR. Despite the promising results reported by literature, we cannot recommend using VR or AR for PLP. Most of the studies are of poor design and have limited sample size with high bias levels. Therefore, no substantial evidence can be derived from them. However, we do believe further research with high-quality randomized controlled trials should take place to increase the knowledge of the potential advantages.
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Suroto H, Rahman A. Traumatic brachial plexus injury: proposal of an evaluation functional prognostic scoring system. Br J Neurosurg 2024; 38:643-647. [PMID: 34240686 DOI: 10.1080/02688697.2021.1947975] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Until now, a scoring system for determining functional prognosis in traumatic brachial plexus injury (TBPI) does not yet exist. MATERIALS AND METHODS This research is a retrospective study with analytic design to find data for each parameter that affect the functional prognosis in patients with TBPI and assess these factors for comparison using the DASH score. The parameters that are proven to affect the functional prognosis included in a scoring system that we have designed. RESULTS It resulted that the functional prognosis of TBPI patients can be determined based on the mechanism of injury, initial pain scale, pain time, level of injury, time of surgery, and initial electromyography (EMG) result. CONCLUSION Based on the scoring system created in this study, we can conclude that the total score <15 has a good functional prognosis, while a score of ≥15 has a bad functional prognosis, with sensitivity and specificity of 76.6% and 70.2% respectively. This research is categorized as level 3 of evidence.
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Affiliation(s)
- Heri Suroto
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Ansari Rahman
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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Widodo W, Widyahening IS, Pratama IK, Kuncoro MW. Prospect of Mesenchymal Stem Cells in Enhancing Nerve Regeneration in Brachial Plexus Injury in Animals: A Systematic Review. THE ARCHIVES OF BONE AND JOINT SURGERY 2024; 12:149-158. [PMID: 38577510 PMCID: PMC10989726 DOI: 10.22038/abjs.2024.68053.3224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/14/2024] [Indexed: 04/06/2024]
Abstract
Objectives Brachial plexus injuries (BPI), although rare, often results in significant morbidity. Stem cell was thought to be one of BPI treatment modalities because of their nerve-forming regeneration potential. Although there is a possibility for the use of mesenchymal stem cells as one of BPI treatment, it is still limited on animal studies. Therefore, this systematic review aimed to analyze the role of mesenchymal stem cells in nerve regeneration in animal models of brachial plexus injury. Method This study is a systematic review with PROSPERO registration number CRD4202128321. Literature searching was conducted using keywords experimental, animal, brachial plexus injury, mesenchymal stem cell implantation, clinical outcomes, electrophysiological outcomes, and histologic outcomes. Searches were performed in the PubMed, Scopus, and ScienceDirect databases. The risk of bias was assessed using SYRCLE's risk of bias tool for animal studies. The data obtained were described and in-depth analysis was performed. Result Four studies were included in this study involving 183 animals from different species those are rats and rabbits. There was an increase in muscle weight and shortened initial onset time of muscle contraction in the group treated with stem cells. Electrophysiological results showed that mesenchymal stem cells exhibited higher (Compound muscle action potential) CMAP amplitude and shorter CMAP latency than control but not better than autograft. Histological outcomes showed an increase in axon density, axon number, and the formation of connections between nerve cells and target muscles. Conclusion Mesenchymal stem cell implantation to animals with brachial plexus injury showed its ability to regenerate nerve cells as evidenced by clinical, electrophysiological, and histopathological results. However, this systematic study involved experimental animals from various species so that the results cannot be uniformed, and conclusion should be drawn cautiously.
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Affiliation(s)
- Wahyu Widodo
- Department of Orthopaedic and Traumatology Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Indah Suci Widyahening
- Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Irfan Kurnia Pratama
- Department of Orthopaedic and Traumatology Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Mohamad Walid Kuncoro
- Department of Orthopaedic and Traumatology Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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Mathew A, Panwar J, Shanmugasundaram D, Thomas BP. Will preoperative combined MRI and high-resolution ultrasonography redefine brachial plexus imaging? A comparative study of preoperative MRI versus combined MRI and high-resolution ultrasonography in assessing usable C5, C6 root-stumps for intra-plexal nerve grafting. Clin Radiol 2023; 78:e1023-e1031. [PMID: 37777386 DOI: 10.1016/j.crad.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/15/2023] [Accepted: 08/29/2023] [Indexed: 10/02/2023]
Abstract
AIM To compare the intraoperative findings with the preoperative imaging in detecting usable root stumps using magnetic resonance imaging (MRI) alone versus MRI combined with high-resolution ultrasonography (HRUS) in adults undergoing post-traumatic brachial plexus (BP) surgery. Further, when root stumps were present, the reliability of their measurements using both imaging methods was compared to their intraoperative length. MATERIALS AND METHODS A consecutive group of adults who were planned for post-traumatic BP surgery between July 2015 and April 2016 were evaluated prospectively. They underwent preoperative MRI and HRUS and the agreement (kappa value) between these imaging methods and their intraoperative findings in categorising roots were then compared. When stumps were present, the reliability of the extraforaminal measurements by each method were compared to their corresponding intraoperative stump length using intraclass correlation coefficients (ICC), and Bland-Altman plots. RESULTS Of the initial 60 patients, 48 patients with 82 roots were included in the study. Greater agreement was observed between HRUS and intraoperative findings in categorising BP root stumps (kappa value 0.70, SE 0.07) versus MRI and intraoperative findings (kappa value 0.42, SE 0.07). Similarly, there was a higher correlation between HRUS and intraoperative findings (ICC: 0.94, p<0.001) than that of MRI and intraoperative findings (ICC: 0.53, p<0.001) regarding stump length measurements. CONCLUSION Combining HRUS with MRI in the preoperative imaging of the adult BP injury can better predict the presence of usable nerve root stumps for intra-plexal nerve grafting. HRUS also gave reliable preoperative stump length measurements, and it was determined that a stump should be at least 1.3 cm to be deemed usable for nerve grafting.
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Affiliation(s)
- A Mathew
- Paul Brand Center for Hand Surgery, Christian Medical College, Vellore 632004, India
| | - J Panwar
- Department of Radiology, Christian Medical College, Vellore 632004, Tamil Nadu, India.
| | - D Shanmugasundaram
- Division of Epidemiology & Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | - B P Thomas
- Paul Brand Center for Hand Surgery, Christian Medical College, Vellore 632004, India
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Saleh U, Tan GY, Fuad M, Abdullah JM, Idris Z, Ghani ARI, Abdul Halim S. Examination Approaches to Brachial Plexus Injury for Neurosurgical Residents. Malays J Med Sci 2023; 30:61-69. [PMID: 38239251 PMCID: PMC10793125 DOI: 10.21315/mjms2023.30.6.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/21/2023] [Indexed: 01/22/2024] Open
Abstract
Background Brachial plexus injury is a severe peripheral nerve injury that affects the upper extremities and causes functional damage and disability. A detailed and accurate clinical examination is required to accurately localise the site of injury. This video manuscript aims to provide guidelines for the structured assessment of a patient with brachial plexus injury, specifically tailored to Malaysian medical students and trainees. Methods A video demonstrating the examination of the brachial plexus was made. This video, created at the School of Medical Sciences at Universiti Sains Malaysia (USM), demonstrates the proper examination technique for brachial plexus. Conclusion We hope that this video will help students and young doctors evaluate patients with brachial plexus injury and reach accurate localisation of the injury.
