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Cao W, Howe BM, Wright DE, Ramanathan S, Rhodes NG, Korfiatis P, Amrami KK, Spinner RJ, Kline TL. Abnormal Brachial Plexus Differentiation from Routine Magnetic Resonance Imaging: An AI-based Approach. Neuroscience 2024; 546:178-187. [PMID: 38518925 DOI: 10.1016/j.neuroscience.2024.03.017] [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] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 03/11/2024] [Accepted: 03/17/2024] [Indexed: 03/24/2024]
Abstract
Automatic abnormality identification of brachial plexus (BP) from normal magnetic resonance imaging to localize and identify a neurologic injury in clinical practice (MRI) is still a novel topic in brachial plexopathy. This study developed and evaluated an approach to differentiate abnormal BP with artificial intelligence (AI) over three commonly used MRI sequences, i.e. T1, FLUID sensitive and post-gadolinium sequences. A BP dataset was collected by radiological experts and a semi-supervised artificial intelligence method was used to segment the BP (based on nnU-net). Hereafter, a radiomics method was utilized to extract 107 shape and texture features from these ROIs. From various machine learning methods, we selected six widely recognized classifiers for training our Brachial plexus (BP) models and assessing their efficacy. To optimize these models, we introduced a dynamic feature selection approach aimed at discarding redundant and less informative features. Our experimental findings demonstrated that, in the context of identifying abnormal BP cases, shape features displayed heightened sensitivity compared to texture features. Notably, both the Logistic classifier and Bagging classifier outperformed other methods in our study. These evaluations illuminated the exceptional performance of our model trained on FLUID-sensitive sequences, which notably exceeded the results of both T1 and post-gadolinium sequences. Crucially, our analysis highlighted that both its classification accuracies and AUC score (area under the curve of receiver operating characteristics) over FLUID-sensitive sequence exceeded 90%. This outcome served as a robust experimental validation, affirming the substantial potential and strong feasibility of integrating AI into clinical practice.
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Affiliation(s)
- Weiguo Cao
- Department of Radiology, Mayo Clinic, 200 First Street SW, Charlton 1, Rochester, MN 55905, USA
| | - Benjamin M Howe
- Department of Radiology, Mayo Clinic, 200 First Street SW, Charlton 1, Rochester, MN 55905, USA
| | - Darryl E Wright
- Department of Radiology, Mayo Clinic, 200 First Street SW, Charlton 1, Rochester, MN 55905, USA
| | - Sumana Ramanathan
- Department of Radiology, Mayo Clinic, 200 First Street SW, Charlton 1, Rochester, MN 55905, USA
| | - Nicholas G Rhodes
- Department of Radiology, Mayo Clinic, 200 First Street SW, Charlton 1, Rochester, MN 55905, USA
| | - Panagiotis Korfiatis
- Department of Radiology, Mayo Clinic, 200 First Street SW, Charlton 1, Rochester, MN 55905, USA
| | - Kimberly K Amrami
- Department of Radiology, Mayo Clinic, 200 First Street SW, Charlton 1, Rochester, MN 55905, USA
| | - Robert J Spinner
- Department of Neurological Surgery, Mayo Clinic, 200 First Street SW, Gonda 8, Rochester, MN 55905, USA
| | - Timothy L Kline
- Department of Radiology, Mayo Clinic, 200 First Street SW, Charlton 1, Rochester, MN 55905, USA.
