Late-onset radiation-induced brachial plexopathy

The late-onset variant of radiation-induced brachial plexopathy is most often seen after treatment for breast or lung cancers. It has an insidious onset, with symptoms noted years after receiving radiotherapy, and the condition gradually continues to deteriorate with time. We present the case of an elderly man who we saw in view of worsening paraesthesias and weakness of his left arm with associated prominent muscle wasting along the left shoulder girdle. Fifteen years prior to this, he had received radiotherapy for the treatment of nasopharyngeal carcinoma.

Transfer of Motor Fascicle From the Median to the Axillary Nerve for Upper Brachial Plexus Injury: A Surgical Technique and Case Report

Upper brachial plexus injury or isolated lesions of the axillary nerve (AN) compromise shoulder functionality significantly. Different surgical techniques have been described for selective reconstruction of the AN, with good results especially in association with repair of the suprascapular nerve. The objective of this study is to describe the transfer of motor fascicles of the median nerve to the AN by an axillary approach in cadavers and the clinical results in 2 patients. Dissections were performed on 5 cadavers, followed by identification and dissection of the AN and its divisions before entering the quadrangular space. We standardized the surgical technique in which the median nerve was first identified and then an intrafascicular dissection was performed. Then we harvested a fascicle and transferred it to the anterolateral branch of the AN. Two patients underwent an operation; at 2 years of follow-up, average abduction of 125 degrees and external rotation of 95 degrees were observed. In conclusion, the transfer of motor fascicles of the median nerve to the AN by an axillary approach could be an alternative technique for the deltoid reinnervation in upper brachial plexus injury. Some advantages are the proximity of the donor nerve to the receptor nerve and the low morbidity of the target muscles of the donor nerve. Studies with a larger number of patients are required to establish its effectiveness compared with other techniques already described.

Brachial Plexus Reconstruction Using Long Nerve Grafts as Spare Parts From an Amputated Limb: A Case Report

CASE

The reconstruction of large nerve gaps remains a reconstructive challenge. Here, we present a case report of brachial plexus reconstruction using nerve grafts harvested as spare parts from an amputated limb. It also allowed us to use motor nerve grafts to reconstruct defects in the posterior cord and musculocutaneous nerve. The patient recovered good shoulder and elbow function at 2.5 years with evidence of innervation distally on electromyography.

CONCLUSION

Spare part surgery should always be kept in a surgeons' reconstructive algorithm. Reconstruction of large nerve gaps can be achieved with autologous nerve grafts in certain circumstances.

Brachial plexopathy as a complication of COVID-19

COVID-19 affects a wide spectrum of organ systems. We report a 52-year-old man with hypertension and newly diagnosed diabetes mellitus who presented with hypoxic respiratory failure due to COVID-19 and developed severe brachial plexopathy. He was not treated with prone positioning respiratory therapy. Associated with the flaccid, painfully numb left upper extremity was a livedoid, purpuric rash on his left hand and forearm consistent with COVID-19-induced microangiopathy. Neuroimaging and electrophysiological data were consistent with near diffuse left brachial plexitis with selective sparing of axillary, suprascapular and pectoral fascicles. Given his microangiopathic rash, elevated D-dimers and paucifascicular plexopathy, we postulate a patchy microvascular thrombotic plexopathy. Providers should be aware of this significant and potentially under-recognised neurologic complication of COVID-19.

Cancer and Peripheral Nerve Disease

Patients with cancer may experience neuropathy at any stage of malignancy, ranging from symptoms that are the earliest signs of cancer to side effects of treatment. Peripheral nerves are affected most commonly in a symmetric, stocking-glove pattern. Sensory neuronopathies, plexopathies, and radiculopathies may also be seen. The most common type of neuropathy in patients with cancer is related to chemotherapy, and recently peripheral nerve complications have been described as an effect of immune checkpoint inhibitors too. Other causes include paraneoplastic syndromes, direct tumor infiltration, and radiation. Treatment focuses on addressing the underlying cancer and management of neuropathic pain.

Shrug radiographs for the diagnosis of long thoracic nerve palsy in traumatic brachial plexus injury

BACKGROUND

Preoperative diagnosis of long thoracic nerve (LTN) palsy is important for shoulder reconstruction after a traumatic brachial plexus injury (BPI). In the present study, we developed an objective diagnostic method for LTN palsy for patients with traumatic BPI.