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Affiliation(s)
- Umaira Saleh
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Department of Neurosurgery, Hospital Pulau Pinang, Pulau Pinang, Malaysia
| | - Guan Yan Tan
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Murni Fuad
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Brain and Behaviour Cluster, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Brain and Behaviour Cluster, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Abdul Rahman Izaini Ghani
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Brain and Behaviour Cluster, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Sanihah Abdul Halim
- Brain and Behaviour Cluster, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Unit of Neurology, Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
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Bhat SG, Shin AY, Kaufman KR. Upper extremity asymmetry due to nerve injuries or central neurologic conditions: a scoping review. J Neuroeng Rehabil 2023; 20:151. [PMID: 37940959 PMCID: PMC10634143 DOI: 10.1186/s12984-023-01277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/01/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Peripheral nerve injuries and central neurologic conditions can result in extensive disabilities. In cases with unilateral impairment, assessing the asymmetry between the upper extremity has been used to assess outcomes of treatment and severity of injury. A wide variety of validated and novel tests and sensors have been utilized to determine the upper extremity asymmetry. The purpose of this article is to review the literature and define the current state of the art for describing upper extremity asymmetry in patients with peripheral nerve injuries or central neurologic conditions. METHOD An electronic literature search of PubMed, Scopus, Web of Science, OVID was performed for publications between 2000 to 2022. Eligibility criteria were subjects with neurological conditions/injuries who were analyzed for dissimilarities in use between the upper extremities. Data related to study population, target condition/injury, types of tests performed, sensors used, real-world data collection, outcome measures of interest, and results of the study were extracted. Sackett's Level of Evidence was used to judge the quality of the articles. RESULTS Of the 7281 unique articles, 112 articles met the inclusion criteria for the review. Eight target conditions/injuries were identified (Brachial Plexus Injury, Cerebral Palsy, Multiple Sclerosis, Parkinson's Disease, Peripheral Nerve Injury, Spinal Cord Injury, Schizophrenia, and stroke). The tests performed were classified into thirteen categories based on the nature of the test and data collected. The general results related to upper extremity asymmetry were listed for all the reviewed articles. Stroke was the most studied condition, followed by cerebral palsy, with kinematics and strength measurement tests being the most frequently used tests. Studies with a level of evidence level II and III increased between 2000 and 2021. The use of real-world evidence-based data, and objective data collection tests also increased in the same period. CONCLUSION Adequately powered randomized controlled trials should be used to study upper extremity asymmetry. Neurological conditions other than stroke should be studied further. Upper extremity asymmetry should be measured using objective outcome measures like motion tracking and activity monitoring in the patient's daily living environment.
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Affiliation(s)
- Sandesh G Bhat
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kenton R Kaufman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
- Motion Analysis Laboratory, Mayo Clinic, DAHLC 4-214A, 200 First Street SW, Rochester, MN, 55905, USA.
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Deodhe NP, Dhage P, Harjpal P. Functional Electrical Stimulation in Conjunction With Proprioceptive Neuromuscular Facilitation (PNF) Technique to Improve Upper Limb Function in Traumatic Brachial Plexus Injury: A Case Report. Cureus 2023; 15:e46386. [PMID: 37927650 PMCID: PMC10620461 DOI: 10.7759/cureus.46386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Traumatic brachial plexus injuries (TBPIs) in the adult population are primarily a result of road traffic accidents or falls on a shoulder, which mainly affects the young population. Adult TBPI is a serious incapacitating injury that affects young adults. It decreases the function of upper extremity muscles, which affects social participation and quality of life. Physiotherapy intervention demonstrates its effectiveness in enhancing and maintaining the function of the upper extremity, eventually decreasing the participation restriction and improving quality of life. The proprioceptive neuromuscular facilitation (PNF) technique has been selected as a useful therapeutic option to enhance upper limb function after TBPI. The preceding case report proved the effectiveness of six weeks of functional electrical stimulation in addition to the PNF technique in improving upper limb function after TBPI.
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Affiliation(s)
- Nishigandha P Deodhe
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pooja Dhage
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pallavi Harjpal
- Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Wiertel-Krawczuk A, Huber J, Szymankiewicz-Szukała A, Wincek A. Neurophysiological Evaluation of Neural Transmission in Brachial Plexus Motor Fibers with the Use of Magnetic versus Electrical Stimuli. SENSORS (BASEL, SWITZERLAND) 2023; 23:s23084175. [PMID: 37112516 PMCID: PMC10146775 DOI: 10.3390/s23084175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 05/13/2023]
Abstract
The anatomical complexity of brachial plexus injury requires specialized in-depth diagnostics. The clinical examination should include clinical neurophysiology tests, especially with reference to the proximal part, with innovative devices used as sources of precise functional diagnostics. However, the principles and clinical usefulness of this technique are not fully described. The aim of this study was to reinvestigate the clinical usefulness of motor evoked potential (MEP) induced by a magnetic field applied over the vertebrae and at Erb's point to assess the neural transmission of brachial plexus motor fibers. Seventy-five volunteer subjects were randomly chosen to participate in the research. The clinical studies included an evaluation of the upper extremity sensory perception in dermatomes C5-C8 based on von Frey's tactile monofilament method, and proximal and distal muscle strength by Lovett's scale. Finally, 42 healthy people met the inclusion criteria. Magnetic and electrical stimuli were applied to assess the motor function of the peripheral nerves of the upper extremity and magnetic stimulus was applied to study the neural transmission from the C5-C8 spinal roots. The parameters of compound muscle action potential (CMAP) recorded during electroneurography and MEP induced by magnetic stimulation were analyzed. Because the conduction parameters for the groups of women and men were comparable, the final statistical analysis covered 84 tests. The parameters of the potentials generated by electrical stimulus were comparable to those of the potentials induced by magnetic impulse at Erb's point. The amplitude of the CMAP was significantly higher following electrical stimulation than that of the MEP following magnetic stimulation for all the examined nerves, in the range of 3-7%. The differences in the potential latency values evaluated in CMAP and MEP did not exceed 5%. The results show a significantly higher amplitude of potentials after stimulation of the cervical roots compared to potentials evoked at Erb's point (C5, C6 level). At the C8 level, the amplitude was lower than the potentials evoked at Erb's point, varying in the range of 9-16%. We conclude that magnetic field stimulation enables the recording of the supramaximal potential, similar to that evoked by an electric impulse, which is a novel result. Both types of excitation can be used interchangeably during an examination, which is essential for clinical application. Magnetic stimulation was painless in comparison with electrical stimulation according to the results of a pain visual analog scale (3 vs. 5.5 on average). MEP studies with advanced sensor technology allow evaluation of the proximal part of the peripheral motor pathway (between the cervical root level and Erb's point, and via trunks of the brachial plexus to the target muscles) following the application of stimulus over the vertebrae.
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Sumarwoto T, Hadinoto SA, Kaldani F, Aprilya D, Abimanyu DR. The Characteristic of 374 Surgically Treated Traumatic Brachial Plexus Injury Patients at an Indonesian Orthopedic Referral Hospital: An Epidemiologic and Sociodemographic View. Orthop Res Rev 2022; 14:419-428. [DOI: 10.2147/orr.s386142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 11/06/2022] [Indexed: 11/16/2022] Open
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Use of Electrodiagnostics in the Diagnosis and Follow-Up of Brachial Plexus Syndrome in a Calf. Vet Sci 2022; 9:vetsci9030136. [PMID: 35324865 PMCID: PMC8950725 DOI: 10.3390/vetsci9030136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 01/25/2023] Open
Abstract
Electrodiagnostic testing by using electromyography (EMG) and nerve conduction studies (NCS) is essential in the evaluation of patients with traumatic brachial plexus injury as it facilitates the localization of the lesion and the prognosis. In this case report, we present a long-term electrodiagnostic follow-up of a 5-day-old female Holstein calf with brachial plexus syndrome. Electrodiagnostic studies were carried out at 2 weeks, 5 weeks, 7 months and 12 months after admission. Initially, EMG confirmed the damage to the brachial plexus, potentially indicating a condition of neurotmesis or axonotmesis. However, motor NCS and the repeated electrodiagnostic follow-up, along with the evolution of the clinical signs, allowed a more favorable diagnosis of axonotmesis to be made. In fact, EMG showed a slow but gradual reduction and finally the disappearance of spontaneous pathological activity, while motor NCS revealed an increase in the amplitude and areas of the compound muscle action potentials. The animal was deemed fully recovered 12 months after admission. To the authors’ knowledge, this is the first report on the use of motor NCS in bovine medicine and it demonstrates that electrodiagnostics represent a useful and practical tool for the evaluation and prognosis of brachial plexus injury cases in cattle.
