Obstetric brachial plexus injury. Knowledge among health care providers in Saudi Arabia

Objectives:

To assess the basic knowledge on obstetric brachial plexus injury among obstetricians, pediatricians, and physio-/occupational therapists in major hospitals in Riyadh. We aimed to identify if inadequate knowledge is the reason behind delayed referrals to the Hand Clinic.

Methods:

This is a cross-sectional questionnaire-based study conducted at 5 major hospitals in Riyadh, Saudi Arabia between June 2015 and August 2015. A questionnaire of 6 questions (multiple choice closed-ended questions) was given to obstetricians, pediatricians, and physio-/occupational therapists’ in these selected hospitals. The total score out of 6 was categorized as good, adequate, and inadequate knowledge if the score is 5-6, 3-4, and less than 3; respectively. The data were analyzed with Chi-square, fisher exact, Analysis of Variance, and Post-hoc tests where appropriate.

Results:

A total of 323 subjects participated in the study. For positions, the best mean score (for all 6 questions) was scored by consultants and the score was only 2.95 out of 6. For hospitals, Hospital IV scored the best mean score (2.99). The mean scores were not significantly different between different specialties.

Conclusion:

Inadequate knowledge seems to be a reason for delayed referrals of cases of obstetric brachial plexus injury to Hand Clinics in Riyadh, Saudi Arabia.

Tolerance of the Brachial Plexus to High-Dose Reirradiation

PURPOSE

To study the tolerance of the brachial plexus to high doses of radiation exceeding historically accepted limits by analyzing human subjects treated with reirradiation for recurrent tumors of the head and neck.

METHODS AND MATERIALS

Data from 43 patients who were confirmed to have received overlapping dose to the brachial plexus after review of radiation treatment plans from the initial and reirradiation courses were used to model the tolerance of this normal tissue structure. A standardized instrument for symptoms of neuropathy believed to be related to brachial plexus injury was utilized to screen for toxicity. Cumulative dose was calculated by fusing the initial dose distributions onto the reirradiation plan, thereby creating a composite plan via deformable image registration. The median elapsed time from the initial course of radiation therapy to reirradiation was 24 months (range, 3-144 months).

RESULTS

The dominant complaints among patients with symptoms were ipsilateral pain (54%), numbness/tingling (31%), and motor weakness and/or difficulty with manual dexterity (15%). The cumulative maximum dose (Dmax) received by the brachial plexus ranged from 60.5 Gy to 150.1 Gy (median, 95.0 Gy). The cumulative mean (Dmean) dose ranged from 20.2 Gy to 111.5 Gy (median, 63.8 Gy). The 1-year freedom from brachial plexus-related neuropathy was 67% and 86% for subjects with a cumulative Dmax greater than and less than 95.0 Gy, respectively (P=.05). The 1-year complication-free rate was 66% and 87%, for those reirradiated within and after 2 years from the initial course, respectively (P=.06).

CONCLUSION

The development of brachial plexus-related symptoms was less than expected owing to repair kinetics and to the relatively short survival of the subject population. Time-dose factors were demonstrated to be predictive of complications.

Severe Brachial Plexus Injuries in American Football

This article reports a series of severe permanent brachial plexus injuries in American football players. The authors describe the mechanisms of injury and outcomes from a more contemporary treatment approach in the form of nerve transfer tailored to the specific injuries sustained. Three cases of nerve transfer for brachial plexus injury in American football players are discussed in detail. Two of these patients regained functional use of the extremity, but 1 patient with a particularly severe injury did not regain significant function. Brachial plexus injuries are found along a spectrum of brachial plexus stretch or contusion that includes the injuries known as "stingers." Early identification of these severe brachial plexus injuries allows for optimal outcomes with timely treatment. Diagnosis of the place of a given injury along this spectrum is difficult and requires a combination of imaging studies, nerve conduction studies, and close monitoring of physical examination findings over time. Although certain patients may be at higher risk for stingers, there is no evidence to suggest that this correlates with a higher risk of severe brachial plexus injury. Unfortunately, no equipment or strengthening program has been shown to provide a protective effect against these severe injuries. Patients with more severe injuries likely have less likelihood of functional recovery. In these patients, nerve transfer for brachial plexus injury offers the best possibility of meaningful recovery without significant morbidity. [ Orthopedics. 2016; 39(6):e1188-e1192.].