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Zhang Y, Li X, Liu Y, Sun Y, Duan L, Zhang Y, Shi R, Yu X, Peng Z. 3D SHINKEI MR neurography in evaluation of traumatic brachial plexus. Sci Rep 2024; 14:6268. [PMID: 38491150 PMCID: PMC10943192 DOI: 10.1038/s41598-024-57022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 03/13/2024] [Indexed: 03/18/2024] Open
Abstract
3D SHINKEI neurography is a new sequence for imaging the peripheral nerves. The study aims at assessing traumatic brachial plexus injury using this sequence. Fifty-eight patients with suspected trauma induced brachial plexus injury underwent MR neurography (MRN) imaging in 3D SHINKEI sequence at 3 T. Surgery and intraoperative somatosensory evoked potentials or clinical follow-up results were used as the reference standard. MRN, surgery and electromyography (EMG) findings were recorded at four levels of the brachial plexus-roots, trunks, cords and branches. Fifty-eight patients had pre- or postganglionic injury. The C5-C6 nerve postganglionic segment was the most common (average 42%) among the postganglionic injuries detected by 3D SHINKEI MRN. The diagnostic accuracy (83.75%) and the specificity (90.30%) of MRN higher than that of EMG (p < 0.001). There was no significant difference in the diagnostic sensitivity of MRN compared with EMG (p > 0.05). Eighteen patients with brachial plexus injury underwent surgical exploration after MRN examination and the correlation between MRN and surgery was 66.7%. Due to the high diagnostic accuracy and specificity, 3D SHINKEI MRN can comprehensively display the traumatic brachial plexus injury. This sequence has great potential in the accurate diagnosis of traumatic brachial plexus injury.
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Affiliation(s)
- Yizhe Zhang
- Department of Radiology, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Xiaona Li
- Department of Radiology, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Ying Liu
- Department of Radiology, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Yingcai Sun
- Department of Radiology, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Luyao Duan
- Department of Radiology, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Yingshuai Zhang
- Department of Radiology, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Ruiqing Shi
- Department of Radiology, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Xiaoman Yu
- Department of Radiology, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Zhigang Peng
- Department of Radiology, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China.
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Ramachandran A, Jana M, Kumar A, Kandasamy D, Naranje P, Gupta AK, Gulati S, Chakrabarty B, Singhal M. Evaluation of Infantile Brachial Plexopathy Using 3T MRI and High-Resolution Ultrasound: Experience From a Tertiary Care Centre. Neurol India 2024; 72:326-333. [PMID: 38691477 DOI: 10.4103/ni.ni_818_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 05/19/2022] [Indexed: 05/03/2024]
Abstract
BACKGROUND Currently, clinical assessment is the main tool for the evaluation of brachial plexus injury, complemented by electrophysiologic studies (EPS), and imaging studies whenever available. Imaging plays an important role as it enables the differentiation of pre-ganglionic and postganglionic injuries, and adds objectivity to presurgical evaluation. OBJECTIVES The primary objective was to evaluate the utility of magnetic resonance imaging (MRI) and high-resolution ultrasonography (USG) in the localization and characterization of brachial plexus injury in infants. MATERIALS AND METHODS In this prospective study, 34 infants with signs and symptoms of brachial plexus injury were evaluated by clinical examination, EPS, MRI, and USG. Imaging findings were correlated with intraoperative findings in infants who underwent surgical management. The association between EPS and MRI findings, and USG and MRI findings were assessed using Fisher's exact test. Semi-quantitative subjective analysis of various MRI sequences was done as well. RESULTS The most common findings of preganglionic injury and postganglionic injury, in our study, were pseudomeningocele and nerve thickening, respectively. MRI detection of injuries had a significant association with EPS findings. All MRI-detected injuries had a muscle power of grade 3 or less. muscle. Three-dimensional (3D) short tau inversion recovery (STIR) sequence was found to be superior for detecting postganglionic injuries (P < 0.05). CONCLUSION Imaging studies enable localization of the site of injury, determining the extent, and nature/morphology of injury. The gamut of findings obtained from MRI is far wider compared to that from USG. USG can be used as the first-line screening investigation.
