Operative management of selected brachial plexus lesions

Morphological Relation of Peripheral Nerve Sheath Tumors and Nerve Fascicles: Prospective Study and Classification

Removal of benign peripheral nerve sheath tumors (bPNST) represents a surgical challenge. The morphological relation of bPNST and healthy nerve fascicles are of utmost importance for achieving both removal of the entire tumor and preservation of functional integrity of the peripheral nerve. Thus, we intraoperatively assessed the morphological patterns between bPNST and nerve fascicles using photo documentation obtained between January 2009 and September 2021. In 31 patients (20 women and 11 men) with a mean age of 48 ± 18 years a total of 34 bPNST were removed. Four constant morphological patterns between bPNST relatively to nerve fascicles were detected: (1) bPNST is located peripherally (n = 16), (2) it splits the nerve into two main fascicles (n = 5), (3) it totally splits up the nerve out of the nerve's center (n = 8) und (4) it encloses the nerve and its fascicles (n = 5) without any detectable boundary layer. Histology revealed 28 schwannomas, five neurofibromas, and one perineurioma. The proposed classification reflects the increasing complexity of tumor removal with a higher type number. This might be beneficial for preoperative diagnostics, i.e., high-resolution ultrasound or MRI-tractography, as well as for planning the bPNST's surgical resection and the possible need for nerve reconstruction.

Clinical Outcomes of Surgical Management of Primary Brachial Plexus Tumors

Introduction  This study evaluates the clinical presentation, tumor characteristics, and clinical outcomes of surgically treated benign and malignant brachial plexus tumors (BPTs).

Methods  A prospective study of patients with BPTs from June 2015 to August 2020 was conducted. All patients underwent surgical resection with microneurolysis and intraoperative electrical stimulation to preserve the functioning nerve fascicles.

Results  Fourteen patients with 15 BPTs underwent surgical resection. Mean age was 37.8 ± 12.3 years; with male to female ratio 4:10. The clinical presentations were swelling (100%), pain (84.6%), and paresthesia (76.9%). The lesions involved roots (5/15), trunk (5/15), division (1/15), and cords (4/15). Thirteen patients had benign pathology (8 schwannomas, 3 neurofibromas, 2 lipomas) and two had malignant neurofibrosarcoma. Gross total resection was achieved in all cases except a dumbbell tumor. The mean follow-up period was 24 ± 5 months. Postoperatively, all patients reported improvement in pain and paresthesia with no new sensory deficit. All patients had developed initial motor weakness (Grades 2–4); however, full power (Grade 5) was recovered by 3 to 5 months.

Conclusion  Total resection can be achieved by appropriate microneural dissection and electrophysiologic monitoring and is potentially curative with preserving function.

Brachial plexus tumors extending into the cervicothoracic spine: a review with operative nuances and outcomes

BACKGROUND

The rarity and anatomical complexity of brachial plexus tumors (BPTs) impose many challenges onto surgeons performing surgical resections, especially when these tumors invade the cervicothoracic spine. Treatment choices and surgery outcomes heavily depend on anatomical location and tumor type.

METHODS

The authors performed an extensive review of the published literature (PubMed) focusing on "brachial plexus tumors" that identified invasion of the cervicothoracic spine.

RESULTS

The search yielded 2774 articles pertaining to "brachial plexus tumors". Articles not in the English language or involving cervicothoracic spinal invasion were excluded.

CONCLUSIONS

Recent research has shown that the most common method used to resect tumors of the proximal roots is the dorsal subscapular approach. Despite its association with high morbidity rate, this technique offers excellent exposure to the spinal roots and intraforaminal portion of the spinal nerve. The dorsal approach is used to resect recurrent lower trunk tumors and dumbbell-shaped neurofibromas, yet it is also the least common overall approach used in brachial plexus tumor resections. The ventral or anterior technique is commonly used to resect tumors at the cord to division level, and root to trunk level. Motor complications, transient nerve palsy, and bleeding are among the most common complications of the anterior supraclavicular approach. Further controlled studies are needed to fully determine the optimal surgical approach used to obtain the best outcomes and least complications for each type of brachial plexus tumor.

Role of tacrolimus in return of hand function after brachial plexus injury in a lung transplantation patient

We report a patient who has been on tacrolimus for bilateral lung transplantation and presented with a brachial plexus injury (BPI), with unusual improvement of lower trunk innervated hand function. The lower trunk injury with resultant left hand paralysis had developed after his sternotomy 18 months ago. He has been treated with tacrolimus as part of his immunosuppression protocol since the surgery, without severe side effects. Physical examination at 18 months demonstrated unusual excellent grip pattern and full opposition of his thumb with slight claw deformity of his ulnar two digits. While the neurotoxic effects of tacrolimus are more emphasised, the neuroregenerative properties have been recently explored. The recovery in this patient is unique and unusual after BPI and is most likely as a result of the low dose tacrolimus treatment.

MANAGEMENT OF BRACHIAL PLEXUS MISSILE INJURIES

SUMMARY – Missile injuries are among the most devastating injuries in general traumatology. Traumatic brachial plexus injuries are the most difficult injuries in peripheral nerve surgery, and most complicated to be surgically treated. Nevertheless, missile wounding is the second most common mechanism of brachial plexus injury. The aim was to evaluate functional recovery after surgical treatment of these injuries. Our series included 68 patients with 202 nerve lesions treated with 207 surgical procedures. Decision on the treatment modality (exploration, neurolysis, graft repair, or combination) was made upon intraoperative finding. Results were analyzed in 60 (88.2%) patients with 173 (85.6%) nerve lesions followed-up for two years. Functional recovery was evaluated according to functional priorities. Satisfactory functional recovery was achieved in 90.4% of cases with neurolysis and 85.7% of cases with nerve grafting. Insufficient functional recovery was verified in ulnar and radial nerve lesions after neurolysis, and in median and radial nerve lesions when graft repair was done. We conclude that the best time for surgery is between two and four months after injury, except for the gunshot wound associated with injury to the surrounding structures, which requires immediate surgical treatment. The results of neurolysis and nerve grafting were similar.

Timing of surgery in traumatic brachial plexus injury: a systematic review

OBJECTIVEIdeal 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.METHODSA 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.RESULTSForty-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.CONCLUSIONSThe 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.

