Relationship between discrepancies in upper-limb anthropometrics and functionality in children with obstetrical brachial plexus injury

BACKGROUND

Children with obstetrical brachial plexus injury often present with relative reduction and deficit (discrepancies) in length, girth and functional performance in their affected upper-limb. However, the relationship between these discrepancies and the functional deficit is still unclear.

OBJECTIVE

This study evaluated discrepancies in upper-limb of children with obstetrical brachial plexus injury, and find the relationship between these discrepancies and the functional performances in the affected upper-limbs.

METHODS

This study involved 50 children with obstetrical brachial plexus injury undergoing rehabilitation at selected secondary and tertiary health institutions in Lagos state, Nigeria. Upper-limb-length, arm-girth and forearm-girth were measured using broad-blade anthropometer and inelastic tape measure. Modified Mallet-Scale was used to assess functional performances of the upper-limbs while joints' range of motion was assessed using a full-circle goniometer. Data was analysed using Pearson's Correlation Coefficient, paired and independent t-test.

RESULTS

Participants were aged 47.86 +/- 124.50 months. Discrepancies in upper-limb length and arm and forearm girth were 2.17 +/- 3.19 cm, 0.21 +/- 0.78 cm and 0.73 +/- 0.73 cm respectively. There was significant discrepancy in lengths, girths and functional performance between affected and unaffected upper-limb. The age of commencement of treatment ranged between one day and 2555 days with a mean of 2224.52 +/- 469.30 days. Time of commencement of treatment was significantly related with lengths, girths and functional performance of the affected upper-limbs.

CONCLUSION

There are significant discrepancy in lengths, girth and functional performance between affected and unaffected upper limb of children with obstetrical brachial plexus injury. There is negative significant relationship between time of commencement of treatments and the discrepancies that occurred in the affected upper-limb of children with obstetrical brachial plexus injury.

Traumatic brachial plexus injury: electrodiagnostic findings from 111 patients in a tertiary care hospital in India

OBJECTIVE

The study aims to characterise the electrodiagnostic findings of patients with traumatic brachial plexus injuries (BPIs) in India and to analyse the association between aetiologies and levels of injuries.

METHODS

A total of 111 consecutive electrodiagnostic studies done between January 2009 and June 2011 on persons with traumatic BPI were retrospectively analysed.

SETTING

Electrodiagnostic Laboratory, Department of Physical Medicine and Rehabilitation in a tertiary care university teaching hospital in South India.

MAIN OUTCOME MEASURES

Nerve conduction velocities and electromyography (EMG) to locate the level of BPI, Dumitru and Wilbourne scale to assess the severity of BPI.

RESULTS

We studied 106 males and five females, ranging from 11 to 59 years of age. All but one had unilateral BPI. Motorcycle crashes were the most frequent cause (n=64, 58%). Isolated supraclavicular injury was found in 98 arms (88%) and infraclavicular injury in seven arms (6%). Root-level injuries were more common in motorcycle crashes and occupation-related trauma, while trunk-level injuries were more often found in automobile crashes, falls, bicycle-related trauma and penetrating wounds. Pan root (C5-T1) involvement was more common in the motorcycle trauma group (74%). There was no significant association between aetiologies and levels of BPIs. A total of 73 (65%) plexus injuries were of 'severe' category as per Dumitru and Wilbourn scale.

CONCLUSIONS

Motorcycle crash is the most common cause of traumatic BPIs. Supraclavicular injury is the rule in most cases. Proper attention needs to be given to differentiate the mild to moderate injuries from the severe injuries with EMG techniques since most of the cases are severe. There was no significant association found between aetiologies and levels of injury.

Isolated musculocutaneous neuropathy in an adolescent baseball pitcher

Injury of the musculocutaneous nerve very rarely occurs in the absence of concomitant injury to other components of the brachial plexus. Until now, the few cases of isolated musculocutaneous nerve palsies have been reported only in adults. We report a case of isolated musculocutaneous neuropathy in a uniquely talented adolescent baseball pitcher. The biomechanics underlying this adolescent's ability to throw with high velocity likely contributed to the musculocutaneous nerve injury in this case.

