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Silveri OC, Dunemann G, Woo C, Gutman J, Palazzi J, Canestrino J, Luke B, Millard JA, Breiner M. Rare case of divided phrenic nerve variation: a cadaveric case report. Surg Radiol Anat 2024; 46:825-828. [PMID: 38597949 DOI: 10.1007/s00276-024-03341-w] [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: 12/28/2023] [Accepted: 03/01/2024] [Indexed: 04/11/2024]
Abstract
The phrenic nerve innervates the respiratory diaphragm, the primary muscle active during ventilation. The canonical path of the phrenic nerve originates from the cervical spine at C3-C5 spinal nerves and travels inferiorly through the neck and thoracic cavity to reach the diaphragm. During a cadaver dissection, a variation of the phrenic nerve was discovered in a 93-year-old male specimen. A traditional origin of the phrenic nerve was noted; however, the nerve branched into medial and lateral components at the level of the superior trunk of the brachial plexus. The branches reconnected at the apex of the aortic arch and continued inferiorly to innervate the ipsilateral diaphragm. This case study describes a rare type of branching of the phrenic nerve and explores its potential impact on clinical procedures.
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Affiliation(s)
- Olivia C Silveri
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA.
| | | | - Christian Woo
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | - Jacob Gutman
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | - Joseph Palazzi
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | | | - Benita Luke
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | | | - Michael Breiner
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
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Fochtmann-Frana A, Pretterklieber B, Radtke C, Pretterklieber ML. Phrenic Nerve Transfer to Musculocutaneous Nerve: An Anatomical and Histological Study. Life (Basel) 2023; 13:1892. [PMID: 37763296 PMCID: PMC10532453 DOI: 10.3390/life13091892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/26/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND To restore elbow flexor muscle function in case of traumatic brachial plexus avulsion, the phrenic nerve transfer to the musculocutaneous nerve has become part of clinical practice. The nerve transfer can be done by means of video-assisted thoracic surgery without nerve graft or via supraclavicular approach in combination with an autograft. This study focuses on a detailed microscopic and macroscopic examination of the phrenic nerve. It will allow a better interpretation of existing clinical results and, thus, serve as a basis for future clinical studies. MATERIAL AND METHODS An anatomical study was conducted on 28 body donors of Caucasian origin (female n = 14, male n = 14). A sliding caliper and measuring tape were used to measure the diameter and length of the nerves. Sudan black staining was performed on 15 µm thick cryostat sections mounted on glass slides and the number of axons was determined by the ImageJ counting tool. In 23 individuals, the phrenic nerve could be examined on both sides. In 5 individuals, however, only one side was examined. Thus, a total of 51 nerves were examined. RESULTS The mean length of the left phrenic nerves (33 cm (29-38 cm)) was significantly longer compared to the mean length of the right phrenic nerves (30 cm (24-33 cm)) (p < 0.001). Accessory phrenic nerves were present in 9 of 51 (18%) phrenic nerves. The mean number of phrenic nerves axons at the level of the first intercostal space in body donors with a right accessory phrenic nerve was significantly greater compared to the mean number of phrenic nerves axons at the same level in body donors without a right accessory phrenic nerve (3145 (range, 2688-3877) vs. 2278 (range, 1558-3276)), p = 0.034. A negative correlation was registered between age and the nerve number of axons in left (0.742, p < 0.001) and right (-0.273, p = 0.197) phrenic nerves. The mean distance from the upper edge of the ventral ramus of the fourth cervical spinal nerve to the point of entrance of the musculocutaneous nerve between the two parts of the coracobrachialis muscle was 19 cm (range, 15-24 cm) for the right and 20 cm (range, 15-25 cm) for the left arm. CONCLUSIONS If an accessory phrenic nerve is available, it presumably should be spared. Thus, in that case, a supraclavicular approach in combination with a nerve graft would probably be of advantage.
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Affiliation(s)
- Alexandra Fochtmann-Frana
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria;
| | - Bettina Pretterklieber
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Auenbruggerplatz 25, 8036 Graz, Austria; (B.P.); (M.L.P.)
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Waehringer Str. 13, 1090 Vienna, Austria
| | - Christine Radtke
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria;
| | - Michael L. Pretterklieber
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Auenbruggerplatz 25, 8036 Graz, Austria; (B.P.); (M.L.P.)
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Waehringer Str. 13, 1090 Vienna, Austria
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Crowe CS, Pulos N, Spinner RJ, Bishop AT, Wigle DA, Shin AY. The diagnostic utility of inspiratory-expiratory radiography for the assessment of phrenic nerve palsy associated with brachial plexus injury. Acta Neurochir (Wien) 2023; 165:2589-2596. [PMID: 37198276 DOI: 10.1007/s00701-023-05622-6] [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: 03/20/2023] [Accepted: 05/06/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND The phrenic nerve is commonly injured with trauma to the brachial plexus. Hemi-diaphragmatic paralysis may be well-compensated in healthy individuals at rest but can be associated with persistent exercise intolerance in some patients. This study aims to determine the diagnostic value of inspiratory-expiratory chest radiography compared to intraoperative stimulation of the phrenic nerve for assessing phrenic nerve injury associated with brachial plexus injury. METHODS Over a 21-year period, the diagnostic utility of three-view inspiratory-expiratory chest radiography for identification of phrenic nerve injury was determined by comparison to intraoperative phrenic nerve stimulation. Multivariate regression analysis was used to identify independent predictors of phrenic nerve injury and having an incorrect radiographic diagnosis. RESULTS A total of 237 patients with inspiratory-expiratory chest radiography underwent intraoperative testing of phrenic nerve function. Phrenic nerve injury was present in approximately one-fourth of cases. Preoperative chest radiography had a sensitivity of 56%, specificity of 93%, positive predictive negative of 75%, and negative predictive value of 86% for identification of a phrenic nerve palsy. Only C5 avulsion was found to be a predictor of having an incorrect diagnosis of phrenic nerve injury on radiography. CONCLUSION While inspiratory-expiratory chest radiography has good specificity for detecting phrenic nerve injuries, a high number of false negatives suggest that it should not be relied upon for routine screening of dysfunction after traumatic brachial plexus injury. This is likely multifactorial and relates to variation in diaphragm shape and position, as well as limitations regarding static image interpretation of a dynamic process.
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Affiliation(s)
- Christopher S Crowe
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA
| | - Nicholas Pulos
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA
| | | | - Allen T Bishop
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA
| | - Dennis A Wigle
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, USA
| | - Alexander Y Shin
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA.
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McCarty PJ, Chaiyamoon A, Cardona JJ, Carrera A, Reina F, Georgiev GP, Iwanaga J, Dumont AS, Tubbs RS. Nerve to subclavius for neurotization procedures: an anatomical feasibility study. Neurosurg Rev 2023; 46:176. [PMID: 37452892 DOI: 10.1007/s10143-023-02079-0] [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: 03/09/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
Injuries to the inferior trunk of the brachial plexus and its components can be debilitating. As such injuries are prioritized by surgeons during repair, an additional nerve transfer is considered herein. In the supine position, 13 adult cadavers (26 sides) underwent dissection of the nerve to subclavius and the proximal brachial plexus in the supraclavicular region. Once the nerve was located and isolated from origin to termination, measurements of its length and diameter were made. Next, the C8 and T1 roots and inferior trunk were identified. The distal end of the nerve to subclavius was transected and swung to these roots and the inferior trunk. Once the nerves to subclavius were transposed and in a tension-free manner, the length of excess nerve following being brought to each of these nerves was measured. A nerve to subclavius was identified on all sides. The nerve originated from the superior trunk and traveled anterior to the middle and inferior trunks on all sides. The mean diameter of the nerve to subclavius was 0.8 mm, and the mean length was 57 mm. After cutting the nerve to subclavius at its entrance into the subclavius muscle, the distal nerve could be transferred tension free to the inferior trunk of the brachial plexus and T1 ventral ramus on all sides. The distal nerve to subclavius reached the T1 ventral ramus with an average of 18 mm of additional length and to the C8 ventral ramus with an average of 19 mm. The nerve also could be transferred to the inferior trunk of the brachial plexus with an average of 20 mm of additional length. The nerve to subclavius was found to have approximately 3000 axons. To our knowledge, use of the nerve to subclavius has previously not been used for nerve transfer procedures. Based on our cadaveric study, this often-overlooked nerve can be easily transposed to other regional nerves such as the inferior trunk of the brachial plexus.