METHODS

This is a retrospective review of 56 patients with traumatic BPI who had been receiving treatment at a single institution for over 8 years. The patients were divided into 2 groups: an LTN palsy group (n = 30) and a no palsy control group (n = 26). The LTN palsy group had 21 different palsy types with 4 and 5 C5-7 and C5-8, whereas the no palsy group had 18 different palsy types with 5 and 3 C5-6 and C5-8, respectively. Preoperative plain anteroposterior radiographs were taken in shoulder adduction and shrug positions. Scapulothoracic (ST) upward rotation and clavicle lateral (CL) rotation angles were measured on X-rays. The differences between the adduction and shrug positions for the respective angles were calculated and defined as Φ_ST and Φ_CL, respectively. The differences in the Φ_ST and Φ_CL values due to the presence or absence of LTN palsy were examined, the cutoff values of Φ_ST and Φ_CL for the diagnosis of LTN palsy were determined, and further sensitivity and specificity were calculated.

RESULTS

Both Φ_ST and Φ_CL were significantly decreased in the LTN palsy group compared with the no palsy control group. The sensitivity and specificity for LTN palsy were 0.833 and 1.000 for Φ_ST and 0.833 and 0.840 for Φ_CL, respectively, when the cutoff value was set as Φ_ST = 15° and Φ_CL ≤ 24°.

CONCLUSION

Dynamic shrug radiographs provide a useful objective diagnosis of LTN palsy after traumatic BPI.

The lower trapezius transfer: a systematic review of biomechanical data, techniques, and clinical outcomes

BACKGROUND

Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs.

METHODS

MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated.

RESULTS

Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation.

CONCLUSION

This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.

Neurological and Dexterity Assessments in a Woman with Radiation-Induced Brachial Plexopathy After Breast Cancer

The aim of this case report is to inform clinicians about radiation-induced brachial plexopathy, a rare complication that often presents well after treatment with inconsistent symptoms and manifestations. It is often a diagnosis of exclusion when a neoplastic or other cause cannot be identified. Electrodiagnostic testing is particularly useful. Here, the results of a standardized grip and pinch strength assessment and dexterity test are presented in a woman whose symptoms first appeared 20 years after completing treatments for stage IIIA breast cancer.

Brachial plexus injury after shoulder dislocation: a literature review

Brachial plexus injuries are among the rarest but at the same time the most severe complications of shoulder dislocation. The symptoms range from transient weakening or tingling sensation of the upper limb to total permanent paralysis of the limb associated with chronic pain and disability. Conflicting opinions exist as to whether these injuries should be treated operatively and if so when surgery should be performed. In this review, available literature dedicated to neurological complications of shoulder dislocation has been analysed and management algorithm has been proposed. Neurological complications were found in 5.4-55% of all dislocations, with the two most commonly affected patient groups being elderly women sustaining dislocation as a result of a simple fall and young men after high-energy injuries, often multitrauma victims. Infraclavicular part of the brachial plexus was most often affected. Neurapraxia or axonotmesis predominated, and complete nerve disruption was observed in less than 3% of the patients. Shoulder dislocation caused injury to multiple nerves more often than mononeuropathies. The axillary nerve was most commonly affected, both as a single nerve and in combination with other nerves. Older patient age, higher energy of the initial trauma and longer period from dislocation to its reduction have been postulated as risk factors. Brachial plexus injury resolved spontaneously in the majority of the patients. Operative treatment was required in 13-18% of the patients in different studies. Patients with suspected neurological complications require systematic control. Surgery should be performed within 3-6 months from the injury when no signs of recovery are present.

[Tendon transfers around the shoulder for patient with brachial plexus injury sequels]

Brachial plexus lesions can significantly affect patient function. The type of management will depend on the severity of the injury as well as the anatomical location. Tendon transfers around the shoulder have emerged as an effective treatment alternative, and therefore we should consider them when faced with patients who might require it. There are various transfer techniques, within which the most frequently used are upper trapezium, latissimus dorsi and lower trapezium transfers, each with its specific indications and objectives depending on the type of patient. These surgeries aim to decrease the pain resulting from the hypotonia and glenohumeral subluxation as well as improve the range of movement of the shoulder, getting the patient to take his hand to the plane that requires to perform his daily life activities. We will provide a description of some of the most commonly used shoulder tendon transfer techniques associated with a bibliographic review and a description of our experience with these surgeries.

Ultrasound-guided peri-brachial plexus polydeoxyribonucleotide injection for a patient with postherpetic brachial plexopathy: A case report

RATIONALE

Although most complications of herpes zoster (HZ) are associated with the spread of varicella-zoster virus from the initially involved sensory ganglion, motor nerve impairment, such as limb weakness, is a rare but severe complication that is difficult to treat.

PATIENT CONCERN

A 73-year-old female presented with sudden left upper limb pain and weakness after HZ.

DIAGNOSIS

Brachial plexopathy following HZ (postherpetic brachial plexopathy).