Shoulder Function Following Late Neurolysis and Bypass Grafting for Upper Brachial Plexus Birth Injuries

Eleven children ranging in age from 9 to 21 months underwent late nerve reconstruction for persistent shoulder paralysis following an upper brachial plexus birth injury. Only neurolysis was performed in three patients. Neurolysis and nerve grafting bypassing the neuroma with proximal and distal end-to-side repairs was performed in the other eight. All patients were followed for 2 or more years. Two patients underwent a secondary procedure before their final follow-up evaluation. All infants demonstrated significant improvement when assessed by a modified Gilbert shoulder motion scale.

Tactile feedback for relief of deafferentation pain using virtual reality system: a pilot study

BACKGROUND

Previous studies have tried to relieve deafferentation pain (DP) by using virtual reality rehabilitation systems. However, the effectiveness of multimodal sensory feedback was not validated. The objective of this study is to relieve DP by neurorehabilitation using a virtual reality system with multimodal sensory feedback and to validate the efficacy of tactile feedback on immediate pain reduction.

METHODS

We have developed a virtual reality rehabilitation system with multimodal sensory feedback and applied it to seven patients with DP caused by brachial plexus avulsion or arm amputation. The patients executed a reaching task using the virtual phantom limb manipulated by their real intact limb. The reaching task was conducted under two conditions: one with tactile feedback on the intact hand and one without. The pain intensity was evaluated through a questionnaire.

RESULTS

We found that the task with the tactile feedback reduced DP more (41.8 ± 19.8 %) than the task without the tactile feedback (28.2 ± 29.5 %), which was supported by a Wilcoxon signed-rank test result (p < 0.05).

CONCLUSIONS

Overall, our findings indicate that the tactile feedback improves the immediate pain intensity through rehabilitation using our virtual reality system.

Do not waste your time: straight to magnetic resonance imaging for pediatric burners and stingers

BACKGROUND

Permanent neurologic injury in pediatric patients with burner and stinger syndrome (BSS) is unlikely. This study aims to assess the feasibility of clinical observation without extensive radiologic workup in this selective population.

METHODS

A retrospective study was conducted of patients aged younger than 18 years evaluated at a level I trauma center from 2012 to 2014. Patients were grouped according to positive deficit (PD) or negative deficit (ND) upon physical examination. Demographics, clinical findings, and outcomes were analyzed.

RESULTS

Thirty patients (ND, n = 14; PD, n = 16) were evaluated for BSS, most often as a result of injurious football tackle. Age and length of stay were similar between groups. Injury Severity Score was lower in the ND group than the PD group (1.6 ± 1.2 vs 3.8 ± 3.1, respectively; P< .05). Cervical computed tomography was performed on 11 patients (78.6%) in the ND group and 15 patients (93.8%) in the PD group at considerable added cost, with only 1 positive result in the ND group and none in the PD group. Magnetic resonance imaging (MRI) revealed 2 positive findings in each group, and no surgical interventions were indicated. Ten ND (71.4%) and 12 PD (75%) patients reported complete resolution of symptoms at discharge (P> .05).

CONCLUSIONS

Children presenting with BSS experience temporary symptoms that resolve without surgical intervention. Magnetic resonance imaging identified more injuries than computed tomographic imaging; therefore, we suggest that management for BSS should include observation, serial neurologic examinations, and MRI evaluation as appropriate.

[SUPRASCAPULAR NEUROPATHY]

Supra-scapular nerve (SSN) damage is a rare, but classical diagnosis that can often be overlooked since the nonspecific clinical history and examination commonly lead to the misdiagnosis of another shoulder disorder. This article details the etiopathology, the patients at risk, the reasons for consultation and the clinical aspects of suprascapular neuropathy; it also outlines its diagnostic and therapeutic approaches.

