Transcanal Transpromontorial Approaches to the Internal Auditory Canal: A Systematic Review

OBJECTIVE

Exclusive endoscopic (EETTA) and expanded (ExpTTA) transcanal transpromontorial approaches have shown promising results for treating internal auditory canal (IAC) lesions. We reviewed the literature to answer the question: "Do EETTA and ExpTTA achieve high rates of complete resection and low rates of complications in treating patients with IAC pathologies?"

DATA SOURCES

PubMed, EMBASE, Scopus, Web of Science, and Cochrane were searched.

REVIEW METHODS

Studies reporting EETTA/ExpTTA for IAC pathologies were included. Indications and techniques were discussed and meta-analyzed rates of outcomes and complications were obtained with random-effect model meta-analyses.

RESULTS

We included 16 studies comprising 173 patients, all with non-serviceable hearing. Baseline FN function was mostly House-Brackmann-I (96.5%; 95% CI: 94.9-98.1%). Most lesions were vestibular/cochlear schwannomas (98.3%; 95% CI: 96.7-99.8%) of Koos-I (45.9%; 95% CI: 41.3-50.3%) or II (47.1%; 95% CI: 43-51.1%). EETTA was performed in 101 patients (58.4%; 95% CI: 52.4-64.3%) and ExpTTA in 72 (41.6%; 95% CI: 35.6-47.6%), achieving gross-total resection in all cases. Transient complications occurred in 30 patients (17.3%; 95% CI: 13.9-20.5%), with meta-analyzed rates of 9% (95% CI: 4-15%), comprising FN palsy with spontaneous resolution (10.4%; 95% CI: 7.7-13.1%). Persistent complications occurred in 34 patients (19.6%; 95% CI: 17.1-22.2%), with meta-analyzed rates of 12% (95% CI: 7-19%), comprising persistent FN palsy in 22 patients (12.7%; 95% CI: 10.2-15.2%). Mean follow-up was 16 months (range, 1-69; 95% CI: 14.7-17.4). Post-surgery FN function was stable in 131 patients (75.8%; 95% CI: 72.1-79.5%), worsened in 38 (21.9%; 95% CI: 18.8-25%), and improved in 4 (2.3%; 95% CI: 0.7-3.9%), with meta-analyzed rates of improved/stable response of 84% (95% CI: 76-90%).

CONCLUSION

Transpromontorial approaches offer newer routes for IAC surgery, but their restricted indications and unfavorable FN outcomes currently limit their use. Laryngoscope, 133:2856-2867, 2023.

Implanted Electrodes for Functional Electrical Stimulation to Restore Upper and Lower Extremity Function: History and Future Directions

Functional electrical stimulation (FES) to activate nerves and muscles in paralyzed extremities has considerable promise to improve outcome after neurological disease or injury, especially in individuals who have upper motor nerve dysfunction due to central nervous system pathology. Because technology has improved, a wide variety of methods for providing electrical stimulation to create functional movements have been developed, including muscle stimulating electrodes, nerve stimulating electrodes, and hybrid constructs. However, in spite of decades of success in experimental settings with clear functional improvements for individuals with paralysis, the technology has not yet reached widespread clinical translation. In this review, we outline the history of FES techniques and approaches and describe future directions in evolution of the technology.

Postintubation Sedation Practices Within Multiple Emergency Departments Across a Large Pediatric Health Care Organization

OBJECTIVE

Children requiring rapid or standard sequence intubation are at risk of experiencing paralysis without adequate sedation when the duration of neuromuscular blockade exceeds the duration of sedation provided by the induction agent. The objective of this study was to evaluate the rate of appropriately timed postintubation sedation (PIS; defined as the administration of PIS before the clinical effects of the induction agent have dissipated) in patients requiring intubation across multiple emergency department/urgent care sites within a large pediatric health care organization.

METHODS

This retrospective cohort study included patients admitted to 1 of 6 affiliated pediatric emergency department or urgent care sites who were intubated with an induction agent and neuromuscular blocker between January 2016 and December 2021. Patients were excluded if they were intubated in the setting of status epilepticus or cardiac arrest. Stepwise logistic regression identified factors associated with appropriately timed PIS.

