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Berger MJ, Adewuyi AA, Doherty C, Hanlan AK, Morin C, O'Connor R, Sharma R, Sproule S, Swong KN, Wu H, Franz CK, Brown E. Segmental infralesional pathological spontaneous activity in subacute traumatic spinal cord injury. Muscle Nerve 2024; 69:403-408. [PMID: 38294062 DOI: 10.1002/mus.28053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 01/13/2024] [Accepted: 01/21/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION/AIMS There is a dearth of knowledge regarding the status of infralesional lower motor neurons (LMNs) in individuals with traumatic cervical spinal cord injury (SCI), yet there is a growing need to understand how the spinal lesion impacts LMNs caudal to the lesion epicenter, especially in the context of nerve transfer surgery to restore several key upper limb functions. Our objective was to determine the frequency of pathological spontaneous activity (PSA) at, and below, the level of spinal injury, to gain an understanding of LMN health below the spinal lesion. METHODS Ninety-one limbs in 57 individuals (53 males, mean age = 44.4 ± 16.9 years, mean duration from injury = 3.4 ± 1.4 months, 32 with motor complete injuries), were analyzed. Analysis was stratified by injury level as (1) C4 and above, (2) C5, and (3) C6-7. Needle electromyography was performed on representative muscles innervated by the C5-6, C6-7, C7-8, and C8-T1 nerve roots. PSA was dichotomized as present or absent. Data were pooled for the most caudal infralesional segment (C8-T1). RESULTS A high frequency of PSA was seen in all infralesional segments. The pooled frequency of PSA for all injury levels at C8-T1 was 68.7% of the limbs tested. There was also evidence of PSA at the rostral border of the neurological level of injury, with 58.3% of C5-6 muscles in those with C5-level injuries. DISCUSSION These data support a high prevalence of infralesional LMN abnormalities following SCI, which has implications to nerve transfer candidacy, timing of the intervention, and donor nerve options.
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Affiliation(s)
- Michael J Berger
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Adenike A Adewuyi
- Regenerative Neurorehabilitation Laboratory, Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christopher Doherty
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amy K Hanlan
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Cynthia Morin
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Russ O'Connor
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Radhika Sharma
- Regenerative Neurorehabilitation Laboratory, Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shannon Sproule
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin N Swong
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Harvey Wu
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Colin K Franz
- Regenerative Neurorehabilitation Laboratory, Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Erin Brown
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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de Padua A, Renfro C, Grabnar M, Kilgore K, Bryden A, Roach MJ, Nemunaitis G. Can the electrically stimulated manual muscle test differentiate upper from lower motor neuron injury in persons with acute SCI? Neurol Res 2023; 45:906-911. [PMID: 32972329 DOI: 10.1080/01616412.2020.1824417] [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: 05/31/2019] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine if the motor response on the stimulated manual muscle test (SMMT) in muscles with a grade 0 motor score on the manual muscle test (MMT) can differentiate lower motor neuron (LMN) from upper motor neuron (UMN) injury based on the presence of spontaneous activity (SA) with needle EMG. DESIGN Prospective Study. PARTICIPANTS/METHODS Twenty-one subjects with acute traumatic cervical SCI. METHODS An upper extremity International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) evaluation was completed on all subjects. A needle EMG and an electrically stimulated manual muscle test (SMMT) were completed on all key upper extremity muscles with a MMT motor score of zero. RESULTS The MMT, SMMT and Needle EMG were done on 77 muscles. The SMMT motor score was 0 on 10 muscles and >1 on 67 muscles. The needle EMG identified spontaneous activity (SA) in 55/77 muscles. Seventy percent (7/10) of the muscles with MMT and SMMT motor score of zero demonstrated SA on EMG. Seventy-two percent (48/67) of the muscles with MMT motor score = 0 and SMMT motor score ≥1 demonstrated SA on EMG. CONCLUSION In our study, 70% of the muscles with a SMMT motor response of zero and 72% of the muscles with a SMMT motor response greater than or equal to one demonstrated SA on EMG. The use of the SMMT as a clinical measure to differentiate LMN from UMN integrity may be limited when applied.
