A prospective study of peripheral nerve lesions occurring in traumatic brain-injured patients

Traumatic injury to peripheral nerves

This article reviews the epidemiology, classification, localization, prognosis, and mechanisms of recovery of traumatic peripheral nerve injuries (PNIs). Electrodiagnostic (EDx) assessments are critical components of treating patients with PNIs. In particular, motor and sensory nerve conduction studies, needle electromyography, and other electrophysiological methods are useful for localizing peripheral nerve injuries, detecting and quantifying the degree of axon loss, and contributing toward treatment decisions as well as prognostication. It is critical that EDx medical consultants are aware of the timing of these changes as well as limitations in interpretations. Mechanisms of recovery may include recovery from conduction block, muscle fiber hypertrophy, distal axonal sprouting, and axon regrowth from the site of injury. Motor recovery generally reaches a plateau at 18 to 24 months postinjury. When patients have complete or severe nerve injuries they should be referred to surgical colleagues early after injury, as outcomes are best when nerve transfers are performed within the first 3 to 6 months after onset.

Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury

OBJECTIVE

To review the literature addressing the assessment and management of pain in patients with polytraumatic injuries including traumatic brain injury (TBI) and blast-related headache, and to identify patient, clinician and systems factors associated with pain-related outcomes.

DESIGN

Systematic review.

METHODS

We conducted searches in MEDLINE of literature published from 1950 through July 2008. Due to a limited number of studies using controls or comparators, we included observational and rigorous qualitative studies. We systematically rated the quality of systematic reviews, cohort, and case-control design studies.

RESULTS

One systematic review, 93 observational studies, and one qualitative research study met inclusion criteria. The literature search yielded no published studies that assessed measures of pain intensity or pain-related functional interference among patients with cognitive deficits due to TBI, that compared patients with blast-related headache with patients with other types of headache, or that assessed treatments for blast-related headache pain. Studies on the association between TBI severity and pain reported mixed findings. There was limited evidence that the following factors are associated with pain among TBI patients: severity, location, and multiplicity of injuries; insomnia; fatigue; depression; and post-traumatic stress disorder.

CONCLUSIONS

Very little evidence is currently available to guide pain assessment and treatment approaches in patients with polytrauma. Further research employing systematic observational as well as controlled intervention designs is clearly indicated.

The characteristics of chronic central pain after traumatic brain injury

Central pain following traumatic brain injury (TBI) has not been studied in depth. Our purpose was to conduct a systematic study of patients with TBI suffering from chronic central pain, and to describe the characteristics of the central pain. Groups were TBI patients with (TBIP) and without central pain (TBINP) and healthy controls. TBI patients with other pain mechanisms were excluded from the study. Participants underwent quantitative somatosensory testing in the painful and pain-free body regions. Thresholds for warmth, cold, heat-pain, touch and graphesthesia were measured and pathologically evoked pain (allodynia, hyperpathia and wind-up pain) evaluated. Chronic pain was mapped and characterized. Chronic pain developed at a relatively late onset (6.6+/-9 months) was almost exclusively unilateral and reported as pricking, throbbing and burning. Although both TBIP and TBINP exhibited a significant reduction in thermal and tactile sensations compared to controls, thermal sensations in the painful regions of TBIP were significantly more impaired than pain-free regions in the same patients (p<0.01) and in TBINP (p<0.01). Painful regions also exhibited very high rates of allodynia, hyperpathia and exaggerated wind-up. The characteristics of the chronic pain resembled those of other central pain patients although TBIP displayed several unique features. The sensory profile indicated that damage to the pain and temperature systems is a necessary but not sufficient condition for the development of chronic central pain following TBI. Neuronal hyperexcitability may be a contributing factor to the chronic pain.

Pain and traumatic brain injury

For the patient who has sustained traumatic brain injury (TBI), understanding the problem and listening to and believing the patient are prerequisites to treating pain. Because the information provided may be limited, communication skills problematic, and consistency variable, the challenge of treating individuals with TBI and pain can be daunting. Most painful conditions after TBI involve the musculoskeletal system; however, in conditions that are neurologically based, a careful and well-organized neurologic examination can be helpful to direct one's attention toward ordering the appropriate tests and treatments. The primary focus for helping patients with pain involves not only understanding the problem and assisting with symptom relief but also providing the opportunity to improve their functioning, physically and cognitively.