RESULTS

A total of 283 patients met the inclusion criteria (mean age, 8 ± 7.6 years; 56% male). Two hundred thirty-eight patients (83%) received some form of PIS (105 [37%] received appropriately timed PIS and 133 [47%] received delayed PIS), and 45 patients (16%) received no PIS. The median time to receive PIS following administration of the induction agent was 21 minutes (interquartile range, 11-40 minutes). Patients induced with fentanyl were the least likely to receive PIS, whereas patients induced with etomidate were the most likely. However, because of the short duration of etomidate, most patients induced with etomidate failed to receive PIS in a timely manner.

CONCLUSIONS

Delayed PIS is common and may result in periods of ongoing paralysis without adequate sedation. Emergency department providers and pharmacists must recognize the brevity of some induction agents and provide more timely PIS.

Grape juice reduces the effects of amyloid β aggregation phenotype and extends the longevity in Caenorhabditis elegans

OBJECTIVES

Alzheimer's disease (AD) is a neurodegenerative disorder characterized by the presence of aggregated amyloid-β (Aβ) peptides. Several natural compounds have been proposed against this disease and grape products are among these. However, little is known about grape juice potential. Transgenic Caenorhabditis elegans (C. elegans) strains that express human Aβ have been used as an in vivo model for AD.

METHODS

In this study, we have exposed CL2006 worms to nine different juices obtained from different cultivars.

RESULTS

Cora, Bordo, Isabel, Isabel Precoce, BRS-Magna, BRS-Rubea and BRS-Violeta juices improved the behavioral phenotype (paralysis) that is caused by Aβ aggregation in the transgenic animals at the concentrations tested and no toxic effects were found. Some juices were also able to increase the worm's lifespan. We could not attribute lifespan increase and paralysis reduction with any specific compound found in the phytochemical analysis.

DISCUSSION

Our data indicate that the rich constitution of the juices is responsible for attenuating the phenotype caused by Aβ aggregation in C. elegans.

Functional reconstruction of elbow flexion with latissimus dorsi muscle rotational transfer: two case reports

BACKGROUND

We report two cases of biceps brachii and brachialis paralysis due to musculocutaneous nerve injury in which elbow joint flexion was reconstructed using rotational transfer of the latissimus dorsi muscle with sutures to the radial and ulnar tuberosities, thereby enabling flexion by simultaneous activation of the humeroradial and humeroulnar joints. In cases of associated brachialis paralysis, weaker flexion strength can be expected when the forearm is in a pronated position than when it is in a supinated state. To the best of our knowledge, no previous study has reported the rotational position of the forearm during elbow joint flexion reconstruction.

CASE PRESENTATION

Case 1 involved a 30-year-old Asian male who presented with a rupture of the musculocutaneous, median, radial, and ulnar nerves. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, the supination and pronation flexion forces were equal. Case 2 involved a 50-year-old Asian man who presented with partial loss of the musculocutaneous nerve, biceps brachii, and pectoralis major due to debridement. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, supination and pronation flexion strengths were demonstrated to be equal. Our reconstruction method used the rotational transfer of the latissimus dorsi muscle; the distal muscle flap was divided into radial and ulnar sides to allow elbow joint flexion by simultaneously activating the humeroradial and humeroulnar joints. These sides were then fixed to the anchors at the radial and ulnar tuberosities. Finally, they were wrapped around the myotendinous junction of the biceps brachii or brachialis and secured using sutures.

CONCLUSIONS

Although larger studies are required to verify these methods, this case study successfully demonstrates the following: (1) the flexion strength in the supinated position was equal to that in the pronated position; (2) the stability of the humeroradial and humeroulnar joints was unaffected by the forearm's rotational position; and (3) a satisfactory range of motion of the elbow joint was obtained, with no complications.

