Brachial plexus injury following median sternotomy

OBJECTIVES

Brachial plexus injury is a rare complication after median sternotomy. We investigated that injury to the brachial plexus was retrospectively assessed in the results of three patients who underwent median sternotomy for open heart surgery.

MATERIALS AND METHODS

All patients were placed in the hands-up position after right internal jugular vein cannulation, and the internal mammary artery was prepared for all of those. Nerve conduction measurements and electromyography were performed besides neurological examination.

RESULTS

Brachial plexus injury was detected in three cases (0.5%) of 575 patients who underwent coronary artery bypass grafting with median sternotomy. The main symptoms were continuous pain, and motor and sensory disturbances at the affected upper extremity (left arm in all cases). The common feature was that in all cases the left internal mammary artery was harvested. While the symptoms were relieved in two patients about six months after the operation, the other one had intractable pain and paresthesia.

CONCLUSION

The most important measure is careful sternal retraction and use of the hands-up position for the low incidence and benign course of brachial plexus problems. Inappropriate sternal retraction during preparation of internal mammary artery should be avoided.

Restoration of shoulder function with nerve transfers in traumatic brachial plexus palsy patients

Shoulder stabilization is of utmost importance in upper extremity reanimation following paralysis from devastating injuries. Although secondary procedures such as tendon and muscle transfers have been used, they never achieve a functional recovery comparable to that following successful reinnervation of the supraspinatus, deltoid, teres minor, and infraspinatus muscles. Early restoration of suprascapular and axillary nerve function through timely brachial plexus reconstruction offers a good opportunity to restore shoulder-joint stability, adequate shoulder abduction, and external rotation function. Overall, in our series, 79% of patients achieved good and excellent shoulder abduction (muscle grade, +3 or more), and 55% of patients achieved good or excellent shoulder external rotation after reinnervation of the suprascapular nerve. The best results were seen when direct neurotization of the suprascapular nerve from the distal spinal accessory nerve or neurotization by the C5 root was carried out. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction and external rotation function.

Upper limb tremor induced by peripheral nerve injury

We report a patient with proximal right upper limb tremor, secondary to direct peripheral nerve lesion caused by prior thoracic surgery. Electromyography demonstrated neurogenic abnormalities and tremor in muscles innervated by the thoracodorsal and long thoracic nerves. Somatosensory evoked potentials, transcranial magnetic stimulation, and MRI of the cervical and thoracic spine were normal. Tremor persisted in REM and non-REM sleep. These findings suggest a peripheral generator.

Radiation-induced brachial plexopathy and hypofractionated regimens in adjuvant irradiation of patients with breast cancer--a review

In order to increase the availability of adjuvant radiotherapy of breast cancer patients and make it more convenient and cheaper, in numerous cancer centres, the dose per fraction has been increased from 2 Gy to 2.25-2.75 Gy and the total dose has been decreased from 50 Gy to 40-45 Gy. The risk of developing any late complications after conventionally fractionated megavoltage radiotherapy is estimated to be below 1%. The aim of this review is to determine whether hypofractionated regimens increase the risk of damage to the brachial plexus. A review of the published literature shows that the use of doses per fraction in the range from 2.2 Gy to 4.58 Gy with the total doses between 43.5 Gy and 60 Gy causes a significant risk of brachial plexus injury which ranged from 1.7% up to 73%. The risk of radiation induced brachial plexopathy was smaller than 1% using regimens with doses per fraction between 2.2 and 2.5 Gy with the total doses between 34 and 40 Gy. Surgical manipulations in the axilla and chemotherapy have to be taken into account as additional factors which may increase the risk of brachial plexopathy.

Benign metastasizing leiomyomatosis with massive brachial plexus involvement mimicking neurofibromatosis type 1

We report the case of a patient who presented with right arm and shoulder pain due to compression of the infraclavicular brachial plexus due to benign metastasizing leiomyomatosis (BML). She was initially and had been repeatedly misdiagnosed as having neurofibromatosis type 1 (NF 1). The diagnosis of BML was not obvious due to its rare nature, the patient's not detailing the specifics of her gynecologic history of having undergone resection of a large uterine leiomyoma and followed by disseminated pelvic leiomyomatous nodules, histologic misinterpretation of an extrauterine lesion of the spine and the brachial plexus as a neurofibroma and the radiologic diagnosis of lung nodules as being "non-specific" in nature. In addition and importantly, no clinical, radiographic or histologic features of NF 1 were present. Although a rare condition, BML should be considered in the differential diagnosis of NF and in patients having a history of uterine leiomyoma. The remarkable, selective involvement of the brachial plexus in this case is unexplained.