INTERVENTION

Despite alleviation of the vesicles with antiviral treatments, the left upper limb weakness and neuropathic pain did not improve. After obtaining patient's consent, ultrasound-guided polydeoxyribonucleotide (PDRN) injection was performed around the left brachial plexus.

OUTCOMES

The patient showed marked improvement in left arm pain from numerical rating scale (NRS) 9 to 4, 1 day after PDRN injection. Subsequently, the pain improved to NRS 3, and motor weakness improved to Medical Research Council grade 2 to 4.

LESSONS

PDRN can be considered a viable substitute for corticosteroid injection in treatment of motor weakness and neuropathic pain after HZ.

Man-In-The-Barrel Syndrome: Acute bilateral brachial plexopathy after recurrent microtrauma

The presence of brachial diplegia despite the normal muscular strength of the lower extremities is called the man-in-the-barrel syndrome (MIBS). Although this rare syndrome often occurs due to the bilateral supratentorial brain lesions, it may also rarely occur as a result of infratentorial causes. In this report, we describe a case presenting with MIBS of which etiological underlying cause was bilateral brachial plexopathy developed secondarily to recurrent microtrauma. A 51-year-old male patient presented to our clinic with complaints of pain and weakness on both arms. After electrodiagnostic examination, bilateral brachial plexopathy was identified. The findings of the patient improved following methylprednisolone therapy. It is very important to determine the treatable causes of this syndrome at an early stage.

Lower Trapezius Transfer for Patients With Brachial Plexus Injury

BACKGROUND

Brachial plexus injury is a complex entity that often results in partial recovery. Most studies to date have focused on improving shoulder abduction. However, a recent technique has been outlined-one that transfers the lower trapezius to improve the external rotation of the shoulder. The primary objective of this study was to evaluate the gains in external rotation of the shoulder in patients who have undergone transfer of the lower trapezius; secondarily, we assessed the range of motion in the elbow and shoulder joints, as well as the muscle strength and quality of life.

METHODS

This article presents a prospective cohort study of 10 patients who underwent transfer of the lower trapezius. During the preoperative period and at 6 months after the operation, both active and passive goniometric measurements were assessed, as were muscle strength, Mallet's classification, and patients' responses to the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

External rotation exhibited an improvement of 17° in the active range of motion and 14° the passive range, which was not statistically significant. Flexion and active abduction of the shoulder, as well as the responses to the DASH, showed positive results. The Mallet's classification and muscle strength measurement results were not significant.

CONCLUSIONS

The procedure might be an alternative for restoration of shoulder function and glenohumeral stabilization and mainly to improve quality of life. However, additional studies are required to define and refine this surgical technique.

Anaesthesia for Robotic-Assisted Radical Prostatectomy: Considerations for Laparoscopy in the Trendelenburg Position

Two cases of anaesthetic complications after robotic-assisted laparoscopic radical prostatectomy using the da Vinci Remote-Controlled Surgical System are presented. Case 1 describes a patient with post-extubation respiratory distress requiring reintubation and subsequent ventilation in an intensive care unit. This was attributed to laryngeal oedema, which was most likely due to the reduction in venous outflow from the head caused by the pneumoperitoneum and prolonged, extreme Trendelenburg position. Case 2 describes a patient with mild brachial plexus neurapraxia, which was most likely due to compression by shoulder braces (to prevent cephalad sliding) during the exaggerated head-down tilt. For this procedure, the authors recommend limiting the duration and extent of head-down tilt as much as possible, avoiding excessive intravenous fluids and careful positioning of the patient with avoidance of shoulder braces whenever possible.

Bilateral Brachial Plexopathy following Laparoscopic Bariatric Surgery

This report describes a case of postoperative bilateral brachial plexopathy following laparoscopic bariatric surgery. The patient, a 39-year-old morbidly obese man, developed motor and sensory deficit, loss of reflexes, and pain in both arms postoperatively. Slow, but complete recovery occurred over nine months. We postulate that the head-up position in obese patients, without specific arm support, is a risk factor for brachial plexus injury.

Unilateral brachial plexus injury following carbon monoxide intoxication: A case report

RATIONALE

We report a 45-year-old male patient with unilateral brachial plexopathy following acute carbon monoxide (CO) intoxication.

PATIENT CONCERNS

The patient suddenly developed severe left upper extremity weakness and cognitive impairment after CO intoxication.

DIAGNOSES

He showed severe weakness in the left upper extremity and decreased cognitive function during physical examination. Whole body bone scan revealed increased radioisotope uptake in the left shoulder, suggesting rhadomyolysis. Brain magnetic resonance imaging showed high signal intensity in both globus pallidus. The electrodiagnostic finding was compatible with incomplete left total brachial plexopathy (axonopathy).