An interesting case of crossed syndrome: ipsilateral facial paralysis with contralateral glossoplegia

BACKGROUND

Stroke is rarely accompanied with peripheral facial paralysis and supranuclear palsy of the hypoglossal nerve. Both sides of the motor cortex innervate the hypoglossal nucleus; therefore, unilateral lesions of the upper motor neurons rarely result in contralateral lingual paresis. We report a rare case of crossed syndrome with associated hyperacute peripheral hemifacial paralysis and contralateral lingual paresis after a lower pontine tegmentum ischemic stroke.

CASE PRESENTATION

A 73-year-old man presented with symptoms of hyperacute peripheral hemifacial paralysis. Upon protrusion, the patient's tongue deviated to the contralateral side, without fasciculation or atrophy. Brain imaging showed focal ischemic stroke in the pontine tegmentum. However, lingual hemiparesis and multimodal neuroimaging findings differed.

CONCLUSIONS

We suggest that cortico-hypoglossal fibers pass through the dorsal pontine. This case of crossed syndrome is a rare report of a lower pontine tegmentum ischemic stroke resembling an upper motor neuron lesion of the contralateral hypoglossal nerve.

Reconstruction of complicated spinal tuberculosis with long-segment fibula transplantation: a case report

BACKGROUND

Treating complex cases of spinal tuberculosis (STB) that involve multiple vertebral bodies and cause destruction of the spinal structure, kyphotic deformity, and acute nerve injury can be challenging. This report describes the course of treatment and 5-year follow-up of a complex case of multisegmental STB.

CASE PRESENTATION

This report describes a case of tuberculosis affecting the vertebrae extending from thoracic 12 to lumbar 5 in a 60-year-old woman who suffered sudden paralysis in both lower extremities. The patient underwent emergency posterior paraspinal abscess clearance, laminectomy with spinal decompression. Partial correction of the kyphotic deformity via long-segment fixation from the T9 vertebral body to the ilium in a one-stage posterior procedure. The patient's neurological status was diagnosed as grade E on the American Spinal Injury Association (ASIA) scale after the one-stage operation. Following standardized 4-combination anti-tuberculosis drug therapy for three months in postoperative patients, the patient underwent two-stage transabdominal anterior abscess removal, partial debridement of the lesion and bilateral fibula graft support. One year after the two-stage operation, the patient's visual analog scale (VAS) score of back pain was 1 point, and the patient's erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels returned to normal. Five years after the second-stage operation, the Oswestry disability index (ODI) of patient quality of life was 14 points. There was a 4-degree change in the Cobb angle over five years. During the five-year follow-up period, the grafted fibula did not experience any subsidence.

CONCLUSION

For patients with spinal tuberculosis and acute paralysis, it is essential to relieve spinal cord compression as soon as possible to recover spinal cord function. For lesions that cannot be debrided entirely, although limited debridement combined with anti-tuberculosis drug therapy has the risk of sinus formation and tuberculosis recurrence, it is much safer than the risk of thorough debridement surgery. In this case, an unconventional long-segment fibula graft, pelvis-vertebral support, was an effective reconstruction method.

SGMS2 in primary osteoporosis with facial nerve palsy

Pathogenic heterozygous variants in SGMS2 cause a rare monogenic form of osteoporosis known as calvarial doughnut lesions with bone fragility (CDL). The clinical presentations of SGMS2-related bone pathology range from childhood-onset osteoporosis with low bone mineral density and sclerotic doughnut-shaped lesions in the skull to a severe spondylometaphyseal dysplasia with neonatal fractures, long-bone deformities, and short stature. In addition, neurological manifestations occur in some patients. SGMS2 encodes sphingomyelin synthase 2 (SMS2), an enzyme involved in the production of sphingomyelin (SM). This review describes the biochemical structure of SM, SM metabolism, and their molecular actions in skeletal and neural tissue. We postulate how disrupted SM gradient can influence bone formation and how animal models may facilitate a better understanding of SGMS2-related osteoporosis.