Evaluation of bone mineral density in children with perinatal brachial plexus palsy: effectiveness of weight bearing and traditional exercises

PURPOSE

(1) To investigate any evidence of bone mineral density (BMD) changes in children with Perinatal Brachial Plexus Palsy (PBPP). (2) To detect any relationship between these changes and the child age, weight, height, BMI, power index, gender, ethnicity, and the side affected. (3) To determine any possible effects of a designed weight bearing exercise program and the traditional one upon BMD of those children.

STUDY DESIGN

Randomized single blind controlled trial.

METHOD

A convenience sampling strategy was used to obtain 45 children with unilateral PBPP. Their ages ranged from 3 to 10 years. They were randomly divided to three equal groups. Groups were, then, randomly assigned to either interventions [Weight Bearing Exercises Program (WBEP) or Traditional Exercises Program (TEP)] or to the control treatment. Dual Energy X-Ray Absorptiometry (DXA) was used to evaluate BMD for all children at entry and approximately after six months treatment period.

RESULTS

We detected significant low entry level measurements of all BMD parameters of the affected side when compared to that of the unaffected sides (p=0.000). The mean value of the entry level calculated Z score for the affected side of all study children was equal to -1.12 ± 0.327 being in the osteopenic risk range. Furthermore, thirty children (66.7%) recorded less than (-1) Z score being in this risky range. Also, we recorded a significant improvement of all BMD parameters of the affected side after treatment in favor of the WBEP group when compared to that of the control and TEP groups (p=0.02, p=0.03 respectively for the affected both bones BMD parameter).

CONCLUSIONS

BMD is significantly reduced in PBPP children. The retardation of bone accrual increases as the child height and weight decreases and the degree of paralysis increases. WBEP significantly promoted BMD improvement when compared to the TEP.

Preventing position-related brachial plexus injury with intraoperative somatosensory evoked potentials and transcranial electrical motor evoked potentials during anterior cervical spine surgery

The use of somatosensory evoked potentials (SSEPs) to monitor upper extremity nerves during surgery is becoming more accepted as a valid and useful technique to minimize intraoperative nerve injuries. We present a case illustrating the benefit of utilizing both SSEPs and transcranial electrical motor evoked potentials (TCeMEPs) for preventing position-related injury during surgery. The patient was a 43-year-old male with a history of neck pain, along with numbness and tingling of the upper extremities. While the patient was being draped, upper extremity SSEPs diminished significantly TCeMEP responses in the hands (abductor pollicus brevis-abductor digiti minimi; APB-ADM) vanished shortly after that, followed by the biceps and left deltoid. The surgeons were notified, and the tape on the shoulders was loosened. No improvements were noted in SSEPs nor TCeMEPs due to this intervention, so all tape was removed and the patient's arms were allowed to rest naturally upon the arm boards. Upper extremity TCeMEP responses could then be elicited and SSEPs improved shortly afterward. Surgery was completed with the arms on the arm boards. All signals remained stable for the remaining three hours of the procedure. At two months follow-up, the patient was well with total pain relief and normal upper extremity function when neurological examination was performed. This report demonstrates a case in which intraoperative neurophysiological monitoring was useful in identifying and reversing impending nerve injury during cervical spine surgery. Significant changes were seen in SSEPs as well as TCeMEPs, so we recommend that TCeMEP monitoring be considered as an adjunct to SSEPs for prevention of injury to the brachial plexus.

Monoparesis secondary to herpes zoster

We describe a 90-year-old woman with right upper limb monoparesis secondary to varicella zoster virus infection as a result of extensive inflammatory involvement of the entire brachial plexus at root level. To our knowledge, this is the first report of entire brachial plexus involvement in a living patient of such advanced age. Despite a delay in presentation and thus initiation of treatment, a favourable clinical response was observed.

Assessment of pain sensitivity in patients with deep bite and sex- and age-matched controls

AIMS

To compare pain sensitivity between deep bite patients and a sex- and age-matched control group with normal occlusion.

