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Li YW, Hsueh YH, Tu YY, Tu YK. Surgical reconstructions for adult brachial plexus injuries. Part II: Treatments for total arm type. Injury 2024; 55:111012. [PMID: 38041925 DOI: 10.1016/j.injury.2023.111012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
Brachial plexus injuries (BPI) contribute not only to physical dysfunction but also to socioeconomic aspects and psychological disability. Patients with total arm-type BPI will lose not only the shoulder and elbow function but also the hand function, making reconstruction particularly challenging. Reconstructive procedures commonly include nerve repair, grafting, neurotization (nerve transfer), tendon transfer and free functional muscle transfer (FFMT). Although it is difficult to achieve prehensile hand function, most of patients with total arm-type BPI can be treated with satisfied outcomes. In addition to surgical techniques, comprehensive rehabilitation is another important factor for successful outcomes, and efficient communication can help to boost patient morale and eliminate uncertainty.
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Affiliation(s)
- Yen-Wei Li
- Department of Orthopedics, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Huan Hsueh
- Department of Orthopedics, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yung-Yi Tu
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
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2
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Torres FDF, Ramalho BL, Rodrigues MR, Schmaedeke AC, Moraes VH, Reilly KT, Carvalho RDP, Vargas CD. Plasticity of face-hand sensorimotor circuits after a traumatic brachial plexus injury. Front Neurosci 2023; 17:1221777. [PMID: 37609451 PMCID: PMC10440702 DOI: 10.3389/fnins.2023.1221777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/17/2023] [Indexed: 08/24/2023] Open
Abstract
Background Interactions between the somatosensory and motor cortices are of fundamental importance for motor control. Although physically distant, face and hand representations are side by side in the sensorimotor cortex and interact functionally. Traumatic brachial plexus injury (TBPI) interferes with upper limb sensorimotor function, causes bilateral cortical reorganization, and is associated with chronic pain. Thus, TBPI may affect sensorimotor interactions between face and hand representations. Objective The aim of this study was to investigate changes in hand-hand and face-hand sensorimotor integration in TBPI patients using an afferent inhibition (AI) paradigm. Method The experimental design consisted of electrical stimulation (ES) applied to the hand or face followed by transcranial magnetic stimulation (TMS) to the primary motor cortex to activate a hand muscle representation. In the AI paradigm, the motor evoked potential (MEP) in a target muscle is significantly reduced when preceded by an ES at short-latency (SAI) or long-latency (LAI) interstimulus intervals. We tested 18 healthy adults (control group, CG), evaluated on the dominant upper limb, and nine TBPI patients, evaluated on the injured or the uninjured limb. A detailed clinical evaluation complemented the physiological investigation. Results Although hand-hand SAI was present in both the CG and the TBPI groups, hand-hand LAI was present in the CG only. Moreover, less AI was observed in TBPI patients than the CG both for face-hand SAI and LAI. Conclusion Our results indicate that sensorimotor integration involving both hand and face sensorimotor representations is affected by TBPI.