Effects of cold storage after cold acclimation on the fitness of Habrobracon hebetor (Hymenoptera: Braconidae)

Habrobracon hebetor (Say) (Hymenoptera: Braconidae) is a cosmopolitan, idiobiont, and gregarious ectoparasitoid, which can parasitize the larvae of several pyralid and noctuid moths. However, adult parasitoids require cold storage to ensure that adequate individuals are available when a pest outbreak occurs. To understand the effects of cold storage after acclimation on offspring fitness of H. hebetor, the development, fecundity, population parameters, and paralysis rate of the F1 generation were evaluated using an age-stage, two-sex life table. Four pairing treatments were used in this study, with refrigerated males and females (ReF×ReM), unrefrigerated females and refrigerated males (UnF×ReM), refrigerated females and unrefrigerated males (ReF×UnM), and unrefrigerated females and males (UnF×UnM, control). Cold storage after acclimation had no significant effect on the fecundity or oviposition period of F0-generation H. hebetor. Moreover, the survival rate (Sa = 61.43%), proportion of females (Nf/N = 0.41), intrinsic rate of increase (r = 0.3450), finite rate of increase (λ = 1.4121), net reproduction rate (R0 = 149.47), and net paralysis rate (C0 = 74.52) of ReF×UnM and UnF×UnM (Sa = 50.00%, Nf/N = 0.34, r = 0.3297, λ = 1.3881, R0 = 155.69, C0 = 62.90, respectively) treatments were significantly higher than those of the ReF×ReM treatment (Sa = 45%, Nf/N = 0.16, r = 0.2277, λ = 1.2558, R0 = 68.81, C0 = 31.61, respectively) (except for the Sa of UnF×UnM treatment), and there was no significant difference between the 2 treatments. Overall, it is advisable to avoid simultaneous cold storage of female and male parasitoids or to add unrefrigerated males appropriately when using cold-stored parasitoids to control pests.

Whole-Genome Sequence and Pathogenicity Analysis of Providencia Heimbachae Causing Diarrhea in Weaned Piglets

Providencia heimbachae was previously identified in piglets with post-weaned diarrhea and associated with hindlimb paralysis. However, the pathogenic mechanisms and virulence factors of P. heimbachae are not fully known. Whole-genome sequence analysis will be helpful to extend our understanding of the characterization of P. heimbachae at a genomic level. In this study, we sequenced the whole genome of P. heimbachae for the first time using PacBio RS II sequencers and assembled de novo through hierarchical genome assembly process (HGAP). Furthermore, we performed further genome annotation. The genome of P. heimbachae 99101 consists of a circular chromosome (4,262,828 bp) and a circular plasmid (231,957 bp) with G + C contents of 40.43 and 47.16%, respectively. Genome-wide sequence analysis yielded a total of 286 predicted virulence factors, 178 resistance genes, 17 chaperone protein manipulators of fimbriae, 47 genes involved in the encoding of flagellin, 12 cell membrane-associated virulence genes, 18 Enterobacteriaceae common antigens, etc. Based on genome analysis, we preliminarily confirmed through animal experiments that the capsule was the virulence factor of P. heimbachae causing hindlimb paralysis in animals. Our study provides a genetic basis for further elucidation of the characteristics and functional mechanisms of P. heimbachae as a conditionally pathogenic bacterium, as well as a direction for research into the mechanism of action of P. heimbachae infecting humans, extending knowledge of P. heimbachae as an important zoonotic pathogen.

Persisting facial nerve palsy or trigeminal neuralgia - red flags for perineural spread of head and neck cutaneous squamous cell carcinoma (HNcSCC)

BACKGROUND

Perineural spread (PNS) of head and neck cutaneous squamous cell carcinoma (HNcSCC) is a unique diagnostic challenge, presenting with insidious trigeminal (CN V) or facial nerve (CN VII) neuropathies without clinically discernible primary masses. These patients are often sub-optimally investigated and misdiagnosed as Bell's palsy or trigeminal neuralgia. This case series highlights the red flags in history and pitfalls that lead to delays to diagnosis and treatment.

METHODS

A retrospective case series of 19 consecutive patients with complete clinical histories with HNcSCC PNS without an obvious cutaneous primary lesion at time of presentation to a quaternary head and neck centre in Australia were identified and included for analysis.