Reliability of the V-scope system in the measurement of arm movement in children with obstetric brachial plexus palsy

This study reports on a novel methodology using the V-scope to quantify elbow and shoulder movement in young children with obstetric brachial plexus palsy (OBPP), and the intra- and interreliability of this method. The V-scope, a portable, inexpensive movement analysis system, was configured in an L-shape, with two transmitting towers placed on the floor and one 1.35m off the ground. These towers received ultrasonic pulses from buttons that were placed over standardized landmarks of the child's trunk, chest, and upper limb. Two physiotherapists (a paediatric and a generalist) facilitated the maximum range of active elbow flexion/extension and shoulder abduction/flexion in 30 children with OBPP (18 females, 12 males; age range 6mo-4y 7mo; mean age 2y 6mo [SD 1y 2mo]). Assessments were conducted on two occasions, one week apart. The V-scope was found to be feasible to use by a specialist and a generalist physiotherapist, demonstrating moderate to high reliability coefficients, small measurement errors, and lack of missing data. The pediatric physiotherapist was more reliable in measuring elbow and shoulder movement compared with the generalist physiotherapist, which suggests that the same experienced, pediatric physiotherapist should assess elbow and shoulder movement across all occasions of testing.

Accessory Nerve to Suprascapular Nerve Transfer to Restore Shoulder Exorotation in Otherwise Spontaneously Recovered Obstetric Brachial Plexus Lesions

OBJECTIVE:

A systematic follow-up of infants with an obstetric brachial plexus lesion of C5 and C6 or the superior trunk showing satisfactory spontaneous recovery of shoulder and arm function except for voluntary shoulder exorotation, who underwent an accessory to suprascapular nerve transfer to improve active shoulder exorotation, to evaluate for functional recovery, and to understand why other superior trunk functions spontaneously recover in contrast with exorotation.

METHODS:

In 54 children, an accessory to suprascapular nerve transfer was performed as a separate procedure at a mean age of 21.7 months. Follow-up examinations were conducted before and at 4, 8, 12, 24, and 36 months after operation and included scoring of shoulder exorotation and abduction. Intraoperative reactivity of spinatus muscles and additional needle electromyographic responses were registered after electrostimulation of suprascapular nerves. Histological examination of suprascapular nerves was performed. Trophy of spinatus muscles was followed by magnetic resonance imaging scanning. The influence of perinatal variables and results of ancillary investigations on outcome were evaluated.

RESULTS:

Exorotation improved from 70 degrees to functional levels exceeding 0 degrees, except in two patients. Abduction improved in 27 patients, with results of 90 degrees or more in 49 patients. Electromyography at 4 months did not show signs of denervation in 39 out of 40 patients. Intraoperative electrostimulation of suprascapular nerves elicited spinatus muscle reaction in 44 out of 48 patients. Histology of suprascapular nerves was normal. Preoperative magnetic resonance imaging scans showed only minor wasting of spinatus muscles in contrast with major wasting after successful operations.

CONCLUSION:

An accessory to suprascapular nerve transfer is effective to restore active exorotation when performed as the primary or a separate secondary procedure in children older than 10 months of age. Contradictory spontaneous recovery of other superior trunk functions and integrity of suprascapular nerves, as well as absence of spinatus muscle wasting direct to central nervous changes are possible main causes for the lack of exorotation.

Bilateral C5 motor paralysis following anterior cervical surgery—a case report

Numerous authors have reported C5 root palsies following posterior cervical surgery, and several mechanisms of injury have been proposed. Similar deficits after anterior cervical procedures are considered to occur less commonly. We report on a 48-year-old male who underwent multi-level anterior discectomy and fusion for cervical spondylotic myelopathy. Bilateral C5 nerve root deficits were noticed in the immediate postoperative period, and treated non-operatively. A postoperative magnetic resonance imaging (MRI) scan showed an increase in cervical lordosis accompanied by a posterior shifting of the spinal cord. Potential mechanisms of nerve root injury in this situation are discussed, and the literature on postoperative C5 root deficits is reviewed. The patient returned to his preoperative occupation as an operating room nurse 6 months following surgery, with complete neurologic recovery occurring over an 11-month period. C5 deficits following anterior cervical surgery occur more frequently than generally assumed. Improved lordosis and longitudinal lengthening of the cervical spinal column in multilevel anterior decompression and interbody fusion can paradoxically result in a traction injury to the spinal cord and C5 nerve roots.

Interobserver reliability of the Mallet score

The interobserver reliability of the Mallet score for active shoulder function was assessed by three experienced observers in a group of 30 children with an obstetric brachial plexus lesion (mean age 7.1 years, range 4.5-10 years). Interobserver reliability, measured using weighted kappa, was good. Kappa varied between 0.37 and 0.84 and differed between the different aspects of the Mallet score and different pairs of observers. In decreasing order, mean weighted kappa was 0.75 for abduction, 0.73 for hand to neck, 0.67 for hand to spine, 0.6 for external rotation and 0.53 for hand to mouth.

