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Leblebicioğlu G, Pondaag W. Brachial plexus birth injury: advances and controversies. J Hand Surg Eur Vol 2024; 49:747-757. [PMID: 38366382 DOI: 10.1177/17531934241231173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
While there is considerable spontaneous recovery in most cases of brachial plexus birth injury, many children are left with significant problems that may lead to lifelong functional limitations, loss of work and social isolation. Detailed treatment with the right strategy can provide very valuable improvement in function. Over the past few years, the clinical approach to brachial plexus birth palsy has entered a new era in both diagnostic and surgical treatment methods. This article reviews four areas of management, the role of imaging in defining the severity of the injury, the optimal timing of for nerve exploration and reconstruction in appropriate cases, the advantages and potential complications of nerve transfers, and the role of physiotherapy. Available evidence is considered. Although it is difficult to make clear and precise inferences on a subject where there are many variables and considerable uncertainties, some currently accepted views will be summarized.Level of evidence: V.
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Affiliation(s)
| | - Willem Pondaag
- Department of Neurosurgery/Leiden Nerve Center, Leiden University Medical Center, Leiden, The Netherlands
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Hannaford A, Paling E, Silsby M, Vincenten S, van Alfen N, Simon NG. Electrodiagnostic studies and new diagnostic modalities for evaluation of peripheral nerve disorders. Muscle Nerve 2024; 69:653-669. [PMID: 38433118 DOI: 10.1002/mus.28068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 03/05/2024]
Abstract
Electrodiagnostic studies (EDx) are frequently performed in the diagnostic evaluation of peripheral nerve disorders. There is increasing interest in the use of newer, alternative diagnostic modalities, in particular imaging, either to complement or replace established EDx protocols. However, the evidence to support this approach has not been expansively reviewed. In this paper, diagnostic performance data from studies of EDx and other diagnostic modalities in common peripheral nerve disorders have been analyzed and described, with a focus on radiculopathy, plexopathy, compressive neuropathies, and the important neuropathy subtypes of Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), vasculitic neuropathy and diabetic neuropathy. Overall EDx retains its place as a primary diagnostic modality in the evaluated peripheral nerve disorders. Magnetic resonance imaging and ultrasound have developed important complementary diagnostic roles in compressive and traumatic neuropathies and atypical CIDP, but their value is more limited in other neuropathy subtypes. Identification of hourglass constriction in nerves of patients with neuralgic amyotrophy may have therapeutic implications. Investigation of radiculopathy is confounded by poor correlation between clinical features and imaging findings and the lack of a diagnostic gold standard. There is a need to enhance the literature on the utility of these newer diagnostic modalities.
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Affiliation(s)
- Andrew Hannaford
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Elijah Paling
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Matthew Silsby
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sanne Vincenten
- Department of Neurology and Clinical Neurophysiology, Radboud University Medical Center, Donders Center for Neuroscience, Nijmegen, the Netherlands
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Radboud University Medical Center, Donders Center for Neuroscience, Nijmegen, the Netherlands
| | - Neil G Simon
- Northern Beaches Clinical School, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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Li H, Chen J, Wang J, Zhang T, Chen Z. Review of rehabilitation protocols for brachial plexus injury. Front Neurol 2023; 14:1084223. [PMID: 37139070 PMCID: PMC10150106 DOI: 10.3389/fneur.2023.1084223] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Brachial plexus injury (BPI) is one of the most serious peripheral nerve injuries, resulting in severe and persistent impairments of the upper limb and disability in adults and children alike. With the relatively mature early diagnosis and surgical technique of brachial plexus injury, the demand for rehabilitation treatment after brachial plexus injury is gradually increasing. Rehabilitation intervention can be beneficial to some extent during all stages of recovery, including the spontaneous recovery period, the postoperative period, and the sequelae period. However, due to the complex composition of the brachial plexus, location of injury, and the different causes, the treatment varies. A clear rehabilitation process has not been developed yet. Rehabilitation therapy that has been widely studied focusing on exercise therapy, sensory training, neuroelectromagnetic stimulation, neurotrophic factors, acupuncture and massage therapy, etc., while interventions like hydrotherapy, phototherapy, and neural stem cell therapy are less studied. In addition, rehabilitation methods in some special condition and group often neglected, such as postoperative edema, pain, and neonates. The purpose of this article is to explore the potential contributions of various methods to brachial plexus injury rehabilitation and to provide a concise overview of the interventions that have been shown to be beneficial. The key contribution of this article is to form relatively clear rehabilitation processes based on different periods and populations, which provides an important reference for the treatment of brachial plexus injuries.