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Elsakka TO, Kotb HT, Farahat AA, Semaya AE, Deif OA, Bastawi RA. Axial T2-DRIVE MRI myelography is highly accurate in diagnosing preganglionic traumatic brachial plexus injuries: why pseudomeningoceles should not be used as a primary diagnostic sign. Clin Radiol 2022; 77:377-383. [PMID: 35210066 DOI: 10.1016/j.crad.2022.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/21/2022] [Indexed: 11/25/2022]
Abstract
AIM To evaluate the accuracy of brachial plexus magnetic resonance imaging (MRI) utilising the three-dimensional (3D)-T2-turbo spin echo (TSE) with 90° flip-back pulse ("DRIVE") myelography in detecting nerve root avulsions in patients with traumatic brachial plexus injuries. MATERIALS AND METHODS A prospective study of 24 patients planned for brachial plexus reconstructive surgery following trauma from April 2019 to October 2021. Preoperative 1.5 T MRI of the brachial plexus was performed utilising axial T2-DRIVE, looking for signs of avulsions (absent dural rootlets, pauci-rootlet appearance and thickened rootlets; the presence of pseudomeningoceles was noted only as an ancillary sign). Comparison against the reference standard of extra-dural brachial plexus exploration was performed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated. RESULTS Eighteen patients had at least one root avulsion at surgery, five showed isolated post-ganglionic injuries, and one had normal brachial plexus exploration. Thirty-nine avulsed roots were found at surgery (out of 108 explored in 24 patients). Preoperative MRI identified the specific avulsed roots accurately in each patient. Two false-positive diagnoses of C5 and C6 avulsions were made in one patient. On MRI, absence of the rootlets was seen in 73.2% (n=30) of avulsions, pauci-rootlet appearance in 24.4% (n=10) and thickening of the rootlets in 2.4% (n=1). Pseudomeningoceles were found only in 68.3% (n=28) of avulsions. The overall sensitivity, specificity, PPV, NPV, and accuracy of MRI were 100%, 97.1%, 95.1%, 100% and 98.1%, respectively. CONCLUSION 3D-T2-DRIVE is highly accurate in evaluating pre-ganglionic traumatic brachial plexus injuries. Pseudomeningoceles can be considered an ancillary feature of avulsion given the clarity of rootlet visualisation by this sequence.
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Affiliation(s)
- T O Elsakka
- Department of Radiodiagnosis and Intervention, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - H T Kotb
- Department of Radiodiagnosis and Intervention, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - A A Farahat
- Department of Radiodiagnosis and Intervention, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - A E Semaya
- Department of Orthopedic Surgery and Traumatology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - O A Deif
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - R A Bastawi
- Department of Radiodiagnosis and Intervention, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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15
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Krishnan KR, Sneag DB, Feinberg JH, Lee SK, Wolfe SW. Localization of Brachial Plexopathies Using a Novel Diagnostic Program. HSS J 2022; 18:78-82. [PMID: 35087336 PMCID: PMC8753543 DOI: 10.1177/15563316211001358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/04/2020] [Indexed: 02/03/2023]
Abstract
Background: Assessing the extent and specific location of brachial plexus injuries can be difficult given the variety of mechanisms of injury and anatomic complexity of the plexus. We developed a program to accurately assess the location of a patient's neurologic injury based on electromyographic data. Purpose: We sought to test our hypothesis that the location of traumatic brachial plexopathies could be accurately assessed with a novel program that processed electromyogram (EMG) and mechanism of injury data. Methods: This retrospective diagnostic cohort study was carried out with a novel diagnostic algorithm developed with the Python programming language. The program accepts user input of muscles demonstrating decreased motor unit recruitment, positive sharp waves, or fibrillation potentials. The testing data set was derived from a registry of brachial plexus injuries treated at our center. The primary outcome was the percent concordance of the algorithm's diagnosis with the surgical diagnosis. Results: Ninety-five cases met the inclusion criteria. Median time from injury onset to EMG examination was 4 months; median time from EMG examination to surgery was 1.2 months. The program diagnosis matched the surgical diagnosis in 92 out of 95 (97%) of cases, including cases with multilevel injuries and additional peripheral nerve injuries. Conclusion: This program accurately localized brachial plexopathies in nearly all cases, including those involving polytrauma or complex patterns of injury. This algorithm may be valuable as an aid to complete electrodiagnostic examinations, a diagnostic adjunct when planning treatment of severe plexus palsies, or an educational tool.
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Affiliation(s)
- Karthik R. Krishnan
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, NY, USA,Weill Cornell Medicine, New York, NY, USA,Karthik Krishnan, MS, Weill Cornell Medicine, New York, NY 10021, USA.
| | - Darryl B. Sneag
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, NY, USA,Weill Cornell Medicine, New York, NY, USA,Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Joseph H. Feinberg
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, NY, USA
| | - Steve K. Lee
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, NY, USA,Weill Cornell Medicine, New York, NY, USA
| | - Scott W. Wolfe
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, NY, USA,Weill Cornell Medicine, New York, NY, USA
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16
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de Santana Chagas AC, Wanderley D, de Oliveira Ferro JK, Alves de Moraes A, Morais de Souza FH, da Silva Tenório A, Araújo de Oliveira D. Physical therapeutic treatment for traumatic brachial plexus injury in adults: A scoping review. PM R 2022; 14:120-150. [PMID: 33543603 DOI: 10.1002/pmrj.12566] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/26/2021] [Indexed: 12/27/2022]
Abstract
Traumatic brachial plexus injury (BPI) is one of the most disabling injuries of the upper extremity, often requiring specialized treatment and a prolonged rehabilitation period. This scoping review was carried out to identify and describe the physical therapy modalities applied in the rehabilitation of adult individuals with BPI. Electronic databases, gray literature, and reference lists were searched, and studies meeting the following eligibility criteria were included: (a) interventions including any physical therapy modality; (b) individuals age ≥18 years old; and (c) a clinical diagnosis of BPI. The literature search yielded 681 articles of which 49 met the inclusion criteria and had their outcomes, treatment parameters, and the differences between conservative and pre- and postoperative treatment phases analyzed. The most commonly used physical therapy interventions were in the subfields of kinesiotherapy (ie, involving range of motion exercises, muscle stretching, and strengthening), electrothermal and phototherapy, manual therapy, and sensory re-education strategies. Although several physical therapy modalities were identified for the treatment of BPI in this scoping review, the combination of low levels of evidence and the identified gaps regarding the treatment parameters challenge the reproducibility of such treatments in clinical practice. Therefore, future controlled clinical trials with clearer treatment protocols for individuals with BPI are needed.
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Affiliation(s)
| | - Débora Wanderley
- Department of Physiotherapy, Federal University of Pernambuco, Pernambuco, Brazil
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17
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Szaro P, Geijer M, Ciszek B, McGrath A. Magnetic resonance imaging of the brachial plexus. Part 2: Traumatic injuries. Eur J Radiol Open 2022; 9:100397. [PMID: 35111891 PMCID: PMC8789590 DOI: 10.1016/j.ejro.2022.100397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/09/2022] [Accepted: 01/18/2022] [Indexed: 01/09/2023] Open
Abstract
The most common indications for magnetic resonance imaging (MRI) of the brachial plexus (BP) are traumatic injuries. The role of MRI of the BP has increased because of recent trends favoring earlier surgery. Determining preganglionic vs. postganglionic injury is essential, as different treatment strategies are required. Thus, MRI of the BP should be supplemented with cervical spine MRI to assess the intradural part of the spinal nerves, including highly T2-weighted techniques. Acute preganglionic injuries usually manifest as various combinations of post-traumatic pseudomeningocele, the absence of roots, deformity of nerve root sleeves, displacement of the spinal cord, hemorrhage in the spinal canal, presence of scars in the spinal canal, denervation of the back muscles, and syrinx. Spinal nerve root absence is more specific than pseudomeningocele on MRI. Acute postganglionic injuries can present as lesions in continuity or tears. The following signs indicate injury to the BP: side-to-side difference, swelling, partial, or total BP rupture. Injury patterns and localization are associated with the mechanism of trauma, which implies a significant role for MRI in the work-up of patients. The identification and description of traumatic lesions involving the brachial plexus need to be systematic and detailed. Using an appropriate MRI protocol, obtaining details about the injury, applying a systematic anatomical approach, and correlating imaging findings to relevant clinical data to make a correct diagnosis. Information about the presence or suspicion of root avulsion should always be provided.