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Affiliation(s)
- Anupama Ramachandran
- Department of Radiodiagnosis and Interventional Radiology, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manisha Jana
- Department of Radiodiagnosis and Interventional Radiology, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis and Interventional Radiology, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Devasenathipathy Kandasamy
- Department of Radiodiagnosis and Interventional Radiology, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Priyanka Naranje
- Department of Radiodiagnosis and Interventional Radiology, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Kumar Gupta
- Department of Radiodiagnosis and Interventional Radiology, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sheffali Gulati
- Department of Pediatrics- Child Neurology Division, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Biswaroop Chakrabarty
- Department of Pediatrics- Child Neurology Division, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Maneesh Singhal
- Department of Plastic, Reconstructive and Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
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Gong W, Jia Y, Hao J, Zhao R, Chen D, Zheng M. Diagnosis of obstetric brachial plexus injury in a 2-year-old girl using high‑frequency ultrasonography. Pediatr Radiol 2024; 54:362-366. [PMID: 38153539 DOI: 10.1007/s00247-023-05835-y] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/08/2023] [Accepted: 12/08/2023] [Indexed: 12/29/2023]
Abstract
We describe an unusual case of infant obstetric brachial plexus injury located in the cervical (C)5-C6 brachial plexus nerve, which was preoperatively diagnosed using high-frequency ultrasonography (US) at 2 years of age. The girl was diagnosed with a right clavicular fracture because of shoulder dystocia. She had been showing movement limitations of her entire right upper limb after fracture healing and was then referred to our hospital at 2 years of age. High-frequency US showed that the roots of the right brachial plexus ran continuously, but the diameter of C6 was thinner on the affected side than on the contralateral side (right 0.12 cm vs. left 0.20 cm). A traumatic neuroma had formed at the upper trunk, which was thicker (diameter: right 0.35 cm vs. left 0.23 cm; cross-sectional area: right 0.65 cm2 vs. left 0.31 cm2) at the level of the supraclavicular fossa. Intraoperative findings were consistent with ultrasound findings. Postoperative pathology confirmed brachial plexus traumatic neuroma.
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Affiliation(s)
- Wenqing Gong
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China
| | - Yunan Jia
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China
| | - Jikun Hao
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China
| | - Rui Zhao
- Department of Hand-Surgery, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Dingzhang Chen
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China.
| | - Minjuan Zheng
- Department of Ultrasound, Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, China
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Zhao L, Zhao J, Ma C, Lu Y, Dong C. Diagnostic Performance of 3D-NERVE as an Adjunct to Electromyography for the Assessment of Brachial Plexus Injury in Infants. J Child Neurol 2023; 38:617-621. [PMID: 37700631 DOI: 10.1177/08830738231200301] [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: 09/14/2023]
Abstract
Objective: This study aimed to explore diagnostic performance of 3D-NERVE as an adjunct to electromyography for the assessment of brachial plexus injury in infants. Methods: Imaging of infants with brachial plexus injury using 3D-NERVE and/or 3D-STIR from 2019 to 2022 were reviewed. Images were evaluated between the 2 sequences for nerve-to-fat ratio, nerve-to-muscle ratio, muscle-to-fat ratio, fat suppression homogeneity, and display rate of brachial plexus branches. Results: This study included 37 infants who were referred for a clinical diagnosis of brachial plexus injury. A total of 21 infants accepted 3D-NERVE sequence scanning, and 16 infants accepted 3D-NERVE and 3D-STIR sequences scanning. The results of examination were generally consistent with electromyography. The 2 sequences were compared, yielding the following results. There were no pulsation artifacts (0/16), and 1 case with heterogeneous fat saturation (1/16) was seen on 3D-NERVE. There were no pulsation artifacts (0/16), and 5 cases with heterogeneous fat saturation (5/16) were seen on 3D-STIR. 3D-NERVE performed better (P < .05) for nerve-to-fat and nerve-to-muscle ratios compared with 3D-STIR, and no significant difference in the muscle-to-fat ratio (P > .05). The 3D-NERVE and STIR helped depict 100% (16/16) of the brachial roots and brachial plexus trunk. Brachial plexus bundles and brachial plexus branches were observed in 93.75% (15/16) and 68.75% (11/16) of the 3D-NERVE and 93.75% (15/16) and 62.5% (10/16) of the 3D-STIR, respectively. The differences were not statistically significant (P > .05). Conclusion: Nerve trauma was better visualized with the 3D-NERVE, which is an effective adjunct to electromyography for doctors to assess brachial plexus injury and consequently helps in better treatment planning.