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Affiliation(s)
- Patrick J McCarty
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Arada Chaiyamoon
- Department of Anatomy, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
| | - Juan J Cardona
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ana Carrera
- Medical Sciences Department, Clinical Anatomy, Embryology and Neurosciences Research Group, University of Girona, Girona, Spain
| | - Francisco Reina
- Medical Sciences Department, Clinical Anatomy, Embryology and Neurosciences Research Group, University of Girona, Girona, Spain
| | - Georgi P Georgiev
- Department of Orthopedics and Traumatology, University Hospital Queen Giovanna-ISUL, Medical University of Sofia, Sofia, Bulgaria
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
- University of Queensland, Brisbane, Australia
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Crowe CS, Pulos BP, Spinner RJ, Shin AY. Respiratory Failure After Supraclavicular Nerve Block in a Patient With a Contralateral Brachial Plexus Injury: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00004. [PMID: 36206361 DOI: 10.2106/jbjs.cc.22.00331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/31/2022] [Indexed: 11/07/2022]
Abstract
CASE A patient with prior left-sided brachial plexus trauma and associated left phrenic nerve paralysis subsequently developed transient respiratory failure after a contralateral supraclavicular nerve block. Her known left phrenic nerve palsy secondary to her index brachial plexus injury was rediscovered during the workup of her acute respiratory distress, which resulted in an emergent intensive care unit admission. CONCLUSION The paralysis of her right phrenic nerve at the time of left-sided regional anesthesia was identified as the etiology of near-complete bilateral diaphragmatic paralysis and respiratory failure.
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Affiliation(s)
- Christopher S Crowe
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota
| | - Bridget P Pulos
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Alexander Y Shin
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota
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Ultrasound-Guided Phrenic Nerve Block for Lung Nodule Biopsy: Single-Center Initial Experience. Acad Radiol 2022; 29 Suppl 2:S118-S126. [PMID: 34108113 DOI: 10.1016/j.acra.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/05/2021] [Accepted: 04/13/2021] [Indexed: 11/22/2022]
Abstract
RATIONALE AND OBJECTIVES Biopsy of lung nodules in the lower lung fields can be difficult because of breathing motion. Ipsilateral phrenic nerve block (PNB) before biopsy should make the biopsy safer, easier, and more precisely targeted. We describe the use of ultrasound-guided PNB before lung nodule biopsy, including relevant anatomy and variations, complications, and technique, along with our first 40 cases. MATERIALS AND METHODS We retrospectively reviewed patients who underwent PNB before computed tomography (CT)- or ultrasound-guided lung nodule biopsy from April 2015 through March 2020. Patient demographics, CT fluoroscopy time, radiation dose, complications, diagnostic yield, and effectiveness of PNB were recorded. Effectiveness of PNB was based on direct observation of diaphragmatic motion. Control group data for biopsies during the same time frame were collected and matched with nodules ≤1 cm from the PNB group. RESULTS Among 40 patients identified, no complications occurred related to the PNB. Mean (SD) nodule size was 12.4 (6.2) mm. True-positive results were obtained in 39 patients (98%), with 1 false-negative after an ineffective PNB. PNB was effective in 70%. When CT fluoroscopy was used for the biopsy, radiation dose was significantly lower after an effective PNB than an ineffective PNB (p < .001). Effective PNB was significantly more common with injection of ≥4 mL of local anesthetic (p = .01). Comparison with 19 matched controls showed significantly fewer instances of pneumothorax (p = .02) and greater diagnostic success (p = .03) for the PNB group. CONCLUSION Ultrasound-guided PNB is safe and effective and can improve outcomes when used before lung nodule biopsy.
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The Terminal Anatomy of Phrenic Nerve: a Deeper Look at Diaphragm Innervation Patterns. World Neurosurg 2022; 161:e101-e108. [PMID: 35077891 DOI: 10.1016/j.wneu.2022.01.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/14/2022] [Accepted: 01/15/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Traumatic brachial plexus injuries are devastating lesions and neurotization is an usually elected surgical therapy. The phrenic nerve has been harvested as motor fibers donor in brachial plexus neurotization, showing great results in terms of motor reinnervation. Unfortunately, these interventions lack solid evidence regarding long-term safety and possible late respiratory function sequelae, raising crescent concerns after the COVID-19 pandemic onset and possibly resulting in reduced propensity to use this technique. The study of the distal anatomy of the phrenic nerves may lead to a better understanding of their branching patterns, and thus the proposition of surgical approaches that better preserve patient respiratory function. METHODS Twenty-one phrenic nerves in ten formalized cadavers were scrutinized. Pre-diaphragmatic branching patterns were inspected through analysis of the distance between the piercing site of the nerve at the diaphragm and the cardiac structures, number of divisions, and length from the point where the main trunk emits its branches to the diaphragm. RESULTS The main trunk of the right phrenic nerve reaches the diaphragm near the inferior vena cava and branches into three major divisions. The left phrenic nerve reaches the diaphragm in variable locations near the heart, branching into two to five main trunks. Moreover, we noticed a specimen presenting two ipsilateral parallel phrenic nerves. CONCLUSION The right phrenic nerve presented greater consistency concerning insertion site, terminal branching point distance to this muscle, and number of rami than the left phrenic nerve.
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Ultrasound-Guided Clavipectoral Fascial Plane Block With Intermediate Cervical Plexus Block for Midshaft Clavicular Surgery: A Prospective Randomized Controlled Trial. Anesth Analg 2022; 135:633-640. [DOI: 10.1213/ane.0000000000005911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Fuller DD, Rana S, Smuder AJ, Dale EA. The phrenic neuromuscular system. HANDBOOK OF CLINICAL NEUROLOGY 2022; 188:393-408. [PMID: 35965035 PMCID: PMC11135908 DOI: 10.1016/b978-0-323-91534-2.00012-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The phrenic neuromuscular system consists of the phrenic motor nucleus in the mid-cervical spinal cord, the phrenic nerve, and the diaphragm muscle. This motor system helps sustain breathing throughout life, while also contributing to posture, coughing, swallowing, and speaking. The phrenic nerve contains primarily efferent phrenic axons and afferent axons from diaphragm sensory receptors but is also a conduit for autonomic fibers. On a breath-by-breath basis, rhythmic (inspiratory) depolarization of phrenic motoneurons occurs due to excitatory bulbospinal synaptic pathways. Further, a complex propriospinal network innervates phrenic motoneurons and may serve to coordinate postural, locomotor, and respiratory movements. The phrenic neuromuscular system is impacted in a wide range of neuromuscular diseases and injuries. Contemporary research is focused on understanding how neuromuscular plasticity occurs in the phrenic neuromuscular system and using this information to optimize treatments and rehabilitation strategies to improve breathing and related behaviors.