Trauma is the most common indication for MRI of the brachial plexus. MRI of the brachial plexus should include cervical spine MRI. Spinal nerve root absence is seen in preganglionic injuries. Determining preganglionic vs. postganglionic injury is essential for treatment planning. Appropriate MRI rapport is crucial in communication with the clinician.
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18
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Nath RK, Somasundaram C. Incidence, Etiology, and Management of Long Thoracic and Accessory Nerve Injuries and Winging Scapula. EPLASTY 2021; 21:e11. [PMID: 35603020 PMCID: PMC9128739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Peripheral nerve injuries make up many upper extremity musculoskeletal disorders (UE-MSDs), as peripheral nerves in the upper extremities are susceptible to damage due to their superficial course and length. The health and economic burdens of peripheral nerve injuries are rising. Upper-limb peripheral nerve injuries caused by prone positioning in COVID-19 patients in intensive care have occurred during the current global pandemic. Understanding the incidence and causation of these injuries is essential, as these affect primarily young workers and athletes with skeletal immaturity and contribute to significant morbidity. METHODS AND PATIENTS A total of 789 patients, 481 of whom were male and 308 female, with limited upper-extremity movements, scapular winging, and pain due to upper brachial plexus, long thoracic and accessory nerve injuries (459 right, 282 left, and 48 bilateral) were included in the study. Patient age at the onset of injury ranged between 11 months and 68 years. RESULTS A total of 18 causes of peripheral nerve injury were identified among the 789 patients with UE-MSD. The most affected patients (12.7%) were involved in sports and related activities, with 20 different sports and related activities reported in this patient population. Weightlifting caused the most (10.9%) number of injuries in this group. Incidences in the least affected patients were due to massage and viral infection, at 0.6% and 0.6% respectively. CONCLUSIONS Sports and recreational-related physical activities are essential components of a healthy lifestyle, and may help decrease the incidence of obesity, diabetes, and cardiovascular diseases. Injury and fear of impairment, however, can be barriers in the participation of these activities. Surgery and other interventions can help maximize return to work and regular activities after UE-MSDs.
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Affiliation(s)
- Rahul K. Nath
- Texas Nerve and Paralysis Institute, Houston, Texas, 77030
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19
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Nazarahari M, Chan KM, Rouhani H. A novel instrumented shoulder functional test using wearable sensors in patients with brachial plexus injury. J Shoulder Elbow Surg 2021; 30:e493-e502. [PMID: 33246080 DOI: 10.1016/j.jse.2020.10.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Because nerve injury of muscles around the shoulder can be easily disguised by "trick movements" of the trunk, shoulder dysfunction following brachial plexus injury is difficult to quantify with conventional clinical tools. Thus, to evaluate brachial plexus injury and quantify its biomechanical consequences, we used inertial measurement units, which offer the sensitivity required to measure the trunk's subtle movements. METHODS We calculated 6 kinematic scores using inertial measurement units placed on the upper arms and the trunk during 9 functional tasks. We used both statistical and machine learning techniques to compare the bilateral asymmetry of the kinematic scores of 15 affected and 15 able-bodied individuals (controls). RESULTS Asymmetry indexes from several kinematic scores of the upper arm and trunk showed a significant difference (P < .05) between the affected and control groups. A bagged ensemble of decision trees trained with trunk and upper arm kinematic scores correctly classified all controls. All but 2 patients were also correctly classified. Upper arm scores showed correlation coefficients ranging from 0.55-0.76 with conventional clinical scores. CONCLUSIONS The proposed wearable technology is a sensitive and reliable tool for objective outcome evaluation of brachial plexus injury and its biomechanical consequences. It may be useful in clinical research and practice, especially in large cohorts with multiple follow-ups.
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Affiliation(s)
- Milad Nazarahari
- Department of Mechanical Engineering, University of Alberta, Donadeo Innovation Centre for Engineering, Edmonton, AB, Canada
| | - Kam Ming Chan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Hossein Rouhani
- Department of Mechanical Engineering, University of Alberta, Donadeo Innovation Centre for Engineering, Edmonton, AB, Canada; Glenrose Rehabilitation Hospital, Alberta Health Services, Edmonton, AB, Canada.
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20
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Gupta R, Chan JP, Uong J, Palispis WA, Wright DJ, Shah SB, Ward SR, Lee TQ, Steward O. Human motor endplate remodeling after traumatic nerve injury. J Neurosurg 2021; 135:220-227. [PMID: 32947259 DOI: 10.3171/2020.8.jns201461] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current management of traumatic peripheral nerve injuries is variable with operative decisions based on assumptions that irreversible degeneration of the human motor endplate (MEP) follows prolonged denervation and precludes reinnervation. However, the mechanism and time course of MEP changes after human peripheral nerve injury have not been investigated. Consequently, there are no objective measures by which to determine the probability of spontaneous recovery and the optimal timing of surgical intervention. To improve guidance for such decisions, the aim of this study was to characterize morphological changes at the human MEP following traumatic nerve injury. METHODS A prospective cohort (here analyzed retrospectively) of 18 patients with traumatic brachial plexus and axillary nerve injuries underwent biopsy of denervated muscles from the upper extremity from 3 days to 6 years after injury. Muscle specimens were processed for H & E staining and immunohistochemistry, with visualization via confocal and two-photon excitation microscopy. RESULTS Immunohistochemical analysis demonstrated varying degrees of fragmentation and acetylcholine receptor dispersion in denervated muscles. Comparison of denervated muscles at different times postinjury revealed progressively increasing degeneration. Linear regression analysis of 3D reconstructions revealed significant linear decreases in MEP volume (R = -0.92, R2 = 0.85, p = 0.001) and surface area (R = -0.75, R2 = 0.56, p = 0.032) as deltoid muscle denervation time increased. Surprisingly, innervated and structurally intact MEPs persisted in denervated muscle specimens from multiple patients 6 or more months after nerve injury, including 2 patients who had presented > 3 years after nerve injury. CONCLUSIONS This study details novel and critically important data about the morphology and temporal sequence of events involved in human MEP degradation after traumatic nerve injuries. Surprisingly, human MEPs not only persisted, but also retained their structures beyond the assumed 6-month window for therapeutic surgical intervention based on previous clinical studies. Preoperative muscle biopsy in patients being considered for nerve transfer may be a useful prognostic tool to determine MEP viability in denervated muscle, with surviving MEPs also being targets for adjuvant therapy.
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Affiliation(s)
- Ranjan Gupta
- 1Peripheral Nerve Research Lab, Department of Orthopaedic Surgery, University of California, Irvine
| | - Justin P Chan
- 1Peripheral Nerve Research Lab, Department of Orthopaedic Surgery, University of California, Irvine
| | - Jennifer Uong
- 1Peripheral Nerve Research Lab, Department of Orthopaedic Surgery, University of California, Irvine
| | - Winnie A Palispis
- 1Peripheral Nerve Research Lab, Department of Orthopaedic Surgery, University of California, Irvine
| | - David J Wright
- 1Peripheral Nerve Research Lab, Department of Orthopaedic Surgery, University of California, Irvine
| | - Sameer B Shah
- 2Department of Orthopaedic Surgery, University of California, San Diego
| | - Samuel R Ward
- 2Department of Orthopaedic Surgery, University of California, San Diego
| | - Thay Q Lee
- 3Congress Medical Foundation, Pasadena; and
| | - Oswald Steward
- 4Reeve-Irvine Research Center, University of California, Irvine, California
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21
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Gebreyohanes AMH, Ahmed AI, Choi D. Dorsal Root Entry Zone Lesioning for Brachial Plexus Avulsion: A Comprehensive Literature Review. Oper Neurosurg (Hagerstown) 2021; 20:324-333. [PMID: 33469654 DOI: 10.1093/ons/opaa447] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/23/2020] [Indexed: 11/14/2022] Open
Abstract
Dorsal root entry zone (DREZ) lesioning is a neurosurgical procedure that aims to relieve severe neuropathic pain in patients with brachial plexus avulsion by selectively destroying nociceptive neural structures in the posterior cervical spinal cord. Since the introduction of the procedure over 4 decades ago, the DREZ lesioning technique has undergone numerous modifications, with a variety of center- and surgeon-dependent technical differences and patient outcomes. We have reviewed the literature to discuss reported methods of DREZ lesioning and outcomes.