Peripheral nerve injuries: A retrospective survey of 456 cases

This 16-year retrospective study reports the data on 456 consecutive patients with 557 peripheral nerve injuries (PNIs) between 1989 and 2004. Most patients were men (74%) and the mean age was 32.4 years. In 83% of cases the PNIs were isolated; combined lesions most commonly involved the ulnar and median nerves. Upper-limb PNIs occurred in 73.5% of cases; the ulnar nerve was most often injured, either singly or in combination. Vehicle accidents affecting the brachial plexus or radial, sciatic, facial, and peroneal nerves were the most common cause of injury. Penetrating trauma commonly affected the ulnar and median nerves; falls and gunshot wounds frequently affected the ulnar, radial, and median nerves; and sports injuries, particularly soccer, affected mainly the peroneal and tibial nerves. More than half of the brachial plexus lesions after vehicular accidents were from motorcycle crashes.

Traumatic injury to peripheral nerves

This article reviews the epidemiology and classification of traumatic peripheral nerve injuries, the effects of these injuries on nerve and muscle, and how electrodiagnosis is used to help classify the injury. Mechanisms of recovery are also reviewed. Motor and sensory nerve conduction studies, needle electromyography, and other electrophysiological methods are particularly useful for localizing peripheral nerve injuries, detecting and quantifying the degree of axon loss, and contributing toward treatment decisions as well as prognostication.

Analysis of upper and lower extremity peripheral nerve injuries in a population of patients with multiple injuries

BACKGROUND

The purpose of this study was to determine the prevalence, cause, severity, and patterns of associated injuries of limb peripheral nerve injuries sustained by patients with multiple injuries seen at a regional Level 1 trauma center.

METHODS

Patients sustaining injuries to the radial, median, ulnar, sciatic, femoral, peroneal, or tibial nerves were identified using a prospectively collected computerized database, maintained by Sunnybrook Health Science Centre, and a detailed chart review was undertaken.

RESULTS

From a trauma population of 5,777 patients treated between January 1, 1986, and November 30, 1996, 162 patients were identified as having an injury to at least one of the peripheral nerves of interest, yielding a prevalence of 2.8%. These 162 patients sustained a total of 200 peripheral nerve injuries, 121 of which were in the upper extremity. The mean patient age was 34.6 years (SEM +/- 1.1 year), and 83% of patients were male. The mean injury severity score was 23.1 (+/-0.90), and the mean length of hospital stay was 28 days (+/-1.8).

CONCLUSIONS

Motor vehicles crashes predominated (46%) as the cause of injury. The most frequently injured nerve was the radial nerve (58 injuries), and in the lower limb, the peroneal nerve was most commonly injured (39 injuries). Diagnosis of a peripheral nerve injury was made within 4 days of admission to Sunnybrook Health Science Centre in 78% of the cases. Surgery was required to treat 54% of patients. Head injuries were the most common associated injury, occurring in 60% of patients. Other common associated injuries included fractures and dislocations. The present report aims to aid in identification and treatment of peripheral nerve injuries.

Radial nerve injury associated with traumatic myositis ossificans in a brain injured patient

As unrelated complications, peripheral nerve injury and heterotopic ossification (HO) are frequently observed in brain injured patients. Our case presentation is a 24-year-old man who sustained a brain injury in a motor vehicle accident. At two months postinjury he remained at a Rancho Level II and had HO identified in eight joints. Over the next several months, his cognition improved and he demonstrated active movement at the left wrist, but no movement at the right wrist. Plain radiographs and bone scan were consistent with myositis ossification posterior to the right mid-humerus and no fracture was identified. Electromyography revealed a right radial nerve injury below the branch to the triceps. Nine months postinjury, the patient had 4-/5 strength in right wrist extension. A thorough evaluation of all possible etiologies for a given impairment may lead to altered treatment and/or prognosis.