RESULTS

Fifteen had CN VII PNS, 17 had CN V PNS, and 13 had both. The overall median symptom-to-diagnosis time was 12-months (IQR-15 months). Eight patients had CN VII PNS and described progressive segmental facial nerve palsy with a median symptom-to-diagnosis time of 9-months (IQR-11.75 months). Eleven patients had primary CN V PNS and described well localized parathesia, formication or neuralgia with a median symptom-to-diagnosis time of 19-months (IQR 27.5 months).

CONCLUSION

PNS is often mistaken for benign cranial nerve dysfunction with delays in diagnosis worsening prognosis. Red flags such as progressive CN VII palsy or persistent CN V paraesthesia, numbness, formication or pain, particularly in the presence of immuno-compromise and/or a history of facial actinopathy should raise suspicion for PNS. Gadolinium-enhanced MR Neurography should be obtained expediently in patients with persistent/progressive CN V/CN VII palsies in patients with red flags, with low threshold for referral to a Head and Neck Surgeon.

Birth injury in breech delivery: a nationwide population-based cohort study in Finland

PURPOSE

Previous studies have examined the optimal mode of breech delivery extensively, but there is a scarcity of publications focusing on the birth injuries of neonates born in breech presentation. This study aimed to examine birth injury in breech deliveries.

METHODS

In this retrospective register-based nationwide cohort study, data on birth injuries in vaginal breech deliveries with singleton live births were compared to cesarean section with breech presentation and cephalic vaginal delivery between 2004 and 2017 in Finland. The data were retrieved from the National Medical Birth Register. Primary outcome variables were severe and mild birth injury. Incidences of birth injuries in different gestational ages and birthweights were calculated in different modes of delivery. Crude odds ratios of risk factors for severe birth injury were analyzed.

RESULTS

In vaginal breech delivery (n = 4344), there were 0.8% of neonates with severe birth injury and 1.5% of neonates with mild birth injury compared to 0.06% and 0.2% in breech cesarean section (n = 16,979) and 0.3% and 1.9% in cephalic vaginal delivery (n = 629,182). Brachial plexus palsy was the most common type of injury in vaginal breech delivery. Increasing gestational age and birthweight had a stronger effect on the risk for injury among cephalic vaginal deliveries than among vaginal breech deliveries.

CONCLUSION

Birth injuries were rare in vaginal breech deliveries. The incidence of severe birth injury was two times higher in vaginal breech delivery compared to cephalic vaginal delivery. Brachial plexus palsy was the most common type of injury in vaginal breech delivery.

Is mirror therapy combined with a routine physiotherapy protocol effective for children with obstetrical upper brachial plexus palsy?

STUDY DESIGN

Randomized controlled study.

INTRODUCTION

Mirror therapy is a rehabilitation strategy based on the repeated use of the mirror illusion and also one of the treatment choice of brachial plexus injuries.

PURPOSE

We aimed to determine the effects of mirror therapy combined with a routine rehabilitation program on upper limb motor function in children with obstetric brachial plexus injury.

METHODS

Twenty children with obstetric brachial palsy were included in this study. They were randomly allocated to either control (n = 10) or mirror therapy (n = 10) group. The following clinical tools were used to assess the upper extremity function: Active Movement Scale (AMS), Modified Mallet Scale (MMS), Hand Grip Strength (HGS) Test, Finger Grip Strength (FGSM) Test, Box and Block Test (BBT), Nine Hole Peg Test (9-HPT), and goniometric measurement. Both groups received the same routine physiotherapy program for 8 weeks. The study group underwent mirror therapy in addition to the rehabilitation program.

RESULTS

The mean age of the study population was 11.35 ± 4.12 years. There was no change in the goniometric values, AMS and MMS scores after the treatment in both groups (p > 0.05), except for the improvement of the wrist extension in the study group (p < 0.05). There was an increase in both HGS and FGS scores in the study group. Only FGS scores improved in the control group after the intervention (p < 0.05). 9-HPT and BBT scores improved in both groups (p < 0.05). All other parameters tested were comparable between the two groups after the treatment.

CONCLUSIONS

The results of this study did not show any additional benefits of mirror therapy combined with a rehabilitation protocol compared to routine physiotherapy treatment, but was not adequately powered to do so.

