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Iwabuchi S, Hara Y, Yoshii Y, Yamazaki M. A favourable suture method for size-mismatched nerve transfer: a case series of intercostal-to-musculocutaneous nerve transfer for brachial plexus injury. J Hand Surg Eur Vol 2024; 49:267-269. [PMID: 37747710 DOI: 10.1177/17531934231201915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
We review a nerve suture method for size-mismatched nerve transfers and report a case series involving patients with brachial plexus injury who underwent intercostal-to-musculocutaneous nerve transfer using this method.
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Affiliation(s)
- Sho Iwabuchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuki Hara
- Department of Orthopaedic Surgery, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Yuichi Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical University Ibaraki Medical Center, Ami, Ibaraki, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Zavala A, Chuieng-Yi Lu J, Zelenski NA, Nai-Jen Chang T, Chwei-Chin Chuang D. Staged Phrenic Nerve Elongation and Free Functional Gracilis Muscle Transplantation-A Possible Option for Late Reconstruction in Chronic Brachial Plexus Injury. J Hand Surg Am 2023; 48:1058.e1-1058.e9. [PMID: 35534324 DOI: 10.1016/j.jhsa.2022.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/26/2022] [Accepted: 03/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios. METHODS A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis). RESULTS Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12-72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1 patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4. CONCLUSIONS A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Abraham Zavala
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan
| | - Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan
| | - Nicole A Zelenski
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan
| | - Tommy Nai-Jen Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan
| | - David Chwei-Chin Chuang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan.
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Veloza MJ, Useche JN, Muñoz SB, Vásquez R, Cardona Ortegón JD. Preganglionic injury of C8 nerve root secondary to shoulder dislocation: Diagnosis based on MRI findings. Curr Med Imaging 2023:CMIR-EPUB-129307. [PMID: 36744690 DOI: 10.2174/1573405619666230206122521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Traumatic spinal root injury caused by shoulder dislocation may involve the brachial plexus or, in some cases, a single nerve. The degree of severity of the injury depends on many patient-specific factors as well as the mechanism of injury. It is essential to suspect this type of lesion by means of a thorough physical examination in order to have better patient outcomes. CASE PRESENTATION We presented the subtle magnetic resonance imaging (MRI) findings in a 35-year-old male with left shoulder trauma and dislocation after falling off a bicycle. He complained of decreased muscle strength and sensitivity in the C8 dermatome. Atrophy of the hypothenar region and flexion deformity of the 4th and 5th digits were noted. Magnetic resonance imaging findings were consistent with a partial preganglionic C8 motor root lesion. We found T2 increased signal intensity and thinning of the intradural segment of the C8 motor nerve root and low signal in the sequence of a multi-echo gradient recalled echo (GRE). CONCLUSION MRI is a noninvasive tool that allows a detailed anatomical characterization of the nerves. In brachial plexus injuries, the use of the GRE sequence is useful to identify the lesions, even if they are subtle; however, some lesions may go unnoticed. It is important to note that these patients require an interdisciplinary group to reach a correct diagnosis, which is vital to establish the appropriate treatment and follow-up.