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Affiliation(s)
- Fernanda de Figueiredo Torres
- Laboratory of Neurobiology of Movement, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratory of Neuroscience and Rehabilitation, Institute of Neurology Deolindo Couto, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Bia Lima Ramalho
- Laboratory of Neurobiology of Movement, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratory of Neuroscience and Rehabilitation, Institute of Neurology Deolindo Couto, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Research, Innovation and Dissemination Center for Neuromathematics, Institute of Mathematics and Statistics, University of São Paulo, São Paulo, Brazil
| | - Marcelle Ribeiro Rodrigues
- Laboratory of Neurobiology of Movement, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratory of Neuroscience and Rehabilitation, Institute of Neurology Deolindo Couto, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Carolina Schmaedeke
- Laboratory of Neurobiology of Movement, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratory of Neuroscience and Rehabilitation, Institute of Neurology Deolindo Couto, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Victor Hugo Moraes
- Laboratory of Neurobiology of Movement, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratory of Neuroscience and Rehabilitation, Institute of Neurology Deolindo Couto, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Karen T. Reilly
- Trajectoires Team, Lyon Neuroscience Research Center, Lyon, France
- University UCBL Lyon 1, University of Lyon, Lyon, France
| | - Raquel de Paula Carvalho
- Laboratory of Neuroscience and Rehabilitation, Institute of Neurology Deolindo Couto, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Research, Innovation and Dissemination Center for Neuromathematics, Institute of Mathematics and Statistics, University of São Paulo, São Paulo, Brazil
- Laboratory of Child Development and Motricity, Department of Human Movement Science, Institute of Health and Society, Universidade Federal de São Paulo, Santos, Brazil
| | - Claudia D. Vargas
- Laboratory of Neurobiology of Movement, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratory of Neuroscience and Rehabilitation, Institute of Neurology Deolindo Couto, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Research, Innovation and Dissemination Center for Neuromathematics, Institute of Mathematics and Statistics, University of São Paulo, São Paulo, Brazil
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Maasarani S, DeLeonibus A, Wee C, Leavitt T, Lee CD, Khalid SI, Layon S, Gharb BB, Rampazzo A, Noland SS. Preinjury Social Determinants of Health Disparities Predict Postinjury Psychosocial Conditions in Adult Traumatic Brachial Plexus Injuries. Neurosurgery 2023; 93:215-223. [PMID: 36807297 DOI: 10.1227/neu.0000000000002406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/12/2022] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Adult traumatic brachial plexus injuries (TBPIs) are life-altering events that can have detrimental effects on a patient's quality of life. OBJECTIVE To examine how social determinants of health (SDOH) disparities influence the risk of developing new psychosocial conditions after TBPIs in previously psychiatric-naïve patients. METHODS Between January 2010 and June 2019, a retrospective analysis was performed using PearlDiver's Mariner, an all-payer claims database, to create 3 cohorts: TBPI disparity cohort: patients with TBPI and presence of at least 1 SDOH disparity before injury, TBPI without disparity cohort: patients with TBPI and the absence of any SDOH disparity, and control cohort: patients without TBPIs. RESULTS The matched population analyzed in this study consisted of 1176 patients who were equally represented in the TBPI disparity cohort (n = 392, 33.33%), TBPI without disparity cohort (n = 392, 33.33%), and control cohort (n = 392, 33.33%). A total of 301 patients developed any psychosocial condition with 4 years of their injury. Patients in the TBPI disparity cohort had significantly higher rates of developing any psychosocial condition (31.12%, P < .0005), depression (22.70%, P = .0032), anxiety (18.62%, P = .0203), drug abuse (7.91%, P = .0060), and alcohol abuse (4.85%, P = .03499) when compared with the other cohorts. Furthermore, the disparity cohort carried a significantly increased risk of developing any psychosocial condition (hazard ratio 1.42, 95% CI 1.09-1.86). The rates of suicide attempt, post-traumatic stress disorder, and divorce did not significantly differ between groups. CONCLUSION TBPI patients with SDOH disparities are at increased risk of developing new-onset psychosocial conditions, such as depression, anxiety, drug abuse, and alcohol abuse. Level of Evidence: Prognostic Level III.