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Affiliation(s)
- David D Fuller
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States; McKnight Brain Institute, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States.
| | - Sabhya Rana
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States; McKnight Brain Institute, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States
| | - Ashley J Smuder
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States; Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, United States
| | - Erica A Dale
- McKnight Brain Institute, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States; Department of Physiology and Functional Genomics, University of Florida, Gainesville, FL, United States
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Kaufman MR, Ferro N, Paulin E. Phrenic nerve paralysis and phrenic nerve reconstruction surgery. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:271-292. [PMID: 36031309 DOI: 10.1016/b978-0-323-91532-8.00003-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Phrenic nerve injury results in paralysis of the diaphragm muscle, the primary generator of an inspiratory effort, as well as a stabilizing muscle involved in postural control and spinal alignment. Unilateral deficits often result in exertional dyspnea, orthopnea, and sleep-disordered breathing, whereas oxygen or ventilator dependency can occur with bilateral paralysis. Common etiologies of phrenic injuries include cervical trauma, iatrogenic injury in the neck or chest, and neuralgic amyotrophy. Many patients have no identifiable etiology and are considered to have idiopathic paralysis. Diagnostic evaluation requires radiographic and pulmonary function testing, as well as electrodiagnostic assessment to quantitate the nerve deficit and determine the extent of denervation atrophy. Treatment for symptomatic diaphragm paralysis has traditionally been limited. Medical therapies and nocturnal positive airway pressure may provide some benefit. Surgical repair of the nerve injury to restore functional diaphragmatic activity, termed phrenic nerve reconstruction, is a safe and effective alternative to static repositioning of the diaphragm (diaphragm plication), in properly selected patients. Phrenic nerve reconstruction has increasingly become a standard surgical treatment for diaphragm paralysis due to phrenic nerve injury. A multidisciplinary approach at specialty referral centers combining diagnostic evaluation, surgical treatment, and rehabilitation is required to achieve optimal long-term outcomes.
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Affiliation(s)
- Matthew R Kaufman
- Institute for Advanced Reconstruction, Shrewsbury, NJ, United States; Division of Plastic and Reconstructive Surgery, UCLA Medical Center, Los Angeles, CA, United States.
| | - Nicole Ferro
- Institute for Advanced Reconstruction, Shrewsbury, NJ, United States
| | - Ethan Paulin
- Institute for Advanced Reconstruction, Shrewsbury, NJ, United States
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Hemidiaphragmatic paralysis following costoclavicular versus supraclavicular brachial plexus block: a randomized controlled trial. Sci Rep 2021; 11:18749. [PMID: 34548555 PMCID: PMC8455610 DOI: 10.1038/s41598-021-97843-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 08/30/2021] [Indexed: 01/21/2023] Open
Abstract
Costoclavicular brachial plexus block is emerging as a promising infraclavicular approach performed just below the clavicle. However, there are relatively little data regarding the hemidiaphragmatic paralysis (HDP) compared to the commonly performed supraclavicular block. We hypothesized that the incidence of HDP in costoclavicular block is lower than supraclavicular block like classical infraclavicular approach. Eighty patients were randomly assigned to ultrasound-guided supraclavicular (group S) or costoclavicular (group C) block with 25 mL of local anesthetics (1:1 mixture of 1% lidocaine and 0.75% ropivacaine). The primary outcome was the incidence of HDP, defined as less than 20% of fractional change in the diaphragm thickness on ultrasound M-mode. Also, pulmonary function test and chest radiograph were assessed before and after the surgery. The incidence of HDP was 4/35 (11.4%) in the group C and 19/40 (47.5%) in the group S (risk difference, − 36%; 95% CI − 54 to − 17%; P = 0.002). The mean (SD) change of DTF values were 30.3% (44.0) and 56.9% (39.3) in the group C and S, respectively (difference in means, − 26.6%; 95% CI − 45.8 to − 7.4%; P = 0.007). The pulmonary function was more preserved in group C than in group S. The determined diagnostic cut off value of the diaphragm elevation on chest radiograph was 29 mm. Despite the very contiguous location of the two approaches around the clavicle, costoclavicular block can significantly reduce the risk of HDP compared with supraclavicular block.
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Padmanaban V, Payne R, Corbani K, Corl S, Rizk EB. Phrenic Nerve Stimulator Placement via the Cervical Approach: Technique and Anatomic Considerations. Oper Neurosurg (Hagerstown) 2021; 21:E215-E220. [PMID: 33677605 DOI: 10.1093/ons/opab047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/25/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Diaphragmatic pacing via phrenic nerve stimulation can help improve breathing and facilitate mechanical ventilation weaning in patients with respiratory failure secondary to brainstem injury, high cervical spinal cord injury, or congenital central hypoventilation. Devices can be placed utilizing several techniques; however, nuances regarding placement are not well published. OBJECTIVE To describe our experience with phrenic nerve stimulator placement via the cervical approach with a focus on surgical anatomy, variations, and technique. METHODS Placement of phrenic nerve stimulator via a cervical approach is described in detail. RESULTS Successful placement of phrenic nerve stimulator without complication. CONCLUSION The cervical approach for the placement of a phrenic nerve stimulator is a safe and effective option for patients. Detailed knowledge of anatomy and anatomic variations is required. Potential advantages and disadvantages are discussed.
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Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Russell Payne
- Department of Neurosurgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Karen Corbani
- Department of Health Sciences, International University of Catalunya, Barcelona, Spain
| | - Sheena Corl
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Elias B Rizk
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Farrell M, Mathew E, Weiss M, Dickerman R. Right hemidiaphragmatic paralysis after cervical transforaminal epidural steroid injection: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20113. [PMID: 35854830 PMCID: PMC9245767 DOI: 10.3171/case20113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/15/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND Cervical radiculopathy is a common cause of neck pain, with radiation into the upper extremity in a dermatomal pattern. Corticosteroid injection is a conservative management option with a low risk of major adverse events. No reviewed literature or case reports have implicated phrenic nerve injury secondary to cervical transforaminal epidural steroid injection (CTFESI). OBSERVATIONS A 45-year-old man with severe right C6 radiculopathy secondary to a large right-sided C5–6 herniated intervertebral disc presented to the pain management clinic, where he received a right-sided C6 CTFESI. An hour after injection, the patient experienced shortness of breath, which was found to be caused by right diaphragmatic paralysis. The patient underwent a C5–6 anterior cervical discectomy and fusion, which provided complete relief of his radicular symptoms. However, the right hemidiaphragmatic paralysis remained at the 1-year postoperative visit. LESSONS Thorough literature review showed no established explanations for phrenic nerve injury after CTFESI. In this study, the authors explored the suspected mechanisms of possible injury to the phrenic nerve. Epidural corticosteroid injection is considered to be a safe option for conservative management of cervical radiculopathy. This study unveiled a unique and important adverse event that should be considered before a patient receives CTFESI.
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Affiliation(s)
- Molly Farrell
- Texas College of Osteopathic Medicine, Fort Worth, Texas
| | - Ezek Mathew
- Texas College of Osteopathic Medicine, Fort Worth, Texas
| | - Martin Weiss
- Cardiology Department, Baylor Scott & White Medical Center, McKinney, Texas; and
| | - Rob Dickerman
- Department of Neurosurgery, Presbyterian Hospital, Plano, Texas
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Hinchcliff KM, Bishop AT, Shin AY, Spinner RJ. Relocating the C5 nerve stump in C5 nerve grafting to prevent iatrogenic phrenic nerve injury. Acta Neurochir (Wien) 2021; 163:829-834. [PMID: 33507373 DOI: 10.1007/s00701-021-04713-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Exploration and grafting of the brachial plexus remains the gold standard for post-ganglionic brachial plexus injuries that present within an acceptable time frame from injury. The most common nerves available for grafting include C5 and C6. During the surgical exposure of C5 and C6, the phrenic nerve is anatomically anterior to the cervical spinal nerves, making it vulnerable to injury while performing the dissection and nerve stump to graft coaptation. We describe a novel technique that protects the phrenic nerve from injury during supraclavicular brachial plexus exposure and grafting of C5 or upper trunk ruptures or neuromas in-continuity. METHODS A 4-step technique is illustrated: (1) The normal anatomic relationships of the phrenic nerve anterior to C5 is displayed in the face of the traumatic scarring. (2) The C5 spinal nerve stump is then transposed from its anatomic position posterior to the phrenic nerve to an anterior position. (3) The C5 stump is then moved medially for retrograde neurolysis of C5 from its phrenic nerve contribution. The graft coaptation to C5 is performed in this medial position, which minimizes retraction of the phrenic nerve. (4) The normal anatomic relationship of the phrenic nerve and the C5 nerve graft is restored. RESULTS We have been routinely relocating the C5 spinal nerve stump around the phrenic nerve for the past 10 years. We have experienced no adverse respiratory events. CONCLUSION This technique facilitates surgical exposure and prevents iatrogenic injury on the phrenic nerve during nerve reconstruction.