Brachial Plexus Injury After Right Hepatectomy

Iatrogenic nerve palsies due to faulty positioning on the operating table are commonly seen over the elbow and popliteal fossa. However, injury to the brachial plexus (BP) is rarely encountered and is a recently reported phenomenon due to the increasing number of complex surgeries including hepatobiliary surgical procedures. Brachial plexus injury (BPI) needs to be recognized as a potential complication of prolonged abdominal surgery. The present case report highlights the potential for BPI and its early recognition, management, and prevention in complex prolonged abdominal surgical procedures. BPI has been described in a 64-year-old patient following a prolonged right hepatectomy.

Large Cervical Vagus Nerve Tumor in a Patient with Neurofibromatosis Type 1 Treated with Gross Total Resection: Case Report and Review of the Literature

Neurofibromas are benign peripheral nerve sheath tumors that occur commonly in individuals with neurocutaneous disorders such as neurofibromatosis type 1. Vagal nerve neurofibromas, however, are a relatively rare occurrence. We present the case of a 22-year-old man with neurofibromatosis type 1 with a neurofibroma of the left cervical vagal nerve. The mass was resected through an anterior approach without major event. In the postoperative course, the patient developed left vocal cord paralysis treated with medialization with injectable gel. We then present a comprehensive review of the literature for surgical resection of vagal nerve neurofibromas.

Health-related quality of life and functional outcomes following nerve transfers for traumatic upper brachial plexus injuries

We report the patient-scored Health-Related Quality of Life (HRQoL) and functional outcomes of a cohort of 21 consecutive patients undergoing nerve transfer surgery for traumatic upper brachial plexus injuries. Outcomes were assessed using the British Medical Research Council power grading system, Short-Form 36, Disability of Arm, Shoulder and Hand questionnaire, and Pain Visual Analogue Scale (PVAS). The mean age of our cohort was 29.8 years (range 18-53 years), with a mean follow-up period of 42.9 months. At follow-up, elbow flexion ≥ M3 strength was achieved in 17/21 patients. Shoulder abduction ≥ M3 was achieved in 14/19 patients. External rotation ≥ M3 strength was achieved in 11/15 patients. Delayed surgical repair correlated negatively with HRQoL outcomes. Higher injury severity scores and smoking were associated with higher PVAS scores. These findings provide key prognostic information for patients and peripheral nerve surgeons embarking upon this intensive pathway to potential recovery.

Iatrogenic Brachial Plexopathy due to Improper Positioning during Radiofrequency Ablation

Iatrogenic peripheral nerve injuries are a common source of postprocedural morbidity. The authors present a case report of a patient who developed brachial plexopathy from positioning during radiofrequency ablation of a renal mass. Though incidence data on the majority of iatrogenic peripheral nerve injury is scarce, there is more concrete data on iatrogenic brachial plexopathy. The incidence of brachial plexopathies is ~0.2% of all patients who receive general anesthesia, with between 7 and 10% of brachial plexopathies being iatrogenic in nature. The mechanism of injury in the majority of cases is due to stretching or compression of the nerve tissue. Treatment is largely supportive. Prevention is key in minimizing this form of patient morbidity. It is the operator's responsibility to mitigate this risk by employing proper positioning techniques and communicating closely with the anesthesia staff when applicable.

External neurolysis may result in early return of function in some muscle groups following brachial plexus surgery

A retrospective chart review, of those individuals seen and operated on by the Multidisciplinary Brachial Plexus Clinic team at the University of Kentucky Chandler Medical Center, was undertaken to determine those individuals who had early return-of-function following surgery for BPI. Seven patients met our criteria, with four of them having substantial improvement of two or more points gained on the MRC rating scale, in one or more muscle groups within six to eight weeks after surgery. Those patients with return-of-function earlier than expected for axonal regrowth from nerve transfer or grafting, had evidence for continuity but no significant reinnervation before surgery in the muscle groups that improved. We theorize that this early improvement is related to a compression-induced dysfunction which inhibited reinnervation and was relieved by performing external neurolysis.

Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy: a systematic review and analysis

BACKGROUND

In treating patients with brachial plexus injury, there are no comparative data on the outcomes of nerve grafts or nerve transfers for isolated upper trunk or C5-C6-C7 root injuries. The purpose of our study was to compare, with systematic review, the outcomes for modern intraplexal nerve transfers for shoulder and elbow function with autogenous nerve grafting for upper brachial plexus traumatic injuries.

METHODS

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies in which patients had surgery for traumatic upper brachial plexus palsy within one year of injury and with a minimum follow-up of twelve months. Strength and shoulder and elbow motion were assessed as outcome measures. The Fisher exact test and Mann-Whitney U test were used to compare outcomes, with an alpha level of 0.05.

RESULTS

Thirty-one studies met the inclusion criteria. Two hundred and forty-seven (83%) and 286 (96%) of 299 patients with nerve transfers achieved elbow flexion strength of grade M4 or greater and M3 or greater, respectively, compared with thirty-two (56%) and forty-seven (82%) of fifty-seven patients with nerve grafts (p < 0.05). Forty (74%) of fifty-four patients with dual nerve transfers for shoulder function had shoulder abduction strength of grade M4 or greater compared with twenty (35%) of fifty-seven patients with nerve transfer to a single nerve and thirteen (46%) of twenty-eight patients with nerve grafts (p < 0.05). The average shoulder abduction and external rotation was 122° (range, 45° to 170°) and 108° (range, 60° to 140°) after dual nerve transfers and 50° (range, 0° to 100°) and 45° (range, 0° to 140°) in patients with nerve transfers to a single nerve.

CONCLUSIONS

In patients with demonstrated complete traumatic upper brachial plexus injuries of C5-C6, the pooled international data strongly favors dual nerve transfer over traditional nerve grafting for restoration of improved shoulder and elbow function. These data may be helpful to surgeons considering intraoperative options, particularly in cases in which the native nerve root or trunk may appear less than optimal, or when long nerve grafts are contemplated.

Reinnervation of thenar muscle after repair of total brachial plexus avulsion injury with contralateral C7 root transfer: report of five cases

OBJECTIVE

In this report, we present the findings of reinnervation of the thenar muscle in five patients who underwent the contralateral C7 nerve root transfers for repair of total brachial plexus root avulsions.