INTERVENTIONS

High oxygen therapy and massive intravenous normal saline infusion were administered immediately after acute CO intoxication. Since then, intensive rehabilitation treatment has been provided.

OUTCOME

Despite having received medical and rehabilitation treatment, the patient has not recovered severe weakness in the left upper extremity and decline in cognition.

LESSONS

Localized swelling in the left shoulder caused by rhabdomyolysis may be a key mechanism in developing unilateral brachial plexopathy after acute CO intoxication. The early diagnosis and treatment of rhadomyolysis might be important preventing peripheral neuropathy. An electrodiagnostic study may be helpful for diagnosis of peripheral neuropathy after CO intoxication and prediction of patient's prognosis.

[«Man-in-the-barrel» syndrome: atypical manifestation of giant cell arteritis]

INTRODUCTION

«Man-in-the-barrel» syndrome refers to diplegia of the upper extremities in which mobility of the head and lower limbs is preserved. Brachial plexitis that presents as «man-in-the-barrel» syndrome is an unusual manifestation of giant cell arteritis. We report a case of C5-C6 plexitis as part of the clinical features of a patient with giant cell arteritis.

CASE REPORT

A 70-year-old male with a two-month history of weight loss, headache, facial pain and jaw claudication, associated with a persistent elevation of acute phase reactants and bilateral brachial plexopathy, with no evidence of neck or brain injuries or occult neoplasm and with negative autoimmunity tests. Results of the biopsy study of the temporal artery were compatible with giant cell arteritis, and the positron emission tomography scan revealed extensive vascular involvement of the aorta and its branches.

CONCLUSIONS

Although the typical clinical manifestations of giant cell arteritis are headache, jaw claudication, loss of sight, constitutional symptoms and polymyalgia rheumatica, its presence must be suspected in patients over the age of 50 who manifest alterations affecting the peripheral nerve, including brachial diplegia with no other demonstrable cause.

Clavicular fracture in the newborn: Is fracture location a risk factor for obstetric brachial palsy?

BACKGROUND

The incidence of clavicle fracture in the newborn population ranges from 0.2 to 3.5% with an associated rate of obstetric brachial palsy (OBP) ranging from 4 to 13% .

METHODS

The aim of this study was to describe the anatomical location of the fracture in the clavicle and its possible correlation with OBP. We retrospectively reviewed all perinatal clavicle fractures diagnosed at our institution over thirteen years.

RESULTS

A total of 155 clavicle fractures were identified among 23508 live newborns representing an incidence of 0.67% . Fracture location was categorized according to the Allman classification. The most frequent location was the mid-shaft (Allman I) (92.90%), followed by the medial third (Allman III) (5.81%) and finally by the lateral third (Allman II) (1.29%). 17 cases had an associated OBP (10.97%). 13 of these cases (76.47%) involved the medial third, 4 involved the midshaft (23.53%) whilst none of the cases with a clavicle fracture involving the lateral third was associated to OBP. We could determine a significant association between the occurrence of OBP and fracture of the clavicle medial third (Allman type III) (p < 0.05).

CONCLUSIONS

To the best of our knowledge this is the first study describing the anatomical location of the fracture in the clavicle and its possible association with OBP. A fracture involving the medial clavicle third in a newborn might alert of the possible event of OBP. Nevertheless, more studies with larger samples will be necessary to confirm these results.

A Review of Brachial Plexus Birth Palsy: Injury and Rehabilitation

Brachial plexus injuries during the birthing process can leave infants with upper extremity deficits corresponding to the location of the lesion within the complex plexus anatomy. Manifestations can range from mild injuries with complete resolution to severe and permanent disability. Overall, patients have a high rate of spontaneous recovery (66-92%).1,2 Initially, all lesions are managed with passive range motion and observation. Prevention and/or correction of contractures with occupational therapy and serial splinting/casting along with encouraging normal development are the main goals of non-operative treatment. Surgical intervention may be war- ranted, depending on functional recovery. [Full article available at http://rimed.org/rimedicaljournal-2017-11.asp].

Muscle training-induced bilateral brachial plexopathy in an adolescent with sporadic hereditary neuropathy with liability to pressure palsies

There have been few studies regarding physical training-induced peripheral nerve dysfunction in patients with hereditary neuropathy with liability to pressure palsies (HNPP), with the exception of soldiers that trained intensively. Here, we report a 15-year-old boy without family history of HNPP who developed bilateral painless brachial plexopathy following short-term barbell and plank training during a school baseball club activity. Muscle training-induced painless brachial plexopathy could be an initial symptom and may be underdiagnosed in adolescents with sporadic HNPP.