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Affiliation(s)
- María José Veloza
- Department of diagnostic imaging, Fundación Santa Fe de Bogotá. Bogotá, Colombia
| | - Juan Nicolás Useche
- Department of diagnostic imaging, Fundación Santa Fe de Bogotá. Bogotá, Colombia
| | - Sonia Bermúdez Muñoz
- Department of diagnostic imaging, Fundación Santa Fe de Bogotá. Bogotá, Colombia
| | - Ricardo Vásquez
- Department of diagnostic imaging, Fundación Santa Fe de Bogotá. Bogotá, Colombia
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Brito S, White J, Hill B, Thomacos N. Effective long-term management of brachial plexus injury following surgery: What is needed from hand therapists' perspectives. J Hand Ther 2022; 35:267-274. [PMID: 35246366 DOI: 10.1016/j.jht.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Traumatic, brachial plexus injuries (BPI) result represent a significant cost to the individual and society. Recovery involves multiple surgeries, takes years, and often results in permanent physical dysfunction. While the last couple of decades have seen advancements in surgical management, the BPI rehabilitation literature has not kept pace with these developments. PURPOSE We aim to explore the experience of public and privately employed hand therapists' in delivering effective long-term rehabilitation services to inviduals with BPI in Australia. METHODS An interpretative qualitative study. Two focus groups were conducted with Australian hand therapists' (n = 10). Data were analyzed using an inductive thematic approach. RESULTS Three key themes were generated from the data. The first theme 'Falling through the gaps: overlooked components of therapy for BPI' captures participants' thoughts on postinjury health care and rehabilitation services. The second 'Developing a therapeutic alliance: underpinned by time and trust' relates to the relationship building challenges and opportunities following trauma that will withstand the long-term recovery of individuals following BPI. The last theme, 'Factors required for professional development: knowledge and support,' considers the variation seen with these clients in relation to therapy needs and outcomes. CONCLUSIONS The findings of this study highlight the need to better equip hand therapists' skills and knowledge in responding to pain and psychological management post BPI. Our results reinforce the benefit of interdisciplinary models of care in the management of individuals with BPI.
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Affiliation(s)
- Sara Brito
- Occupational Therapy Department, Federation University, Churchill, Victoria, Australia; Department of Occupational Therapy, Monash University, Frankston, Victoria, Australia.
| | - Jennifer White
- Department of Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Bridget Hill
- Epworth Monash Rehabilitation Medicine Unit, Epworth Hospital, Richmond, Victoria Australia
| | - Nikos Thomacos
- Department of Occupational Therapy, Monash University, Frankston, Victoria, Australia
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Sun J, Chen L, Hu S, Song J, Wu J, Gu Y. Morphological basis of radial nerve dysfunction in newborns differs from that of no radial nerve dysfunction in adults in C5-C6-C7 injuries to the brachial plexus: a cadaveric study. Br J Neurosurg 2021; 35:643-649. [PMID: 34259110 DOI: 10.1080/02688697.2021.1947980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Injuries to the upper and middle trunks of brachial plexus result in dysfunction of radial nerves in newborns but do not in adults. We hypothesized that the radial nerve had a lower proportion of myelinated nerve fibers (MNFs) from the lower trunk in newborns than in adults, and in newborns those MNFs were less developed than MNFs in the radial nerve from the middle and upper trunks. METHODS We dissected bilateral brachial plexus of six newborn and six adult cadavers. The radial nerve and its fascicles were separated proximally to posterior divisions of the upper, middle and lower trunks, and fascicles of the radial nerve were harvested from three trunks to calculate respective percentage of MNFs accounting for the total number of MNFs in the radial nerve. We determined diameters of axons and g-ratios of MNFs in the radial nerve from three trunks. RESULTS Compared with adults, the percentage of MNFs in the radial nerve from the lower trunk was lower (p < 0.05), from the middle trunk higher (p < 0.05) and from the upper trunk similar (p > 0.05) in newborns, though MNF counts from three trunks were higher in newborns, respectively (p < 0.01, all). In newborns, MNFs in the radial nerve from the lower trunk had smaller axonal diameters and higher g-ratios than those from the middle and upper trunks (p < 0.017, all), while in adults there were no such differences. CONCLUSIONS Lower proportion of MNFs in the radial nerve from the lower trunk in newborns than in adults, and in newborns immaturity of MNFs from the lower trunk relative to MNFs from the middle and upper trunks may be the major morphological basis of difference in clinical appearances of radial nerve palsy caused by injuries to C5-C6-C7 between newborns and adults.