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Portwood KE, Albayram MS, Stone S, Zingariello CD, Sladky JT, Chim H, Kang PB. Clinical, electrophysiological, and imaging findings in childhood brachial plexus injury. Dev Med Child Neurol 2022; 64:1254-1261. [PMID: 35524644 PMCID: PMC9544348 DOI: 10.1111/dmcn.15255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022]
Abstract
AIM To assess the prognostic capabilities of various diagnostic modalities for childhood brachial plexus injuries (BPIs) and brachial plexus birth injury (BPBI) and postneonatal BPI. METHOD In this single-center retrospective cross-sectional study, we examined children with BPIs diagnosed or confirmed by electrodiagnostic studies between 2013 and 2020, and compared the prognostic value of various components of the electrophysiologic findings, magnetic resonance imaging (MRI) data, and the Active Movement Scale (AMS). We developed scoring systems for electrodiagnostic studies and MRI findings, including various components of nerve conduction studies and electromyography (EMG) for electrodiagnostic studies. RESULTS We identified 21 children (10 females and 11 males) aged 8 days to 21 years (mean 8y 6.95mo) who had a total of 30 electrodiagnostic studies, 14 brachial plexus MRI studies, and 10 surgical procedures. Among the diagnostic modalities assessed, brachial plexus MRI scores, EMG denervation scores, and mean total EMG scores were the most valuable in predicting surgical versus non-surgical outcomes. Correspondingly, a combined MRI/mean total EMG score provided prognostic value. INTERPRETATION Brachial plexus MRI scores and specific electrodiagnostic scores provide the most accurate prognostic information for children with BPI. Our grading scales can assist a multidisciplinary team in quantifying results of these studies and determining prognosis in this setting. WHAT THIS PAPER ADDS A new scoring system to quantify results of electrodiagnostic and magnetic resonance imaging (MRI) studies is presented. Severity of denervation has good prognostic value for childhood brachial plexus injuries (BPIs). Composite electromyography scores have good prognostic value for childhood BPIs. Brachial plexus MRI has good prognostic value for childhood BPIs.
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Affiliation(s)
- Katherin E. Portwood
- Division of Pediatric Neurology, Department of PediatricsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Mehmet S. Albayram
- Department of RadiologyUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Sarah Stone
- Division of Pediatric Neurology, Department of PediatricsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Carla D. Zingariello
- Division of Pediatric Neurology, Department of PediatricsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - John T. Sladky
- Division of Pediatric Neurology, Department of PediatricsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Harvey Chim
- Division of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Peter B. Kang
- Division of Pediatric Neurology, Department of PediatricsUniversity of Florida College of MedicineGainesvilleFloridaUSA,Paul & Sheila Wellstone Muscular Dystrophy CenterUniversity of Minnesota Medical SchoolMinneapolisMinnesotaUnited States,Department of NeurologyUniversity of Minnesota Medical SchoolMinneapolisMinnesotaUnited States,Institute for Translational NeuroscienceUniversity of Minnesota Medical SchoolMinneapolisMinnesotaUSA
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Karakis I. Thumbs up for electrodiagnosis in neonatal brachial plexopathy. Muscle Nerve 2022; 66:3-5. [PMID: 35342970 DOI: 10.1002/mus.27538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
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Hearn SL, Pieper JR, Yang LJS, Chang KWC, Kratz AL. Implications of median sensory study to the thumb and deltoid/biceps motor unit recruitment on identifying C6 root avulsion in upper neonatal brachial plexus palsy. Muscle Nerve 2022; 66:24-30. [PMID: 35396858 DOI: 10.1002/mus.27550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 03/03/2022] [Accepted: 03/05/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION/AIMS Anatomic representation suggests that a median sensory nerve conduction study recording the thumb (median D1 NCS) may effectively assess upper neonatal brachial plexus palsy (NBPP). We sought to determine the feasibility of technique, establish reference data, and assess its ability to: (a) identify focal upper plexus lesions; and (b) identify C6 root avulsion. In a secondary analysis, we explored the association between absence/presence of motor unit action potentials (MUAPs) during needle electromyography (EMG) of the deltoid and biceps brachii muscles and C6 avulsion status. METHODS A retrospective chart review was performed of surgical patients with severe upper NBPP who ultimately underwent surgical reconstruction (between 2017 and 2020). Median D1 sensory nerve action potential (SNAP) amplitude ranges were determined in affected and contralateral limbs and analyzed by C6 root avulsion status. Also, presence/absence of MUAPs during EMG of the deltoid and biceps brachii was compared between C6 avulsion patients and controls. RESULTS Thirty-eight patients were included in our analysis. A median D1 NCS study was readily performed, showing a contralateral limb mean amplitude of 27.42 μV (range, 3.8-54.7 μV). Most patients had a low ipsilateral median D1 SNAP amplitude, regardless of C6 avulsion status. Detectable MUAPs in either deltoid or biceps brachii on EMG were atypical in C6 root avulsion. DISCUSSION The median D1 NCS identifies upper NBPP, but does not distinguish C6 avulsions from post-ganglionic lesions, likely due to the frequent co-occurrence of post-ganglionic axonal disruption. The presence of MUAPs on deltoid/biceps brachii EMG suggests C6 avulsion is unlikely.