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Affiliation(s)
- Axumawi Mike Hailu Gebreyohanes
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom.,University College London (UCL) Medical School, London, United Kingdom
| | - Aminul Islam Ahmed
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - David Choi
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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22
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Abstract
Brachial plexus injuries are still challenging for every surgeon taking part in treating patients with BPI. Injuries of the brachial plexus can be divided into injuries of the upper trunk, extended upper trunk, injuries of the lower trunk and swinging hand where all of the roots are involved in this type of the injury. Brachial plexus can be divided in five anatomical sections from its roots to its terminal branches: roots, trunks, division, cords and terminal branches. Brachial plexus ends up as five terminal branches, responsible for upper limb innervation, musculocutaneous, median nerve, axillary nerve, radial and ulnar nerve. According to the findings from the preoperative investigation combined with clinically found functional deficit, the type of BPI will be confirmed and that is going to determine which surgical procedure, from variety of them (neurolysis, nerve graft, neurotization, arthrodesis, tendon transfer, free muscle transfer, bionic reconstruction) is appropriate for treating the patient.
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23
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A quantitative analysis of the dimensions and content of the vertebral triangle. Surg Radiol Anat 2021; 43:881-888. [PMID: 33528604 DOI: 10.1007/s00276-020-02645-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The vertebral triangle (VT) located in the root of the neck most commonly contains the vertebral artery (VA), cervical sympathetic chain and certain roots of the brachial plexus. Although other structures have been reported, few studies have reported on the overall content of this space. Based on the current literature, there is a general paucity of anatomical information pertaining to the dimensional anatomy of the VT and specifically the structures related to it. Therefore, this study aimed to quantitatively analyze the size, position, content, and anatomical structures in relation to the vertebral triangle in a South African sample. METHODS Forty-three VTs were dissected on bodies donated to science. Measurements taken include the dimensions of the triangle, as well as distances between prominent structures and landmarks of the VT. Observations were made on the presence/absence of the varying neurovascular structures within the VT. RESULTS Mean height was 30.1 ± 1.51 mm (R) and 32.9 ± 1.78 mm (L). Mean width was 18.3 ± 0.74 mm (R) and 19.3 ± 0.98 mm (L). The C8 spinal nerve was found on average approximately halfway [16.4 ± 0.74 mm (R) and 15.9 ± 0.95 mm (L)] in the VT. The VA was present in the VT in 100% of the sample and the C7 spinal nerve and inferior sympathetic ganglia were present in more than 80% of the sample. CONCLUSION Understanding the VT and the content is of the utmost importance and of great interest to neurosurgeons, to avoid these important neurovascular structures and prevent iatrogenic complications during surgery.
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24
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Heinzel J, Längle G, Oberhauser V, Hausner T, Kolbenschlag J, Prahm C, Grillari J, Hercher D. Use of the CatWalk gait analysis system to assess functional recovery in rodent models of peripheral nerve injury - a systematic review. J Neurosci Methods 2020; 345:108889. [PMID: 32755615 DOI: 10.1016/j.jneumeth.2020.108889] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/28/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
Injuries of the peripheral nervous system are common among the population affecting around 3% of all trauma patients. This high clinical need in the field of peripheral nerve injury and regeneration has been steadily driving experimental and epidemiological research. Thereby, it is crucial to determine the exact degree of recovery of end-organ function. Regeneration after nerve injuries is assessed by a wide variety of techniques and pre-clinical model systems, where rodent models are among the most widely used. However, results from rodents are difficult to translate to human patients in general, and reproducible and comparable assessment of functional recovery is of highest importance. Computerized gait analysis allows comprehensive acquisition of locomotor function. As the animals cross the recording device voluntarily, functional recovery is assessable with a minimum degree of human interference on their behavior. This article aims to give a detailed overview on the existing literature on CatWalk gait analysis in rodent models of peripheral nerve injuries of upper and lower extremities, e.g. axonotmesis, neurotmesis or fibrosis, with special emphasis on differences between models. Researchers interested in assessment of locomotor function in such models will especially benefit from this work as it will provide them with an overview of the various experimental setups and expected outcomes. This work also addresses potential pitfalls and hurdles in order to promote well designed, comparable studies allowing for accelerated development of therapeutic strategies in peripheral repair and regeneration.
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Affiliation(s)
- Johannes Heinzel
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University, Tuebingen, Germany; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstraße 13, 1020, Vienna, Austria; Austrian Cluster for Tissue Regeneration, Austria
| | - Gregor Längle
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstraße 13, 1020, Vienna, Austria; Austrian Cluster for Tissue Regeneration, Austria
| | - Viola Oberhauser
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstraße 13, 1020, Vienna, Austria; Austrian Cluster for Tissue Regeneration, Austria
| | - Thomas Hausner
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstraße 13, 1020, Vienna, Austria; Austrian Cluster for Tissue Regeneration, Austria
| | - Jonas Kolbenschlag
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Cosima Prahm
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Johannes Grillari
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstraße 13, 1020, Vienna, Austria; Austrian Cluster for Tissue Regeneration, Austria; Institute of Molecular Biotechnology, Department of Biotechnology, BOKU - University of Natural Resources and Life Sciences Vienna, Muthgasse 18, 1190, Vienna, Austria
| | - David Hercher
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstraße 13, 1020, Vienna, Austria; Austrian Cluster for Tissue Regeneration, Austria.
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25
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Chagas ACDS, Wanderley D, Barboza PJM, Martins JVP, de Moraes AA, de Souza FHM, de Oliveira DA. Proprioceptive neuromuscular facilitation compared to conventional physiotherapy for adults with traumatic upper brachial plexus injury: A protocol for a randomized clinical trial. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2020; 26:e1873. [PMID: 32790955 DOI: 10.1002/pri.1873] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/13/2020] [Accepted: 07/24/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND Traumatic upper plexus injury affects daily living activities performance and participation of individuals. Physical therapy treatment has a fundamental role on functional recovery, but it is still an unexplored and challenging field. AIM To develop a protocol to evaluate the efficacy of Proprioceptive Neuromuscular Facilitation (PNF) compared to conventional physiotherapy (CPT group) on functionality and quality of life. METHODS A committee was formed by four physical therapists to develop the treatment protocol. A Delphi study was carried out in order to quantify the level of agreement. A protocol for a randomized controlled trial was proposed to evaluate the effectiveness of the protocol in improving functionality and quality of life, according Consolidated Standards of Reporting Trials. Participants will be randomly assigned (1:1) to PNF or CPT group and two weekly sessions will be carried out for 12 months postsurgery, with a three-month follow-up. The main outcome measurements are: upper limb functionality, quality of life, range of motion, muscle strength, tactile sensitivity, and pain, which will be assessed at baseline, on the 6th, 9th, and 12th months postsurgery. RESULT A PNF protocol was developed for traumatic upper brachial plexus injury, consisting of 11 illustrated exercises, three for immediate postoperative and eight for postoperative. Biomechanical objectives, observations, positions of patients and therapists and PNF principles, procedures and techniques have been described. An 80% agreement on all items in the first round of the Delphi study was achieved. CONCLUSION A protocol based on the PNF-concept was developed with the aim of improving the functionality and quality of life of individuals undergoing nerve transfer after traumatic injury to the upper plexus. The detailed description of a physical therapy treatment protocol through an appropriate method will allow its use in clinical practice and in future studies with this population.