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Affiliation(s)
- Jiayu Sun
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Liang Chen
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Shaonan Hu
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jie Song
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jixin Wu
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Yudong Gu
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
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Dolan RT, Cronin KJ, Cogswell LK, Giele HP. Free Vascularized Rectus Abdominis Transfer With Pedicled Intercostal Innervation for Functional Reconstruction of the Elbow in Total Brachial Plexus Palsy. J Hand Surg Am 2021; 46:147.e1-147.e8. [PMID: 33008693 DOI: 10.1016/j.jhsa.2020.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 05/25/2020] [Accepted: 07/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Reanimation of palsied upper limbs usually follows an escalating pattern of nerve repair, nerve transfers, and musculotendinous transfers and culminates in free functioning muscle transfers. When there are no other musculotendinous options, we explored the possibility of transferring the rectus abdominus to the biceps by maintaining the nerve pedicle but dividing the vascular pedicle and anastomosing it to the brachial artery. METHODS We performed anatomical dissection of the nerve and blood supply of 6 rectus abdominis muscles in 3 cadavers. A retrospective analysis of 4 patients in whom a rectus abdominus muscle transfer with a pedicled nerve, but free vascular supply, was then performed. RESULTS The anatomical feasibility study demonstrated that it was possible to elevate the rectus abdominis on its intercostal nerve supply to the midaxillary line, allowing the muscle to be pedicled on its nerve supply and be transferred to the arm to reconstruct biceps. The vascular supply could be reestablished by anastomosis of inferior epigastric vessels to the brachial artery and veins. In 4 patients, elbow flexion strength of M3 or greater was achieved. Average elbow range of dynamic flexion was 120° (range, 92° to 131°). Shoulder stability and external rotation improved in all patients with resolution of shoulder subluxation. Two patients developed donor site hernias requiring mesh reconstruction. Complications included a hypertrophic recipient site scar in one patient, and recipient site wound dehiscence in another. CONCLUSIONS Rectus abdominus can be transferred to reconstruct elbow flexion when other musculotendinous transfers are unavailable and as an alternative to free functioning muscle transfer. However, rectus abdominus transfer still requires microsurgical skills for the vessel anastomoses. This is an effective procedure for functional reconstruction of the elbow and adds to the armamentarium in the management of brachial plexus pathology when other transfers are unavailable. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Roisin T Dolan
- Oxford Reconstructive Plastic Hand Innovation Collaboration, Oxford University Hospitals NHS Foundation Trust, United Kingdom; Department of Plastic, Reconstructive and Hand Surgery, Oxford University Hospitals NHS Foundation Trust, United Kingdom; Nuffield Department of Surgical Sciences, Oxford University Hospitals NHS Foundation Trust, United Kingdom
| | - Kevin J Cronin
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Lucy K Cogswell
- Department of Plastic, Reconstructive and Hand Surgery, Oxford University Hospitals NHS Foundation Trust, United Kingdom; Nuffield Department of Surgical Sciences, Oxford University Hospitals NHS Foundation Trust, United Kingdom
| | - Henk P Giele
- Oxford Reconstructive Plastic Hand Innovation Collaboration, Oxford University Hospitals NHS Foundation Trust, United Kingdom; Department of Plastic, Reconstructive and Hand Surgery, Oxford University Hospitals NHS Foundation Trust, United Kingdom; Nuffield Department of Surgical Sciences, Oxford University Hospitals NHS Foundation Trust, United Kingdom.