[The Mysterious Paresis]

Internal jugular central venous line placement is a standardized and common clinical procedure. However, even the most skillful physician may face complications. Careful patient evaluation and detailed vascular anatomical knowledge can minimize the risk of iatrogenic injuries. Following a strict protocol in case of unsuccessful attempts of venous puncture helps to improve patient outcome. In this case report, we present a patient who suffered an unusual injury. Further, we discuss current treatment options for pseudoaneurysms.

Radiation-induced brachial plexopathy in patients with nasopharyngeal carcinoma: a retrospective study

Radiation-induced brachial plexopathy (RIBP) is one of the late complications in nasopharyngeal carcinoma (NPC) patients who received radiotherapy. We conducted a retrospective study to investigate its clinical characteristics and risk factors.Thirty-onepatients with RIBP after radiotherapy for NPC were enrolled. Clinical manifestations of RIBP, electrophysiologic data, magnetic resonance imaging (MRI), and the correlation between irradiation strategy and incidence of RIBP were evaluated. The mean latency at the onset of RIBP was 4.26 years. Of the symptoms, paraesthesia usually presented first (51.6%), followed by pain (22.6%) and weakness (22.6%). The major symptoms included paraesthesia (90.3%), pain (54.8%), weakness (48.4%), fasciculation (19.3%) and muscle atrophy (9.7%). Nerve conduction velocity (NCV) and electromyography (EMG) disclosed that pathological changes of brachial plexus involved predominantly in the upper and middle trunks in distribution. MRI of the brachial plexus showed hyper-intensity on T1, T2, post-contrast T1 and diffusion weighted whole body imaging with background body signal suppression (DWIBS) images in lower cervical nerves. Radiotherapy with Gross Tumor volume (GTVnd) and therapeutic dose (mean 66.8±2.8Gy) for patients with lower cervical lymph node metastasis was related to a significantly higher incidence of RIBP (P<0.001).Thus, RIBP is a severe and progressive complication of NPC after radiotherapy. The clinical symptoms are predominantly involved in upper and middle trunk of the brachial plexus in distribution. Lower cervical lymph node metastasis and corresponding radiotherapy might cause a significant increase of the RIBP incidence.

Therapeutic application of electrical stimulation and constraint induced movement therapy in perinatal brachial plexus injury: A case report

Infants and children with perinatal brachial plexus injury (PBPI) have motion limitations in the shoulder, elbow, forearm and hand that are dependent on the level of injury and degree of recovery. The injury and subsequent recovery period occur during critical periods of central and spinal neural development placing infants and children at-risk for developmental disregard and disuse of the affected arm and hand. A case report outlines the therapy and surgical interventions provided in the first 2 years of life for a child with global PBPI and a positive Horner's sign. Electrical stimulation and constraint induced movement therapy provided sequentially were effective therapy interventions. Neurosurgery to repair the brachial plexus was performed at an optimal time period.(2) The Assisting Hand Assessment,(12) Modified Mallet(13) and Active Movement Scale(14) are effective outcome measures in PBPI and served as valuable guides for therapy intervention. Oxford Level of Evidence: 3b; Individual Case Control Study.

Brachial plexus birth palsy: Management during the first year of life

Brachial plexus birth palsy (BPBP) is defined as an injury to any nerve root of the brachial plexus during difficult delivery. BPBP is relatively rare; its incidence has remained constant over the last few decades, mostly due to unpredictable risk factors, such as shoulder dystocia. Both diagnosis and assessment of spontaneous recovery is based on clinical examination. Electromyography is difficult to interpret in the newborn and is therefore not meaningful. MRI of the cervical spine requires sedation or general anesthesia. Searching for a pre-ganglion tear prior to surgery is indicted. Prognosis depends on the level of the injury (pre- or post-ganglion), size and severity of the post-ganglion tears, speed of recovery, and quality of initial management. Although spontaneous recovery is frequent, some children suffer various degrees of sequelae, up to complete loss of function of the affected upper limb. Recent publications have improved general knowledge and indications for surgery. However, some aspects, such as indication and timing of nerve repair continue to be debated.