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Affiliation(s)
- Ashley de Padua
- Dept. PM&R, St. Luke's University Health Network, Bethlehem, PA, USA
| | | | - Maria Grabnar
- Dept. PM&R, MetroHealth Medical System, Cleveland, OH, USA
| | - Kevin Kilgore
- Dept. PM&R, MetroHealth Medical System, Cleveland, OH, USA
- Dept. PM&R, Case Western Reserve University, Cleveland, OH, USA
| | - Anne Bryden
- Dept. PM&R, MetroHealth Medical System, Cleveland, OH, USA
| | - Mary Joan Roach
- Dept. PM&R, MetroHealth Medical System, Cleveland, OH, USA
- Dept. PM&R, Case Western Reserve University, Cleveland, OH, USA
- Center for Health Research & Policy, Cleveland, OH, USA
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Mahmoodkhani M, Riazi A, Askari N, Mahdkhah A. Pneumocephalus without Pneumorrhachis after penetrating spinal trauma. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
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Shin AY, Bishop AT, Loosbroch MF, Spinner RJ. A multidisciplinary approach to the management of brachial plexus injuries: experience from the Mayo Clinic over 100 years. J Hand Surg Eur Vol 2022; 47:1103-1113. [PMID: 35833214 DOI: 10.1177/17531934221110733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A multidisciplinary brachial plexus clinic has been a relatively new concept, offering different surgical speciality perspectives on the treatment of brachial plexus injuries. The resulting collaborative effort has proven to be greater than the sum of its parts. In this review, the history, philosophy of care, development/implementation and impact of a creation of a multidisciplinary brachial plexus team at the Mayo Clinic are detailed.
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Affiliation(s)
- Alexander Y Shin
- Department of Orthopedic Surgery, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen T Bishop
- Department of Orthopedic Surgery, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle F Loosbroch
- Department of Orthopedic Surgery, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert J Spinner
- Department of Orthopedic Surgery, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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Brogan DM, Osei DA, Colorado BS, Sneag DB, Van Voorhis A, Dy CJ. Team Approach: Management of Brachial Plexus Injuries. JBJS Rev 2022; 10:01874474-202204000-00005. [PMID: 35427254 DOI: 10.2106/jbjs.rvw.21.00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Traumatic brachial plexus injuries are relatively rare but potentially devastating injuries with substantial functional, psychological, and economic consequences. » Prompt referral (ideally within 6 weeks of injury) to a center with a team of experts experienced in the diagnosis and management of these injuries is helpful to achieving optimal outcomes. » Preoperative and intraoperative decision-making to diagnose and plan reconstructive procedures is complex and must take into account a number of factors, including the time from injury, concomitant injuries, preservation of cervical nerve roots, and the availability of intraplexal and extraplexal donor nerves for nerve transfer. » A team approach is essential to ensure accurate localization of the pathology before surgery and to maximize rehabilitation after surgery, necessitating close contact between the surgical team, physiatrists, radiologists, and therapists.
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Affiliation(s)
- David M Brogan
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | | | - Berdale S Colorado
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | | | - Anna Van Voorhis
- Program in Occupational Therapy, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher J Dy
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
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Pneumocephalus from brachial plexus avulsion: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Suroto H, Antoni I, Siyo A, Steendam TC, Prajasari T, Mulyono HB, De Vega B. Traumatic Brachial Plexus Injury in Indonesia: An Experience from a Developing Country. J Reconstr Microsurg 2021; 38:511-523. [PMID: 34470060 PMCID: PMC9470278 DOI: 10.1055/s-0041-1735507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background
Brachial plexus injuries (BPI) cause severe physical disability and major psycho-socioeconomic burden. Although various countries have reported BPI incidence, the data from Indonesia as the fourth most populated country in the world remains unknown. We aim to assess the distribution of traumatic BPI, patients' characteristics, and treatment modalities in Indonesia.