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Affiliation(s)
| | - Débora Wanderley
- Department of Physiotherapy, Federal University of Pernambuco, Recife, Brazil
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26
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Belviso I, Palermi S, Sacco AM, Romano V, Corrado B, Zappia M, Sirico F. Brachial Plexus Injuries in Sport Medicine: Clinical Evaluation, Diagnostic Approaches, Treatment Options, and Rehabilitative Interventions. J Funct Morphol Kinesiol 2020; 5:jfmk5020022. [PMID: 33467238 PMCID: PMC7739249 DOI: 10.3390/jfmk5020022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 01/11/2023] Open
Abstract
The brachial plexus represents a complex anatomical structure in the upper limb. This "network" of peripheral nerves permits the rearrangement of motor efferent fibers, coming from different spinal nerves, in several terminal branches directed to upper limb muscles. Moreover, afferent information coming from different cutaneous regions in upper limb are sorted in different spinal nerves through the brachial plexus. Severe brachial plexus injuries are a rare clinical condition in the general population and in sport medicine, but with dramatic consequences on the motor and sensory functions of the upper limb. In some sports, like martial arts, milder injuries of the brachial plexus can occur, with transient symptoms and with a full recovery. Clinical evaluation represents the cornerstone in the assessment of the athletes with brachial plexus injuries. Electrodiagnostic studies and imaging techniques, like magnetic resonance and high-frequency ultrasound, could be useful to localize the lesion and to define an appropriate treatment and a functional prognosis. Several conservative and surgical techniques could be applied, and multidisciplinary rehabilitative programs could be performed to guide the athlete toward the recovery of the highest functional level, according to the type of injury.
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Affiliation(s)
- Immacolata Belviso
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (I.B.); (S.P.); (A.M.S.); (V.R.); (B.C.)
| | - Stefano Palermi
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (I.B.); (S.P.); (A.M.S.); (V.R.); (B.C.)
| | - Anna Maria Sacco
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (I.B.); (S.P.); (A.M.S.); (V.R.); (B.C.)
| | - Veronica Romano
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (I.B.); (S.P.); (A.M.S.); (V.R.); (B.C.)
| | - Bruno Corrado
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (I.B.); (S.P.); (A.M.S.); (V.R.); (B.C.)
| | - Marcello Zappia
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy;
- Musculoskeletal Radiology Unit, Varelli Institute, 80126 Naples, Italy
| | - Felice Sirico
- Department of Public Health, University of Naples “Federico II”, 80131 Naples, Italy; (I.B.); (S.P.); (A.M.S.); (V.R.); (B.C.)
- Correspondence: ; Tel.: +39-081-746-3508
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Chan GYY, Nonato LG, Chu A, Raghavan P, Aluru V, Silva CT. Motion Browser: Visualizing and Understanding Complex Upper Limb Movement Under Obstetrical Brachial Plexus Injuries. IEEE TRANSACTIONS ON VISUALIZATION AND COMPUTER GRAPHICS 2019; 26:981-990. [PMID: 31449022 DOI: 10.1109/tvcg.2019.2934280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The brachial plexus is a complex network of peripheral nerves that enables sensing from and control of the movements of the arms and hand. Nowadays, the coordination between the muscles to generate simple movements is still not well understood, hindering the knowledge of how to best treat patients with this type of peripheral nerve injury. To acquire enough information for medical data analysis, physicians conduct motion analysis assessments with patients to produce a rich dataset of electromyographic signals from multiple muscles recorded with joint movements during real-world tasks. However, tools for the analysis and visualization of the data in a succinct and interpretable manner are currently not available. Without the ability to integrate, compare, and compute multiple data sources in one platform, physicians can only compute simple statistical values to describe patient's behavior vaguely, which limits the possibility to answer clinical questions and generate hypotheses for research. To address this challenge, we have developed MOTION BROWSER, an interactive visual analytics system which provides an efficient framework to extract and compare muscle activity patterns from the patient's limbs and coordinated views to help users analyze muscle signals, motion data, and video information to address different tasks. The system was developed as a result of a collaborative endeavor between computer scientists and orthopedic surgery and rehabilitation physicians. We present case studies showing physicians can utilize the information displayed to understand how individuals coordinate their muscles to initiate appropriate treatment and generate new hypotheses for future research.
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Laohaprasitiporn P, Wongtrakul S, Vathana T, Limthongthang R, Songcharoen P. Is Pseudomeningocele an Absolute Sign of Root Avulsion Brachial Plexus Injury? J Hand Surg Asian Pac Vol 2018; 23:360-363. [PMID: 30282542 DOI: 10.1142/s2424835518500376] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The finding of pseudomeningocele from cervical myelogram is widely accepted as a pathognomonic sign for diagnosing root avulsion in brachial plexus injury. In general, motor power in this setting should be absent. However, in clinical practice, we observed that motor power in some patients was still preserved. The objective of this study is to evaluate the accuracy of pseudomeningocele from cervical myelogram for predicting root avulsion in brachial plexus injury. METHODS We retrospectively reviewed 201 patients with brachial plexus injury from 2007-2011. Four patients were excluded due to open wound injury. Motor power of the key muscle of each nerve root was evaluated by skilled hand surgeons. All cervical myelogram was interpreted by radiologists. Sensitivities, specificities, positive predictive values and negative predictive values were calculated with 95% confidence interval. RESULTS Thirty and 29% of pseudomeningocele occurred at C7 and C8 level, respectively. The sensitivity of pseudomeningocele of each root from C5 to T1 was low (range, 10-62%). The specificity was high only at C5 (91%) and T1 (96.2%). Over 20% of patients with pseudomeningocele at C6-8 levels had some motor function. The initial muscle power of these patients was M1 or M2 and 70% of them recovered to at least M3 at the final follow-up. CONCLUSIONS Pseudomeningocele is not an absolute sign for diagnosing of root avulsion in brachial plexus injury due to its high false positive rate when compared with preoperative motor function of each root. Careful examination of the key muscle of each root is extremely crucial to prevent unnecessary operation on that cervical nerve root.
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Affiliation(s)
- Panai Laohaprasitiporn
- * Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Thailand
| | - Saichol Wongtrakul
- * Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Thailand
| | - Torpon Vathana
- * Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Thailand
| | - Roongsak Limthongthang
- * Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Thailand
| | - Panupan Songcharoen
- * Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Thailand
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The Multidisciplinary Approach to the Diagnosis and Management of Nonobstetric Traumatic Brachial Plexus Injuries. AJR Am J Roentgenol 2018; 211:1319-1331. [DOI: 10.2214/ajr.18.19887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Zapałowicz K, Radek M. The distribution of brachial plexus lesions after experimental traction: a cadaveric study. J Neurosurg Spine 2018; 29:704-710. [PMID: 30265223 DOI: 10.3171/2018.5.spine171148] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 05/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe objective of the present study was to determine experimentally the distribution of lesions caused in the cadaveric brachial plexus (BP) by excessive stretching. The authors attempted to delineate the correlation between the direction of stretching and sites of lesions.METHODSFifteen specimens (each comprised the spinal segment C4-T2 with 2 BPs) were harvested from adult cadavers. Each BP was stretched in a mechanical testing machine at a constant speed of 200 mm/min. Specimens were divided into 3 groups: in group A the BPs were stretched caudally at a 45° angle to the spinal midline; in group B they were stretched perpendicularly to the spinal midline; and in group C the stretching was caudally parallel to the midline. Lesions of each BP were identified and analyzed. A graph of load against dislocation was registered when stretching to delineate the maximal force (Fmax), defined as the maximum load at which BP failure occurs.RESULTSBased on macroscopic examination, 140 sites of mechanical damage were identified in 30 BPs. Preganglionic injuries (63.6% of lesions), defined as avulsions of the spinal ganglia with their rootlets, were found in 89 spinal nerves. In group B-in which specimens were stretched perpendicularly to the spinal segment-preganglionic injuries were significantly more frequent (41 avulsed spinal nerves) than in groups A and C (21 and 27 avulsed spinal nerves, respectively). Postganglionic lesions equivalent to neurotmesis were found in 51 sites (36.4% of all lesions) along spinal nerves, trunks, divisions, and cords. Postganglionic lesions in group B were much less frequent (8) as compared with groups A and C (24 and 19, respectively).CONCLUSIONSPredominance of preganglionic lesions suggests that attachments of the BP to the spine are more susceptible to traction than postganglionic elements. Preganglionic lesions were mainly produced in C7, C8, and T1 spinal nerves, suggesting their weaker attachment to the spine than in the case of C5 and C6 nerves. Preganglionic lesions were highly correlated with a traction perpendicular to the spine, whereas postganglionic lesions were provoked mainly by traction directed at 45° caudally or by means of caudal traction parallel to the midline. This discrepancy implies a relationship between mechanical resistance of pre- and postganglionic elements of the BP and the vector of force.