Quality of life following traumatic brachial plexus injury: A questionnaire study

There is limited qualitative research available that explores the impact of a traumatic brachial plexus injury on patients and their quality of life experiences. This paper builds upon previous work on this subject by this author. Patients were selected from those who were on the database for the Scottish National Brachial Plexus Injury Service between 2011 and 2013. The World Health Organization (WHO) Quality of Life (QoL) - BREF questionnaire was used and 47 questionnaires were distributed with 22 returned. Findings included patients' ratings of their quality of life, physical and psychological health along with their perceived satisfaction with social relationships.

[Neonatal complications related to shoulder dystocia]

OBJECTIVE

To describe neonatal complications related to shoulder dystocia.

METHODS

This systematic evidence review is based on PubMed search, Cochrane library and experts' recommendations.

RESULTS

The risks of brachial plexus birth injury, clavicle and humeral fracture, perinatal asphyxia, hypoxic-ischemic encephalopathy and perinatal mortality are increased after shoulder dystocia. The medical team should be able to provide neonatal resuscitation in the delivery room in case of perinatal asphyxia following shoulder dystocia, according to national and international guidelines. The initial clinical examination should search for complications such as brachial plexus birth injury or clavicle fracture.

CONCLUSION

The risk of perinatal complications is increased in newborn after shoulder dystocia. The medical team should be able to manage these complications.

Brachial Plexus Block for Cancer-Related Pain: A Case Series

Neoplastic brachial plexopathy (NBP) is caused by a cancerous infiltration into the brachial plexus, presenting often as severe pain in the affected upper extremity. Such pain can be resistant to medical treatment. Invasive interventions such as brachial plexus neurolysis with phenol or cordotomy may result in severe complications including permanent neurological damage and death. Continuous brachial plexus and paravertebral block with local anesthetic have been reported to successfully control pain from NBP, but these techniques are logistically challenging and frequently have catheter-related complications. We report a series of patients who received single-shot brachial plexus blocks with a mixture of local anesthetic and corticosteroid (bupivacaine 0.25% with methyl-prednisolone 20-120 mg) for the treatment of refractory cancer-related pain in the brachial plexus territory, mostly from NBP. Theoretically, such blocks could provide immediate analgesia from the local anesthetic and a longer-lasting analgesia from the slow-release steroids. Responders reported a sustained decrease in their pain (lasting from 2 weeks to 10 months), a significant decrease in their opioid and non-opioid (ketamine, gabapentin) consumption, overall satisfaction with the block, and unchanged or improved function of their limb. The ideal candidate for this procedure is a patient who has pain that is predominantly neuropathic from a lesion within the brachial plexus and with anatomy amenable to ultrasound-guided nerve block. Our case series suggests that, in the appropriately selected patient, this technique can safely and effectively alleviate pain from NBP. The procedure is simple, spares limb function, and can be diagnostic, predicting response to more complex procedures. To the best of our knowledge, this is the first report using this technique for NBP.

Neuropathic pain after brachial plexus avulsion--central and peripheral mechanisms

REVIEW

The pain that commonly occurs after brachial plexus avulsion poses an additional burden on the quality of life of patients already impaired by motor, sensory and autonomic deficits. Evidence-based treatments for the pain associated with brachial plexus avulsion are scarce, thus frequently leaving the condition refractory to treatment with the standard methods used to manage neuropathic pain. Unfortunately, little is known about the pathophysiology of brachial plexus avulsion. Available evidence indicates that besides primary nerve root injury, central lesions related to the abrupt disconnection of nerve roots from the spinal cord may play an important role in the genesis of neuropathic pain in these patients and may explain in part its refractoriness to treatment.