METHODS

Pain sensitivity was assessed by injections of the excitatory amino acid glutamate into the masseter and brachioradialis muscles. Intensity of glutamate-evoked pain was scored by the subjects ( n = 60) on a 0 to 10 cm visual analog scale. Subjects drew the perceived pain area on a face and arm chart and described the quality of pain on the McGill Pain Questionnaire. Thresholds for cold detection, cold pain, cold tolerance, warmth detection, heat pain, and heat tolerance were assessed on the masseter and brachioradialis muscles. Pressure pain threshold and pain tolerance threshold were determined on the temporomandibular joint, masseter, anterior temporalis, and brachioradialis muscles. The differences between groups, age, and gender were tested by two-way ANOVA, and the significant differences were then tested for the effect of the presence of temporomandibular disorder (TMD) by linear regression.

RESULTS

Glutamate-evoked pain intensity was significantly different between groups with no gender differences. Quality of pain did not vary between groups, but significant gender-related differences were observed. Significant differences in thermal sensitivity between groups and gender were found, whereas mechanical sensitivity did not vary between groups but between genders. None of the significant differences were due to the effect of TMD.

CONCLUSION

These data provide further evidence of gender-related differences in somatosensory sensitivity and for the first time indicate that subjects with deep bite may be more sensitive to glutamate-evoked pain and thermal stimuli.

[Clinical study on acupuncture and Tuina for treatment of birth brachial plexus injury]

OBJECTIVE

To compare the difference of therapeutic effect between acupuncture combined with Tuina and Nobex for treatment of birth brachial plexus injury.

METHODS

Forty cases with birth brachial plexus injury were randomly divided into a acupuncture combined with Tuina group (group A) and a Nobex group (group B), 20 cases in each group. The group A was treated with acupuncture at 3 points, i. e. Jianyu (LI 15), Jianliao (TE 14), Jianzhen (SI 9) on shoulder, Binao (LI 14), Shouwuli (LI 13), Quchi (LI 11), etc. combined with Tuina using a single thumb and rolling method, and the group B was treated with intramuscular injection of Nobex. The clinical effects and the changes of the symptom, scores and the electromyogram were observed before and after treatment.

RESULTS

The total effective rate of 90.0% (18/20) in the group A was better than that of 55.0% (11/20) in the group B, with a significant difference between the two groups (P < 0.05). The effective rate of the electromyogram improvement in the group A was 90.0% (18/20), which was better than 45.0% (9/20) in the group B (P < 0. 05), and the symptom scores in the group A were lower than those in the group B (P < 0.01).

CONCLUSION

Acupuncture combined with Tuina can improve the recovery of nerve and upper extremity function and its therapeutic effect is superior to that of intramuscular injection with Nobex.

Pain, referred sensations, and involuntary muscle movements in brachial plexus injury

OBJECTIVES

Examination of the relationship between pain, sensory hypersensitivity, referred sensations and involuntary muscle jerks in patients with brachial plexus injury.

MATERIALS AND METHODS

Fourteen patients with brachial plexus lesions were included. Spontaneous background and paroxysmal pain and mechanically and thermally evoked pain were recorded. Areas with sensory hypersensitivity and referred pain were mapped on a body chart. This was supplemented by electrophysiological analysis in three patients.

RESULTS

Sensory hypersensitivity and areas with pinprick-induced referred phantom sensations were present in adjacent dermatomes. There was no clear relationship between chronic neuropathic pain and referred sensations, but there was a correlation between pain paroxysms and sensory hypersensitivity in dermatomes adjacent to deafferented areas. In three patients, simultaneous referred sensations and short latency motor action potentials ipsilateral to the denervated side suggested origin at subcortical sites.

CONCLUSION

The study suggests a possible role of a spinal generator for sensory hypersensitivity and referred sensations following denervation.

[Ultrasound-guided bilateral infraclavicular block: case report]

Bilateral brachial plexus block is rarely performed due to the risk of systemic toxicity of local anesthetics. Therefore, general anesthesia is generally preferred in bilateral extremity operations. However, usage of ultrasound allows easy visualization of the structures of the vessels and the nerves. In this case report, we present a 28-year-old man who was scheduled for bilateral hand surgery with ultrasound-guided bilateral infraclavicular block after he refused general anesthesia. After visualization of the axillary artery and the cords of the brachial plexus with linear ultrasound probe, the mixture of local anesthetics, which was prepared as 20 ml for each extremity (10 ml 2% lidocaine (with 5 microg x ml(-1) adrenaline) + 10 ml 7.5% levobupivacaine), was injected using triple injection method. During block performance, no complication developed. In conclusion, we think that infraclavicular block can be safely performed bilaterally with ultrasound guidance, which allows a reduction in the dose of local anesthetic.