Methods
A retrospective investigation was performed comprising 491 BPI patients at a tertiary referral hospital in Indonesia from January 2003 to October 2019. Demographic and outcomes data were retrieved from medical records.
Results
The average BPI patients' age was 27.3 ± 11.6 years old, with a male/female ratio of 4.6:1. Motorcycle accidents caused the majority (76.1%) of all BPI cases. Concomitant injuries were present in 62.3% of patients, dominated by fractures (57.1%) and brain injuries (25.4%). BPI lesion type was classified into complete (C5-T1, observed in 70% patients), upper (C5-C6, in 15% patients), extended upper (C5-C7, in 14% patients), and lower type (C8-T1, in 1% patients). The average time to surgery was 16.8 months (range 1–120 months), with the majority (76.6%) of the patients was operated on six months after the trauma. Free functional muscle transfer (FFMT) was the most common procedure performed (37%). We also analyzed the functional outcomes (active range of motion (AROM) and muscle power), DASH (Disabilities of the Arm, Shoulder, and Hand) score, and VAS (Visual Analogue Scale) across four most frequent procedures involving nerve reconstruction (FFMT, nerve transfer, external neurolysis, and nerve grafting). We found that FFMT was significantly better than nerve transfer in terms of DASH score and VAS (
p
= 0.000 and
p
= 0.016, respectively) in complete BPI (C5-T1). Moreover, we also found that nerve grafting resulted in a significantly better shoulder abduction AROM than nerve transfer and external neurolysis in extended upper BPI (C5-C7) (
p
= 0.033 and
p
= 0.033, respectively). Interestingly, no significant differences were observed in other measurements.
Conclusion
This study provides an overview of traumatic BPI patients in a single tertiary trauma center in Indonesia, expressing the profile of their characteristics and functional outcomes after surgical procedures.
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Affiliation(s)
- Heri Suroto
- Department of Orthopaedic and Traumatology, Dr Soetomo General Academic Hospital/ Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia
| | - Irene Antoni
- Research Fellow at Cell and Tissue Bank Regenerative Medicine, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Angelina Siyo
- Research Fellow at Cell and Tissue Bank Regenerative Medicine, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | | | - Tabita Prajasari
- Department of Orthopaedic and Traumatology, Dr Soetomo General Academic Hospital/ Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia
| | | | - Brigita De Vega
- Research Fellow at Cell and Tissue Bank Regenerative Medicine, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.,Institute of Orthopaedics and Musculoskeletal Science, University College London, United Kingdom
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Missed bilateral radial head fractures in central cord syndrome. Spinal Cord Ser Cases 2020; 6:97. [DOI: 10.1038/s41394-020-00347-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 11/08/2022] Open
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Hitchman N, Finlayson H, Krassioukov A. Radial palsy in an individual with high-level chronic spinal cord injury. Spinal Cord Ser Cases 2020; 6:52. [PMID: 32601268 PMCID: PMC7324385 DOI: 10.1038/s41394-020-0304-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/13/2020] [Accepted: 06/14/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Prolonged compression is a common cause of radial neuropathy in able-bodied individuals but has not been reported in individuals with chronic SCI. This is despite the fact that individuals with SCI may be at increased risk of peripheral nerve injuries due to wheelchair mobility and baseline sensory deficits. Furthermore, diagnosis of peripheral nerve injury poses a unique challenge in this population because symptoms and signs are superimposed on pre-existing central deficits. CASE PRESENTATION We present the case of a 48-year-old man with a C6 AIS A SCI from a motor vehicle accident 22 years earlier who had a new onset compressive radial neuropathy. At initial assessment he complained of paresthesia along his lateral right arm accompanied by new onset wrist-drop. Subsequent radial nerve conduction studies revealed severe reductions in amplitude for sensory and motor action potentials. The patient was managed with mobility exercises and vitamin B supplementation and showed full recovery of motor and sensory function to baseline levels on follow-up 4 months after the injury. DISCUSSION The electrophysiologic profile of this patient is illustrative of severe nerve compression for an extended time period. Unlike able-bodied individuals who can reposition themselves to alleviate nerve compression, individuals with SCI may be unaware of nerve compression or unable to reposition themselves. This highlights the need for precautionary measures such as maneuvers and devices to provide trunk and limb stability along with the use of medical alert devices that allow individuals to access timely help when unattended.