CONCLUSIONS

The understanding of both central and peripheral mechanisms that contribute to the development of pain is of major importance in order to propose more effective treatments for brachial plexus avulsion-related pain. This review focuses on the current understanding about the occurrence of neuropathic pain in these patients and the role played by peripheral and central mechanisms that provides insights into its treatment. Pain after brachial plexus avulsion involves both peripheral and central components; thereby it is characterized as a mixed (central and peripheral) neuropathic pain syndrome.

Results of nerve reconstructions in treatment of obstetrical brachial plexus injuries

BACKGROUND

The aim of this study was to evaluate the results achieved using various surgical techniques in patients with partial and total obstetrical brachial plexus palsy.

METHODS

From 2000 to 2013, 33 patients with obstetrical brachial plexus injury underwent surgery. Twenty had follow-up periods greater than 24 months and met the criteria for inclusion in the study. All patients were evaluated using the Active Movement Scale.

RESULTS

The outcomes of different nerve reconstructive procedures including nerve transfers, nerve grafting after neuroma resection and end-to-side neurorrhaphy are presented. The overall success rate in upper plexus birth injury was 80 % in shoulder abduction, 50 % in external rotation and 81.8 % in elbow flexion with median follow-ups of 36 months. Success rate in complete paralysis was 87 % in finger and thumb flexion, 87 % in shoulder abduction and 75 % in elbow flexion; the median follow-up was 46 months. Useful reanimation of the hand was obtained in both patients who underwent end-to-side neurotization.

CONCLUSION

Improved function can be obtained in infants with obstetrical brachial plexus injury with early surgical reconstruction.

Clinical assessment of the infant and child following perinatal brachial plexus injury

STUDY DESIGN

Literature review.

INTRODUCTION

After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome.

PURPOSE

To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians.

METHODS

We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians.

DISCUSSION

With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest.

Clinical diagnostic features of surgical treatment for thoracic outlet syndrome

The thoracic outlet syndrome is characterized by a variety of clinical signs due to multiple causes resulting in compression of a neurovascular bundle in a relatively narrow anatomical space. Despite the frequently encountered clinical symptoms, inadequate attention is paid to their analysis, and their diagnostic and surgical aspects require a modern approach. The study included 46 patients. The main clinical sign is a persistent pain syndrome of the cervico-occipital localization that affects the shoulder girdle, suprascapular and infrascapular regions and spreads to the arm in combination with trophic, sensory and vascular disorders. SCT angiography of the superior thoracic outlet structures has been used as a priority instrumental method of research. The macro- and micro factors of compression are the main cause for the development of neurological symptoms, and their removal is the main task of surgical treatment. Surgical approaches were planned depending on the nature and extent of injury. 36 patients underwent 42 surgical interventions. The proper assessment of the neurological status in combination with modern paraclinical diagnostic methods and selection of an adequate surgical approach provided satisfactory outcomes in 33 cases.

Brachial Plexus Involvement of Myeloid Sarcoma Detected by Reconstruction Magnetic Resonance Neurography

Myeloid sarcoma is a rare hematological disorder that presents as an extramedullary mass of immature myeloid precursors. We herein present the case of a 57-year-old man with a seven-month history of progressive weakness in the right upper extremity. Reconstruction magnetic resonance neurography showed a marked enlargement of the right brachial plexus. Fluorodeoxyglucose positron emission tomography revealed a radioactive lesion in the sacrum, in addition to the right brachial plexus, and a biopsy of the sacrum revealed myeloid sarcoma. The brachial plexus lesion was also regarded as myeloid sarcoma because of the treatment response. Isolated myeloid sarcoma involving the brachial plexus is very rare and its diagnosis is difficult as there was neither a history of leukemia nor bone marrow involvement in this patient. In this case, reconstructed magnetic resonance neurography was useful for detecting the brachial plexus mass lesion which led to an early diagnosis and good recovery.