PATIENTS AND METHODS

Five (2 children and 3 adults) of 32 patients who received two-staged procedures of the contralateral C7 nerve root transfers to the median nerves showed reinnervation of thenar muscle were evaluated. The patients also received other procedures including the intercostal nerve transfer to the musculocutaneous nerve, the spinal accessory nerve to the suprascapular nerve, and the ipsilateral phrenic nerve to the musculocutaneous nerve before the contralateral C7 nerve root transfers. The patients were followed up from 24 to 118 months after surgery.

RESULTS

Varied degrees of functional restorations were achieved after different procedures. The strength of abductor pollicis brevis (APB) muscle with Grade M2 was found in four patients. The incomplete interference pattern in the APB muscle was detected by electromyogram (EMG) in two patients, and the minority motor unit potential (MUP) was detected in other two patients. The strength of APB muscle was found with Grade M1 in one patient with EMG showing MUP.

CONCLUSION

The findings from our series show reinnervation of thenar muscles after repair of the median nerve with the contralateral C7 nerve root transfer, which provides evidence for further investigation of reconstruction of the brachial plexus root avulsion injury with this procedure.

Gunshot injuries to the brachial plexus during wartime

Gunshot injuries of the brachial plexus are a challenging issue among peripheral nerve lesions. Surgical reconstruction of such injuries is difficult and the clinical outcome depends on several factors. The aim of this study was to present the outcome of surgical management of gunshot injuries of the brachial plexus that occurred following Iran-Iraq war. Twenty patients with 55 injured elements of the brachial plexus underwent surgery in Loghman-Hakim Hospital during 1982 and 1992. Reconstructive procedures included neurolysis in 30 injured elements, nerve grafting in 17 and a combination of these two methods in 8 cases. Surgical procedure was selected based on the microscopic findings during the operation. Final recovery outcome was assessed at least 3 years after surgery on the basis of motor and sensory recoveries. Final outcome was defined as poor, intermediate, and good. Both good and intermediate outcomes were considered as useful recovery. An acceptable recovery was obtained in 28 of 30 (94%) injured elements undergone neurolysis, 15 of 17 (89%) elements in nerve graft group, and 7 of 8 (87.5%) elements reconstructed with neurolysis in combination with nerve graft. In neurolysis, good recovery was more frequent and obtained in 23 of 30 (77.5%) lesions. Best treatment outcome was observed in lesions of lateral cord to musculocutaneous nerve which all injured elements showed good recovery. Impairment in none of the lesions in the level of posterior cord and lower trunk or C8-T1 led to good recovery. In surgical reconstruction of gunshot injuries of the brachial plexus the most favorable results were observed in the neurolysis reconstruction of the lesions in the lateral cord to musculocutaneous nerve. In the absence of spontaneous improvement of neurologic deficit, surgical procedures should be done as soon as possible according to the type and location of injury.

A morphometric aspect of the brachial plexus in the periclavicular region

OBJECTIVE

The purpose of this study was to determine the normal morphometric landmarks of the uniting and dividing points of the brachial plexus (BP) in the periclavicular region to provide useful guidance in surgery of BP injuries.

METHODS

A total of 20 brachial plexuses were obtained from 10 adult, formalin-fixed cadavers. Distances were measured on the basis of the Chassaignac tubercle (CT), and the most lateral margin of the BP (LMBP) crossing the superior and inferior edge of the clavicle.

RESULTS

LMBP was located within 25 mm medially from the midpoint in all subjects. In the supraclavicular region, the upper trunk uniting at 21 +/- 7 mm from the CT, separating into divisions at 42 +/- 5 mm from the CT, and dividing at 19 +/- 4 mm from the LMBP crossing the superior edge of the clavicle. In the infraclavicular region, the distance from the inferior edge of the clavicle to the musculocutaneous nerve (MCN) origin was 49 +/- 1 mm, to the median nerve origin 57 +/- 7 mm, and the ulnar nerve origin 48 +/- 6 mm. From the lateral margin of the pectoralis minor to the MCN origin the distance averaged 3.3 +/- 10 mm. Mean diameter of the MCN was 4.3 +/- 1.1 mm (range, 2.5-6.0) in males (n = 6), and 3.1 +/- 1.5 mm (range, 1.6-4.0) in females (n = 4).

CONCLUSION

We hope these data will aid in understanding the anatomy of the BP and in planning surgical treatment in BP injuries.

Surgical outcomes of the brachial plexus lesions caused by gunshot wounds in adults

BACKGROUND

The management of brachial plexus injuries due to gunshot wounds is a surgical challenge. Better surgical strategies based on clinical and electrophysiological patterns are needed. The aim of this study is to clarify the factors which may influence the surgical technique and outcome of the brachial plexus lesions caused by gunshot injuries.

METHODS

Two hundred and sixty five patients who had brachial plexus lesions caused by gunshot injuries were included in this study. All of them were male with a mean age of 22 years. Twenty-three patients were improved with conservative treatment while the others underwent surgical treatment. The patients were classified and managed according to the locations, clinical and electrophysiological findings, and coexisting lesions.

RESULTS

The wounding agent was shrapnel in 106 patients and bullet in 159 patients. Surgical procedures were performed from 6 weeks to 10 months after the injury. The majority of the lesions were repaired within 4 months were improved successfully. Good results were obtained in upper trunk and lateral cord lesions. The outcome was satisfactory if the nerve was intact and only compressed by fibrosis or the nerve was in-contunuity with neuroma or fibrosis.

CONCLUSION

Appropriate surgical techniques help the recovery from the lesions, especially in patients with complete functional loss. Intraoperative nerve status and the type of surgery significantly affect the final clinical outcome of the patients.

Fibrosarcoma of the brachial plexus presenting in childhood

We report a case of malignant fibrosarcoma involving the brachial plexus presenting in childhood. Primary malignant tumours of the brachial plexus are rare entities. In particular, fibrosarcoma of the brachial plexus occurring in a child has not been previously reported. Dilemmas in resolving the management and long-term consequences of this condition are discussed.

Pectoralis major inverse plasty for functional reconstruction in patients with anterolateral deltoid deficiency

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°.

The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved.