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Affiliation(s)
- Leilei Zhao
- Department of Radiology, Jinan Children's Hospital, Qilu Children's Hospital of Shandong University, Jinan, China
| | - Jianshe Zhao
- Department of Radiology, Jinan Children's Hospital, Qilu Children's Hospital of Shandong University, Jinan, China
| | - Changyou Ma
- Department of Radiology, Jinan Children's Hospital, Qilu Children's Hospital of Shandong University, Jinan, China
| | - Yi Lu
- Department of Radiology, Jinan Children's Hospital, Qilu Children's Hospital of Shandong University, Jinan, China
| | - Chunhua Dong
- Department of Radiology, Jinan Children's Hospital, Qilu Children's Hospital of Shandong University, Jinan, China
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Crowe CS, Pulos N, Spinner RJ, Bishop AT, Wigle DA, Shin AY. The diagnostic utility of inspiratory-expiratory radiography for the assessment of phrenic nerve palsy associated with brachial plexus injury. Acta Neurochir (Wien) 2023; 165:2589-2596. [PMID: 37198276 DOI: 10.1007/s00701-023-05622-6] [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] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/06/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND The phrenic nerve is commonly injured with trauma to the brachial plexus. Hemi-diaphragmatic paralysis may be well-compensated in healthy individuals at rest but can be associated with persistent exercise intolerance in some patients. This study aims to determine the diagnostic value of inspiratory-expiratory chest radiography compared to intraoperative stimulation of the phrenic nerve for assessing phrenic nerve injury associated with brachial plexus injury. METHODS Over a 21-year period, the diagnostic utility of three-view inspiratory-expiratory chest radiography for identification of phrenic nerve injury was determined by comparison to intraoperative phrenic nerve stimulation. Multivariate regression analysis was used to identify independent predictors of phrenic nerve injury and having an incorrect radiographic diagnosis. RESULTS A total of 237 patients with inspiratory-expiratory chest radiography underwent intraoperative testing of phrenic nerve function. Phrenic nerve injury was present in approximately one-fourth of cases. Preoperative chest radiography had a sensitivity of 56%, specificity of 93%, positive predictive negative of 75%, and negative predictive value of 86% for identification of a phrenic nerve palsy. Only C5 avulsion was found to be a predictor of having an incorrect diagnosis of phrenic nerve injury on radiography. CONCLUSION While inspiratory-expiratory chest radiography has good specificity for detecting phrenic nerve injuries, a high number of false negatives suggest that it should not be relied upon for routine screening of dysfunction after traumatic brachial plexus injury. This is likely multifactorial and relates to variation in diaphragm shape and position, as well as limitations regarding static image interpretation of a dynamic process.
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Affiliation(s)
- Christopher S Crowe
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA
| | - Nicholas Pulos
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA
| | | | - Allen T Bishop
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA
| | - Dennis A Wigle
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, USA
| | - Alexander Y Shin
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA.
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Gu S, Zhao Q, Yao J, Zhang L, Xu L, Chen W, Gu Y, Xu J. Diagnostic Ability of Ultrasonography in Brachial Plexus Root Injury at Different Stages Post-trauma. Ultrasound Med Biol 2022; 48:1122-1130. [PMID: 35331579 DOI: 10.1016/j.ultrasmedbio.2022.02.013] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 01/30/2022] [Accepted: 02/10/2022] [Indexed: 06/14/2023]
Abstract
Brachial plexus (BP) root injury often results in disability of the upper extremities. Improvements in high-frequency ultrasonography have enabled the visualization of BP nerve roots. This study was aimed at quantifying the diagnostic accuracy of ultrasonography in BP root injury at different stages post-trauma. A consecutive series of 170 patients with BP root injury between 2015 and 2019 were studied retrospectively and divided into three groups on the basis of time between injury and ultrasound examination (≤1 mo, 1-3 mo, >3 mo). Diagnosis of complete BP root injury under ultrasound was determined using a pre-defined criterion, including pseudomeningocele, retraction and rupture. Diagnostic accuracy was calculated based on surgical findings and intra-operative electrophysiological tests. Rates of detection of the cervical (C5-C8) and thoracic (T1) nerve roots under ultrasound were 99.4%, 99.4%, 99.4%, 95.9% and 79.4%, respectively. The sensitivity for complete BP root injury was 0.74, and the specificity was 0.91. No significant differences in sensitivity or specificity were observed across time stages. Ultrasound exhibited substantial consistency with surgical findings (κ = 0.70) for complete BP root injury at any stage post-injury. Ultrasound can be an optional method of diagnosis of complete BP root injury at an early stage post-injury.