[Faciobrachial dystonic seizures. Semiologic diagnosis in limbic encephalitis]

Limbic encephalitis (LE) associated with positive potassium channel complex antibodies often manifests with faciobrachial dystonic seizures (FBDS). We retrospectively analyze two cases, admitted to our video-EEG unit between 2006 and 2014. Both patients were males, aged 66 and 76 years respectively, presenting with brief, but very frequent uni/bilateral dystonic brachial movements, hand posturing and ipsilateral facial grimacing. Severe hyponatremia was found in both patients who went on to develop cognitive impairment. Immunosuppressive therapy improved both seizures and cognitive dysfunction. Serology testing confirmed anti VGKC antibody presence. FBDS are often the first manifestation of LE associated to positive anti VGKC antibodies, and are refractory to treatment with antiepileptic drugs. Early diagnosis and treatment of FBDS with immunosuppressive therapy is important, not only because of seizure suppression, but also because it may help limit the extent of the cognitive damage.

Dosimetric benefits of placing dose constraints on the brachial plexus in patients with nasopharyngeal carcinoma receiving intensity-modulated radiation therapy: a comparative study

This study aimed to evaluate whether placing dose constraints on the brachial plexus (BP) could provide dosimetric benefits in patients with nasopharyngeal carcinoma (NPC) undergoing intensity-modulated radiation therapy (IMRT). Planning CT images for 30 patients with NPC treated with definitive IMRT were retrospectively reviewed. Target volumes, the BP and other critical structures were delineated; two separate IMRT plans were designed for each patient: one set no restrictions for the BP; the other considered the BP as a critical structure for which a maximum dose limit of ≤66 Gy was set. No significant differences between the two plans were observed in the conformity index, homogeneity index, maximum dose to the planning target volumes (PTVs), minimum dose to the PTVs, percentages of the volume of the PTVnx and PTVnd receiving more than 110% of the prescribed dose, or percentages of the volume of the PTVs receiving 95% and > 93% of the prescribed dose. Dose constraints significantly reduced the maximum dose, mean dose, V45, V50, V54, V60, V66 and V70 to the BP. Dose constraints significantly reduced the maximum dose to the BP, V45, V60 and V66 in both N0-1 and N2-3 disease; however, the magnitude of the dosimetric gain for each parameter between N0-1 and N2-3 disease was not significantly different, except for the V60 and V66. In conclusion, placing dose constraints on the BP can significantly decrease the irradiated volume and dose, without compromising adequate dose delivery to the target volume.

[Brachial plexopathy after breast cancer]

Neoplastic plexopathy is an unusual, but known cause of neuropathy. This is a case report of a patient, who developed brachial plexopathy years after completing treatment for breast cancer. The patient presented with pain in one arm and, subsequently, developed sensory deficits and muscle atrophy, resulting in severely impaired hand function. Repeated magnetic resonance imaging and positron emission tomography scans were necessary before the final diagnosis could be made. The case report illustrates the importance of a thorough and repeated diagnostic work-up, when metastatic cancer is a perhaps unlikely but possible cause of plexopathy.

[Topical pharmacologic approach with 5% lidocaine medicated plaster in the treatment of localized neuropathic pain]

The treatment of neuropathic pain is a medical challenge. The responsiveness to the different classes of drugs is often unsatisfactory and frequently associated to a wide range of side effects. International guidelines suggest for the "localized" neuropathic pain the topical treatment with 5% lidocaine medicated plaster, alone or associated to systemic drugs, as the first choice since its favorable efficacy and tolerability profile. Many clinical experiences support the rationale for using 5% lidocaine medicated plaster in different kinds of localized neuropathic pain, such as postherpetic and trigeminal neuralgia, compressive syndromes, painful diabetic polyneuropathy and pain secondary to trauma or surgical interventions. This paper reports a series of clinical cases whose heterogeneity suggests the wide burden of applicability of the topical 5% lidocaine, either alone and associated to systemic drugs. All the described conditions were characterized by a highly intense pain, not adequately controlled by actual medications, which improved after the use of topical lidocaine. The good response to lidocaine allowed the reduction, of even the withdrawal, of concurrent drugs and improved the patients' quality of life.