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Affiliation(s)
- Samantha Maasarani
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Anthony DeLeonibus
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Corinne Wee
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tripp Leavitt
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Christina D Lee
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Syed I Khalid
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Sarah Layon
- University of Minnesota School of Medicine, Minneapolis, Minnesato, USA
| | - Bahar Bassiri Gharb
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Shelley S Noland
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Miller C, Jerosch-Herold C, Cross J. Brachial plexus injury: living with uncertainty. Disabil Rehabil 2022:1-7. [PMID: 35722825 DOI: 10.1080/09638288.2022.2080287] [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: 11/03/2022]
Abstract
PURPOSE A traumatic brachial plexus injury (BPI) has life-changing consequences for patients and their families. Despite advancements in treatments final outcome is unpredictable depending on factors including time to treatment, injury severity, neural regeneration, and available interventions. The final outcome may not be seen for up to four years. This study aimed to explore the impact of uncertainty on people with a traumatic BPI. METHODS Secondary qualitative analysis was conducted on data from a study exploring outcomes important to patients with a traumatic BPI. Data from semi-structured interviews with adult traumatic BPI patients (n = 13) were analyzed using reflexive thematic analysis. RESULTS Three major themes were identified in the qualitative data: (i) "I don't know what happened to me," focused on uncertainty in diagnosis. (ii) "I went to work one day… and then it all changed" centered around uncertainty in the future. (iii) Coping with uncertainty. CONCLUSION The results illustrate that people with a traumatic BPI face uncertainty regarding diagnosis, prognosis, and surrounding their roles in the future. Individuals respond to uncertainty in different ways and this needs to be understood by health care professionals. IMPLICATIONS FOR REHABILITATIONHealth professionals should consider uncertainty in all their contacts with people who have experienced a traumatic brachial plexus injury.People with a traumatic brachial plexus injury experience uncertainty in different ways therefore education and information given may be optimized if tailored to the individual rather than generic.Increasing awareness of the injury and its presentation in non-specialist acute care clinicians may accelerate diagnosis and reduce initial uncertainty.Acknowledging the presence of uncertainty is important during the shared decision-making in brachial plexus injuries.
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Affiliation(s)
- Caroline Miller
- School of Health Sciences, University of East Anglia, Norwich, UK.,Therapy Services, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | | | - Jane Cross
- School of Health Sciences, University of East Anglia, Norwich, UK
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Dhawan S, Alattar AA, Bartek J, Ma J, Bydon M, Venteicher AS, Chen CC. Racial disparity in recommendation for surgical resection of skull base chondrosarcomas: A Surveillance, Epidemiology, and End Results (SEER) analysis. J Clin Neurosci 2021; 94:186-191. [PMID: 34863436 DOI: 10.1016/j.jocn.2021.09.039] [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: 05/13/2021] [Revised: 08/09/2021] [Accepted: 09/26/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION There is increased appreciation of racial disparities in the delivery of neurosurgical care. Here, we explore whether race influences surgical recommendations in the management of skull base chondrosarcomas. METHODS We identified 493 patients with skull base chondrosarcoma using the Surveillance, Epidemiology, and End Results (SEER) registry (November 2017 submission). Regression analyses were performed to identify demographic variables associated with recommendation against surgery. Univariate and multivariate cox proportional hazards models were used for survival analysis. RESULTS In a univariate analysis, we found that the African-American race was associated with an increased likelihood of surgeon recommendation against surgery (OR = 4.416, 95% CI = 1.893-10.302, p = 0.001). This association remained robust in the multivariate model that controlled for other covariates, including age of diagnosis (OR = 5.091, 95% CI = 2.127-12.187, p < 0.001). For patients who received a recommendation against surgery, the likelihood of dying from non-chondrosarcoma causes was comparable between Caucasian and African-American patients, suggesting that the prevalence and severity of medical conditions that increase the risk of death were comparable between these cohorts (HR = 0.466, 95% CI = 0.057-3.802, p = 0.475). The likelihood of dying from chondrosarcoma was comparable between Caucasian and African-American patients who underwent surgery (HR = 0.982, 95% CI = 0.353-2.732, p = 0.973), suggesting absence of race-specific surgical benefits. CONCLUSION We identified a racial disparity against African-Americans in recommendations for surgical resection of skull base chondrosarcomas.
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Affiliation(s)
- Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Ali A Alattar
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience and Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jun Ma
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA.