Arthroscopic Reduction and Internal Fixation in Patients with Acetabular Posterior Wall Fractures

Background

This study aimed to access the radiologic and clinical outcomes after arthroscopic reduction and internal fixation with screws in patients with posterior wall fractures of the acetabulum.

Methods

From May 2013 to December 2019, 13 patients (11 men and 2 women) with posterior wall fractures of the acetabulum were treated with arthroscopic reduction and internal fixation with screws at two medical centers. The mean age at the index operation was 39 years (range, 22-58 years). The mean duration of follow-up was 23 months (range, 12-46 months). Clinical assessment was performed using the modified Merle d'Aubigné and Postel functional scoring system. The maximum displacement of acetabular or femoral head fragments detected on radiographs was used as radiographic results. Secondary osteoarthritis, osteonecrosis, or heterotrophic ossification was assessed at the latest follow-up.

Results

Bony union was shown at 12 weeks of follow-up in all patients. The radiologic outcomes showed an anatomical reduction in 11 patients and a satisfactory reduction in 2 patients. The modified Merle d'Aubigné and Postel functional score was excellent in 7 patients, good in 5 patients, and fair in 1 patient. Two patients had transient pudendal nerve palsy after hip arthroscopy. However, no sciatic nerve palsy occurred. At the latest follow-up, there was no heterotopic ossification, osteonecrosis of the femoral head, or posttraumatic osteoarthritis.

Conclusions

Arthroscopic reduction and internal fixation with cannulated screws can be good alternative options with good radiographic and clinical outcomes, convenient removal of intra-articular loose body, and low complication rates.

Characterization and Localization of Sol g 2.1 Protein from Solenopsis geminata Fire Ant Venom in the Central Nervous System of Injected Crickets (Acheta domestica)

Solenopsis geminata is recognized for containing the allergenic proteins Sol g 1, 2, 3, and 4 in its venom. Remarkably, Sol g 2.1 exhibits hydrophobic binding and has a high sequence identity (83.05%) with Sol i 2 from S. invicta. Notably, Sol g 2.1 acts as a mediator, causing paralysis in crickets. Given its structural resemblance and biological function, Sol g 2.1 may play a key role in transporting hydrophobic potent compounds, which induce paralysis by releasing the compounds through the insect's nervous system. To investigate this further, we constructed and characterized the recombinant Sol g 2.1 protein (rSol g 2.1), identified with LC-MS/MS. Circular dichroism spectroscopy was performed to reveal the structural features of the rSol g 2.1 protein. Furthermore, after treating crickets with S. geminata venom, immunofluorescence and immunoblotting results revealed that the Sol g 2.1 protein primarily localizes to the neuronal cell membrane of the brain and thoracic ganglia, with distribution areas related to octopaminergic neuron cell patterns. Based on protein-protein interaction predictions, we found that the Sol g 2.1 protein can interact with octopamine receptors (OctRs) in neuronal cell membranes, potentially mediating Sol g 2.1's localization within cricket central nervous systems. Here, we suggest that Sol g 2.1 may enhance paralysis in crickets by acting as carriers of active molecules and releasing them onto target cells through pH gradients. Future research should explore the binding properties of Sol g 2.1 with ligands, considering its potential as a transporter for active molecules targeting pest nervous systems, offering innovative pest control prospects.

High degree of consensus on diagnosis and management of rotator cuff tears: a Delphi approach

PURPOSE

To develop a consensus on diagnosis and treatment of rotator cuff tears. The study focused on selected areas: imaging, prognostic factors, treatment options, surgical techniques.

METHODS

Panel was composed of all members of the shoulder committee of the Italian Society of Arthroscopy, Knee, Upper arm, Sport, Cartilage and Orthopedic techniques (SIAGASCOT). Four rounds were performed. The first round consisted of gathering questions which were then divided into seven blocks referring to: imaging, patient-related prognostic factors, treatment options, surgical steps, reparative techniques, surgical predictive factors, advanced techniques. Subsequent rounds consisted of condensation by means of online questionnaire and debates. Consensus was defined as two-thirds agreement on one answer. Descriptive statistic was used to summarize the data.