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Affiliation(s)
- Nathan Hitchman
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- MD Undergraduate Program, University of British Columbia, Vancouver, BC, Canada
| | - Heather Finlayson
- Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC, Canada
| | - Andrei Krassioukov
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
- Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada.
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC, Canada.
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Kaiser R, Waldauf P, Ullas G, Krajcová A. Epidemiology, etiology, and types of severe adult brachial plexus injuries requiring surgical repair: systematic review and meta-analysis. Neurosurg Rev 2020; 43:443-452. [PMID: 30014280 DOI: 10.1007/s10143-018-1009-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
Abstract
The literature describing epidemiology, etiology, and types of serious brachial plexus injuries (BPIs) is sparse. The aim of this review was to investigate the epidemiological and etiopathogenetical data of serious BPIs undergoing surgical reconstruction. A systematic search was conducted from January 1985 to December 2017. All studies that reported data about prevalence of specific types and causes of BPIs in adults treated surgically were included and cumulatively analyzed. Ten studies including 3032 patients were identified. The pooled prevalence of closed BPIs was 93% (95% CI: 87-97%), lacerations accounted for 3% (95% CI: 1-6%), and gunshot wounds (GSWs) for 3% (95% CI: 0-7%). The prevalence of male patients was 93% (95% CI: 90-96%) and female cases 7% (95% CI: 4-10%). The most common cause of closed BPI was motorcycle accidents with 67% (95% CI: 49-82%) prevalence followed by car crashes with 14% (95% CI: 8-20%). Other causes were rare. Ninety percent (95% CI: 78-98%) of patients suffered from a supraclavicular or combined supra-/infraclavicular trauma, while 10% (95% CI: 2-22%) from isolated infraclavicular injury. The prevalence of complete lesions was 53% (95% CI: 47-58%) followed by upper plexus lesion with 39% (95% CI: 31-48%) and lower plexus injury with 6% (95% CI: 1-12%). This meta-analysis demonstrates that the typical patient suffering from severe BPI is a male after motorcycle accident with closed supraclavicular injury causing complete or slightly less commonly upper plexus palsy. Lacerations and GSWs of brachial plexus are rare.
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Affiliation(s)
- Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czech Republic.
| | - Petr Waldauf
- Department of Anesthesiology and Critical Care Medicine, Third Faculty of Medicine, Charles University and Hospital Královské Vinohrady, Prague, Czech Republic
| | - Gautham Ullas
- Department of ENT, Cumberland Infirmary, North Cumbria University Hospitals NHS Trust, Carlisle, UK
| | - Aneta Krajcová
- Department of Plastic Surgery, First Faculty of Medicine, Charles University and Hospital Na Bulovce, Prague, Czech Republic
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Huang AE, Noland SS, Spinner RJ, Bishop AT, Shin AY. Outcomes of Reconstructive Surgery in Traumatic Brachial Plexus Injury with Concomitant Vascular Injury. World Neurosurg 2019; 135:e350-e357. [PMID: 31837496 DOI: 10.1016/j.wneu.2019.11.166] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate functional outcome from reconstructive surgery in adult traumatic brachial plexus injury (AT-BPI) with associated vascular lesions. METHODS A retrospective review was performed of 325 patients with AT-BPI who underwent reconstructive surgery between 2001 and 2012. Patients with (vascular group) and without (control group) vascular injuries were identified by review of medical documentation. Patient presentation, characteristics of nerve and associated lesions, and surgical management were evaluated to identify prognostic variables. Postoperative muscle strength, range of motion, and patient-reported disability scores were analyzed to determine long-term outcome. RESULTS Sixty-eight patients had a concomitant vascular injury. There were no significant differences in age or sex between the control and vascular groups. The vascular group was more likely to have pan-plexus lesions (P < 0.0001), with significantly more associated upper extremity injuries (P < 0.0001). The control group underwent more nerve transfers, whereas the vascular group underwent more nerve grafting (P = 0.003). Complete outcome data were obtained in 139 patients, which included 111 control (43% of all control subjects) and 28 vascular patients (41%). There was no significant difference in patient-reported disability scores between the 2 groups. However, 73% of control subjects had grade 3 or greater postoperative elbow flexion, whereas only 43% of vascular patients achieved this strength (P = 0.003). Control patients demonstrated a greater increase in strength of shoulder abduction as well (P = 0.004). Shoulder external rotation strength was grade 0 in most patients, with no difference between the 2 groups. CONCLUSIONS Concomitant vascular injury leads to worse functional outcome after reconstructive surgery of traumatic brachial plexus injury.