Brachial plexopathy due to malignant peripheral nerve sheath tumor in neurofibromatosis type 1: case report and subject review

Neurofibromatosis type 1 (NF1) is a common tumor predisposition syndrome affecting approximately 1 in 4,000 persons. It is an autosomal-dominant disorder with half of the cases resulting from spontaneous mutations. This genetic defect leads to the formation of benign tumors or neurofibromas of the peripheral nervous system. Dermal neurofibromas may cause local discomfort and itching but are rarely associated with neurological deficit and do not undergo malignant change. The more extensive plexiform neurofibromas produce neurological complications in 27%-43% of patients with NF1 and may undergo malignant degeneration in 5% of cases. Patients with NF1 who develop pain or new neurological symptoms should have a rapid and thorough assessment for malignancy. In this report, we illustrate this point by presenting a patient who developed acute shoulder pain and weakness due to malignant degeneration of a plexiform neurofibroma involving the left brachial plexus, and review the literature on this subject.

Dystrophic calcification and infraclavicular brachial plexopathy: case report

OBJECTIVE

Dystrophic calcification refers to heterotopic formation of calcium in soft tissue. There have been few reports that describe dystrophic calcification causing brachial plexopathies. We describe a unique case of dystrophic calcification that caused entrapment of the posterior cord of the brachial plexus, something not previously described in the literature.

CLINICAL PRESENTATION

We report the case of a 43-year-old woman with a medical history of congenital lymphangiomas of the left chest wall and axilla, for which she had undergone multiple surgeries and radioactive seed implantation. She presented 41 years later with progressive left arm paresthesias, pain, and weakness. Neurological findings were confined to the distribution of the posterior cord of the plexus. Radiographic evaluation demonstrated a 3 x 3 x 4-cm calcified mass in the axilla and proximal arm.

INTERVENTION

A careful neurolysis and mass resection was performed. At exploration, the posterior cord, proximal radial nerve, and brachial artery were found to be densely adherent to a calcified mass. Reconstruction of the brachial artery and free tissue transfer were required for healing of the severely scarred wound. Pathological examination revealed dense, calcified connective tissue consistent with dystrophic calcification. She made an excellent recovery.

CONCLUSION

We describe a rare case of dystrophic calcification of the proximal arm causing symptomatic brachial plexopathy, with onset many years after surgery and radiation. Diagnostic evaluation and surgical management are discussed.

A Retrospective Study of the Incidence of Neurological Injury after Axillary Brachial Plexus Block

BACKGROUND

It has been suggested that performing a nerve block under general anesthesia, as customary in pediatric population, may predispose to nerve injury. However, few clinical data exist to either support or refute this assertion.

METHODS

We retrospectively reviewed data on all patients who received an axillary block for upper extremity surgery in our institution during an eight-year period. The blocks were performed under sedation or general anesthesia, without using a nerve stimulator. Perioperative records from the Hand Surgery Unit Clinic were reviewed for postoperative complaints and complications.

RESULTS

In the eight-year period of the review, 336 patients had axillary block. In total, 230 received the block with sedation and 106 during general anesthesia. All the sedated patients were older than 14 years (mean age 45.2), while of the general anesthesia patients 48 were older than 14 years (mean age 13.9 years). There were six cases of postoperative nerve injury in sedated patients (2.6%) vs. eight cases (7.5%) in the general anesthesia patients. Most patients recovered fully within several weeks. One patient had permanent nerve injury.

CONCLUSIONS

Definitive conclusions cannot be drawn because of disparities in patient group demographics (majority of pediatric patients were in the general anesthesia group) and the retrospective nature of this study. Nevertheless, the findings suggest that the conduct of axillary block under general anesthesia in pediatric patients holds a greater potential for nerve injury than when the block is performed under sedation in adults.

The effect of derotational humeral osteotomy on global shoulder function in brachial plexus birth palsy

BACKGROUND

Derotational humeral osteotomies have been used in older children with brachial plexus birth palsy and glenohumeral joint deformity to place the upper extremity in a more functional position. The purpose of this study was to determine the effects of these procedures on shoulder function and joint morphology.

METHODS

Forty-three patients underwent a derotational humeral osteotomy for functional impairment in the setting of internal rotation contracture and/or glenohumeral joint deformity at our institution from 1996 to 2004. Osteotomies were performed proximal to the deltoid insertion and were stabilized with plate-and-screw fixation. The average age of the patients at the time of surgery was 7.6 years (range, 2.3 to 17.0 years). Shoulder function was graded according to the modified Mallet classification system. Glenohumeral deformity was graded according to the classification scheme of Waters et al. The results for twenty-seven patients who were followed for a minimum of two years (average, 3.7 years) are reported.