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Bordalo-Rodrigues M, Siqueira MG, Kurimori CO, Carneiro ACR, Martins RS, Foroni L, Oliveira AJM, Solla DJF. Diagnostic accuracy of imaging studies for diagnosing root avulsions in post-traumatic upper brachial plexus traction injuries in adults. Acta Neurochir (Wien) 2020; 162:3189-3196. [PMID: 32591949 DOI: 10.1007/s00701-020-04465-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is no consensus about which type of imaging study, computed tomography myelography (CTM) or magnetic resonance imaging (MRI), provides better information concerning root avulsion in adult brachial plexus injuries. METHODS Patients with upper brachial plexus traumatic injuries underwent both CTM and MRI and surgical exploration. The imaging studies were analyzed by two independent radiologists and the data were compared with the intraoperative findings. The statistical analysis was based on dichotomous classification of the nerve roots (normal or altered). The interobserver agreement was assessed using Cohen's Kappa. The accuracy of CTM and MRI in comparison with the intraoperative findings was evaluated using the same methodology. RESULTS Fifty-two adult patients were included. CTM tended to yield slightly higher percentages of alterations than MRI The interobserver agreement was better on CTM than on MRI for all nerve roots: C5, 0.9960 (strong) vs. 0.145 (poor); C6, 0.970 (strong) vs. 0.788 (substantial); C7, 0.969 (strong) vs. 0.848 (strong). The accuracy regarding the intraoperative findings was also higher on CTM (moderate, kappa 0.40-0.59) than on MRI (minimal, kappa 0.20-0.39) for all nerve roots. Accordingly, the overall percentage concordance (both normal or both altered) was superior in the CTM evaluation (approx. 70-75% vs. 60-65%). CTM was superior for both sensitivity and specificity at all nerve roots. CONCLUSION CTM had greater interobserver agreement and higher diagnostic accuracy than MRI in adult patients with root avulsions due to brachial plexus injury.
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Song J, Qiu WJ, Chen L, Hu SN, Wu JX, Gu YD. Transfers of the Ipsilateral C7 Plus the Spinal Accessory Nerve Versus Triple Nerve Transfers for Treatment of C5-C6 Avulsion of the Brachial Plexus. J Hand Surg Am 2020; 45:363.e1-363.e6. [PMID: 31718845 DOI: 10.1016/j.jhsa.2019.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 06/28/2019] [Accepted: 09/07/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the long-term results of transfers of the ipsilateral C7 (IC7) plus spinal accessory nerve (SAN) with those of triple nerve transfers (TNT) using one fascicle of the ulnar nerve to the biceps motor branch (Oberlin's procedure), SAN transferred to the suprascapular nerve, and transfer of the long head of triceps nerve branch to the anterior branch of axillary nerve to treat C5-C6 avulsion of the brachial plexus. METHODS The IC7 group included 9 patients undergoing transfers of IC7 to the upper trunk and SAN to the suprascapular nerve. Median age at surgery was 26 years and interval between injury and surgery was 2.8 months. Patients were observed for a median of 118 months. The TNT group contained 13 patients, median age 33 years; interval between injury and surgery was 3.1 months. Patients were observed for a median of 103 months. RESULTS In the IC7 group, median shoulder abduction was 105° and median external rotation of the shoulder was 64°, which was similar to that of the TNT group (89° abduction and 58° external rotation). Eight of nine patients recovered at least M3 (Modified Narakas scale) strength of deltoid in the IC7 group, which was similar to that in the TNT group (11 of 13 patients). Six of nine patients achieved at least Medical Research Council grade 3 (MRC3) strength of biceps in the IC7 group, which was similar to that in the TNT group (11 of 13 patients). Of 4 patients in the IC7 group with a preoperative latissimus dorsi strength of MRC3 or less, 3 gained a deltoid strength of M3 or less, and 3 a biceps strength of MRC2 or less. CONCLUSIONS Transfers of IC7 plus SAN provide results comparable to those of TNT for treatment of C5-C6 avulsion. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Jie Song
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, People's Republic of China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
| | - Wen-Jun Qiu
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Liang Chen
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, People's Republic of China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China.