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'Being a patient the rest of my life'- The influence of patient participation during recovery after brachial plexus injury. J Hand Ther 2021; 36:60-65. [PMID: 34819254 DOI: 10.1016/j.jht.2021.10.002] [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] [Received: 09/10/2020] [Revised: 12/10/2020] [Accepted: 10/02/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Given the modest functional outcomes seen after surgical reconstruction and subsequent therapy, increasing attention is being directed to patient satisfaction and psychological aspects of recovery after brachial plexus injury (BPI). PURPOSE To better understand the recovery course after surgical reconstruction for BPI, we used qualitative interviews and focused on common points of frustration for patients. STUDY DESIGN Qualitative, interpretive description study METHODS: We conducted semi-structured interviews with BPI patients who were 6+ months post-surgical reconstruction. The interview focused on the patients' experience with BPI, focusing on emotional aspects of recovery. Interviews were transcribed and independently coded by 2 researchers. We used inductive and deductive analysis to organize codes into themes. Once thematic saturation was reached, no additional interviews were conducted. RESULTS We interviewed 15 BPI patients at median 13 months after surgery (range: 6-43 months). Our analysis revealed: (1) BPI patients expressed variable degrees of participation during recovery, with the indeterminate state of function making it difficult to adjust to life after BPI. (2) The uncertainty while waiting for improved function is frustrating to BPI patients, with many patients expressing concern for activities and moments they are missing due to injury. (3) While many BPI patients feel left out of decision-making, those who felt engaged in the process expressed less frustration and more acceptance of their status. CONCLUSION Traumatic BPI patients those who felt engaged in decision-making were more receptive to adjustment to their new state of function. When coordinating multidisciplinary care, measures to encourage patients to feel agency over their outcome and to develop self-management skills have the potential to improve patient satisfaction.
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Sturma A, Hruby LA, Boesendorfer A, Pittermann A, Salminger S, Gstoettner C, Politikou O, Vujaklija I, Farina D, Aszmann OC. Prosthetic Embodiment and Body Image Changes in Patients Undergoing Bionic Reconstruction Following Brachial Plexus Injury. Front Neurorobot 2021; 15:645261. [PMID: 33994986 PMCID: PMC8119996 DOI: 10.3389/fnbot.2021.645261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/01/2021] [Indexed: 01/10/2023] Open
Abstract
Brachial plexus injuries with multiple-root involvement lead to severe and long-lasting impairments in the functionality and appearance of the affected upper extremity. In cases, where biologic reconstruction of hand and arm function is not possible, bionic reconstruction may be considered as a viable clinical option. Bionic reconstruction, through a careful combination of surgical augmentation, amputation, and prosthetic substitution of the functionless hand, has been shown to achieve substantial improvements in function and quality of life. However, it is known that long-term distortions in the body image are present in patients with severe nerve injury as well as in prosthetic users regardless of the level of function. To date, the body image of patients who voluntarily opted for elective amputation and prosthetic reconstruction has not been investigated. Moreover, the degree of embodiment of the prosthesis in these patients is unknown. We have conducted a longitudinal study evaluating changes of body image using the patient-reported Body Image Questionnaire 20 (BIQ-20) and a structured questionnaire about prosthetic embodiment. Six patients have been included. At follow up 2.5–5 years after intervention, a majority of patients reported better BIQ-20 scores including a less negative body evaluation (5 out of 6 patients) and higher vital body dynamics (4 out of 6 patients). Moreover, patients described a strong to moderate prosthesis embodiment. Interestingly, whether patients reported performing bimanual tasks together with the prosthetic hand or not, did not influence their perception of the prosthesis as a body part. In general, this group of patients undergoing prosthetic substitution after brachial plexus injury shows noticeable inter-individual differences. This indicates that the replacement of human anatomy with technology is not a straight-forward process perceived in the same way by everyone opting for it.