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Socolovsky M, Cardoso MDM, Lovaglio A, di Masi G, Bonilla G, de Amoreira Gepp R. Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series. Oper Neurosurg (Hagerstown) 2020; 19:249-254. [PMID: 32497215 DOI: 10.1093/ons/opaa163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/06/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The phrenic nerve has been extensively reported to be a very powerful source of transferable axons in brachial plexus injuries. The most used technique used is supraclavicular sectioning of this nerve. More recently, video-assisted thoracoscopic techniques have been reported as a good alternative, since harvesting a longer phrenic nerve avoids the need of an interposed graft. OBJECTIVE To compare grafting vs phrenic nerve transfer via thoracoscopy with respect to mean elbow strength at final follow-up. METHODS A retrospective analysis was conducted among patients who underwent phrenic nerve transfer for elbow flexion at 2 centers from 2008 to 2017. All data analysis was performed in order to determine statistical significance among the analyzed variables. RESULTS A total of 32 patients underwent supraclavicular phrenic nerve transfer, while 28 underwent phrenic nerve transfer via video-assisted thoracoscopy. Demographic characteristics were similar in both groups. A statistically significant difference in elbow flexion strength recovery was observed, favoring the supraclavicular phrenic nerve section group against the intrathoracic group (P = .036). A moderate though nonsignificant difference was observed favoring the same group in mean elbow flexion strength. Also, statistical differences included patient age (P = .01) and earlier time from trauma to surgery (P = .069). CONCLUSION Comparing supraclavicular sectioning of the nerve vs video-assisted, intrathoracic nerve sectioning to restore elbow flexion showed that the former yielded statistically better results than the latter, in terms of the percentage of patients who achieve at least level 3 MRC strength at final follow-up. Furthermore, larger scale prospective studies assessing the long-term effects of phrenic nerve transfers remain necessary.
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Affiliation(s)
- Mariano Socolovsky
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | | | - Ana Lovaglio
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gilda di Masi
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gonzalo Bonilla
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
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Burt BM, Palivela N, Goodman MB. Transthoracic Robotic First Rib Resection: Technique Crystallized. Ann Thorac Surg 2020; 110:e71-e73. [DOI: 10.1016/j.athoracsur.2019.12.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/31/2019] [Indexed: 10/24/2022]
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Phrenic nerve neurotization utilizing half of the spinal accessory nerve to the functional restoration of the paralyzed diaphragm in high spinal cord injury secondary to brain tumor resection. Childs Nerv Syst 2020; 36:1307-1310. [PMID: 31912225 DOI: 10.1007/s00381-019-04490-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022]
Abstract
The authors present a case of functional improvement of diaphragmatic paralysis in high spinal cord injury, performing a neurotization of the phrenic nerve with accessory spinal nerve hemisection. A C1-C2 injury of the spinal cord was diagnosed in a 12-year-old male, secondary to resection of a brainstem glioma. The patient did not have diaphragmatic motility at the moment that the mechanical ventilation was removed; however, he presented apnea. The patient underwent neurotization of the right phrenic nerve with the right spinal accessory nerve, 5 months after the injury and 6 months after nerve transfer; he had complete mobilization of the right hemidiaphragm, nevertheless persisted with paralysis of the left hemidiaphragm. This achievement reduced the use of mechanical ventilation during the day.
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Burt BM, Palivela N, Karimian A, Goodman MB. Transthoracic robotic first rib resection: Twelve steps. JTCVS Tech 2020; 1:104-109. [PMID: 34317727 PMCID: PMC8288632 DOI: 10.1016/j.xjtc.2020.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 11/18/2019] [Accepted: 01/03/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Bryan M. Burt
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Address for reprints: Bryan M. Burt, MD, Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
| | - Nihanth Palivela
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
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[Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study]. Rev Bras Anestesiol 2019; 69:580-586. [PMID: 31796298 DOI: 10.1016/j.bjan.2019.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/11/2019] [Accepted: 09/12/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block. METHODS Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥ 25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed. RESULTS Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale (NRS) at 24 hours did not differ between groups. CONCLUSIONS Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.
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Anatomic Variation of the Phrenic Nerve and Brachial Plexus Encountered during 100 Supraclavicular Decompressions for Neurogenic Thoracic Outlet Syndrome with Associated Postoperative Neurologic Complications. Ann Vasc Surg 2019; 62:70-75. [PMID: 31207398 DOI: 10.1016/j.avsg.2019.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/29/2019] [Accepted: 04/07/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. METHODS A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. RESULTS In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function. CONCLUSIONS Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.
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Kikuta S, Iwanaga J, Kusukawa J, Tubbs RS. Triangles of the neck: a review with clinical/surgical applications. Anat Cell Biol 2019; 52:120-127. [PMID: 31338227 PMCID: PMC6624334 DOI: 10.5115/acb.2019.52.2.120] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/25/2019] [Accepted: 02/04/2019] [Indexed: 11/27/2022] Open
Abstract
The neck is a geometric region that can be studied and operated using anatomical triangles. There are many triangles of the neck, which can be useful landmarks for the surgeon. A better understanding of these triangles make surgery more efficient and avoid intraoperative complications. Herein, we provide a comprehensive review of the triangles of the neck and their clinical and surgical applications.
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Affiliation(s)
- Shogo Kikuta
- Seattle Science Foundation, Seattle, WA, USA
- Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, WA, USA
- Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Fukuoka, Japan
- Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan
| | - Jingo Kusukawa
- Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - R. Shane Tubbs
- Seattle Science Foundation, Seattle, WA, USA
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
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Abstract
Pathologic processes that involve the central nervous system, phrenic nerve, neuromuscular junction, and skeletal muscle can impair diaphragm function. When these processes are of sufficient severity to cause diaphragm dysfunction, respiratory failure may be a consequence. This article reviews basic diaphragm anatomy and physiology and then discusses diagnostic and therapeutic approaches to disorders that result in unilateral or bilateral diaphragm dysfunction. This discussion provides a context in which disorders of the diaphragm and their implications on respiratory function can be better appreciated.
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Affiliation(s)
- F Dennis McCool
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA.
| | - Kamran Manzoor
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA
| | - Taro Minami
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA
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Cardoso MDM, Gepp RDA, Mamare E, Guedes-Correa JF. Results of Phrenic Nerve Transfer to the Musculocutaneous Nerve Using Video-Assisted Thoracoscopy in Patients with Traumatic Brachial Plexus Injury: Series of 28 Cases. Oper Neurosurg (Hagerstown) 2018; 17:261-267. [DOI: 10.1093/ons/opy350] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Indexed: 01/18/2023] Open
Abstract
Abstract
BACKGROUND
The phrenic nerve can be transferred to the musculocutaneous nerve using video-assisted thoracoscopy, aiming at the recovery of elbow flexion in patients with traumatic brachial plexus injuries. There are few scientific papers in the literature that evaluate the results of this operative technique.
OBJECTIVE
To evaluate biceps strength and pulmonary function after the transfer of the phrenic nerve to the musculocutaneous nerve using video-assisted thoracoscopy.
METHODS
A retrospective study was carried out in a sample composed of 28 patients who were victims of traumatic injury to the brachial plexus from 2008 to 2013. Muscle strength was graded using the British Medical Research Council (BMRC) scale and pulmonary function through spirometry. Statistical tests, with significance level of 5%, were used.
RESULTS
In total, 74.1% of the patients had biceps strength greater than or equal to M3. All patients had a decrease in forced vital capacity and forced expiratory volume in 1 s, with no evidence of recovery over time.
CONCLUSION
Transferring the phrenic nerve to the musculocutaneous nerve using video-assisted thoracoscopy may lead to an increase in biceps strength to BMRC M3 or greater in most patients. Considering the deterioration in the parameters of spirometry observed in our patients and the future effects of aging in the respiratory system, it is not possible at the moment to guarantee the safety of this operative technique in the long term.