| | - Shao-Nan Hu
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, People's Republic of China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
| | - Ji-Xin Wu
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, People's Republic of China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
| | - Yu-Dong Gu
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, People's Republic of China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
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Prasad GL. An All-Anterior Approach for Quadruple Nerve Transfer for Upper Trunk Brachial Plexus Injuries. World Neurosurg 2018; 120:e651-e659. [PMID: 30165220 DOI: 10.1016/j.wneu.2018.08.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The most commonly performed nerve transfers in upper trunk (UT) or partial brachial plexus injuries (BPIs) include the spinal accessory nerve to suprascapular nerve, Oberlin, and, lately, radial nerve (RN) (branch to triceps) to axillary nerve (AN) transfers. Routinely, the former 3 procedures are performed through an anterior approach (supraclavicular plus infraclavicular), while the triceps branch of the RN-AN transfer has been performed through a posterior approach with the patient in either the prone or semilateral position, which requires a separate incision in the posterior arm. The aim of the present study was to report the outcomes for 4 cases of quadruple nerve transfers performed for UT BPI using an all-anterior approach. METHODS The functional outcomes of 4 consecutive cases of UT BPI treated using an all-anterior approach were analyzed in terms of improvement in motor power and range of motion at the shoulder and elbow joints. RESULTS The mean age was 27.5 years (range, 16-40). All had sustained injuries from road traffic accidents. The mean injury to surgery interval was 4.5 months (range, 3-6). Of the 4 patients, 2 each had pre- and postganglionic injuries. All 4 patients had 0 of M0 power in shoulder abduction and external rotation, and elbow flexion. At a mean follow-up of 28.6 months, the average shoulder abduction was 157°, with an average of 82° of external rotation. The mean elbow flexion was 104°. CONCLUSIONS This technique appears to be feasible, with good-to-excellent outcomes achieved without requiring a separate posterior arm incision for the RN-AN transfer.
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Affiliation(s)
- G Lakshmi Prasad
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India.
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Casal D, Cunha T, Pais D, Iria I, Angélica-Almeida M, Millan G, Videira-Castro J, Goyri-O'Neill J. A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report. J Med Case Rep 2017; 11:6. [PMID: 28049512 PMCID: PMC5209886 DOI: 10.1186/s13256-016-1162-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/30/2016] [Indexed: 11/24/2022] Open
Abstract
Background Although open injuries involving the brachial plexus are relatively uncommon, they can lead to permanent disability and even be life threatening if accompanied by vascular damage. We present a case report of a brachial plexus injury in which the urgency of the situation precluded the use of any ancillary diagnostic examinations and forced a rapid clinical assessment. Case presentation We report a case of a Portuguese man who had a stabbing injury at the base of his left axilla. On observation in our emergency room an acute venous type of bleeding was present at the wound site and, as a result of refractory hypotension after initial management with fluids administered intravenously, he was immediately carried to our operating room. During the course of transportation, we observed that he presented hypoesthesia of the medial aspect of his arm and forearm, as well as of the ulnar side of his hand and of the palmar aspect of the last three digits and of the dorsal aspect of the last two digits. Moreover, he was not able to actively flex the joints of his middle, ring, and small fingers or to adduct or abduct all fingers. Exclusively relying on our anatomical knowledge of the axillary region, the site of the stabbing wound, and the physical neurologic examination, we were able to unequivocally pinpoint the place of the injury between the anterior division of the lower trunk of his brachial plexus and the proximal portion of the following nerves: ulnar, medial cutaneous of his arm and forearm, and the medial aspect of his median nerve. Surgery revealed a longitudinal laceration of the posterior aspect of his axillary vein, and confirmed a complete section of his ulnar nerve, his medial brachial and antebrachial cutaneous nerves, and an incomplete section of the ulnar aspect of his median nerve. All structures were repaired microsurgically. Three years after the surgery he showed a good functional outcome. Conclusions We believe that this case report illustrates the relevance of a sound anatomical knowledge of the brachial plexus in an emergency setting.
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Affiliation(s)
- Diogo Casal
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal. .,Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal.
| | - Teresa Cunha
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Diogo Pais
- Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
| | - Inês Iria
- UCIBIO, Life Sciences Department, Faculty of Sciences and Technology, Universidade NOVA de Lisboa, Caparica, Portugal.,CEDOC, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Maria Angélica-Almeida
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.,Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
| | - Gerardo Millan
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - José Videira-Castro
- Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - João Goyri-O'Neill
- Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
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Abstract
The restoration of shoulder function after brachial plexus injury represents a significant challenge facing the peripheral nerve surgeons. This is owing to a combination of the complex biomechanics of the shoulder girdle, the multitude of muscles and nerves that could be potentially injured, and a limited number of donor options. In general, nerve transfer is favored over tendon transfer, because the biomechanics of the musculotendinous units are not altered. This article summarizes the surgical techniques and clinical results of nerve transfers for restoration of shoulder function.