Management of brachial plexus region tumours and tumour-like conditions: relevant diagnostic and surgical features in a consecutive series of eighteen patients

BACKGROUND

Tumours of the brachial plexus region are rare and most publications are case reports or studies with a small series of patients. The aim of this study is to present our experience in managing these lesions.

METHODS

We review 18 patients with tumours in the brachial plexus region submitted to surgical treatment in a 6 year period, including their clinical presentation, neuro-imaging data, surgical findings and outcome.

FINDINGS

The tumours comprised a heterogeneous group of lesions, including schwannomas, neurofibromas, malignant peripheral nerve sheath tumour (MPNST), sarcomas, metastases, desmoids and an aneurysmal bone cyst. The most common presentation was an expanding lump (83.33%). Eleven tumours were benign and 7 were malignant. Neurofibromatosis was present in only 2 patients (11.11%). Gross total resection was achieved in 14 patients and sub-total resection in the others. Only 3 patients presented with new post-operative motor deficits. The incidence of complications was low (16.5 %).

CONCLUSIONS

The majority of tumours were benign and most of them could be excised with a low incidence of additional deficits. Some of the malignant tumours could be controlled by surgery plus adjuvant therapy, but this category is still associated with high morbidity and mortality rates.

Atypical chest pain: evidence of intercostobrachial nerve sensitization in Complex Regional Pain Syndrome

BACKGROUND

Atypical chest pain is a common complaint among Complex Regional Pain Syndrome (CRPS) patients with brachial plexus involvement. Anatomically, the intercostobrachial nerve (ICBN) is connected to the brachial plexus and innervates the axilla, medial arm and anterior chest wall. By connecting to the brachial plexus, the ICBN could become sensitized by CRPS spread and become a source of atypical chest pain.

OBJECTIVE

To evaluate the sensitivity of chest areas in CRPS patients and normal controls.

DESIGN

Prospective investigation of pressure algometry in chest areas to determine chest wall sensitivity.

METHODS

CRPS patients and normal controls volunteered to participate in our study. Each individual was examined to meet inclusion criteria. Patients' report of chest pain history was collected from every participant. Pressure algometry was used to measure pressure sensitivity in the axilla, anterior axillary line second intercostal space, mid-clavicular third rib, mid-clavicular tenth rib, and midsternal. Each of these measurements were compared to an intra-participant abdominal measure to control for an individuals generalized sensitivity. The ratios of chest wall sensitivities were compared between CRPS patients and normal controls.

RESULTS

A history of chest pain was reported by a majority (94%) of CRPS patients and a minority (19%) of normal controls. CRPS patients reported lifting their arm as a major initiating factor for chest pain. To pressure algometry, the ratios of CRPS patients were significantly greater than control subjects (p< 0.02 throughout), indicating increased chest wall sensitivity.

LIMITATIONS

This study is limited by the relatively small number of patients (n=35) and controls (n=21) used.

CONCLUSION

The results of this study support the idea that chest pain is greater in CRPS patients than normal controls. The ICBN could be the source of this sensitization by CRPS spread from the brachial plexus.

Painful brachial plexopathies in SEPT9 mutations: adverse outcome related to comorbid states

Hereditary neuralgic amyotrophy (HNA), an autosomal dominant disorder associated with SEPT9 mutation located on chromosome 17q25, causes recurrent painful weakness with sensory disturbances in a brachial distribution. We present electrophysiological, clinical phenotype, and molecular genetic data of three members from a family with HNA with the C262T SEPT9 mutation. The degree of motor weakness and recovery is variable within this family. Severity and recovery from motor deficits may have been a function of comorbid medical conditions. To our knowledge, this is the first report to confirm SEPT9 mutation in a family with suspected HNA.