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Affiliation(s)
- Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Neurorehabilitation Engineering Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Laura A Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Boesendorfer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Pittermann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Clinical Psychology, General Hospital of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Olga Politikou
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Ivan Vujaklija
- Bionic and Rehabilitation Engineering Research Group, Department of Electrical Engineering and Automation, Aalto University, Espoo, Finland
| | - Dario Farina
- Neurorehabilitation Engineering Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Hong GH, Liu JB, Liu YZ, Gao KM, Zhao X, Lao J. Modified contralateral C7 nerve transfer: the possibility of permitting ulnar nerve recovery is confirmed by 10 cases of autopsy. Neural Regen Res 2019; 14:1449-1454. [PMID: 30964072 PMCID: PMC6524498 DOI: 10.4103/1673-5374.253530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Contralateral C7 nerve transfer surgery is one of the most important surgical techniques for treating total brachial plexus nerve injury. In the traditional contralateral C7 nerve transfer surgery, the whole ulnar nerve on the paralyzed side is harvested for transfer, which completely sacrifices its potential of recovery. In the present, novel study, we report on the anatomical feasibility of a modified contralateral C7 nerve transfer surgery. Ten fresh cadavers (4 males and 6 females) provided by the Department of Anatomy, Histology, and Embryology at the Medical College of Fudan University, China were used in modified contralateral C7 nerve transfer surgery. In this surgical model, only the dorsal and superficial branches of the ulnar nerve and the medial antebrachial cutaneous nerve on the paralyzed side (left) were harvested for grafting the contralateral (right) C7 nerve and the recipient nerves. Both the median nerve and deep branch of the ulnar nerve on the paralyzed (left) side were recipient nerves. To verify the feasibility of this surgery, the distances between each pair of coaptating nerve ends were measured by a vernier caliper. The results validated that starting point of the deep branch of ulnar nerve and the starting point of the medial antebrachial cutaneous nerve at the elbow were close to each other and could be readily anastomosed. We investigated whether the fiber number of donor and recipient nerves matched one another. The axons were counted in sections of nerve segments distal and proximal to the coaptation sites after silver impregnation. Averaged axon number of the ulnar nerve at the upper arm level was approximately equal to the sum of the median nerve and proximal end of medial antebrachial cutaneous nerve (left: 0.94:1; right: 0.93:1). In conclusion, the contralateral C7 nerve could be transferred to the median nerve but also to the deep branch of the ulnar nerve via grafts of the ulnar nerve without deep branch and the medial antebrachial cutaneous nerve. The advantage over traditional surgery was that the recovery potential of the deep branch of ulnar nerve was preserved. The study was approved by the Ethics Committee of Fudan University (approval number: 2015-064) in July, 2015.
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Affiliation(s)
- Guang-Hui Hong
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jing-Bo Liu
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Yu-Zhou Liu
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Kai-Ming Gao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Xin Zhao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jie Lao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
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Martin E, Senders JT, DiRisio AC, Smith TR, Broekman MLD. Timing of surgery in traumatic brachial plexus injury: a systematic review. J Neurosurg 2019; 130:1333-1345. [PMID: 29999446 DOI: 10.3171/2018.1.jns172068] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 01/10/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Ideal timeframes for operating on traumatic stretch and blunt brachial plexus injuries remain a topic of debate. Whereas on the one hand spontaneous recovery might occur, on the other hand, long delays are believed to result in poorer functional outcomes. The goal of this review is to assess the optimal timeframe for surgical intervention for traumatic brachial plexus injuries. METHODS A systematic search was performed in January 2017 in PubMed and Embase databases according to the PRISMA guidelines. Search terms related to "brachial plexus injury" and "timing" were used. Obstetric plexus palsies were excluded. Qualitative synthesis was performed on all studies. Timing of operation and motor outcome were collected from individual patient data. Patients were categorized into 5 delay groups (0-3, 3-6, 6-9, 9-12, and > 12 months). Median delays were calculated for Medical Research Council (MRC) muscle grade ≥ 3 and ≥ 4 recoveries. RESULTS Forty-three studies were included after full-text screening. Most articles showed significantly better motor outcome with delays to surgery less than 6 months, with some studies specifying even shorter delays. Pain and quality of life scores were also significantly better with shorter delays. Nerve reconstructions performed after long time intervals, even more than 12 months, can still be useful. All papers reporting individual-level patient data described a combined total of 569 patients; 65.5% of all patients underwent operations within 6 months and 27.4% within 3 months. The highest percentage of ≥ MRC grade 3 (89.7%) was observed in the group operated on within 3 months. These percentages decreased with longer delays, with only 35.7% ≥ MRC grade 3 with delays > 12 months. A median delay of 4 months (IQR 3-6 months) was observed for a recovery of ≥ MRC grade 3, compared with a median delay of 7 months (IQR 5-11 months) for ≤ MRC grade 3 recovery. CONCLUSIONS The results of this systematic review show that in stretch and blunt injury of the brachial plexus, the optimal time to surgery is shorter than 6 months. In general, a 3-month delay appears to be appropriate because while recovery is better in those operated on earlier, this must be considered given the potential for spontaneous recovery.