The influence of pre-surgical delay on functional outcome after reconstruction of brachial plexus injuries

It has been proposed that delayed surgery after traumatic brachial plexus injury may adversely affect functional outcome. In this study the influence of pre-surgical delay on the outcome of brachial plexus reconstruction was examined retrospectively. All patients who underwent surgery for traumatic brachial plexus injury in the Leeds Plastic and Reconstructive Surgery unit (UK), between 1987 and 2002, were identified. Of the 110 patients identified, 27 had nerve grafting to the upper trunk to restore shoulder and biceps muscle function. Postoperative functional outcome was evaluated in this subgroup of patients. The 27 patients were divided into three groups: surgery <2 weeks (n=10), 2 weeks to 2 months (n=10) and >2 months (n=7) following injury. The efficacy of nerve grafting was correlated to pre- and postoperative biceps strength, which was assessed using the British Medical Research Council (MRC) Motor Grading Scale. In all patients the preoperative elbow grade was M0. The results showed that in the <2 weeks, 2 weeks-2 months and >2 months delay groups, the mean postoperative elbow MRC grades were 4.2+/-SD 1.0, 3.8+/-SD 0.8 and 1.1+/-SD 1.7, respectively. Functionally better results were obtained with early surgery. When surgery was delayed beyond 2 months there was no significant difference between mean pre- and postoperative elbow grades. We therefore believe that early exploration and reconstruction of adult traumatic brachial plexus injuries minimises the pernicious adverse effects of delay attributable to recent findings of the neurobiological effects of axonal damage.

TRAUMATIC LESIONS OF THE BRACHIAL PLEXUS

OBJECTIVE

To analyze retrospectively the outcomes of primary as well as secondary functional reconstructions in 49 patients with traumatic brachial plexus lesions from a single service. Guidelines for treatment might be extracted from this analysis.

METHODS

Among 152 cases of traumatic lesion of the brachial plexus presented to our clinic, 58 underwent primary brachial plexus reconstructive surgery. On exploration, all patients showed stretching and scarring of plexus elements; root avulsions were found in 28 patients (48%). Outcome evaluation was carried out in 49 of these patients with a follow-up period of 1 year or longer (mean follow-up, 27.9 mo; range, 12–72 mo). A total of 43 secondary reconstructive procedures to improve functionality of the involved arm were performed at a later stage in 25 of 58 patients. Outcomes of the secondary functional restorative procedures were evaluated (mean follow-up, 11.5 mo; range, 3–60 mo in 43 procedures).

RESULTS

Patients with neurolysis as a stand-alone procedure (11 patients) showed an outcome grade of 4 or 5. The average outcome of the 19 patients with C5, C6, and C7 grafting was Grade 3, the same as in patients with nerve transfers to the upper plexus elements (C5–C6 root avulsions, 13 patients). Patients with multiple root avulsions (five cases) showed an overall poor outcome (Grades 0–2). Secondary functional restorative surgery was performed in 43% of the patients and helped improve individual outcomes, providing a favorable effect on the general functionality of the arm. Among the restorative operations performed, the Steindler procedure, wrist extension restoration, claw hand correction, and free functional muscle flap transfer to the arm and forearm were the most rewarding.

CONCLUSION

A combination of primary brachial plexus reconstruction and carefully evaluated, selected, and planned function-restorative secondary procedures might offer favorable outcomes in patients with partial or total brachial plexus lesions.

Neurofibromatosis 1 and 2

Neurofibromatosis (NF) 1 and 2 are multisystem disorders associated with a variety of neoplastic and non-neoplastic manifestations that typically progress in severity during the lifetime of the affected patient. The importance of appropriately diagnosing these disorders stems from the fact that the natural history of an associated neoplasm, such as a peripheral nerve tumor or an optic glioma, may be significantly different depending on whether or not the lesion arises in a person with NF. In addition, the indications for therapeutic intervention, hierarchy of treatment options and long-term management goals may differ substantially for patients with NF-related versus sporadic tumors. Finally, recognition of the diagnosis comprises an essential step for providing appropriate multidisciplinary evaluation and counseling to affected patients and their families. This article addresses the principal manifestations of these disorders and provides a contemporary review of the diagnostic and therapeutic issues that arise in children with NF1 and NF2.

FUNCTIONAL OUTCOME OF BRACHIAL PLEXUS RECONSTRUCTION AFTER TRAUMA

OBJECTIVE

Traumatic brachial plexopathies can be devastating injuries. In addition to motor and sensory deficits, pain and functional limitations can be equally debilitating. We sought to evaluate functional outcome and quality of life using statistically validated tools.

METHODS

The authors identified a consecutive series of patients who underwent surgical repair of a brachial plexus injury by the same surgeon between 1997 and 2004 at the McGill University Health Center. Participating patients were sent a package containing the Short Form 36, the Disability of the Arm, Shoulder, and Hand questionnaire, a pain visual analog scale, and an additional question on their satisfaction with the surgery. Data was recorded and analyzed using statistical software (SPSS version 13.0 for Windows; SPSS, Inc., Chicago, IL).

RESULTS

Thirty-one patients with a mean age of 32.7 years at the time of injury participated in this study. The mean time to surgery was 7.5 months, and the mean follow-up period was 42.7 months. Patients who underwent surgery within 6 months of injury scored consistently better on the Disability of the Arm, Shoulder, and Hand questionnaire (P = 0.03) and the Short Form 36 subscale scores. There was no difference between supra- and infraclavicular injuries; however, patients with root avulsion injuries were more likely to have pain (P = 0.04) and scored lower on the Disability of the Arm, Shoulder, and Hand questionnaire (P = 0.05).

CONCLUSION

Statistically validated tools can be used to evaluate the quality of life, upper extremity function, and pain after brachial plexus repairs. Root avulsion injuries and delayed surgical repair correlated negatively with functional outcomes.

Surgical repair of ulnar nerve lesions caused by gunshot and shrapnel: results in 407 lesions

Object

Ulnar nerve lesions caused by gunshot wounds have rarely been reported in the current literature. The authors describe the outcome after surgical repair of such injuries, and the factors influencing the results of treatment.

Methods

This retrospective study includes 455 patients with 462 ulnar nerve injuries caused by gunshot wounds who were treated at Gulhane Military Medical Academy over a 40-year period. A total of 407 ulnar lesions were surgically repaired at that institution between 1966 and 2005; 237 patients were injured by shrapnel and 218 patients by gunshot. The authors evaluated the motor, sensory, and electrophysiological recovery in these patients, as well as the patients' judgment of the outcome. The authors also tested the effect of repair level, nerve graft length, time to operation, repair technique used, and the presence of coexisting damages in the nerve repair region. The final outcome in these patients was defined as poor, fair, or good on the basis of the British Medical Research Council scores.