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Affiliation(s)
- Alice E Huang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shelley S Noland
- Department of Plastic Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Robert J Spinner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen T Bishop
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Abstract
Adult traumatic brachial plexus injuries are devastating life-altering injuries occurring with increasing frequency. Evaluation includes a detailed physical examination and radiologic and electrodiagnostic studies. Critical concepts in surgical management include knowledge of injury patterns, timing of surgery, prioritization in restoration of function, and management of patient expectations. Options for treatment include neurolysis, nerve grafting, or nerve transfers and should be generally performed within 6 months of injury. The use of free functioning muscle transfers can improve function both in the acute and late setting. Modern patient-specific management can often permit consistent restoration of elbow flexion and shoulder stability with the potential of prehension of the hand. Understanding the basic concepts of management of this injury is essential for all orthopaedic surgeons who treat trauma patients.
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Clifton WE, Stone JJ, Kumar N, Marek T, Spinner RJ. Delayed Myelopathy in Patients with Traumatic Preganglionic Brachial Plexus Avulsion Injuries. World Neurosurg 2019; 122:e1562-e1569. [DOI: 10.1016/j.wneu.2018.11.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
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15
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Delayed diagnosis of traumatic gunshot wound Brown-Sequard-plus syndrome due to associated brachial plexopathy. Spinal Cord Ser Cases 2018; 4:44. [PMID: 29844927 DOI: 10.1038/s41394-018-0075-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/24/2018] [Accepted: 04/05/2018] [Indexed: 11/08/2022] Open
Abstract
Introduction Brown-Séquard Syndrome (BSS) is one of the rarest incomplete spinal cord syndromes. The combination of injuries to peripheral nerves and the central nervous system result in an array of symptoms that can result in overlapping clinical presentations and delayed diagnosis. Early detection of spinal cord injury in patients with peripheral nerve injury has been observed to have a positive effect on outcomes. Case presentation This report discusses the case of a 29-year-old male patient with Brown-Sequard-Plus Syndrome (BSPS) and Brachial Plexopathy (BP) secondary to gunshot wound in the left inferior neck. The patient was found initially with left hemibody weakness. A chest CT Scan demonstrated a fracture of the left T2 transverse process. Imaging studies of the spinal cord were not performed in the acute setting. Evaluation in an outpatient setting 3 weeks later showed significant left upper extremity weakness with improvement of left lower extremity strength. Also present were loss of pain and temperature sensation on the right side below the T2 dermatome level. A cervico-thoracic MRI was requested and revealed a T2 level spinal cord contusion. Electrodiagnostic studies confirmed a lower trunk left BP. Discussion The patient was diagnosed with BSPS and associated left lower trunk BP. To our knowledge, this is the first reported case of a concomitant BSPS and BP secondary to a gunshot wound. Delayed diagnosis of BSPS may occur in a trauma setting underlying the importance of a detailed history and physical examination for favorable outcomes.