RESULTS

The average amount of external rotation achieved with osteotomy was 64 degrees (range, 35 degrees to 90 degrees). The mean aggregate Mallet classification score improved from 13 to 18 points (p < 0.01). The mean Mallet classification scores for the individual elements similarly demonstrated improvement following osteotomy, with the greatest gains in hand-to-mouth, hand-to-neck, and external rotation motions. The mean classification of the glenohumeral deformity was type IV preoperatively and postoperatively, signifying the persistence of glenohumeral dysplasia. There were no nonunions. One patient required a revision osteotomy for inadequate initial correction. One patient sustained a humeral fracture distal to the plate fixation because of sports-related trauma.

CONCLUSIONS

Derotational humeral osteotomy improves shoulder function in patients with brachial plexus birth palsy, internal rotation contracture, and/or advanced glenohumeral joint deformity. This osteotomy provides an attractive treatment option for patients with brachial plexus birth palsy who have advanced glenohumeral dysplasia precluding soft-tissue releases and tendon transfers.

Spinal injuries in contact sports

Contact and collision sports such as American football expose the athlete to a wide array of potential injuries. Knee injuries garner much of the attention, but spinal injuries are potentially catastrophic and all levels of medical coverage of football must be knowledgeable and prepared to attend to an athlete with a neck injury. Of the other possible spinal conditions, some resolve on their own, others might require conservative therapy, and still others might require surgical intervention. The spectrum of potential injury is wide, yet the medical team must practice and prepare to treat the possible catastrophic neck injury.

[Epidemiological study of the traumatic brachial plexus injuries in adults]

OBJECTIVE

This study aims to provide information about epidemiological factors related to traumatic brachial plexus injuries in adults.

METHOD

Prospective analysis of 35 consecutive cases, observed in a period of one year.

RESULTS

Most of the lesions were supraclavicular (62%). Twenty-one cases occurred due to traction (60%), 9 to gun shot wound (25%), 3 to compression (8.5%) and two perforation/laceration (5.7%). Motorcycle accidents were the cause of trauma in 54% of patients. CT myelography demonstrated root avulsion in 16 cases (76%). Partial spontaneous neurological recovery was observed in 43% of the patients. Neuropathic pain occurred in 25 (71%) cases, and the use of some oral intake drugs (as amitriptyline or carbamazepine) controlled it in 64% of times.

CONCLUSION

Traction is the most frequent mechanism related to brachial plexus injuries, and root avulsions are common in this cases. Pain and concomitant lesions are frequently observed in these group. In this series, the rate of incidence to the local population was 1.75/100000/year.

Medical and legal issues related to brachial plexus injuries in neonates

Injuries to the brachial plexus in neonates present a malpractice dilemma not only for physicians who provide obstetric care, but also for those who administer immediate postnatal treatment for newborns who have these injuries and comorbid medical conditions. Although trauma remains the probable etiology for many brachial plexus injuries, other, nontraumatic etiologies need to be considered. The authors review current medical and legal principles related to brachial plexus injuries-principles that are of concern to all practitioners who provide obstetric and newborn care. They also make a number of recommendations for practitioners to reduce the risk of malpractice lawsuits related to these injuries. Among these recommendations are increasing one's awareness of nontraumatic origins; making sure that appropriate testing (eg, electromyography) is performed for infants whose conditions fail to improve within several months after birth; and taking a proactive role in discussing brachial plexus injuries with patients' families.

Botulinum toxin as an adjunct to motor learning therapy and surgery for obstetrical brachial plexus injury

Following obstetrical brachial plexus injury, infants are unable to learn specific patterns of movement due to the disruption of neural pathways. Even with successful reinnervation (spontaneously or post surgical reconstruction), function can be suboptimal due to overactivity in antagonist muscles preventing movement of reinnervated muscles. Botulinum toxin type A (BTX-A) was used to temporarily weaken antagonistic muscles early in the reinnervation process following brachial plexus injury, with the aim of facilitating functional improvement. A case series of eight children (five females, three males; mean age 12.5mo [SD 6.43]; range 5-22mo) with significant muscle imbalances but evidence of reinnervation were given BTX-A injections into the triceps, pectoralis major, and/or latissimus dorsi muscles. After a single injection, all parents reported improvement in function. Active Movement Scale total score changed significantly between pre BTX-A and 1 month (p=0.014), and 4 months (p=0.022) post BTX-A injection. It is proposed that BTX-A facilitated motor learning through improved voluntary relaxation of antagonist muscles while allowing increased activity in reinnervated muscles.

Shoulder function following partial spinal accessory nerve transfer for brachial plexus birth injury

Over a 5-year-period, 26 infants underwent a partial transfer of the spinal accessory nerve into the suprascapular nerve using a nerve graft, as part of the repair of a brachial plexus birth injury. At a minimum follow-up of 2.5 years, all children had shoulder function of Grade 4 or better using a modified Gilbert Scale. Average lateral rotation was measured at 53 degrees.