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Affiliation(s)
| | | | - Eduardo Mamare
- Department of Thoracic Surgery, Sarah Network of Rehabilitation Hospitals, Brasilia, Brazil
| | - José Fernando Guedes-Correa
- Division of Neurosurgery, Gaffree e Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
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The human phrenic nerve serves as a morphological conduit for autonomic nerves and innervates the caval body of the diaphragm. Sci Rep 2018; 8:11697. [PMID: 30076368 PMCID: PMC6076324 DOI: 10.1038/s41598-018-30145-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/16/2018] [Indexed: 01/08/2023] Open
Abstract
Communicating fibres between the phrenic nerve and sympathetic nervous system may exist, but have not been characterized histologically and immunohistochemically, even though increased sympathetic activity due to phrenic nerve stimulation for central sleep apnoea may entail morbidity and mortality. We, therefore, conducted a histological study of the phrenic nerve to establish the presence of catecholaminergic fibres throughout their course. The entire phrenic nerves of 35 formalin-fixed human cadavers were analysed morphometrically and immunohistochemically. Furthermore, the right abdominal phrenic nerve was serially sectioned and reconstructed. The phrenic nerve contained 3 ± 2 fascicles in the neck that merged to form a single fascicle in the thorax and split again into 3 ± 3 fascicles above the diaphragm. All phrenic nerves contained catecholaminergic fibres, which were distributed homogenously or present as distinct areas within a fascicle or as separate fascicles. The phrenicoabdominal branch of the right phrenic nerve is a branch of the celiac plexus and, therefore, better termed the “phrenic branch of the celiac plexus”. The wall of the inferior caval vein in the diaphragm contained longitudinal strands of myocardium and atrial natriuretic peptide-positive paraganglia (“caval bodies”) that where innervated by the right phrenic nerve.
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Respiratory Synkinesis Seen in the Biceps Brachii Muscle Resulting From Meningitis 20 Years Ago. Am J Phys Med Rehabil 2018; 97:e117. [PMID: 29794820 DOI: 10.1097/phm.0000000000000963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lev-Ran O, Abrahamov D, Baram N, Matsa M, Ishai Y, Gabai O, Refaely Y, Abu Salah M, Sahar G. In-situ left-sided bilateral internal thoracic artery: elevated hemidiaphragm. Asian Cardiovasc Thorac Ann 2018; 26:94-100. [PMID: 29363317 DOI: 10.1177/0218492317754143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Procurement of the internal thoracic artery risks ipsilateral phrenic nerve injury and elevated hemidiaphragm. Anatomical variations increase the risk on the right side. Patients receiving left-sided in-situ right internal thoracic artery configurations appear to be at greatest risk. Methods From 2014 to 2016, 432 patients undergoing left-sided in-situ bilateral internal thoracic artery grafting were grouped according to right internal thoracic artery configuration: retroaortic via transverse sinus (77%) or ante-aortic (23%); targets were the circumflex and left anterior descending artery territories, respectively. Elevated hemidiaphragm was assessed by serial chest radiographs and categorized by side, complete (≥2 intercostal spaces) versus partial, and permanent versus transient. Results Right elevated hemidiaphragm occurred in 4.2% of patients. The incidence of radiological complete right elevated hemidiaphragm was 2.8% (12/432); 8 cases were transient with recovery in 3.5 ± 0.3 weeks. Permanent right elevated hemidiaphragm occurred in 0.9% (retroaortic group only). Permanent left elevated hemidiaphragm occurred in 0.9% and was significantly higher in the ante-aortic group (3/99 vs. 1/333, p = 0.039). No bilateral hemidiaphragm elevation was documented. Partial right elevated hemidiaphragm occurred in 1.4% and was not associated with adverse early or late respiratory outcomes. Conclusions Despite susceptible right phrenic nerve-internal thoracic artery anatomy, the incidence of permanent right elevated hemidiaphragm is low and no higher than left-sided in prone bilateral internal thoracic artery subsets. This reflects skeletonized internal thoracic artery procurement. Although statistical significance was not achieved, a retroaortic right internal thoracic artery configuration may constitute a higher risk of right phrenic nerve injury.
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Affiliation(s)
- Oren Lev-Ran
- 1 Department of Cardiothoracic Surgery, 26746 Soroka University Medical Center , Beer-Sheva, Israel
| | - Dan Abrahamov
- 1 Department of Cardiothoracic Surgery, 26746 Soroka University Medical Center , Beer-Sheva, Israel
| | - Nina Baram
- 2 Department of Radiology, 26746 Soroka University Medical Center , Beer-Sheva, Israel
| | - Menachem Matsa
- 1 Department of Cardiothoracic Surgery, 26746 Soroka University Medical Center , Beer-Sheva, Israel
| | - Yaron Ishai
- 1 Department of Cardiothoracic Surgery, 26746 Soroka University Medical Center , Beer-Sheva, Israel
| | - Ohad Gabai
- 1 Department of Cardiothoracic Surgery, 26746 Soroka University Medical Center , Beer-Sheva, Israel
| | - Yael Refaely
- 1 Department of Cardiothoracic Surgery, 26746 Soroka University Medical Center , Beer-Sheva, Israel
| | - Mahmud Abu Salah
- 1 Department of Cardiothoracic Surgery, 26746 Soroka University Medical Center , Beer-Sheva, Israel
| | - Gideon Sahar
- 1 Department of Cardiothoracic Surgery, 26746 Soroka University Medical Center , Beer-Sheva, Israel
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Verin E, Morelot-Panzini C, Gonzalez-Bermejo J, Veber B, Perrouin Verbe B, Soudrie B, Leroi AM, Marie JP, Similowski T. Reinnervation of the diaphragm by the inferior laryngeal nerve to the phrenic nerve in ventilator-dependent tetraplegic patients with C3-5 damage. ERJ Open Res 2017; 3:00052-2017. [PMID: 29181382 PMCID: PMC5699880 DOI: 10.1183/23120541.00052-2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/11/2017] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to evaluate the feasibility of unilateral diaphragmatic reinnervation in humans by the inferior laryngeal nerve. This pilot study included chronically ventilated tetraplegic patients with destruction of phrenic nerve motoneurons. Five patients were included. They all had a high level of tetraplegia, with phrenic nerve motor neuron destruction. They were highly dependent on ventilation, without any possibility of weaning. They did not have other chronic pathologies, especially laryngeal disease. They all had diaphragmatic explorations to diagnose the destruction of the motoneurons of the phrenic nerves and nasoendoscopy to be sure that they did not have laryngeal or pharyngeal disease. Then, surgical anastomosis of the right phrenic nerve was performed with the inferior laryngeal nerve, by a cervical approach. A laryngeal reinnervation was performed at the same time, using the ansa hypoglossi. One patient was excluded because of a functional phrenic nerve and one patient died 6 months after the surgery of a cardiac arrest. The remaining three patients were evaluated after the anastomosis every 6 months. They did not present any swallowing or vocal alterations. In these three patients, the diaphragmatic explorations showed that there was a recovery of the diaphragmatic electromyogram of the right and left hemidiaphragms after 1 year. Two patients had surgical diaphragmatic explorations for diaphragmatic pacing 18-24 months after the reinnervation with excellent results. At 36 months, none of the patients could restore their automatic ventilation. In conclusion, this study demonstrated that diaphragmatic reinnervation by the inferior laryngeal nerve is effective, without any vocal or swallowing complications.