RESULTS

Forty-one shoulder experts were involved. Fifty-six statements were finally formulated. A consensus could be achieved on 51. Experts agreed that preoperative magnetic resonance imaging is strongly recommended because it allows a careful evaluation of tear characteristics, while the role of US remains debatable. Controversial patient-related factors such as age, comorbidities, smoking and stiffness do not contraindicate the repair. From a surgical standpoint, the experts highlighted that pseudo-paralysis is not a contraindication to rotator cuff repair. Consensus on specific surgical steps was also achieved: capsular release should be performed only in stiff shoulders; footprint preparation is mandatory, while debridement of tendon edges is not essential. If necessary, a rotator interval release could be performed without interrupting the continuity between subscapularis and supraspinatus tendon; posterior delamination should be always included in the repair. Advanced techniques such as tendon transfers should be selected based on the main clinical deficit, while the superior capsule reconstruction plays a role only in combination with a functional repair.

CONCLUSION

A consensus was achieved almost on every topic of controversy explored. Particularly, MRI was deemed necessary to determine tear characteristics, while radiographs remain important for differential diagnosis; age should not be considered a contraindication to surgery; pseudo-paralysis does not represent a contraindication to arthroscopic rotator cuff repair, but superior capsule reconstruction plays a role only in combination with a functional repair. Latissimus dorsi transfer plays a role when the main functional deficit is in elevation, while the lower trapezius transfer plays a role when the main functional deficit is the external-rotation.

LEVEL OF EVIDENCE

V.

Royle's sympathectomy for spastic paralysis: Sorry saga or scientific awakening?

On October 20, 1924, at the Waldorf-Astoria Hotel in New York City, two medical graduates of the University of Sydney delivered the John B. Murphy Oration to the American College of Surgeons on the topic of sympathetic ramisection for the treatment of spastic paralysis. The surgery was regarded as a triumph. The triumph, however, was short-lived, when one of the speakers, John Irvine Hunter, a promising anatomist, died prematurely. Norman Royle, an orthopedic surgeon, continued the research program and continued to perform these operations. Within a few short years, however, the theory of the dual nerve supply of skeletal muscle, which underpinned the procedure, and the results of surgery for spastic paralysis came under question. Nevertheless, Royle's sympathectomy found another indication and became the treatment of choice for peripheral vascular disease for several decades thereafter. Although Hunter and Royle's original work was discredited, their research turned their sorry saga into a scientific awakening of the sympathetic nervous system.

Highly pathogenic avian influenza (H5N1) infection in crows through ingestion of infected crow carcasses

The present study was aimed to investigate the role of cannibalism in transmission of H5N1 avian influenza virus to house crows (Corvus splendens). Four crows were intranasally inoculated with 108.0 EID50 (A/crow/India/01CA249/2021) H5N1 highly pathogenic avian influenza (HPAI) virus and were observed for 14 days for any overt signs of illness. Two of the infected crows showed signs of wing paralysis, incoordination, and torticollis. For cannibalism experiment, two crows showing clinical signs were euthanized on 14th day post-infection (dpi) and were kept in the isolator and four naïve healthy crows were introduced along with the euthanized crows. The viscera from the infected carcasses were eaten by all the four crows. Oropharyngeal and cloacal swabs were collected up to 14 days to assess virus excretion. All four crows showed clinical signs viz., dullness, reluctance to move with ruffled feathers on 6th day post cannibalism along with neurological signs including incoordination and paralysis of the wings. All the crows gradually recovered after showing clinical signs and were euthanized on 21st day of observation period. Virus excretion was observed from 3rd to 11th day post cannibalism through both oropharyngeal and cloacal routes with maximum shedding through oropharyngeal route. The virus was isolated from lungs and trachea of one the infected crows at 21st day after euthanasia. All the four crows seroconverted against H5N1 virus infection at 14th day post cannibalism. Our study confirms the transmission of H5N1 virus in crows through cannibalism and highlights how H5N1 virus might circulate in a crow colony once they become infected.