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Outcomes of Muscle Brachialis Transfer to Restore Finger Flexion in Brachial Plexus Palsy. Plast Reconstr Surg 2017; 140:307e-317e. [PMID: 28746282 DOI: 10.1097/prs.0000000000003563] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In adults with lower trunk brachial plexus injury, proximal nerve surgery for restoration of prehension demonstrates poor outcomes secondary to long distances required for nerve regeneration and time-dependent degradation of motor endplates. Options for reconstruction are limited to distal tendon or nerve transfers and free-functioning muscle transfers. In this article, the authors describe the long-term outcomes of brachialis muscle-to-flexor digitorum profundus transfer to restore prehension in patients with traumatic lower trunk brachial plexus injuries. METHODS Eighteen adult patients with lower trunk brachial plexus palsy underwent brachialis muscle-to-flexor digitorum profundus transfer with the goal of restoring rudimentary prehensile function at a single institution. The patients were followed throughout their recovery with functional outcomes and patient satisfaction ratings. RESULTS Brachialis muscle transfer resulted in restoring modified British Medical Research Council grade 3 or better function in 11 of 18 patients and grade 4 function in eight of 18 patients. Eleven of the 18 patients demonstrated a postoperative functional grasp for assistance with activities of daily living. Overall patient satisfaction following brachialis muscle transfer was 56 percent. Patient preoperative wrist extension (p < 0.018) and finger extension (p < 0.029) strength correlated with improved outcomes, whereas concomitant upper extremity fracture (p < 0.023) was associated with poorer outcomes. CONCLUSIONS Brachialis muscle transfer is an option for reconstruction of prehensile function in patients with lower trunk brachial plexus palsy with preserved wrist extension. Brachialis muscle transfer is particularly useful in patients who are poor candidates for microsurgical free-functioning muscle transfer for grasp; however, its functional outcomes are not universally successful. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Ali ZS, Johnson VE, Stewart W, Zager EL, Xiao R, Heuer GG, Weber MT, Mallela AN, Smith DH. Neuropathological Characteristics of Brachial Plexus Avulsion Injury With and Without Concomitant Spinal Cord Injury. J Neuropathol Exp Neurol 2016; 75:69-85. [PMID: 26671984 PMCID: PMC6322589 DOI: 10.1093/jnen/nlv002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Neonatal brachial plexus avulsion injury (BPAI) commonly occurs as a consequence of birth trauma and can result in lifetime morbidity; however, little is known regarding the evolving neuropathological processes it induces. In particular, mechanical forces during BPAI can concomittantly damage the spinal cord and may contribute to outcome. Here, we describe the functional and neuropathological outcome following BPAI, with or without spinal cord injury, in a novel pediatric animal model. Twenty-eight-day-old piglets underwent unilateral C5–C7 BPAI with and without limited myelotomy. Following avulsion, all animals demonstrated right forelimb monoparesis. Injury extending into the spinal cord conferred greater motor deficit, including long tract signs. Consistent with clinical observations, avulsion with myelotomy resulted in more severe neuropathological changes with greater motor neuron death, progressive axonopathy, and persistent glial activation. These data demonstrate neuropathological features of BPAI associated with poor functional outcome. Interestingly, in contrast to adult small animal models of BPAI, a degree of motor neuron survival was observed, even following severe injury in this neonatal model. If this is also the case in human neonatal BPAI, repair may permit functional restoration. This model also provides a clinically relevant platform for exploring the complex postavulsion neuropathological responses that may inform therapeutic strategies.