[Idiopathic brachial neuritis following general anesthesia]

A 25-year-old woman complained of intense pain in her left shoulder several hours after augmentation mammaplasty under general anesthetic; pain was followed by marked sensory and motor deficit in the same arm. A diagnosis of idiopathic brachial neuritis was made after the main causes of intraoperative nerve damage had been ruled out. The shoulder pain resolved after 3 weeks but the sensory and motor deficit remained unchanged. An electrophysiological study performed at 4 weeks revealed abnormalities suggestive of edema or inflammation and an absence of signs of denervation. These findings and the favorable clinical course confirmed the diagnosis of idiopathic brachial neuritis. After 3 months, only mild weakness and numbness in the deltoid region persisted. Although most postoperative neuropathies are iatrogenic, idiopathic brachial neuritis should be included in the differential diagnosis when no evident cause is found. This syndrome is rare but may appear spontaneously after any type of surgery or anesthetic technique; the prognosis is good. Diagnosis, which can be based on symptoms, imaging and electrophysiological studies, is important both for clinical management and for establishing medical and legal liability.

[The electroneuromyographic study of the radial nerve: compressive ischemic neuropathy of the posterior interosseous nerve]

The electroneuromyographic study of the posterior interosseous nerve (PIN) with determination of conduction block (CB) at the level of the upper third of the forearm using the surface electrodes has been carried out. Seven healthy volunteers, 22 patients with compressive-ischemic neuropathy (CIN) at the level of the supinator, 14 patients with the total affection of the radical nerve, aged from 21 to 64 years, have been studied. The M-response has been recorded from the extensor digitorum communis. Stimulation has been performed at: (1) the middle of the forearm; (2) the lateral brachium; (3) the axillary crease; (4) the Erb's point; (5) the sulcus of ulnar nerve; (6) the cubital flexion; (7) the inner part of the shoulder. A method of stepwise stimulation has been used in the segment "a middle third of the forearm--a middle third of the shoulder". The M-responses of similar shape and amplitude have been recorded by stimulation of the first and second points in the controls. The M-responses recorded by stimulation of the brachial plexus were higher by average of 44,2% compared to the radical nerve in the shoulder area. The focal CB was found between two stimulation points in 86,4% of patients with PIN CIN that was confirmed by the method of stepwise nerve stimulation as well. The correlation between CB and the data of the global electromyogram was revealed. In patients with the total affection of the radical nerve, the M-responses during stimulation of distal and proximal PIN points were absent and the similar M-responses were recorded by stimulation of the brachial plexus (the Erb's point and the axillary crease) as well as the inner part of the shoulder.

Saturday night brachial plexus palsy

An unusual case of brachial plexopathy following an alcohol binge is presented. The patient developed numbness and weakness of his right hand and neurophysiological tests demonstrated that the lesion level was at the brachial plexus. MRI of the brachial plexus, cerebrospinal fluid examination and DNA analysis for hereditary neuropathy with liability to pressure palsies were normal. Repeated neurological examination and neurophysiological studies 60 days later were normal. A diagnosis of brachial plexus neuropathy consequent to non-traumatic stretching of the middle and the lower trunks was made.

Aspects cliniques, électroneuromyographiques et IRM des traumatismes du plexus brachial

OBJECTIVES

Management of traumatic lesions of the brachial plexus mainly depends on whether the injury is pre- (nerve root avulsion) or postganglionic (trunks and cords). The aim of this study was to assess the diagnostic and prognostic value of MRI in such lesions, and to determine any correlations among radiological, clinical and electroneuromyographical (EMG) data from both the initial and follow-up studies.

MATERIAL AND METHODS

Nine patients with acute traumatic lesions of the brachial plexus were investigated by MRI and EMG. Five further patients served as controls. The MRI protocol included fast spin-echo (FSE) T2-weighted and STIR sequencing. These scans were independently interpreted by two senior radiologists. Their findings were then validated during consensus meetings of surgeons, radiologists and neurologists to identify the exact localization and mechanism of each lesion, and to determine the advantages and drawbacks of each technique.

RESULTS

Among the nine patients, MRI scans were judged as normal in three whereas EMG showed distal lesions in two of them. In a further three patients, STIR MRI sequences demonstrated high signal intensities from the trunks and cords of C5 to T1. Among these three patients, MRI at three months showed persistence of these signal anomalies in one patient, and partial regression in the two others. In the remaining three patients, three-dimensional T2-weighted sequences showed nerve root avulsion, consistent with the initial EMG findings.