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Affiliation(s)
- Sandra L Hearn
- Department of Physical Medicine & Rehabilitation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Joel R Pieper
- Department of Physical Medicine & Rehabilitation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Lynda J-S Yang
- Department of Neurological Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kate W-C Chang
- Department of Neurological Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Anna L Kratz
- Department of Physical Medicine & Rehabilitation, University of Michigan Medical School, Ann Arbor, Michigan
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Van der Looven R, Hermans L, Coupe AM, De Muynck M, Vingerhoets G. Neonatal brachial plexus palsy and hand representation in children and young adults. Dev Med Child Neurol 2022; 64:183-191. [PMID: 34405401 DOI: 10.1111/dmcn.15008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 11/27/2022]
Abstract
AIM To assess the impact of neonatal brachial plexus palsy (NBPP) on higher-order hand representation. METHOD Eighty-two left-handed children and adolescents with and without right-sided NBPP were recruited. Thirty-one participants with NBPP (mean age [SD] 11y 4mo [4y 4mo]; age range 6y 2mo-21y 0mo; 15 females; C5-6, n=4, C5-7, n=12, C5-T1, n=11, C5-T1 with Horner sign, n=4) were assessed along with 30 controls (mean age 11y 5mo [4y 4mo]; age range 6y 7mo-21y 7mo; 14 females). Participants' estimated hand size and shape on measure of implicit and explicit hand representation was assessed. A linear mixed model (LMM) was used to investigate the effect of condition, sensorimotor impairment, and age. RESULTS Individuals with NBPP showed a significant difference in implicit hand representation between affected and non-affected hands. LMM confirmed a significant influence of the severity of sensorimotor injury. Only the estimated implicit hand representation was associated with age, with a significant difference between 6- to 8-year-olds and 9- to 10-year-olds. INTERPRETATION The effect of sensorimotor impairment on central hand representation in individuals with NBPP is specific due to its implicit component and is characterized by finger length underestimation in the affected hand compared to the characteristic underestimation in the unaffected hand. Neither NBPP nor age impacted the explicit hand estimate. This study confirms the importance of sensorimotor contribution to the development of implicit hand representation.
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Affiliation(s)
- Ruth Van der Looven
- Department of Physical and Rehabilitation Medicine, Child Rehabilitation, Ghent University Hospital, Ghent, Belgium
| | - Linda Hermans
- Department of Physical and Rehabilitation Medicine, Child Rehabilitation, Ghent University Hospital, Ghent, Belgium
| | - Anna Maria Coupe
- Department of Physical and Rehabilitation Medicine, Child Rehabilitation, Ghent University Hospital, Ghent, Belgium
| | - Martine De Muynck
- Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Guy Vingerhoets
- Department of Experimental Psychology, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
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Mansukhani KA, Thatte MR, Sharma A, Balakrishnan L, Chavan P. Breathing Muscles Produces a "Dystonia Like" Contraction. Ann Indian Acad Neurol 2021; 24:439-441. [PMID: 34447018 PMCID: PMC8370146 DOI: 10.4103/aian.aian_485_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/02/2020] [Accepted: 08/12/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Khushnuma A Mansukhani
- Department of Clinical Neurophysiology (ENMG & EP), Plastic Bombay Hospital, Mumbai, Maharashtra, India
| | - Mukund R Thatte
- Department of Plastic Surgery, Bombay Hospital, Mumbai, Maharashtra, India
| | - Alika Sharma
- Department of Clinical Neurophysiology (ENMG & EP), Plastic Bombay Hospital, Mumbai, Maharashtra, India
| | - Lajita Balakrishnan
- Department of Neurophysiology, Apollo Hospital, Navi Mumbai, Maharashtra, India
| | - Priyanka Chavan
- Department of Clinical Neurophysiology (ENMG & EP), Plastic Bombay Hospital, Mumbai, Maharashtra, India
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Bovbjerg ML, Misra D, Snowden JM. Current Resources for Evidence-Based Practice, November 2020. J Obstet Gynecol Neonatal Nurs 2020; 49:605-619. [PMID: 33096044 PMCID: PMC7575432 DOI: 10.1016/j.jogn.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of diversity in the maternity care workforce and commentaries on reviews focused on burnout in midwifery and a cross-national comparison of guidelines for uncomplicated childbirth.