Results

A good outcome was noted in 15.06% of patients who underwent high-level repair, 29.60% of patients who underwent intermediate-level repair, and 49.68% of patients after low-level repair. On average, patients with successful outcomes had a significantly shorter time to operation than those with unsuccessful outcomes. The critical period for surgery was within 6 months of injury. Although the optimal graft length was found to be 5 cm, this finding was not statistically significant.

Conclusions

The reported outcome of repairs to ulnar nerves damaged by gunshot has varied in the literature, but there is a consensus that the duration of the interval to surgery, the repair level, and the graft length used influence the outcome of surgical repair for ulnar nerve lesions.

Video-assisted thoracoscopic dissection of the brachial plexus: cadaveric study and illustrative case

OBJECTIVE

Standard surgical approaches to the brachial plexus require an open operative technique with extensive soft tissue dissection. A transthoracic endoscopic approach using video-assisted thoracoscopic surgery (VATS) was studied as an alternative direct operative corridor to the proximal inferior brachial plexus.

METHODS

VATS was used in cadaveric dissections to study the anatomic details of the brachial plexus at the thoracic apex. After placement of standard thoracoscopic ports, the thoracic apex was systematically dissected. The limitations of the VATS approach were defined before and after removal of the first rib. The technique was applied in a 22-year-old man with neurofibromatosis who presented with a large neurofibroma of the left T1 nerve root.

RESULTS

The cadaveric study demonstrated that VATS allowed for a direct cephalad approach to the inferior brachial plexus. The C8 and T1 nerve roots as well as the lower trunk of the brachial plexus were safely identified and dissected. Removal of the first rib provided exposure of the entire lower trunk and proximal divisions. After the fundamental steps to the dissection were identified, the patient underwent a successful gross total resection of a left T1 neurofibroma with VATS.

CONCLUSION

VATS provided an alternative surgical corridor to the proximal inferior brachial plexus and obviated the need for the extensive soft tissue dissection associated with the anterior supraclavicular and posterior subscapular approaches.

Management of birth brachial plexus palsy

INTRODUCTION

The indications for surgical repair of congenital brachial plexus palsy are controversial. Our objective was to determine the results of early brachial plexus surgery following obstetric-induced brachial plexus palsy.

METHODS

We performed a retrospective analysis of the outcome of 58 cases of brachial plexus surgery. The indication for operation consisted of the presence of less than antigravity strength in the biceps, triceps, and deltoid muscle groups at 6 months of age. Data gathered prospectively, previously, showed the likelihood of improvement with less than antigravity strength in these cases to be poor.

RESULTS

Follow-up data were obtained on 52 of the 58 cases. Overall mean follow-up was 2 years. Twelve patients had more than 3 years follow-up (mean 5.5 years, range 3-11.5 years). Significant improvement was seen in all injury patterns i.e., C5-C6, C5-C7, and C5-C8, T1. Greater than antigravity strength in the biceps, triceps, and deltoid muscle groups was seen in the majority of cases at follow-up.

CONCLUSIONS

Repair of obstetrical brachial plexus palsy in children at 6 months of age that is based on less than antigravity strength in the biceps, triceps, and deltoid muscle groups produces improvement in functional capabilities. Children with obstetrical brachial plexus palsy should be referred soon after birth to a center that specializes in the treatment of this type of palsy.

A successful case of sural nerve cable grafting after a gunshot wound to the knees

OBJECTIVE

To describe a successful case of sural nerve cable grafting to the leg following a gunshot injury.

CLINICAL PRESENTATION AND INTERVENTION

A 28-year-old man was shot at close range, sustaining extensive damage to the left popliteal fossa. Initial exploratory operation revealed a pierced sciatic nerve proximal to its bifurcation into the tibial and common peroneal branches. The 60% division 3.5-cm common peroneal deficit and the complete transection of the tibial division were repaired using an ipsilateral sural cable nerve graft that was not reversed. Initial re-assessment in the clinic setting revealed a denervation atrophy of all 3 leg compartments and paraesthesia below the left knee sparing the sural nerve. After 3 months, the patient had a significant improvement in both power and sensation which was felt to be due to a resolution of a neuropraxic component to the nerve injury. Re-assessment at 9 months and later at 14 months revealed an almost full recovery, suggestive of the success of the nerve grafting procedure.

CONCLUSION

This report shows that, given favourable conditions, a good result is possible following use of cable nerve grafting to treat nerve damage from gunshot.

Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases

Object. Surgical therapy for traumatic brachial plexus lesions is still a great challenge in the field of peripheral nerve surgery. The aim of this study was to present the results of different surgical interventions in patients with this lesion type.

Methods. One hundred thirty-four patients with traumatic brachial plexus lesions underwent surgery between January 1991 and September 1999. In more than 50% of the patients, injury was caused by a motorbike accident. Patients underwent surgery a mean of 6.3 months posttrauma. The following surgical techniques were applied: neurolysis for nerve lesions in continuity (27 cases), grafting for lesions in discontinuity (149 cases), and neurotization for root avulsions (67 cases). Sixty-five patients were evaluated for at least 30 months (mean follow up 42.1 months) after surgery.

Function was graded using the Louisiana State University Health Sciences Center classification system. Only 2% of the patients had Grade 3 or better function preoperatively, increasing to 52% postoperatively. The effect of surgical measures on the functional results for different muscles were compared (supra- or infraspinatus, deltoid, biceps, and triceps muscles); the best results were obtained for biceps muscle function (57% of patients with Medical Research Council Grades M3–M5 function). Graft reconstruction yielded a better outcome than neurotization. Surgery within 5 months posttrauma clearly resulted in improved recovery of motor function compared with later interventions. Sural nerve grafts (monofascicular nerves) showed better results.

Conclusions. The results of neurosurgical interventions for brachial plexus lesions are satisfactory, especially when the operation is performed between 3 and 6 months after trauma.

Brachial plexopathies: classification, causes, and consequences

The brachial plexus, which is the most complex structure of the peripheral nervous system, supplies most of the upper extremity and shoulder. The high incidence of brachial plexopathies reflects its vulnerability to trauma and the tendency of disorders involving adjacent structures to affect it secondarily. The combination of anatomic, pathophysiologic, and neuromuscular knowledge with detailed clinical and ancillary study evaluations provides diagnostic and prognostic information that is important to clinical management. Since most brachial plexus disorders do not involve the entire brachial plexus but, rather, show a regional predilection, a regional approach to assessment of plexopathies is necessary.