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Affiliation(s)
- Eric Verin
- EA 3830, Normandy University, Groupe de recherche sur le handicap ventilatoire (GRHV), Université de Rouen, Rouen, France.,Service de physiologie, CHU de Rouen, Rouen, France.,CRMPR les herbiers, Bois Guillaume, France
| | - Capucine Morelot-Panzini
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
| | - Jesus Gonzalez-Bermejo
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
| | - Benoit Veber
- Service de réanimation chirurgicale, CHU de Rouen, Rouen, France
| | | | | | | | - Jean Paul Marie
- EA 3830, Normandy University, Groupe de recherche sur le handicap ventilatoire (GRHV), Université de Rouen, Rouen, France.,Service d'ORL et Chirurgie Cervicofaciale CHU de Rouen, Rouen, France
| | - Thomas Similowski
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
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Jiang Y, Lao J. The phrenic nerve transfer in the treatment of a septuagenarian with brachial plexus avulsion injury: a case report. Int J Neurosci 2017; 128:467-471. [PMID: 29077513 DOI: 10.1080/00207454.2017.1398154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Phrenic nerve transfer has been a well-established procedure for restoring elbow flexion function in patients with brachial plexus avulsion injury. Concerning about probably detrimental respiratory effects brought by the operation, however, stirred up quite a bit of controversy. We present a case report of the successful application of phrenic nerve as donor to reinnervate the biceps in a septuagenarian with brachial plexus avulsion injury, not accompanied with significant clinical respiratory problem.
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Affiliation(s)
- Ye Jiang
- a Department of Hand Surgery, Huashan Hospital , Fudan University , Shanghai , China.,b Key Laboratory of Hand Reconstruction , Ministry of Health , Shanghai , China.,c Shanghai Key Laboratory of Peripheral Nerve and Microsurgery , Shanghai , China
| | - Jie Lao
- a Department of Hand Surgery, Huashan Hospital , Fudan University , Shanghai , China.,b Key Laboratory of Hand Reconstruction , Ministry of Health , Shanghai , China.,c Shanghai Key Laboratory of Peripheral Nerve and Microsurgery , Shanghai , China
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30
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Graves MJ, Henry BM, Hsieh WC, Sanna B, PĘkala PA, Iwanaga J, Loukas M, Tomaszewski KA. Origin and prevalence of the accessory phrenic nerve: A meta-analysis and clinical appraisal. Clin Anat 2017; 30:1077-1082. [DOI: 10.1002/ca.22956] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 07/17/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Matthew J. Graves
- International Evidence-Based Anatomy Working Group; Krakow Poland
- Department of Anatomy; Jagiellonian University Medical College; Krakow Poland
| | - Brandon Michael Henry
- International Evidence-Based Anatomy Working Group; Krakow Poland
- Department of Anatomy; Jagiellonian University Medical College; Krakow Poland
| | - Wan Chin Hsieh
- International Evidence-Based Anatomy Working Group; Krakow Poland
- First Faculty of Medicine; Charles University; Prague Czech Republic
| | - Beatrice Sanna
- Faculty of Medicine and Surgery, University of Cagliari; Sardinia Italy
| | - PrzemysŁaw A. PĘkala
- International Evidence-Based Anatomy Working Group; Krakow Poland
- Department of Anatomy; Jagiellonian University Medical College; Krakow Poland
| | - Joe Iwanaga
- Seattle Science Foundation; Seattle Washington
- Department of Anatomy; Kurume University School of Medicine; Kurume Fukuoka Japan
| | - Marios Loukas
- Department of Anatomical Sciences; St. George's University; Grenada, West Indies
| | - Krzysztof A. Tomaszewski
- International Evidence-Based Anatomy Working Group; Krakow Poland
- Department of Anatomy; Jagiellonian University Medical College; Krakow Poland
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Abstract
Abstract
Regional anesthesia has an established role in providing perioperative analgesia for shoulder surgery. However, phrenic nerve palsy is a significant complication that potentially limits the use of regional anesthesia, particularly in high-risk patients. The authors describe the anatomical, physiologic, and clinical principles relevant to phrenic nerve palsy in this context. They also present a comprehensive review of the strategies for reducing phrenic nerve palsy and its clinical impact while ensuring adequate analgesia for shoulder surgery. The most important of these include limiting local anesthetic dose and injection volume and performing the injection further away from the C5–C6 nerve roots. Targeting peripheral nerves supplying the shoulder, such as the suprascapular and axillary nerves, may be an effective alternative to brachial plexus blockade in selected patients. The optimal regional anesthetic approach in shoulder surgery should be tailored to individual patients based on comorbidities, type of surgery, and the principles described in this article.
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Nayak SR, Krishnamurthy A, Prabhu LV, Ramanathan L, Pai MM, Potu BK, Das S. Incidence of Accessory Phrenic Nerve and its Clinical Significance: A Cadaveric Study. ACTA MEDICA (HRADEC KRÁLOVÉ) 2017; 51:181-4. [DOI: 10.14712/18059694.2017.21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The description of accessory phrenic nerve (APN) in the standard textbooks and available literature is vague and sometimes limited to few lines. The incidence of APN varies a great deal from 17.6 % to 80.9 % in the available literature. The aim of the present study was to calculate the incidence and variation of APN in Indian population. Material and methods: Forty five adult formalin-fixed cadavers (35 male, 10 female; 90 sides) used for gross anatomy dissection for undergraduates; during the 2 year period 2006–2007 were considered. Findings were recorded at different stages of the dissection. Results: Out of 90 body sides studied, the APN was present in 48 sides (53.3 %). In 17 of the above sides the APN was confined to the cervical region (Cervical type) and in 31 sides the APN entered the thorax (Thoracic type), all anterior to the subclavian vein (SV). In eleven specimens the APN was found bilaterally. Conclusion: The incidence of APN, with its course and relation to the various structures in cervical and thoracic region will help the surgeons while performing internal thoracic artery (ITA) grafting and other radical neck surgery.
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Paraskevas G, Koutsouflianiotis K, Kitsoulis P, Spyridakis I. Abnormal Origin and Course of the Accessory Phrenic Nerve: Case Report. ACTA MEDICA (HRADEC KRÁLOVÉ) 2017; 59:70-1. [PMID: 27526310 DOI: 10.14712/18059694.2016.55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In the current cadaveric study an unusual sizeable accessory phrenic nerve (APN) was encountered emerging from the trunk of the supraclavicular nerves and forming a triangular loop that was anastomosing with the phrenic nerve. That neural loop surrounded the superficial cervical artery which displayed a spiral course. The form of a triangular loop of APN involving the aforementioned artery and originating from the supraclavicular nerve to the best of our knowledge has not been documented previously in the literature. The variable morphological features of the APN along with its clinical applications are briefly discussed.
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Affiliation(s)
- George Paraskevas
- Department of Anatomy, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | | | - Panagiotis Kitsoulis
- Department of Anatomy, Histology and Embryology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Ioannis Spyridakis
- Department of Anatomy, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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de Mendonça Cardoso M, Gepp R, Correa JFG. Outcome following phrenic nerve transfer to musculocutaneous nerve in patients with traumatic brachial palsy: a qualitative systematic review. Acta Neurochir (Wien) 2016; 158:1793-800. [PMID: 27260490 DOI: 10.1007/s00701-016-2855-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 05/18/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND The phrenic nerve can be transferred to the musculocutaneous nerve in patients with traumatic brachial plexus palsy in order to recover biceps strength, but the results are controversial. There is also a concern about pulmonary function after phrenic nerve transection. In this paper, we performed a qualitative systematic review, evaluating outcomes after this procedure. METHOD A systematic review of published studies was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Data were extracted from the selected papers and related to: publication, study design, outcome (biceps strength in accordance with BMRC and pulmonary function) and population. Study quality was assessed using the "strengthening the reporting of observational studies in epidemiology" (STROBE) standard or the CONSORT checklist, depending on the study design. RESULTS Seven studies were selected for this systematic review after applying inclusion and exclusion criteria. One hundred twenty-four patients completed follow-up, and most of them were graded M3 or M4 (70.1 %) for biceps strength at the final evaluation. Pulmonary function was analyzed in five studies. It was not possible to perform a statistical comparison between studies because the authors used different parameters for evaluation. Most of the patients exhibited a decrease in pulmonary function tests immediately after surgery, with recovery in the following months. Study quality was determined using STROBE in six articles, and the global score varied from 8 to 21. CONCLUSIONS Phrenic nerve transfer to the musculocutaneous nerve can recover biceps strength ≥M3 (BMRC) in most patients with traumatic brachial plexus injury. Early postoperative findings revealed that the development of pulmonary symptoms is rare, but it cannot be concluded that the procedure is safe because there is no study evaluating pulmonary function in old age.