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Maldonado AA, Kircher MF, Spinner RJ, Bishop AT, Shin AY. The role of elective amputation in patients with traumatic brachial plexus injury. J Plast Reconstr Aesthet Surg 2015; 69:311-7. [PMID: 26776904 DOI: 10.1016/j.bjps.2015.10.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 07/10/2015] [Accepted: 10/19/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIM Despite undergoing complex brachial plexus, surgical reconstructions, and rehabilitation, some patients request an elective amputation. This study evaluates the role of elective amputation after brachial plexus injury. METHODS A retrospective chart review was performed for all the 2140 patients with brachial plexus injuries treated with elective amputation between 1999 and 2012 at a single institution. Analysis was conducted on the potential predisposing factors for amputation, amputation level, and postamputation complications. Patients were evaluated using pre- and postamputation Disabilities of the Shoulder, Arm, and hand scores in addition to visual analog pain scores. RESULTS The following three conditions were observed in all nine patients who requested an elective amputation: (1) Pan-plexus injury; (2) non-recovery (mid-humeral amputation) or elbow flexion recovery only (forearm amputation) 1 year after all other surgical options were performed; and (3) at least one chronic complication (chronic infection, nonunion fractures, full-thickness burns, chronic neck pain with arm weight, etc.). Pain improvement was found in five patients. Subjective patient assessments and visual analog pain scores before and after amputation did not show a statistically significant improvement in Disabilities of the Shoulder, Arm, and Hand Scores. However, four patients reported that their shoulder pain felt "better" than it did before the amputation, and two patients indicated they were completely cured of chronic pain after surgery. CONCLUSIONS Elective amputation after brachial plexus injury should be considered as an option in the above circumstances. When the informed and educated decision is made, patients can have satisfactory outcomes regarding amputation.
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Affiliation(s)
- Andrés A Maldonado
- Mayo Clinic, Department of Orthopedic Surgery, Division of Hand Surgery, 200 1st Street South West, Rochester, MN 55905, USA
| | - Michelle F Kircher
- Mayo Clinic, Department of Orthopedic Surgery, Division of Hand Surgery, 200 1st Street South West, Rochester, MN 55905, USA
| | - Robert J Spinner
- Mayo Clinic, Department of Neurologic Surgery and Department of Orthopedic Surgery, Division of Hand Surgery, 200 1st Street South West, Rochester, MN 55905, USA
| | - Allen T Bishop
- Mayo Clinic, Department of Orthopedic Surgery, Division of Hand Surgery, 200 1st Street South West, Rochester, MN 55905, USA
| | - Alexander Y Shin
- Mayo Clinic, Department of Orthopedic Surgery, Division of Hand Surgery, 200 1st Street South West, Rochester, MN 55905, USA.
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Abstract
Management of brachial plexus injury is a demanding field of hand and upper extremity surgery. With currently available microsurgical techniques, functional gains are rewarding in upper plexus injuries. However, treatment options in the management of flail and anaesthetic limb are still evolving. Last three decades have witnessed significant developments in the management of these injuries, which include a better understanding of the anatomy, advances in the diagnostic modalities, incorporation of intra-operative nerve stimulation techniques, more liberal use of nerve grafts in bridging nerve gaps, and the addition of new nerve transfers, which selectively neurotise the target muscles close to the motor end plates. Newer research works on the use of nerve allografts and immune modulators (FK 506) are under evaluation in further improving the results in nerve reconstruction. Direct reimplantation of avulsed spinal nerve roots into the spinal cord is another area of research in brachial plexus reconstruction.
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Affiliation(s)
- Prem Singh Bhandari
- Department of Plastic Surgery, Command Hospital (NC), Panchkula, Haryana, India
| | - Sanjay Maurya
- Command Hospital (WC), Chandimandir Cantt, Panchkula, Haryana, India
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