MR imaging of brachial plexus

The brachial plexus is a complex anatomic component originating from ventral rami of the lower cervical nerve roots from C5 to C8 and upper thoracic spinal nerve roots from T1, providing sensory and motor innervation to the upper extremities. As it is inaccessible to palpation, clinical evaluation of the brachial plexus is very challenging and localizing lesions along its course is very difficult. The gamut of pathologic conditions involving the brachial plexus includes primary tumor, direct extension of adjacent tumor, metastasis, trauma, or an inflammatory condition. MR imaging provides superior diagnostic ability due to its ability of multiplanar imaging and greater soft tissue contrast. This article discusses MR imaging findings in a variety of pathologic conditions, with special emphasis on neoplastic process.

Penetrating injuries due to gunshot wounds involving the brachial plexus

The authors review 118 operative brachial plexus gunshot wounds (GSWs), causing 293 element injuries that were managed over a 30-year period at Louisiana State University Health Sciences Center (LSUHSC). Retrospective chart reviews were performed. Using the LSUHSC grading system for motor sensory function, each element's grades were combined and averaged.

Most of the 293 injured elements were found to have gross continuity at operation and of 202 elements with complete neurological loss, only 16 (8%) exhibited total disruption. Of 293 injuries, 128 elements with complete or incomplete loss were not only in continuity when explored but also had positive intraoperative nerve action potentials (NAPs). After neurolysis, 120 of 128 elements in continuity (94%) improved to greater than or equal to Grade 3 function. Elements not regenerating early usually required repair. One hundred fifty-six of 202 completely or incompletely injured elements (77%) required resection and suture or graft repair based on intraoperative NAPs. Neurolysis achieved greater than or equal to Grade 3 results in 42 (91%) of 46 elements with complete loss. Suture repair resulted in good outcomes in 14 (67%) of 21 and in 73 (54%) of 135 undergoing graft repairs (1 to 3.5 cm length) and presenting with complete loss.

Of 91 incomplete elements, intraoperative NAPs were positive in 82 (90%) and 78 of 82 had good results. Nine had negative NAPs and six elements required suture repair. Three required grafts with results of greater than or equal to Grade 3 in five (83%) of six and two (67%) of three, respectively.

Based on 118 patient results with 293 injured elements, guidelines for the management of GSWs were established as described in this paper.

Mechanisms of injury in operative brachial plexus lesions

Object

The authors focus on injury mechanisms involved in 1019 operative brachial plexus injuries (BPIs) managed between 1968 and 1998 at Louisiana State University Health Sciences Center (LSUHSC).

Methods

Data regarding these mechanisms of injury were obtained via retrospective chart reviews of patients who had undergone operations at LSUHSC.

Five main mechanisms of injury to the brachial plexus occurred in the series. These included 509 stretch/contusion injuries (49%) with four patterns of presentation in 366 patients: 208 C5–T1 nerve injuries; 75 C5–7, 55 C5–6 injuries; and 28 involving the C8–T1 or C7–T1 nerves. Stretch/contusion injury was followed in frequency by gunshot wound (GSW), resulting in 118 injuries (12%). Most of the 293 involved plexus elements had some gross continuity when surgically exposed. Seventy-one lacerations involved the brachial plexus (7%), including 83 sharp lacerations caused by knives or glass; 61 blunt transections due to automobile metal, fan, and motor blades, chain saws, or animal bites.

Nontraumatic BPIs included 160 cases of thoracic outlet syndrome or 16% of the total of 1019 BPIs. There were 161 tumors (16%) of neural sheath origin including 55 solitary neurofibromas (34%), 32 neurofibromas associated with von Recklinghausen disease (20%), 54 schwannomas (34%), and 20 malignant nerve sheath tumors (20%) removed. Obstetrical BPI was not included in the original series; however, the current literature is reviewed in this paper.

Conclusions

The conclusion of this study is that the brachial plexus can be injured by multiple mechanisms of which stretch/contusion injury is the most frequently encountered, followed by GSWs.

Surgical management of brachial plexus region tumors

BACKGROUND

Brachial plexus region tumors are uncommon and often present a challenge to neurosurgeons.

METHODS

Provide a brief historical overview, a description of the anatomy, and contribute information that provides management guidelines and improves surgical outcomes for tumors of the brachial plexus region. We also review different surgical approaches followed by surgical outcome from recent studies, as well as our own experience of treating 42 patients with tumors of the brachial plexus region at the University of Pennsylvania Medical Center between 1990 and 2001.

RESULTS

A thorough understanding of the anatomy, the clinical presentation, imaging techniques, and the various surgical approaches for brachial plexus tumor resection is necessary to ensure the best possible treatment outcome.

CONCLUSION

We conclude that with proper patient selection and appropriate perioperative and intraoperative management, neurologic deficits from brachial plexus tumor surgery can be minimized.

Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center

OBJECT

Outcomes of 1019 brachial plexus lesions in patients who underwent surgery at Louisiana State University Health Sciences Center during a 30-year period are reviewed in this paper to provide management guidelines.

METHODS

Causes of brachial plexus lesions included 509 stretches/contusions (50%), 161 plexus tumors (16%), 160 thoracic outlet syndromes (TOSs, 16%), 118 gunshot wounds (12%), and 71 lacerations (7%). Many features of clinical presentation, including prior treatment, patient's neurological status, results of electrophysiological studies, intraoperative findings, and postoperative level of function, were studied. The minimum follow-up period was 18 months and the mean follow-up period was 42 months. Repairs were best for injuries located at the C-5, C-6, and C-7 levels, the upper and middle trunk, the lateral cord to the musculocutaneous nerve, and the median and posterior cords to the axillary and radial nerves. Conversely, results were poor for injuries at the C-8 and T-1 levels, and for lower trunk and medial cord lesions, with the exception of injuries of the medial cord to the median nerve. Outcomes were most favorable when patients were carefully evaluated and selected for surgery, although variables such as lesion type, location, and severity, as well as time since injury also affected outcome. This was true also of TOSs and tumors arising from the plexus, especially if they had not been surgically treated previously.

CONCLUSIONS

Surgical exploration and repair of brachial plexus lesions is technically feasible and favorable outcomes can be achieved if patients are thoroughly evaluated and appropriately selected.