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Affiliation(s)
- Marcio de Mendonça Cardoso
- Department of Neurological Surgery, Sarah Network of Rehabilitation Hospitals, 70673-208, SQSW 302, Brasilia, Brazil.
| | - Ricardo Gepp
- Department of Neurological Surgery, Sarah Network of Rehabilitation Hospitals, 70673-208, SQSW 302, Brasilia, Brazil
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The internal anatomy of the inferior vena cava with specific emphasis on the entrance of the renal, gonadal and lumbar veins. Surg Radiol Anat 2015; 38:107-14. [DOI: 10.1007/s00276-015-1527-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 07/25/2015] [Indexed: 12/18/2022]
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Mejia-Terrazas GE, Garduño-Juárez MDÁ, Limón-Muñoz M, Torres-Maldonado AS, Carrillo-Esper R. Bloqueo bilateral del plexo braquial. Reporte de casos y revisión sistemática de la literatura. CIR CIR 2015; 83:312-8. [DOI: 10.1016/j.circir.2015.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 11/06/2014] [Indexed: 10/23/2022]
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Socolovsky M, di Masi G, Bonilla G, Paez MD, Robla J, Cabrera CC. The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis. Acta Neurochir (Wien) 2015; 157:1077-86; discussion 1086. [PMID: 25833303 DOI: 10.1007/s00701-015-2387-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Controversy exists surrounding the use of the phrenic nerve for transfer in severe brachial plexus injuries. The objectives of this study are: (1) to present the experience of the authors using the phrenic nerve in a single institution; and (2) to thoroughly review the existing literature to date. METHODS Adult patients with C5-D1 and C5-C8 lesions and a phrenic nerve transfer were retrospectively included. Patients with follow-up shorter than 18 months were excluded. The MRC muscle strength grading system was used to rate the outcome. Clinical repercussions relating to sectioning of the phrenic nerve were studied. An intense rehabilitation program was started after surgery, and compliance to this program was monitored using a previously described scale. Statistical analysis was performed with the obtained data. RESULTS Fifty-one patients were included. The mean time between trauma and surgery was 5.7 months. Three-quarters of the patients had C5-D1, with the remainder C5-C8. Mean post-operative follow-up was 32.5 months A MRC of M4 was achieved in 62.7% patients, M3 21.6%, M2 in 3.9%, and M1 in 11.8%. The only significant differences between the two groups were in graft length (9.8 vs. 15.1 cm, p = 0.01); and in the rehabilitation compliance score (2.86 vs. 2.00, p = 0.01). CONCLUSIONS Results of phrenic nerve transfer are predictable and good, especially if the grafts are short and the rehabilitation is adequate. It may adversely affect respiratory function tests, but this rarely correlates clinically. Contraindications to the use of the phrenic nerve exist and should be respected.
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Kramer C, Jordan D, Kretschmer A, Lehmeyer V, Kellermann K, Schaller SJ, Blobner M, Kochs EF, Fink H. Electromyographic permutation entropy quantifies diaphragmatic denervation and reinnervation. PLoS One 2014; 9:e115754. [PMID: 25532023 PMCID: PMC4274091 DOI: 10.1371/journal.pone.0115754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 11/11/2014] [Indexed: 02/04/2023] Open
Abstract
Spontaneous reinnervation after diaphragmatic paralysis due to trauma, surgery, tumors and spinal cord injuries is frequently observed. A possible explanation could be collateral reinnervation, since the diaphragm is commonly double-innervated by the (accessory) phrenic nerve. Permutation entropy (PeEn), a complexity measure for time series, may reflect a functional state of neuromuscular transmission by quantifying the complexity of interactions across neural and muscular networks. In an established rat model, electromyographic signals of the diaphragm after phrenicotomy were analyzed using PeEn quantifying denervation and reinnervation. Thirty-three anesthetized rats were unilaterally phrenicotomized. After 1, 3, 9, 27 and 81 days, diaphragmatic electromyographic PeEn was analyzed in vivo from sternal, mid-costal and crural areas of both hemidiaphragms. After euthanasia of the animals, both hemidiaphragms were dissected for fiber type evaluation. The electromyographic incidence of an accessory phrenic nerve was 76%. At day 1 after phrenicotomy, PeEn (normalized values) was significantly diminished in the sternal (median: 0.69; interquartile range: 0.66-0.75) and mid-costal area (0.68; 0.66-0.72) compared to the non-denervated side (0.84; 0.78-0.90) at threshold p<0.05. In the crural area, innervated by the accessory phrenic nerve, PeEn remained unchanged (0.79; 0.72-0.86). During reinnervation over 81 days, PeEn normalized in the mid-costal area (0.84; 0.77-0.86), whereas it remained reduced in the sternal area (0.77; 0.70-0.81). Fiber type grouping, a histological sign for reinnervation, was found in the mid-costal area in 20% after 27 days and in 80% after 81 days. Collateral reinnervation can restore diaphragm activity after phrenicotomy. Electromyographic PeEn represents a new, distinctive assessment characterizing intramuscular function following denervation and reinnervation.
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Affiliation(s)
- Christopher Kramer
- Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
| | - Denis Jordan
- Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
- * E-mail:
| | - Alexander Kretschmer
- Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
| | - Veronika Lehmeyer
- Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
| | - Kristine Kellermann
- Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
| | - Stephan J. Schaller
- Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
| | - Manfred Blobner
- Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
| | - Eberhard F. Kochs
- Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
| | - Heidrun Fink
- Klinik für Anaesthesiologie, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
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Hamada T, Usami A, Kishi A, Kon H, Takada S. Anatomical study of phrenic nerve course in relation to neck dissection. Surg Radiol Anat 2014; 37:255-8. [PMID: 25026999 DOI: 10.1007/s00276-014-1343-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/07/2014] [Indexed: 10/25/2022]
Abstract
The present study sought to clarify the course of the phrenic nerve and its correlation with anatomical landmarks in the neck region. We examined 17 cadavers (30 sides). In each, the phrenic nerves was dissected from the lateral side of the neck, and its position within the triangle formed by the mastoid process and sternal and acromial ends of the clavicle was determined. The point where the phrenic nerve arises in the posterior triangle was found to be similar to the point where the cutaneous blanches of the cervical plexus emerge at the middle of the posterior border of the sternocleidomastoid muscle. In the supraclavian triangle, the phrenic nerve crosses the anterior border of the anterior scalene muscle near Erb's point where the superficial point is 2-3 cm superior from the clavicle and posterior border of the sternocleidomastoid muscle. The phrenic nerve arises in the posterior triangle near the nerve point, then descends to the anterior surface of the anterior scalene muscle in the supraclavian triangle. It is necessary to be aware of the supraclavian triangle below Erb's point during neck dissection procedures.