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Affiliation(s)
- Shihui Gu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Qian Zhao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jing Yao
- Department of Ultrasound, Huashan Hospital, Fudan University, Shanghai, China
| | - Li Zhang
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Lei Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Weiming Chen
- Department of Ultrasound, Huashan Hospital, Fudan University, Shanghai, China
| | - Yudong Gu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jianguang Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China.
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Perumal AR, Anyamele UA, Bhogal RK, McCauley G, Teh I, Bourke G, Rankine JJ, Wade RG. Incidental findings associated with magnetic resonance imaging of the brachial plexus. Br J Radiol 2021; 94:20200921. [PMID: 33156721 PMCID: PMC7774680 DOI: 10.1259/bjr.20200921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The identification and management of incidental findings is becoming increasingly problematic, particularly in relation to brachial plexus imaging because the prevalence is unknown. Therefore, we aimed to estimate the prevalence of incidental findings in symptomatic patients undergoing MRI of the brachial plexus. METHODS This retrospective cohort study included all children and adults who underwent MRI over a 12-year period, in a tertiary care centre in the UK. An incidental finding was any abnormality which was not a direct injury to or disease-process of the brachial plexus. An "incidentaloma" was defined by the need for further investigation or treatment. Multivariable logistic regression was used to estimate the odds ratio (OR) of an "incidentaloma". To estimate which factors were associated with the incident rate ratio (IRR) of incidental findings, multivariable Poisson regression was used. RESULTS Overall, 502 scans (72%) reported incidental anomalies. Although the number of MRIs performed per annum increased by 23%, the prevalence of "incidentalomas" remained static (p = 0.766). Musculoskeletal incidental findings were the most prevalent (63%) and when identified, there were a median of 3 incidental anomalies per patient. Overall, 125 (18%) anomalies were "incidentalomas" which required further investigation or treatment. The odds of having further investigation or treatment was strongly related to the frequency of incidental findings [adjusted OR 1.16 (95% CI 1.08, 1.24)] and when a tumour was identified [adjusted OR 2.86 (95% CI 1.81, 4.53)]. The number of incidental findings recorded per scan increased when trainees co-reported with consultants [adjusted IRR 0.36 (95% CI 0.05, 0.67)] and in the presence of a tumour [adjusted IRR 0.39 (95% CI 0.28, 0.49)]. CONCLUSIONS The prevalence of clinically important incidental findings on brachial plexus MRI is lower than organ-specific imaging, but still 18% of scans identified an 'incidentaloma' which required further investigation or treatment. ADVANCES IN KNOWLEDGE This cohort study shows that approximately 1 in 5 symptomatic patients undergoing a brachial plexus MRI had a clinically important incidental findings, which required further investigation or treatment. This information can be used to inform patients consenting to clinical or research imaging.