Brachial plexus injury: factors affecting functional outcome in spinal accessory nerve transfer for the restoration of elbow flexion

OBJECT

Between 1994 and 1998, 44 nerve transfers were performed using a graft between a branch of the accessory nerve and musculocutaneous nerve to restore the flexion of the arm in patients with traumatic brachial plexus injuries. A retrospective study was conducted, including statistical evaluation of the following pre- and intraoperative parameters in 39 patients: 1) time interval between injury and surgery; and 2) length of the nerve graft used to connect the accessory and musculocutaneous nerves.

METHODS

The postoperative follow-up interval ranged from 23 to 84 months, with a mean +/- standard deviation of 36 +/- 13 months. Reinnervation of the biceps muscle was achieved in 72% of the patients. Reinnervation of the musculocutaneous nerve was demonstrated in 86% of the patients who had undergone surgery within the first 6 months after injury, in 65% of the patients who had undergone surgery between 7 and 12 months after injury, and in only 50% of the patients who had undergone surgery 12 months after injury. A statistical comparison of the different preoperative time intervals (0-6 months compared with 7-12 months) showed a significantly better outcome in patients treated with early surgery (p < 0.05). An analysis of the impact of the length of the interposed nerve grafts revealed a statistically significant better outcome in patients with grafts 12 cm or shorter compared with that in patients with grafts longer than 12 cm (p < 0.005).

CONCLUSIONS

Together, these results demonstrated that outcome in patients who undergo accessory to musculocutaneous nerve neurotization for restoration of elbow flexion following brachial plexus injury is greatly dependent on the time interval between trauma and surgery and on the length of the nerve graft used.

Neurofibromatosis type I: clinical and imaging features of Von Recklinghausen's disease

OBJECTIVE

To discuss the case of a 45-year-old woman, with a prior diagnosis of neurofibromatosis type 1 (NF-1), complaining of low back and cervical spine pain with bilateral upper extremity paresthesias.

CLINICAL FEATURES

The patient had a dull, achy, constant low-back pain of 4 months' duration, with mild headaches and upper extremity paresthesias. Multiple skin lesions and spinopelvic postural imbalances were present. Diagnostic radiography, along with advanced imaging, demonstrated multilevel dysplastic osseous changes, with dural ectasia, scoliosis, and tumor extension. In addition to the previous diagnosis of NF-1, our clinical diagnosis included segmental dysfunction with resultant cervicalgia, lumbalgia, and myospasm.

INTERVENTION AND OUTCOME

Treatment consisted of a course of spinal manipulation of the lumbopelvic region, with adjunctive therapy consisting of interferential therapy, heat, and rehabilitative exercise. Marked reduction in pain and paresthesia with improved function were achieved.

CONCLUSIONS

NF-1 is a multisystem disease with neoplasia of the skin and nervous system. Patients experience a lifetime of morbidity and increased risk of mortality, depending on the extent of the disease. A multitude of therapeutic regimens may be engaged to improve NF-1-associated symptomatology and morbidity. Chiropractic spinal manipulation may have a positive effect in pain reduction and improved function in patients who have NF-1 without spinal instability.

The comparison of electrophysiologic findings of traumatic brachial plexopathies in a tertiary care center

This study was undertaken to demonstrate the distribution of causative factors of brachial plexopathy (BP), to assess the association between the mechanism of injuries and the predominant level of the brachial plexus involved in the injuries, and to characterize the extent and degree of severity of injury in patients with BPI. It consisted of a cross-sectional, retrospective review of electrophysiological data of 5547 patients with 117 patients being identified as having BPI, of whom 86 patients were recruited into the study. The patients were divided into six subgroups according to the mechanism of the damage. The injury was subdivided according to the brachial plexus levels predominantly affected, and each component of the four major anatomical plexus levels-root, trunk, cord and nerve levels was analyzed. The affiliation between the type of injuries and the specified brachial plexus levels was calculated via a two-tailed Fisher's exact test. These findings demonstrated that the type of brachial plexus injury (BPI) is significantly related to the brachial plexus level involved. The motorcycle and birth injury groups were affected at the trunk level, the fall group at the nerve level, the automobile group at the cord level, and the blunt injury group at the cord or nerve level. Moreover, the majority of patients in the motorcycle, fall, and pedestrian groups suffered from severe, incomplete lesions, while the neurophysiological results of the other groups varied.

Bilateral multiple cervical root avulsions without skeletal or ligamentous damage resulting from blast injury: case report

OBJECTIVE AND IMPORTANCE

We describe a unique case of multiple bilateral cervical root injuries without ligamentous or bony injury secondary to a sandblast accident.

CLINICAL PRESENTATION

A 19-year-old man sustained a sandblast injury to his face, neck, chest, and upper extremities, with immediate loss of motor and sensory function occurring in both of his upper extremities. Cervical spine x-rays, computed tomography, and magnetic resonance imaging demonstrated no fracture, soft tissue abnormality, or malalignment. The restriction of deficits to the patient's upper extremities suggested a central cervical spinal cord injury, bilateral brachial injuries, or a conversion disorder.

INTERVENTION

Cervical computed tomographic myelography revealed multiple bilateral nerve root injuries.

CONCLUSION

This case report is unique in the literature in that it describes a patient with multiple cervical nerve root injuries secondary to sandblast injury without ligamentous or bony injury. Although magnetic resonance imaging remains the diagnostic modality of choice in patients with acute spinal cord injury, it is deficient in demonstrating cervical root injury in the acute setting. In this setting, computed tomographic myelography is superior.