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Stilwill SE, Mills MK, Hansford BG, Allen H, Mahan M, Moore KR, Hanrahan CJ. Practical Approach and Review of Brachial Plexus Pathology With Operative Correlation: What the Radiologist Needs to Know. Semin Roentgenol 2018; 54:92-112. [PMID: 31128744 DOI: 10.1053/j.ro.2018.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sarah E Stilwill
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT.
| | - Megan K Mills
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT.
| | - Barry G Hansford
- Department of Diagnostic Radiology, Oregon Health and Science University, Portland, OR.
| | - Hailey Allen
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT.
| | - Mark Mahan
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT.
| | - Kevin R Moore
- Intermountain Pediatric Imaging, Primary Children's Hospital, Medical Imaging Department, Salt Lake City, UT.
| | - Christopher J Hanrahan
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT.
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Ganaha S, Lara-Velazquez M, Yoon JW, Akinduro OO, Clendenen SR, Murray PM, Pichelmann MA, Quinones-Hinojosa A, Deen HG. Challenges of Managing Patients with Symptomatic Large Traumatic Cervical Pseudomeningoceles. World Neurosurg 2018; 115:128-133. [PMID: 29654960 DOI: 10.1016/j.wneu.2018.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/02/2018] [Accepted: 04/03/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Traumatic cervical pseudomeningoceles (TCPs) occur secondary to traction of the cervical nerve roots resulting in violation of the dura. Surgical repair is not necessary in most cases because pseudomeningoceles have a high propensity to spontaneously resolve with conservative management alone. Currently, there are a limited number of cases of large TCPs (large is defined as ≥6 cm in greatest diameter), and there is no established guideline for the management of such lesions. CASE DESCRIPTION We describe the cases of 2 young men in their 20s who were involved in a motor vehicle accident. Both patients suffered a brachial plexus injury and developed large TCPs. Patient 1 was treated surgically for TCP using a combined intra-/extradural approach using a fascia lata graft. Patient 2 was ultimately treated nonsurgically because a spontaneous resolution of the pseudomeningocele was achieved over the period of 7 months after the accident. Both patients underwent brachial plexus repair surgery consisting of spinal accessory nerve transfer to the suprascapular nerve and intercostal nerve transfer to the musculocutaneous nerve. CONCLUSIONS Disease progression of TCPs is a dynamic process, and even large lesions may spontaneously resolve without surgical intervention. When surgery is indicated, a definitive dural repair using a fascia lata graft to cover the dural tear intra- and extradurally is an effective method. Surgery must be planned carefully on a case-by-case basis, and close follow-up with thorough physical examination and serial imaging is critical to monitor disease progression.
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Affiliation(s)
- Sara Ganaha
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Jang W Yoon
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Peter M Murray
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - H Gordon Deen
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA.
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Duffy BJ, Tubog TD. The Prevention and Recognition of Ulnar Nerve and Brachial Plexus Injuries. J Perianesth Nurs 2017; 32:636-649. [PMID: 29157770 DOI: 10.1016/j.jopan.2016.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 05/10/2016] [Accepted: 06/04/2016] [Indexed: 11/19/2022]
Abstract
Perioperative peripheral nerve injury is a serious yet preventable perioperative complication. Since the inception of the American Association of Anesthesiologists Closed Claim Project, the incidence of peripheral nerve injury has remained constant with an overall reported prevalence rate of 15% to 16%. To date, the most frequent nerve injuries are ulnar nerve neuropathy and brachial plexus injury. This article will review the clinical presentation, pathophysiology, causative and risks factors, and preventive measures for the two most common nerve injuries. Knowledge of the anatomical structures and components of peripheral nerves prone to injuries during surgery can assist in defining precautionary actions in the perioperative setting. Positioning techniques in the operating room, early recognition of neuropathies, and use of a perioperative tool in the postoperative setting are keys to reduce significant clinical complications.
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Abstract
Traumatic injuries to the brachial plexus are typically high impact and can be debilitating, life-changing injuries. Backpack palsy is a rare but well-established cause of brachial plexus injury, arising as a result of heavy backpack use. We present an unusual case of backpack palsy with Horner's syndrome.
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Affiliation(s)
- Olivia Sharp
- Department of Plastic Surgery, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Kai Yuen Wong
- Department of Plastic Surgery, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Paul Stephens
- Department of Plastic Surgery, Salisbury NHS Foundation Trust, Salisbury, UK
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Abstract
Neurologic complications in polytrauma can be classified by etiology and clinical manifestations: neurovascular, delirium, and spinal or neuromuscular problems. Neurovascular complications include ischemic strokes, intracranial hemorrhage, or the development of traumatic arteriovenous fistulae. Delirium and encephalopathy have a reported incidence of 67-92% in mechanically ventilated polytrauma patients. Causes include sedation, analgesia/pain, medications, sleep deprivation, postoperative state, toxic ingestions, withdrawal syndromes, organ system dysfunction, electrolyte/metabolic abnormalities, and infections. Rapid identification and treatment of the underlying cause are imperative. Benzodiazepines increase the risk of delirium, and alternative agents are preferred sedatives. Pharmacologic treatment of agitated delirium can be achieved with antipsychotics. Nonconvulsive seizures and status epilepticus are not uncommon in surgical/trauma intensive care unit (ICU) patients, require electroencephalography for diagnosis, and need timely management. Spinal cord ischemia is a known complication in patients with traumatic aortic dissections or blunt aortic injury requiring surgery. Thoracic endovascular aortic repair has reduced the paralysis rate. Neuromuscular complications include nerve and plexus injuries, and ICU-acquired weakness. In polytrauma, the neurologic examination is often confounded by pain, sedation, mechanical ventilation, and distracting injuries. Regular sedation pauses for examination and maintaining a high index of suspicion for neurologic complications are warranted, particularly because early diagnosis and management can improve outcomes.
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Casal D, Cunha T, Pais D, Iria I, Angélica-Almeida M, Millan G, Videira-Castro J, Goyri-O'Neill J. A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report. J Med Case Rep 2017; 11:6. [PMID: 28049512 PMCID: PMC5209886 DOI: 10.1186/s13256-016-1162-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/30/2016] [Indexed: 11/24/2022] Open
Abstract
Background Although open injuries involving the brachial plexus are relatively uncommon, they can lead to permanent disability and even be life threatening if accompanied by vascular damage. We present a case report of a brachial plexus injury in which the urgency of the situation precluded the use of any ancillary diagnostic examinations and forced a rapid clinical assessment. Case presentation We report a case of a Portuguese man who had a stabbing injury at the base of his left axilla. On observation in our emergency room an acute venous type of bleeding was present at the wound site and, as a result of refractory hypotension after initial management with fluids administered intravenously, he was immediately carried to our operating room. During the course of transportation, we observed that he presented hypoesthesia of the medial aspect of his arm and forearm, as well as of the ulnar side of his hand and of the palmar aspect of the last three digits and of the dorsal aspect of the last two digits. Moreover, he was not able to actively flex the joints of his middle, ring, and small fingers or to adduct or abduct all fingers. Exclusively relying on our anatomical knowledge of the axillary region, the site of the stabbing wound, and the physical neurologic examination, we were able to unequivocally pinpoint the place of the injury between the anterior division of the lower trunk of his brachial plexus and the proximal portion of the following nerves: ulnar, medial cutaneous of his arm and forearm, and the medial aspect of his median nerve. Surgery revealed a longitudinal laceration of the posterior aspect of his axillary vein, and confirmed a complete section of his ulnar nerve, his medial brachial and antebrachial cutaneous nerves, and an incomplete section of the ulnar aspect of his median nerve. All structures were repaired microsurgically. Three years after the surgery he showed a good functional outcome. Conclusions We believe that this case report illustrates the relevance of a sound anatomical knowledge of the brachial plexus in an emergency setting.