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Affiliation(s)
- Antonia R Perumal
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
| | | | - Rayna K Bhogal
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
| | | | - Irvin Teh
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - James J Rankine
- Department of Radiology, Leeds Teaching Hospitals Trust, Leeds, UK
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Yukata K, Doi K, Okabayashi T, Hattori Y, Sakamoto S. Shrug radiographs for the diagnosis of long thoracic nerve palsy in traumatic brachial plexus injury. J Shoulder Elbow Surg 2020; 29:2595-2600. [PMID: 33190758 DOI: 10.1016/j.jse.2020.03.052] [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: 12/27/2019] [Accepted: 03/25/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Preoperative diagnosis of long thoracic nerve (LTN) palsy is important for shoulder reconstruction after a traumatic brachial plexus injury (BPI). In the present study, we developed an objective diagnostic method for LTN palsy for patients with traumatic BPI. METHODS This is a retrospective review of 56 patients with traumatic BPI who had been receiving treatment at a single institution for over 8 years. The patients were divided into 2 groups: an LTN palsy group (n = 30) and a no palsy control group (n = 26). The LTN palsy group had 21 different palsy types with 4 and 5 C5-7 and C5-8, whereas the no palsy group had 18 different palsy types with 5 and 3 C5-6 and C5-8, respectively. Preoperative plain anteroposterior radiographs were taken in shoulder adduction and shrug positions. Scapulothoracic (ST) upward rotation and clavicle lateral (CL) rotation angles were measured on X-rays. The differences between the adduction and shrug positions for the respective angles were calculated and defined as ΦST and ΦCL, respectively. The differences in the ΦST and ΦCL values due to the presence or absence of LTN palsy were examined, the cutoff values of ΦST and ΦCL for the diagnosis of LTN palsy were determined, and further sensitivity and specificity were calculated. RESULTS Both ΦST and ΦCL were significantly decreased in the LTN palsy group compared with the no palsy control group. The sensitivity and specificity for LTN palsy were 0.833 and 1.000 for ΦST and 0.833 and 0.840 for ΦCL, respectively, when the cutoff value was set as ΦST = 15° and ΦCL ≤ 24°. CONCLUSION Dynamic shrug radiographs provide a useful objective diagnosis of LTN palsy after traumatic BPI.
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Affiliation(s)
- Kiminori Yukata
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Kazuteru Doi
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan.
| | - Toshitaka Okabayashi
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Yasunori Hattori
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
| | - Sotetsu Sakamoto
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
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van Rosmalen MHJ, Goedee HS, van der Gijp A, Witkamp TD, van Eijk RPA, Asselman FL, van den Berg LH, Mandija S, Froeling M, Hendrikse J, van der Pol WL. Quantitative assessment of brachial plexus MRI for the diagnosis of chronic inflammatory neuropathies. J Neurol 2020; 268:978-988. [PMID: 32965512 PMCID: PMC7914242 DOI: 10.1007/s00415-020-10232-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 12/22/2022]
Abstract
Objective This study aimed at developing a quantitative approach to assess abnormalities on MRI of the brachial plexus and the cervical roots in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) and to evaluate interrater reliability and its diagnostic value. Methods We performed a cross-sectional study in 50 patients with CIDP, 31 with MMN and 42 disease controls. We systematically measured cervical nerve root sizes on MRI bilaterally (C5, C6, C7) in the coronal [diameter (mm)] and sagittal planes [area (mm2)], next to the ganglion (G0) and 1 cm distal from the ganglion (G1). We determined their diagnostic value using a multivariate binary logistic model and ROC analysis. In addition, we evaluated intra- and interrater reliability. Results Nerve root size was larger in patients with CIDP and MMN compared to controls at all predetermined anatomical sites. We found that nerve root diameters in the coronal plane had optimal reliability (intrarater ICC 0.55–0.87; interrater ICC 0.65–0.90). AUC was 0.78 (95% CI 0.69–0.87) for measurements at G0 and 0.81 (95% CI 0.72–0.91) for measurements at G1. Importantly, our quantitative assessment of brachial plexus MRI identified an additional 10% of patients that showed response to treatment, but were missed by nerve conduction (NCS) and nerve ultrasound studies. Conclusion Our study showed that a quantitative assessment of brachial plexus MRI is reliable. MRI can serve as an important additional diagnostic tool to identify treatment-responsive patients, complementary to NCS and nerve ultrasound. Electronic supplementary material The online version of this article (10.1007/s00415-020-10232-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marieke H J van Rosmalen
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Stephan Goedee
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands.