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Affiliation(s)
- Enrico Martin
- 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joeky T Senders
- 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aislyn C DiRisio
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marike L D Broekman
- 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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10
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Socioeconomic Disparities in Brachial Plexus Surgery: A National Database Analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2118. [PMID: 30881842 PMCID: PMC6416135 DOI: 10.1097/gox.0000000000002118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 11/26/2022]
Abstract
Background Brachial plexus injuries have devastating effects on upper extremity function, with significant pain, psychosocial stress, and reduced quality of life. The aim of this study is to identify socioeconomic disparities in the receipt of brachial plexus repair in the emergent versus elective setting, and in the use of supported services on discharge. Methods Analysis of the Healthcare Cost and Utilization Project National Inpatient Sample Database was performed for the years 2009-2014. Adults with brachial plexus injury with or without nerve repair were identified; patient and hospital specific factors were analyzed. Results Overall, 6,618 cases of emergent brachial plexus injury were retrieved. Six hundred sixty cases of brachial plexus repair were identified in the emergency and elective settings over the study period. Of the 6,618 injured, 153 (2.3%) underwent nerve surgery during the admission. Patients undergoing repair in the elective setting were more likely to be white males with private insurance. Patients treated in the emergency setting were more likely to be African American and in the lowest income quartile. Significant differences were also seen in supported discharge: more likely males (P < 0.001), >55 years of age (P < 0.001), white (P < 0.001), with government-based insurance (P < 0.001). Conclusions There are significant disparities in the timing of brachial plexus surgery. These relate to timing rather than receipt of nerve repair; socioeconomically advantaged individuals with private insurance in the higher income quartiles are more likely to undergo surgery in the elective setting and have a supported discharge.
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11
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Wali AR, Santiago-Dieppa DR, Brown JM, Mandeville R. Nerve transfer versus muscle transfer to restore elbow flexion after pan-brachial plexus injury: a cost-effectiveness analysis. Neurosurg Focus 2018; 43:E4. [PMID: 28669295 DOI: 10.3171/2017.4.focus17112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pan-brachial plexus injury (PBPI), involving C5-T1, disproportionately affects young males, causing lifelong disability and decreased quality of life. The restoration of elbow flexion remains a surgical priority for these patients. Within the first 6 months of injury, transfer of spinal accessory nerve (SAN) fascicles via a sural nerve graft or intercostal nerve (ICN) fascicles to the musculocutaneous nerve can restore elbow flexion. Beyond 1 year, free-functioning muscle transplantation (FFMT) of the gracilis muscle can be used to restore elbow flexion. The authors present the first cost-effectiveness model to directly compare the different treatment strategies available to a patient with PBPI. This model assesses the quality of life impact, surgical costs, and possible income recovered through restoration of elbow flexion. METHODS A Markov model was constructed to simulate a 25-year-old man with PBPI without signs of recovery 4.5 months after injury. The management options available to the patient were SAN transfer, ICN transfer, delayed FFMT, or no treatment. Probabilities of surgical success rates, quality of life measurements, and disability were derived from the published literature. Cost-effectiveness was defined using incremental cost-effectiveness ratios (ICERs) defined by the ratio between costs of a treatment strategy and quality-adjusted life years (QALYs) gained. A strategy was considered cost-effective if it yielded an ICER less than a willingness-to-pay of $50,000/QALY gained. Probabilistic sensitivity analysis (PSA) was performed to address parameter uncertainty. RESULTS The base case model demonstrated a lifetime QALYs of 22.45 in the SAN group, 22.0 in the ICN group, 22.3 in the FFMT group, and 21.3 in the no-treatment group. The lifetime costs of income lost through disability and interventional/rehabilitation costs were $683,400 in the SAN group, $727,400 in the ICN group, $704,900 in the FFMT group, and $783,700 in the no-treatment group. Each of the interventional modalities was able to dramatically improve quality of life and decrease lifelong costs. A Monte Carlo PSA demonstrated that at a willingness-to-pay of $50,000/QALY gained, SAN transfer dominated in 88.5% of iterations, FFMT dominated in 7.5% of iterations, ICN dominated in 3.5% of iterations, and no treatment dominated in 0.5% of iterations. CONCLUSIONS This model demonstrates that nerve transfer surgery and muscle transplantation are cost-effective strategies in the management of PBPI. These reconstructive neurosurgical modalities can improve quality of life and lifelong earnings through decreasing disability.