Shoulder extension impairment with residual neonatal brachial plexus injury

BACKGROUND

Impairment of both shoulder extension and behind-the-back function are common in patients with residual neonatal brachial plexus injury (NBPI), but have scarcely been studied or reported in the literature. Behind-the-back function is classically evaluated using the hand-to-spine task used for the Mallet score. Angular measurements of shoulder extension with residual NBPI have generally been studied utilizing kinematic motion laboratories. To date, no validated clinical examination method for this has been described.

METHODS

Intraobserver and interobserver reliability analyses of 2 shoulder extension angles-passive glenohumeral extension (PGE) and active shoulder extension (ASE)-were performed. Afterwards, a retrospective clinical study was conducted on prospectively collected data on 245 children with residual BPI treated from January 2019 through August 2022. Demographic characteristics, level of palsy, previous surgical procedures, modified Mallet score, and bilateral PGE and ASE data were analyzed.

RESULTS

All inter- and intraobserver agreements were excellent, ranging from 0.82 to 0.86. The median patient age was 8.1 years (3.5-21). Among the 245 children, 57.6% had Erb's palsy, 28.6% extended Erb's palsy, and 13.9% global palsy. One hundred sixty-eight (66%) of the children could not touch their lumbar spine, among whom 26.2% (n = 44) had to swing the arm to reach it. Both the degrees of ASE and PGE achieved correlation significantly with the hand-to-spine score, the ASE strongly (r = 0.705) and the PGE weakly (r = 0.372) (both P < .0001). Significant correlations also were found between lesion level and the hand-to-spine Mallet score (r = -0.339; P < .0001) and ASE (r = -0.299; P < .0001), and between patient age and the PGE (P = .0416, r = -0.130). A statistically significant decrease in PGE and incapacity to reach the spine were found in patients who underwent glenohumeral reduction, shoulder tendon transfer, or humeral osteotomy, relative to those who had microsurgery or no surgery. Receiver operating curves showed that, for both PGE and ASE, the minimum extension angle required to successfully perform the hand-to-spine task was 10°, with sensitivity levels of 69.9 and 82.2, and specificity levels of 69.5 and 87.8 (both P < .0001), respectively.

CONCLUSIONS

Glenohumeral flexion contracture and lost ASE are extremely common in children with residual NBPI. Both the PGE and ASE angles can be measured reliably with a clinical exam, with at least 10° of PGE and ASE necessary to perform the hand-to-spine Mallet task.

Muscle MRI in periodic paralysis shows myopathy is common and correlates with intramuscular fat accumulation

INTRODUCTION/AIMS

The periodic paralyses are muscle channelopathies: hypokalemic periodic paralysis (CACNA1S and SCN4A variants), hyperkalemic periodic paralysis (SCN4A variants), and Andersen-Tawil syndrome (KCNJ2). Both episodic weakness and disabling fixed weakness can occur. Little literature exists on magnetic resonance imaging (MRI) in muscle channelopathies. We undertake muscle MRI across all subsets of periodic paralysis and correlate with clinical features.

METHODS

A total of 45 participants and eight healthy controls were enrolled and underwent T1-weighted and short-tau-inversion-recovery (STIR) MRI imaging of leg muscles. Muscles were scored using the modified Mercuri Scale.

RESULTS

A total of 17 patients had CACNA1S variants, 16 SCN4A, and 12 KCNJ2. Thirty-one (69%) had weakness, and 9 (20%) required a gait-aid/wheelchair. A total of 78% of patients had intramuscular fat accumulation on MRI. Patients with SCN4A variants were most severely affected. In SCN4A, the anterior thigh and posterior calf were more affected, in contrast to the posterior thigh and posterior calf in KCNJ2. We identified a pattern of peri-tendinous STIR hyperintensity in nine patients. There were moderate correlations between Mercuri, STIR scores, and age. Intramuscular fat accumulation was seen in seven patients with no fixed weakness.

DISCUSSION

We demonstrate a significant burden of disease in patients with periodic paralyses. MRI intramuscular fat accumulation may be helpful in detecting early muscle involvement, particularly in those without fixed weakness. Longitudinal studies are needed to assess the role of muscle MRI in quantifying disease progression over time and as a potential biomarker in clinical trials.