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Affiliation(s)
- Diogo Casal
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal. .,Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal.
| | - Teresa Cunha
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Diogo Pais
- Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
| | - Inês Iria
- UCIBIO, Life Sciences Department, Faculty of Sciences and Technology, Universidade NOVA de Lisboa, Caparica, Portugal.,CEDOC, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Maria Angélica-Almeida
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.,Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
| | - Gerardo Millan
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - José Videira-Castro
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - João Goyri-O'Neill
- Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
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Karalija A, Novikova LN, Orädd G, Wiberg M, Novikov LN. Differentiation of Pre- and Postganglionic Nerve Injury Using MRI of the Spinal Cord. PLoS One 2016; 11:e0168807. [PMID: 28036395 PMCID: PMC5201258 DOI: 10.1371/journal.pone.0168807] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/06/2016] [Indexed: 01/09/2023] Open
Abstract
Brachial plexus injury (BPI) is a devastating type of nerve injury, potentially causing loss of motor and sensory function. Principally, BPI is either categorized as preganglionic or postganglionic, with the early establishment of injury level being crucial for choosing the correct treatment strategy. Despite diagnostic advances, the need for a reliable, non-invasive method for establishing the injury level remains. We studied the usefulness of in vivo magnetic resonance imaging (MRI) of the spinal cord for determination of injury level. The findings were related to neuronal and glial changes. Rats underwent unilateral L4 & L5 ventral roots avulsion or sciatic nerve axotomy. The injuries served as models for pre- and postganglionic BPI, respectively. MRI of the L4/L5 spinal cord segments 4 weeks after avulsion showed ventral horn (VH) shrinkage on the injured side compared to the uninjured side. Axotomy induced no change in the VH size on MRI. Following avulsion, histological sections of L4/L5 revealed shrinkage in the VH grey matter area occupied by NeuN-positive neurons, loss of microtubular-associated protein-2 positive dendritic branches (MAP2), pan-neurofilament positive axons (PanNF), synaptophysin-positive synapses (SYN) and increase in immunoreactivity for the microglial OX42 and astroglial GFAP markers. Axotomy induced no changes in NeuN-reactivity, modest decrease of MAP2 immunoreactivity, no changes in SYN and PanNF labelling, and a modest increase in OX42 and SYN labeling. Histological and radiological findings were congruent when assessing changes after axotomy, while MRI somewhat underestimated the shrinkage. This study indicates a potential diagnostic value of structural spinal cord MRI following BPI.
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Affiliation(s)
- Amar Karalija
- Department of Integrative Medical Biology, Section of Anatomy, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Science, Section of Hand and Plastic Surgery, Umeå University, Umeå, Sweden
- * E-mail:
| | - Liudmila N. Novikova
- Department of Integrative Medical Biology, Section of Anatomy, Umeå University, Umeå, Sweden
| | - Greger Orädd
- Department of Integrative Medical Biology, Section of Physiology, Umeå University, Umeå, Sweden
- Umeå Centre for Comparative Biology, Umeå University, Umeå, Sweden
| | - Mikael Wiberg
- Department of Integrative Medical Biology, Section of Anatomy, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Science, Section of Hand and Plastic Surgery, Umeå University, Umeå, Sweden
| | - Lev N. Novikov
- Department of Integrative Medical Biology, Section of Anatomy, Umeå University, Umeå, Sweden
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Fisher S, Wadhwa V, Manthuruthil C, Cheng J, Chhabra A. Clinical impact of magnetic resonance neurography in patients with brachial plexus neuropathies. Br J Radiol 2016; 89:20160503. [PMID: 27558928 DOI: 10.1259/bjr.20160503] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To study the impact of brachial plexus MR neurography (MRN) in the diagnostic thinking and therapeutic management of patients with suspected plexopathy. METHODS MRN examinations of adult brachial plexuses over a period of 18 months were reviewed. Relevant data collection included-patient demographics, clinical history, pre-imaging diagnostic impression, pre-imaging treatment plan, post-imaging diagnosis, post-imaging treatment plan, surgical notes and electrodiagnostic (ED) results. Impact of imaging on the pre-imaging clinical diagnosis and therapeutic management were classified as no change, mild change or substantial change. RESULTS Final sample included 121 studies. The common aetiologies included inflammatory in 31 (25.6%) of 121 patients, trauma in 29 (23.9%) of 121 patients and neoplastic in 26 (21.5%) of 121 patients. ED tests were performed in 47 (38.8%) of 121 patients and these showed concordance with MRN findings in 31 (66.0%) of 47 patients. Following MRN, there was change in the pre-imaging clinical impression for 91 (75.2%) of 121 subjects, with a mild change in diagnosis in 57 (47.1%) of 121 patients and a substantial change in 34 (28.0%) of 121 patients. 19 (15.7%) of 121 patients proceeded to therapies that would not have been performed in the same manner without the information obtained from MRN. CONCLUSION MRN of the brachial plexus significantly impacts clinical decision-making and should be routinely performed in suspected brachial plexopathy. Advances in knowledge: MRN significantly impacts the diagnostic thinking and therapeutic management of patients with suspected brachial plexopathy. MRN not only provides concordant information to ED tests in majority of cases, but also supplements with additional diagnostic data in patients who are ED negative.
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Affiliation(s)
- Stephen Fisher
- 1 Musculoskeletal Imaging Division, Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Vibhor Wadhwa
- 2 Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Christine Manthuruthil
- 1 Musculoskeletal Imaging Division, Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan Cheng
- 3 Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Avneesh Chhabra
- 1 Musculoskeletal Imaging Division, Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
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Dawson A, Vasquez E, Garrett Jr D, Harris FS, El Nihum IM, Dayawansa S, Huang JH, Singel S. Simultaneous Erb’s and Klumpke’s palsy: Case report. World J Clin Cases 2015; 3:984-987. [PMID: 26677447 PMCID: PMC4677086 DOI: 10.12998/wjcc.v3.i12.984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 05/06/2015] [Accepted: 08/14/2015] [Indexed: 02/05/2023] Open
Abstract
Mapping nerve deficits during a physical exam after trauma to the upper extremity can help determine not only if the brachial plexus was injured but also which nerve roots were involved. A 28-year-old male presented with simultaneous signs and symptoms of Erb’s (C5) and Klumpke’s (C8, T1) palsy, with sparing of the C6 and C7 roots. The patient presented several months ago to his local emergency room with shortness of breath, which was determined to be caused by left diaphragmatic paralysis through clinical and radiographical evidence. However, the etiology of the current nerve dysfunction in the upper extremity remained unknown. With persistent questioning and establishing the patient’s trust in the caregivers, it was revealed that the patient had attempted suicidal hanging. We describe the clinical features and the likely mechanism of injury leading to this previously unreported combination of brachial plexus injuries. The unique injuries to this patient’s brachial plexus can be explained by the sequence of events during the attempted suicidal hanging. The upper brachial plexus was injured during the initial moments where the neck was excessively stretched and the lower brachial plexus was injured due to the patient reaching up and holding himself by his arm for an extended period of time.
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