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Affiliation(s)
- Zarina S. Ali
- From the Department of Neurosurgery (ZAS, VEJ, WS, ELZ, MTW, ANM, DHS), Penn Center for Brain Injury and Repair (ZAS, VEJ, WS, MTW, ANM, DHS), Department of Biostatistics and Epidemiology (RX), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK (WS); Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GGH)
| | - Victoria E. Johnson
- From the Department of Neurosurgery (ZAS, VEJ, WS, ELZ, MTW, ANM, DHS), Penn Center for Brain Injury and Repair (ZAS, VEJ, WS, MTW, ANM, DHS), Department of Biostatistics and Epidemiology (RX), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK (WS); Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GGH)
| | - William Stewart
- From the Department of Neurosurgery (ZAS, VEJ, WS, ELZ, MTW, ANM, DHS), Penn Center for Brain Injury and Repair (ZAS, VEJ, WS, MTW, ANM, DHS), Department of Biostatistics and Epidemiology (RX), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK (WS); Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GGH)
| | - Eric L. Zager
- From the Department of Neurosurgery (ZAS, VEJ, WS, ELZ, MTW, ANM, DHS), Penn Center for Brain Injury and Repair (ZAS, VEJ, WS, MTW, ANM, DHS), Department of Biostatistics and Epidemiology (RX), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK (WS); Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GGH)
| | - Rui Xiao
- From the Department of Neurosurgery (ZAS, VEJ, WS, ELZ, MTW, ANM, DHS), Penn Center for Brain Injury and Repair (ZAS, VEJ, WS, MTW, ANM, DHS), Department of Biostatistics and Epidemiology (RX), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK (WS); Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GGH)
| | - Gregory G. Heuer
- From the Department of Neurosurgery (ZAS, VEJ, WS, ELZ, MTW, ANM, DHS), Penn Center for Brain Injury and Repair (ZAS, VEJ, WS, MTW, ANM, DHS), Department of Biostatistics and Epidemiology (RX), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK (WS); Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GGH)
| | - Maura T. Weber
- From the Department of Neurosurgery (ZAS, VEJ, WS, ELZ, MTW, ANM, DHS), Penn Center for Brain Injury and Repair (ZAS, VEJ, WS, MTW, ANM, DHS), Department of Biostatistics and Epidemiology (RX), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK (WS); Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GGH)
| | - Arka N. Mallela
- From the Department of Neurosurgery (ZAS, VEJ, WS, ELZ, MTW, ANM, DHS), Penn Center for Brain Injury and Repair (ZAS, VEJ, WS, MTW, ANM, DHS), Department of Biostatistics and Epidemiology (RX), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK (WS); Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GGH)
| | - Douglas H. Smith
- From the Department of Neurosurgery (ZAS, VEJ, WS, ELZ, MTW, ANM, DHS), Penn Center for Brain Injury and Repair (ZAS, VEJ, WS, MTW, ANM, DHS), Department of Biostatistics and Epidemiology (RX), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK (WS); Division of Neurosurgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GGH)
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18
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Gritti P, Lanterna LA, Brembilla C, Lorini FL. Appearance deceives: unusual pneumothorax: traumatic phrenic nerve paralysis. Intern Emerg Med 2015; 10:247-8. [PMID: 25139212 DOI: 10.1007/s11739-014-1114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 07/30/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Paolo Gritti
- Department of Anaesthesia and Intensive Care, Ospedale Papa Giovanni XXIII°, Bergamo, Italy,
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Fu G, Qin B, Jiang L, Huang X, Lu Q, Zhang D, Liu X, Zhu J, Zheng J, Li X, Gu L. Penile erectile dysfunction after brachial plexus root avulsion injury in rats. Neural Regen Res 2014; 9:1839-43. [PMID: 25422647 PMCID: PMC4239775 DOI: 10.4103/1673-5374.143432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2014] [Indexed: 01/22/2023] Open
Abstract
Our previous studies have demonstrated that some male patients suffering from brachial plexus injury, particularly brachial plexus root avulsion, show erectile dysfunction to varying degrees. However, the underlying mechanism remains poorly understood. In this study, we evaluated the erectile function after establishing brachial plexus root avulsion models with or without spinal cord injury in rats. After these models were established, we administered apomorphine (via a subcutaneous injection in the neck) to observe changes in erectile function. Rats subjected to simple brachial plexus root avulsion or those subjected to brachial plexus root avulsion combined with spinal cord injury had significantly fewer erections than those subjected to the sham operation. Expression of neuronal nitric oxide synthase did not change in brachial plexus root avulsion rats. However, neuronal nitric oxide synthase expression was significantly decreased in brachial plexus root avulsion + spinal cord injury rats. These findings suggest that a decrease in neuronal nitric oxide synthase expression in the penis may play a role in erectile dysfunction caused by the combination of brachial plexus root avulsion and spinal cord injury.