| | - Anouk van der Gijp
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theo D Witkamp
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ruben P A van Eijk
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
- Biostatistics and Research Support, Julius Centre for Healthy Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Fay-Lynn Asselman
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Stefano Mandija
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
- Computational Imaging Group for MR Diagnostic and Therapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn Froeling
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
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Vuillermin C, Bauer AS, Kalish LA, Lewine EB, Bae DS, Waters PM. Follow-up Study on the Effects of Tendon Transfers and Open Reduction on Moderate Glenohumeral Joint Deformity in Brachial Plexus Birth Injury. J Bone Joint Surg Am 2020; 102:1260-1268. [PMID: 32675676 DOI: 10.2106/jbjs.19.00685] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Soft-tissue contractures about the shoulder in patients with brachial plexus birth injury are common and can lead to progressive shoulder displacement and glenohumeral dysplasia. Open or arthroscopic reduction with musculotendinous lengthening and tendon transfers have become the standard of care. The clinical function and radiographic joint remodeling beyond the first 2 years after surgery are not well understood. METHODS We performed a follow-up study of 20 patients with preexisting mild to moderate glenohumeral joint deformity who had undergone open glenohumeral joint reduction with latissimus dorsi and teres major tendon transfers and concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis. Prospective collection of Modified Mallet and Active Movement Scale (AMS) scores and radiographic analysis of cross-sectional imaging for glenoid version, humeral head subluxation, and glenohumeral joint deformity classification were analyzed for changes over time. RESULTS The average duration of radiographic follow-up was 4.2 years (range, 2 to 6 years). The mean glenoid version improved from -31.8° to -15.4° (p < 0.0001). The mean percentage of the humeral head anterior to the middle of the glenoid (PHHA) improved from 9.6% to 30.4% (p < 0.0001). The mean glenohumeral joint deformity score improved from 3.7 to 2.1 (p < 0.0001). CONCLUSIONS All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up. There were no significant changes beyond the 1-year time point in the Mallet scores, AMS scores, or radiographic outcome measures, possibly because of insufficient power, although trends of improvement were noted for some outcomes. No decline in outcome measures was found during the study period. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Carley Vuillermin
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Andrea S Bauer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Leslie A Kalish
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | | | - Donald S Bae
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Peter M Waters
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
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12
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Jan AU, Cheema TA, Ahmad S, Shafiq M, Hussain B, Ullah F. Outcome Of Dynamic Compression Plate With Dorsal Radial Sliding Graft Technique For Wrist Arthrodesis In Brachial Plexus Injury Patients. J Ayub Med Coll Abbottabad 2019; 31:141-145. [PMID: 31094104] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The incidence of brachial plexus injuries have shown to increase over the years. It is 1- 2% worldwide according to the WHO. In global brachial plexus injuries and lower root injures when the wrist and hand functions are lost, wrist arthrodesis is a viable option. In other cases, when there are some residual hand functions, wrist arthrodesis stabilizes the wrist as well as provides donor muscles tendons to enhance finger functions. Apart from these, wrist arthrodesis increase grip strength and power, and also wrist in extension assume a better shape cosmetically. PURPOSE Outcome of dynamic compression plate with dorsal radial sliding graft for wrist arthrodesis in terms of time to union and complications in brachial plexus injury patients. METHODS This is a retrospective chart review of patients treated in National Orthopaedic Hospital Bahawalpur, from January 2011 to Sep 2017. All the patients with brachial plexopathies of both genders from age 14 to 60 were included in the study. Data was analysed using MS Excel 2010. RESULTS A total of 34 patients were included in the study. Road traffic accidents was the major cause of the injury having 30 (88%) patients whereas birth palsy and gunshots had 2 patients each (6%). Twenty-three patients had no associated fracture while remaining 11 patients had a fracture. There was union in all patients (100 %) and mean time to union was 6.5 weeks (range 6-8) radiologically. Mean follow up was 20.2 months (range 1.5-72).