CONCLUSION

MRI is the best technique to demonstrate nerve root avulsion. However, unlike EMG, MRI does not allow visualization of distal lesions of the brachial plexus. Differentiation between edema (reversible) and demyelination (irreversible) of trunk and cord lesions remains difficult, and requires EMG or late MRI.

Brachial plexopathies: etiology, frequency, and electrodiagnostic localization

OBJECTIVES

Brachial plexopathy is clinically, and electrodiagnostically, a well-recognized entity. However, the involvement pattern of different parts of the plexus with different etiologies has not been well-characterized.

METHODS

A retrospective analysis of clinical and electrophysiologic findings in 203 patients with brachial plexopathies was performed.

RESULTS

Of 203 patients with brachial plexopathy, 182 (90%) were supraclavicular and 21 (10%) were infraclavicular. The following localizations were noted: upper trunk (UT) 27%; lower trunk (LT) 11%; UT + MT (middle trunk) 11%; LT + MT 7%; UT + MT + LT 25%; and UT + LT 1. Among the patients with brachial neuritis, 47% patients did not have pain before the onset and only 28% had a definable antecedent illness.

CONCLUSION

We report the largest to date reported case series of well-characterized brachial plexopathy patients. Upper trunk was the most frequently affected site of injury. In brachial neuritis, absence of pain and antecedent viral illness is more common than described in the literature.

Infiltrations, blocs et neurolyses en pathologie ostéo-articulaire

Computed Tomography fluoroscopy for blocks and neurolysis provides a minimally-invasive, accurate and rapid alternative to surgery. Spinal and peri-spinal ultrasound-guided procedures, excluding peripheral procedures, will be discussed as well. The imaging-guided procedures discussed are performed using small needles. These percutaneous procedures must be performed with maximum patient comfort and cause as little complications as possible. These procedures should be performed by an experienced radiologist after discussion with the treating clinician.

[Forensic analysis on injuries involving main branches of brachial plexus in 66 cases]

OBJECTIVE

To study injuries involving brachial plexus and its branches.

METHODS

66 cases collected from 2003 to 2005 in our department were analyzed statistically.

RESULTS

94% of injuries involved young adult males; 94% were blunt force injuries; 34% involved both nerve and bone mainly involving ulnar nerve and ulnar bone (50%); 40% of the injured nerves received electromyogram and 15 nerves were diagnosed with injuries clinically.

CONCLUSION

Forensic determination on severity of brachial plexus injuries mainly depends on movement recovery of limb. The best time for forensic appraisal is 20 d post operation+L (length of nerve severed distally)/R (growth rate)+90 d.

An accessory middle scalene muscle causing thoracic outlet syndrome

The aim of our study is to present a very rare accessory middle scalene muscle, leading to thoracic outlet syndrome. In particular, a muscular bundle was discovered on a male cadaver connecting the middle portion of the middle scalene muscle with the anterior scalene muscle insertion to Lisfranc's tubercle. This triangular accessory muscle and, especially, its sharp medial border compressed the middle and lower trunk of the brachial plexus and the subclavian artery. This anomaly is of great importance because it emphasises the fact that it is not primarily the anterior scalene muscle that produces symptoms of thoracic outlet syndrome but the anterior displacement of the middle scalene muscle or its accessory muscular bands. We also present the relative international literature and the clinical significance of our finding.

Neuropathic arthropathy caused by syringomyelia in different joints and lesion of brachial plexus at right upper extremity: a case report

Syringomyelia is characterized by slow progression; the joints involved most frequently are the shoulders and elbows. Neuropathic arthropathy of the hand is quite rare. Herewith, we present a case of neuropathic arthropathy (NA) of the joints in the upper limb secondary to Syringomyelia. Atypical features of the case included NA of the shoulder, elbow and metacarpophalengeal joint in the same upper limb. These atypical features superimposed shoulder subluxation and brachial plexopathy which diagnosed by electrophysiologic studies. To the best of our knowledge, our study is the first of its kind that reports a patient who had all the above mentioned symptoms in the same upper limb.