Electrophysiologic findings and muscle strength grading in brachioplexopathies

The electrophysiological evaluations and the British Medical Research Council (MRC) scale (0-5) findings of target muscles in brachioplexopathies before surgery and 1 year postsurgery were conducted. Each component of the brachial plexus was analyzed in 15 patients with injuries, among them, to 5 roots, 19 trunks, 7 cords, and 13 terminal nerves. In each of these cases, neurolysis and/or nerve transfer and/or neurotization were performed, within 3 weeks to 6 months after the injury was incurred, to ameliorate the resulting severe disabilities. The degrees of impairment were graded using a modified version of Dumitru's and Wilbourn's scale (mild: normal to slight decrease of SNAP amplitude and CMAP amplitude, and occasional denervation; moderate: profound decrease of SNAP amplitude and CMAP amplitude, constant denervation, and normal to slight decrease in motor unit recruitment; severe: absent SNAP amplitude, absent CMAP amplitude, marked denervation, and profound decrease or no volitional motor unit recruitment. mild = 1; moderate = 2; severe = 3). The motor power of the target muscles was graded through MRC scores. The presurgical versus postsurgical differences in the severity of the injury to each brachial plexus component, and differences in the grading of target muscle power, were calculated through the Wilcoxon signed-rank test. The presurgical degrees of the severity of injury, as measured by the electromyography (EMG) were 3.00 +/- 0.00 (mean +/- SD) in root, 2.84 +/- 0.50 in trunk, 3.00 +/- 0.00 in cord, and 2.85 +/- 0.38 in terminal nerves. The postsurgical results were 2.60 +/- 0.55 in root, 2.53 +/- 0.70 in trunk, 2.43 +/- 0.53 in cord, and 1.77 +/- 0.73 in terminal nerves. There was significant improvement at the trunk, cord, and terminal nerve levels after repair, but not at the root levels. Moreover, although the MRC grading showed significant motor recovery in the infraspinatus, deltoid, biceps, and triceps muscles, there was little apparent improvement in the pectoralis major, EDC, APB, and ADM muscles. Nerve repair was notably successful in all plexuses except at the root level. However, our cases demonstrated only poor motor power gains in the forearm and the hand muscles. Consequently, future surgical techniques for brachioplexopathy repairs need further improvement.

Immunohistochemical characterization of axonal sprouting and reactive tissue changes after long-term implantation of a polyimide sieve electrode to the transected adult rat sciatic nerve

The development of artificial microstructures suited for interfacing of peripheral nerves is not only relevant for basic neurophysiological research but also for future prosthetic approaches. Aim of the present study was to provide a detailed analysis of axonal sprouting and reactive tissue changes after implantation of a flexible sieve electrode to the proximal stump of the adult rat sciatic nerve. We report here that massive neurite growth after implantation, steadily increasing over a period of 11 months, was observed. Parallel to this increase was the expression of myelin markers like Po, whereas non-myelin-forming Schwann cells did not change. Compared to five weeks post-implantation. where both Schwann-cell phenotypes were intermingled with each other, non-myelin-forming Schwann cells occupied a peripheral position in each microfascicle after 11 months. After an initial increase, hematogenous macrophages were down-regulated in number but maintained close contact with the implant. However, at no time were signs of its degradation observed. It is concluded that the introduced flexible polyimide electrode is suitable for contacting peripheral nerves since it permits substantial neurite growth and offers excellent long-term stability.

Outcomes in a consecutive series of 111 surgically treated plexal tumors: a review of the experience at the Louisiana State University Health Sciences Center

OBJECT

The authors conducted a retrospective study of 107 consecutive patients with 111 brachial plexus tumors surgically treated at the Louisiana State University Health Sciences Center (LSUHSC).

METHODS

During a 12-year period, from 1986 to 1998, 371 patients with lesions of the brachial plexus underwent surgery at LSUHSC. Among this group, 107 patients harbored 111 tumors of the brachial plexus. Neural sheath tumors were the most commonly found and included 33 neurofibromas (20 of which were associated with von Recklinghausen disease), 36 schwannomas, and 12 malignant neural sheath tumors. Of the non-neural sheath tumors, 13 were benign and 17 were malignant. Presenting symptoms included pain (59%), palpable mass (52%), paresthesias (30%), and paresis (29%). Anterior supraclavicular (82%) or posterior subscapular (18%) approaches were used to achieve gross-total (79%) or subtotal (21%) resection of tumor. The average follow-up period was 38.3 months or 3.2 years. Seventy percent of patients with benign neural sheath tumors became free from pain postoperatively or reported improvement in their preoperative pain status. Function remained intact or improved in 50% and remained stable postoperatively in another 20% of cases. Preservation of function was more likely in patients who presented intact and in those who had not undergone a previous attempted biopsy procedure or resection than in those in whom such manipulation had occurred.

CONCLUSIONS

Resection of most plexal tumors is technically feasible and associated with acceptable morbidity and mortality rates.

Nerve entrapment in athletes

Nerve entrapment syndromes can occur in athletes. The repetitive and vigorous use or overuse of the upper extremity makes the athlete particularly vulnerable to disorders of peripheral nerves. Understanding the clinical signs and symptoms is essential to treatment. The pertinent anatomy, clinical presentation, treatment, and rehabilitation necessary for return to sports for various nerve entrapments have been described. This should enable the physician caring for the athlete to help prevent injury and to guide appropriate treatment, if intervention becomes necessary.

The surgical treatment of brachial plexus injuries in adults

Posttraumatic brachial plexus palsy is a severe injury primarily affecting young individuals at the prime of their life. The devastating neurological dysfunction inflicted in those patients is usually lifelong and creates significant socioeconomic issues. During the past 30 years, the surgical repair of these injuries has become increasingly feasible. At many centers around the world, leading surgeons have introduced new microsurgical techniques and reported a variety of different philosophies for the reconstruction of the plexus. Microneurolysis, nerve grafting, recruitment of intraplexus and extraplexus donors, and local and free-muscle transfers are used to achieve optimal outcomes. However, there is yet no consensus on the priorities and final goals of reconstruction among the various centers.

Intraneural nerve metastasis with multiple mononeuropathies

Although cancer is a frequent condition, neoplastic involvement of the peripheral nervous system is rare. The mechanisms are heterogeneous and include lesions within the cerebrospinal fluid (CSF) space, local invasion (e.g. brachial plexus), compression, rarely direct infiltration, perineurial spread and even rarer intranerval metastasis. A 47-year-old woman had been treated for a carcinoid 10 years earlier and had received axillar irradiation. At presentation she suffered from weakness of the biceps brachii and was experiencing pain radiating from the axilla into the forearm and thumb. MR scans of the brachial plexus were negative and her symptoms were primarily considered to stem from a postradiation brachial plexopathy, Because of increasing pain, the brachial plexus was explored and a metastasis in the left musculocutaneous nerve was resected. Several months later, numbness and pain appeared in the ulnar nerve and another intrafascicular metastasis in the ulnar nerve was discovered. Resection with preservation of remaining fascicles was performed. This rare case report demonstrates that multiple mononeuropathies, resembling multiplex neuropathy, may be caused by intranerval metastasis.