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Affiliation(s)
- Tomohiro Hamada
- Department of Oral and Maxillofacial Surgery, Ohu University School of Dentistry, 31-1, Misumido, Tomita, Koriyama, Fukushima, 963-8611, Japan,
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Communication of the transverse cervical nerve with the marginal mandibular nerve: a previously unreported anatomical variant. Br J Oral Maxillofac Surg 2014; 52:577-8. [DOI: 10.1016/j.bjoms.2014.03.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 03/27/2014] [Indexed: 11/15/2022]
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Yang CW, Jung SM, Kwon HU, Kang PS, Cho CK, Choi HJ. Transient hemidiaphragmatic paresis after ultrasound-guided lateral sagittal infraclavicular block. J Clin Anesth 2013; 25:496-8. [DOI: 10.1016/j.jclinane.2013.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Revised: 03/20/2013] [Accepted: 04/01/2013] [Indexed: 10/26/2022]
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Mendelsohn AH, DeConde A, Lambert HW, Dodson SC, Daney BT, Stark ME, Berke GS, Wisco JJ. Cervical variations of the phrenic nerve. Laryngoscope 2011; 121:1920-3. [DOI: 10.1002/lary.21894] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 04/06/2011] [Indexed: 11/10/2022]
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Yang ML, Li JJ, Zhang SC, Du LJ, Gao F, Li J, Wang YM, Gong HM, Cheng L. Functional restoration of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization utilizing the functional spinal accessory nerve. J Neurosurg Spine 2011; 15:190-4. [PMID: 21529201 DOI: 10.3171/2011.3.spine10911] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report a case of functional improvement of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization using a functional spinal accessory nerve. Complete spinal cord injury at the C-2 level was diagnosed in a 44-year-old man. Left diaphragm activity was decreased, and the right diaphragm was completely paralyzed. When the level of metabolism or activity (for example, fever, sitting, or speech) slightly increased, dyspnea occurred. The patient underwent neurotization of the right phrenic nerve with the trapezius branch of the right spinal accessory nerve at 11 months postinjury. Four weeks after surgery, training of the synchronous activities of the trapezius muscle and inspiration was conducted. Six months after surgery, motion was observed in the previously paralyzed right diaphragm. The lung function evaluation indicated improvements in vital capacity and tidal volume. This patient was able to sit in a wheelchair and conduct outdoor activities without assisted ventilation 12 months after surgery.
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Affiliation(s)
- Ming-liang Yang
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Jian-jun Li
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | | | - Liang-jie Du
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Feng Gao
- 4Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China
| | - Jun Li
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Yu-ming Wang
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Hui-ming Gong
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Liang Cheng
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
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Cartography of human diaphragmatic innervation: Preliminary data. Respir Physiol Neurobiol 2011; 176:68-71. [DOI: 10.1016/j.resp.2010.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 11/03/2010] [Indexed: 11/23/2022]
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Paraskevas GK, Raikos A, Chouliaras K, Papaziogas B. Variable anatomical relationship of phrenic nerve and subclavian vein: clinical implication for subclavian vein catheterization. Br J Anaesth 2011; 106:348-51. [PMID: 21233111 DOI: 10.1093/bja/aeq373] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND During subclavian vein catheterization, a potential, but rare, hazard is the phrenic nerve injury, which compromises respiratory function. We conducted a cadaver study focused on the possible anatomical relationships between the subclavian vein and the phrenic nerve. METHODS Forty-two adult cadavers (84 heminecks) were dissected. Special attention was given to the topography of the phrenic nerve and subclavian vein. RESULTS In all but three cases (81 of 84), normal topography was present, that is, the nerve was posterior to the vein. In two cases, the phrenic nerve crossed anterior to the subclavian vein and in one case traversed the anterior wall of the subclavian vein. CONCLUSIONS Variants of the relationship of the subclavian vein and the phrenic nerve should be familiar to anaesthesiologists during subclavian vein cannulation in order to achieve successful vein approach without causing phrenic nerve palsy.
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Affiliation(s)
- G K Paraskevas
- Department of Anatomy, Medical School of Aristotle University of Thessaloniki, PO Box 300, 54124 Thessaloniki, Greece.
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Brennan PA, Gholmy MA, Ounnas H, Zaki GA, Puxeddu R, Standring S. Communication of the anterior branch of the great auricular nerve with the marginal mandibular nerve: A prospective study of 25 neck dissections. Br J Oral Maxillofac Surg 2010; 48:431-3. [DOI: 10.1016/j.bjoms.2009.07.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2009] [Indexed: 10/20/2022]
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Siqueira MG, Martins RS. PHRENIC NERVE TRANSFER IN THE RESTORATION OF ELBOW FLEXION IN BRACHIAL PLEXUS AVULSION INJURIES. Neurosurgery 2009; 65:A125-31. [DOI: 10.1227/01.neu.0000338865.19411.7f] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Abstract
OBJECTIVE
Phrenic nerve transfer has been used for treating lesions of the brachial plexus since 1970. Although, today, surgeons are more experienced with the technique, there are still widespread concerns about its effects on pulmonary function. This study was undertaken to evaluate the effectiveness and safety of this procedure.
METHODS
Fourteen patients with complete palsy of the upper limb were submitted to phrenic nerve transfer as part of a strategy for surgical reconstruction of their plexuses. Two patients were lost to follow-up, and 2 patients were followed for less than 2 years. Of the remaining 10 patients, 9 (90%) were male. The lesions affected both sides equally. The mean age of the patients was 24.8 years (range, 14–43 years), and the mean interval from injury to surgery was 6 months (range, 3–9 months). The phrenic nerve was always transferred to the musculocutaneous nerve, and a nerve graft (mean length, 8 cm; range, 4.5–12 cm) was necessary in all cases.
RESULTS
There was no major complication related to the surgery. Seven patients (70%) recovered functional level biceps strength (Medical Research Council grade ≥3). All of the patients exhibited a transient decrease in pulmonary function tests, but without clinical respiratory problems.
CONCLUSION
On the basis of our small series and data from the literature, we conclude that phrenic nerve transfer in well-selected patients is a safe and effective procedure for recovering biceps function.
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Affiliation(s)
- Mario G. Siqueira
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, São Paulo University Medical School, São Paulo, Brazil
| | - Roberto S. Martins
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, São Paulo University Medical School, São Paulo, Brazil
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Canella C, Demondion X, Delebarre A, Moraux A, Cotten H, Cotten A. Anatomical study of phrenic nerve using ultrasound. Eur Radiol 2009; 20:659-65. [DOI: 10.1007/s00330-009-1579-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 07/01/2009] [Accepted: 07/16/2009] [Indexed: 11/29/2022]
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Mears JA, Lachman N, Christensen K, Asirvatham SJ. The Phrenic Nerve And Atrial Fibrillation Ablation Procedures. J Atr Fibrillation 2009; 2:176. [PMID: 28496627 DOI: 10.4022/jafib.176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2009] [Revised: 04/19/2009] [Accepted: 05/14/2009] [Indexed: 11/10/2022]
Abstract
Radiofrequency ablation is increasingly used as an option to optimally manage patients with symptomatic atrial fibrillation. Presently, ablationists strive to improve success rates, particularly with persistent atrial fibrillation, while simultaneously attempting to reduce complications. A well-recognized complication with atrial fibrillation ablation is injury to the phrenic nerve giving rise to diaphragmatic paresis and patient discomfort.Phrenic nerve damage may occur when performing common components of atrial fibrillation ablation including pulmonary and superior vena caval isolation. The challenge for ablationists is to successfully target the arrhythmogenic substrate while avoiding this complication. In order to do this, a thorough knowledge of phrenic nerve anatomy, points in the ablation procedure where nerve damage is more likely, and an understanding of the presently utilized techniques to avoid this complication is required. In addition, when this complication does arise, prompt recognition of its occurrence, knowledge of the natural history, and available methods for management are needed.In this review, we discuss the underlying anatomic principles, techniques of avoiding phrenic nerve damage, and presently available methods of diagnosing and managing this complication.
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Affiliation(s)
- Jennifer A Mears
- Division of Cardiovascular Diseases and Internal Medicine Mayo Clinic, Rochester, Minnesota
| | | | | | - Samuel J Asirvatham
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine.,Division of Cardiovascular Diseases and Internal Medicine Mayo Clinic, Rochester, Minnesota
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Lee HS, Lee JH, Cha YD, Park SK, Seo CH, Han JU. Phrenic nerve palsy following coracoid infraclavicular brachial plexus block. Korean J Anesthesiol 2009; 57:515-517. [DOI: 10.4097/kjae.2009.57.4.515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Hong Sik Lee
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
| | - Jae Hak Lee
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
| | - Young Deog Cha
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
| | - Sang Kyu Park
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
| | - Chu Hwan Seo
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
| | - Jeong Uk Han
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
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