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Affiliation(s)
- Arvin R Wali
- Department of Neurological Surgery, University of California, San Diego, California
| | | | - Justin M Brown
- Department of Neurological Surgery, University of California, San Diego, California
| | - Ross Mandeville
- Department of Neurological Surgery, University of California, San Diego, California
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Wilson TJ, Chang KWC, Yang LJS. Depression and Anxiety in Traumatic Brachial Plexus Injury Patients Are Associated With Reduced Motor Outcome After Surgical Intervention for Restoration of Elbow Flexion. Neurosurgery 2017; 78:844-50. [PMID: 26516821 DOI: 10.1227/neu.0000000000001086] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Depression has been associated with poor outcomes in neurosurgical patients, including increased pain, poorer functional recovery, delayed return to work, and decreased patient satisfaction. No reports exist regarding an association of psychiatric diagnoses with outcomes after brachial plexus reconstruction. As outcomes and patient satisfaction become increasingly important to payers and physician reimbursement, assessing modifiable preoperative risk factors for their association with poor outcome and patient satisfaction is imperative. OBJECTIVE To analyze patients undergoing brachial plexus reconstruction to assess the relationship of depression/anxiety with functional outcome. METHODS Data were collected retrospectively on all patients who underwent brachial plexus reconstruction to restore elbow flexion between 2005 and 2013. Elbow flexion, graded via the Medical Research Council scale, was assessed at latest follow-up. Multiple variables, including the presence of Axis I psychiatric diagnoses, were assessed for their association with the dichotomous outcome of Medical Research Council scale score ≥3 (antigravity) vs <3 elbow flexion. Standard statistical methods were used. RESULTS Thirty-seven patients met inclusion criteria. The median postsurgical follow-up time was 21 months. Operations included neurolysis (n = 3), nerve graft repair (n = 6), and nerve transfer (n = 28). Depression was present in 10 of 37 patients (27%). Of variables tested, only depression was associated with poor elbow flexion outcome (odds ratio: 6.038; P = .04). CONCLUSION Preoperative depression is common after brachial plexus injury. The presence of depression is associated with reduced elbow flexion recovery after reconstruction. Our data suggest assessment and treatment of preoperative mental health is important in designing a comprehensive postoperative management plan to optimize outcomes and patient satisfaction. ABBREVIATIONS MRC, Medical Research CouncilTBI, traumatic brain injury.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Dy CJ, Baty J, Saeed MJ, Olsen MA, Osei DA. A Population-Based Analysis of Time to Surgery and Travel Distances for Brachial Plexus Surgery. J Hand Surg Am 2016; 41:903-909.e3. [PMID: 27570225 PMCID: PMC5004775 DOI: 10.1016/j.jhsa.2016.07.054] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Despite the importance of timely evaluation for patients with brachial plexus injuries (BPIs), in clinical practice we have noted delays in referral. Because the published BPI experience is largely from individual centers, we used a population-based approach to evaluate the delivery of care for patients with BPI. METHODS We used statewide administrative databases from Florida (2007-2013), New York (2008-2012), and North Carolina (2009-2010) to create a cohort of patients who underwent surgery for BPI (exploration, repair, neurolysis, grafting, or nerve transfer). Emergency department and inpatient records were used to determine the time interval between the injury and surgical treatment. Distances between treating hospitals and between the patient's home ZIP code and the surgical hospital were recorded. A multivariable logistic regression model was used to determine predictors for time from injury to surgery exceeding 365 days. RESULTS Within the 222 patients in our cohort, median time from injury to surgery was 7.6 months and exceeded 365 days in 29% (64 of 222 patients) of cases. Treatment at a smaller hospital for the initial injury was significantly associated with surgery beyond 365 days after injury. Patient insurance type, travel distance for surgery, distance between the 2 treating hospitals, and changing hospitals between injury and surgery did not significantly influence time to surgery. CONCLUSIONS Nearly one third of patients in Florida, New York, and North Carolina underwent BPI surgery more than 1 year after the injury. Patients initially treated at smaller hospitals are at risk for undergoing delayed BPI surgery. CLINICAL RELEVANCE These findings can inform administrative and policy efforts to expedite timely referral of patients with BPI to experienced centers.