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Affiliation(s)
- Guo Fu
- Department of Orthopedic Trauma & Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Bengang Qin
- Department of Orthopedic Trauma & Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Li Jiang
- Orthopedic Institute, Eastern Hospital, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xijun Huang
- Department of Upper Limb Orthopedics, Eastern Hospital, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Qinsen Lu
- Emergency Department, Shandong Provincial Hospital, Jinan, Shandong Province, China
| | - Dechun Zhang
- Department of Orthopedics, the Affiliated Hospital of Binzhou Medical College, Binzhou, Shandong Province, China
| | - Xiaolin Liu
- Department of Orthopedic Trauma & Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jiakai Zhu
- Department of Orthopedic Trauma & Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jianwen Zheng
- Department of Orthopedic Trauma & Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xuejia Li
- Office of Research Service, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Liqiang Gu
- Department of Orthopedic Trauma & Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
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20
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Peripheral nerve injuries: advancing the field through research, collaboration, and education. J Hand Surg Am 2014; 39:2052-8. [PMID: 25124088 DOI: 10.1016/j.jhsa.2014.06.126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 06/24/2014] [Accepted: 06/24/2014] [Indexed: 02/02/2023]
Abstract
The Andrew J. Weiland Medal is presented each year by the American Society for Surgery of the Hand and the American Foundation for Surgery of the Hand for a body of work related to hand surgery research. This essay, awarded the Weiland Medal in 2013, focuses on advancing the field of peripheral nerve injuries through research, collaboration, and education.
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Kim SY, Kim TU, Lee SJ, Hyun JK. Prognosis for patients with traumatic cervical spinal cord injury combined with cervical radiculopathy. Ann Rehabil Med 2014; 38:443-9. [PMID: 25229022 PMCID: PMC4163583 DOI: 10.5535/arm.2014.38.4.443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 06/05/2014] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To delineate cervical radiculopathy that is found in combination with traumatic cervical spinal cord injury (SCI) and to determine whether attendant cervical radiculopathy affects the prognosis and functional outcome for SCI patients. METHODS A total of 66 patients diagnosed with traumatic cervical SCI were selected for neurological assessment (using the International Standards for the Neurological Classification of Spinal Cord Injury [ISNCSCI]) and functional evaluation (based on the Korean version Modified Barthel Index [K-MBI] and Functional Independence Measure [FIM]) at admission and upon discharge. All of the subjects received a preliminary electrophysiological assessment, according to which they were divided into two groups as follows: those with cervical radiculopathy (the SCI/Rad group) and those without (the SCI group). RESULTS A total of 32 patients with cervical SCI (48.5%) had cervical radiculopathy. The initial ISNCSCI scores for sensory and motor, K-MBI, and total FIM did not significantly differ between the SCI group and the SCI/Rad group. However, at discharge, the ISNCSCI scores for motor, K-MBI, and FIM of the SCI/Rad group showed less improvement (5.44±8.08, 15.19±19.39 and 10.84±11.49, respectively) than those of the SCI group (10.76±9.86, 24.79±19.65 and 17.76±15.84, respectively) (p<0.05). In the SCI/Rad group, the number of involved levels of cervical radiculopathy was negatively correlated with the initial and follow-up motors score by ISNCSCI. CONCLUSION Cervical radiculopathy is not rare in patients with traumatic cervical SCI, and it can impede neurological and functional improvement. Therefore, detection of combined cervical radiculopathy by electrophysiological assessment is essential for accurate prognosis of cervical SCI patients in the rehabilitation unit.
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Affiliation(s)
- Seo Yeon Kim
- Department of Rehabilitation Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Tae Uk Kim
- Department of Rehabilitation Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seong Jae Lee
- Department of Rehabilitation Medicine, National Rehabilitation Center, Seoul, Korea
| | - Jung Keun Hyun
- Department of Rehabilitation Medicine, Dankook University College of Medicine, Cheonan, Korea. ; Department of Nanobiomedical Science, BK21 PLUS NBM Global Research Center for Regenerative Medicine, Dankook University, Cheonan, Korea. ; Institute of Tissue Regeneration Engineering, Dankook University, Cheonan, Korea
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