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Rehm A, Thahir A. Letter regarding "Early electrodiagnosis in the management of neonatal brachial plexus palsy: A systematic review". Muscle Nerve 2020; 62:E70-E71. [PMID: 32567689 DOI: 10.1002/mus.27013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 04/26/2020] [Accepted: 04/29/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Andreas Rehm
- Department of Paediatric Orthopaedics, Paediatric Division, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Azeem Thahir
- Department of Trauma & Orthopaedics, Cambridge University Hospitals NHS Trust, Cambridge, UK
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Rubin DI. Brachial and lumbosacral plexopathies: A review. Clin Neurophysiol Pract 2020; 5:173-193. [PMID: 32954064 PMCID: PMC7484503 DOI: 10.1016/j.cnp.2020.07.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/09/2020] [Accepted: 07/31/2020] [Indexed: 12/11/2022] Open
Abstract
Diseases of the brachial and lumbosacral plexus are uncommon and complex. The diagnosis of plexopathies is often challenging for the clinician, both in terms of localizing a patient's symptoms to the plexus as well as determining the etiology. The non-specific clinical features and similar presentations to other root, nerve, and non-neurologic disorders emphasize the importance of a high clinical index of suspicion for a plexopathy and comprehensive clinical evaluation. Various diagnostic tests, including electrodiagnostic (EDX) studies, neuroimaging (including ultrasound, MRI, or PET), serologic studies, and genetic testing, may be used to confirm a plexopathy and assist in identifying the underlying etiology. EDX testing plays an important role in confirming a plexopathy defining the localization, pathophysiology, chronicity, severity, and prognosis. Given the complexity of the plexus anatomy, multiple common and uncommon NCS and an extensive needle examination is often required, and a comprehensive, individualized approach to each patient is necessary. Treatment of plexopathies often focuses on symptomatic management although, depending on the etiology, specific targeted treatments may improve outcome. This article reviews the clinical features, EDX approaches, and evaluation and treatment of brachial and lumbosacral plexopathies.
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Affiliation(s)
- Devon I. Rubin
- Electromyography Laboratory, Mayo Clinic, Jacksonville, FL, USA
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Clinical, Electrodiagnostic Findings and Quality of Life of Dogs and Cats with Brachial Plexus Injury. Vet Sci 2020; 7:vetsci7030101. [PMID: 32751944 PMCID: PMC7558042 DOI: 10.3390/vetsci7030101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 11/17/2022] Open
Abstract
Brachial plexus injury (BPI) represents a common consequence of road traffic accidents in humans and small animals. In humans, neuropathic pain is a common symptom after BPI. The aim of the study was to describe the clinical signs, the electrodiagnostic findings, the outcome and the quality of life (QoL) of a cohort of dogs and cats with BPI. Clinical records of 40 dogs and 26 cats with BPI were retrospectively reviewed. Specific attention was put on the evaluation of electrodiagnostic findings (35/40 dogs; 14/26 cats) and telephonic interview results (26/40 dogs; 18/26 cats). The most common neurological condition was the inability to bear weight and sensory deficits on the affected limb. Radial and ulnar motor nerve conduction studies (MNCSs) were absent respectively in 47% (radial) and 62% (ulnar) of dogs and 57% (radial) and 57% (ulnar) of cats. The absence of radial (p = 0.003) and ulnar (p = 0.007) MNCSs in dogs and ulnar MNCSs in cats (p = 0.02) was significantly associated to the amputation of the affected limb. The owners described signs of pain/discomfort in 73% of dogs and 56% of cats. This is the first report suggesting that neuropathic pain/discomfort should be adequately considered in order to improve the QoL.
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Van der Looven R, Pitt M. Response to the "letter to editor": Critical appraisal of systematic review. Muscle Nerve 2020; 62:E72-E73. [PMID: 32572968 DOI: 10.1002/mus.27012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Ruth Van der Looven
- Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Matthew Pitt
- Department of clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
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