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Affiliation(s)
- Christopher J. Dy
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery Washington University School of Medicine – St. Louis, MO,Department of Surgery, Division of Public Health Sciences Washington University School of Medicine – St. Louis, MO
| | - Jack Baty
- Division of Biostatistics, Washington University School of Medicine – St. Louis, MO
| | - Mohammed J Saeed
- Department of Medicine, Division of Infectious Diseases; Center for Administrative Data Research; Washington University School of Medicine – St. Louis, MO
| | - Margaret A. Olsen
- Department of Surgery, Division of Public Health Sciences Washington University School of Medicine – St. Louis, MO,Department of Medicine, Division of Infectious Diseases; Center for Administrative Data Research; Washington University School of Medicine – St. Louis, MO
| | - Daniel A. Osei
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery Washington University School of Medicine – St. Louis, MO
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Morris MT, Daluiski A, Dy CJ. A Thematic Analysis of Online Discussion Boards for Brachial Plexus Injury. J Hand Surg Am 2016; 41:813-8. [PMID: 27311862 DOI: 10.1016/j.jhsa.2016.05.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/06/2016] [Accepted: 05/16/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Patients with brachial plexus injury (BPI) and their family members contribute to Internet discussion groups dedicated to BPI. We hypothesized that a thematic analysis of posts from BPI Internet discussion groups would reveal common themes related to the BPI patient experience, providing topics for patient education and counseling. METHODS Internet discussion boards were identified using the search term "brachial plexus injury support group" in Google, Bing, and Yahoo! search engines. Two discussion boards had substantially more posts than other Web sites and were chosen for analyses. Posts from January 1, 2015, through January 1, 2016, were examined. Using an iterative and established process, 2 investigators (M.T.M. and C.J.D) independently analyzed each post using thematic analysis in 3 steps (open coding, axial coding, and selective coding) to determine common themes. In this process, each post was reviewed 3 times. RESULTS A total of 328 posts from the 2 leading discussion boards were analyzed. Investigators reached a consensus on themes for all posts. One central theme focused on emotional aspects of BPI. Four other central themes regarding information support were identified: BPI disease, BPI treatment, recovery after BPI treatment, and process of seeking care for BPI. CONCLUSIONS Examination of posts on Internet support groups for BPI revealed recurring concerns, questions, and opinions of patients and their family members. The most common themes related to disease information, treatment, recovery, and the emotional element of BPI. CLINICAL RELEVANCE These findings provide a helpful starting point in refining topics for patient education and support that are targeted on patients' interests and concerns.
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Affiliation(s)
- Marie T Morris
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Washington University School of Medicine, St. Louis, MO
| | - Aaron Daluiski
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Washington University School of Medicine, St. Louis, MO; Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO.
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Kumar A, Kalliainen LK. Cleft Lip Surgical Intervention in Resource Constraint Settings: A Case Report. Health (London) 2016. [DOI: 10.4236/health.2016.85050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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