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Affiliation(s)
| | | | - Sajjad Ahmad
- Department of Orthopedics and Spine, Hayat Abad Medical Complex, Peshawar, Pakistan
| | | | - Baqir Hussain
- Department of Orthopedics and Spine, Hayat Abad Medical Complex, Peshawar, Pakistan
| | - Farman Ullah
- Department of Orthopedics and Spine, Hayat Abad Medical Complex, Peshawar, Pakistan
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13
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Ditzler MG, Kan JH, Artunduaga M, Jadhav SP, Bell BR, Zhang W, Orth RC. Modified Friedman technique: a new proposed method of measuring glenoid version in the setting of glenohumeral dysplasia. Pediatr Radiol 2018; 48:1779-1785. [PMID: 29978295 DOI: 10.1007/s00247-018-4196-7] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/14/2018] [Accepted: 06/24/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Glenoid version angles are measured to objectively follow changes related to glenohumeral dysplasia in the setting of brachial plexus birth palsy. Measuring glenoid version on cross-sectional imaging was initially described by Friedman et al. in 1992. Recent literature for non-dysplastic shoulders advocates time-consuming reconstructions and reformations for an accurate assessment of glenoid version. OBJECTIVE To compare Friedman's original method for measuring glenoid version to a novel technique we developed ("modified Friedman") with the reference standard of true axial reformations. MATERIALS AND METHODS With institutional review board approval, we retrospectively examined 30 normal and dysplastic shoulders obtained from magnetic resonance imaging examinations of 30 patients with an established diagnosis of brachial plexus birth palsy between January 2012 and September 2017. Four pediatric radiologists performed glenoid version measurements using Friedman's method, the modified Friedman method and a previously described true axial reformation method. The modified Friedman technique better accounts for scapular positioning by selecting a reference point related to the acromion-scapular body interface. Inter-rater reliability and inter-method agreement were assessed using intraclass correlation, paired t-tests and mixed linear model analysis. Equivalence tests between methods were performed per reader. RESULTS Glenoid version measurements were significantly different when comparing Friedman's method to true axial reformations in normal (-10.8±5.7° [mean±standard deviation] vs. -8.8±5.3°; P≤0.001) and dysplastic shoulders (-34.6±17.7° vs. -28.1±17.5°; P≤0.001). Glenoid version measurements were not significantly different when comparing the modified Friedman's method to true axial reformations in normal (-6.3±5.8° vs. -8.8±5.3°; P=0.06) and dysplastic shoulders (-29.0±18.3° vs. -28.1±17.5°; P=0.06). Friedman's method was not equivalent to true axial reformations for measurements in dysplastic shoulders for all readers (P=0.68, 0.81, 0.86, 0.99); the modified Friedman method was equivalent to of true axial reformations for measurements in dysplastic shoulders for 3 of 4 readers (P≤0.001, P≤0.001, P≤0.001, P=0.10). CONCLUSION In glenohumeral dysplasia, the modified Friedman method and post-processed true axial reformations provide statistically similar and reproducible values. We propose that our modified Friedman technique can be performed in lieu of post-processed true axial reformations to generate glenoid version measurements.
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Affiliation(s)
- Matthew G Ditzler
- Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA.
| | - J Herman Kan
- Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA
| | - Maddy Artunduaga
- Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA
| | - Siddharth P Jadhav
- Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA
| | - Bryce R Bell
- Department of Orthopedics, Texas Children's Hospital, Houston, TX, USA
| | - Wei Zhang
- Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA
| | - Robert C Orth
- Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA
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Abstract
RATIONALE Brachial plexus schwannomas are rare benign tumors that are derived from Schwann cells. Because they are rare, and because of the complexity of the anatomy of the neck, these tumors can be a challenge to diagnose for radiologists and clinicians. In the present study, we describe a clinical case of brachial plexus schwannoma detected on ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI), and presenting as a palpable neck mass. PATIENT CONCERNS A 49-year-old woman had a palpable mass in the right neck, which had been there for the last 1 year. Metastatic cervical lymphadenopathy was suspected in the primary health clinic; therefore, the patient was referred to our hospital. DIAGNOSES The right neck mass was a well-circumscribed oval soft tissue mass on US, CT, and MRI. US-guided core needle biopsy was performed and the mass was proved to be a schwannoma. INTERVENTIONS The patient did not undergo surgical excision because the brachial plexus schwannoma was small and there was no accompanying neurological symptom. OUTCOMES The patient is being followed up regularly at the outpatient department. LESSONS Brachial plexus schwannoma should be considered for a differential diagnosis in patients with a palpable neck mass, and imaging studies play an important role in diagnosing the brachial plexus schwannoma.
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Affiliation(s)
- Kyeong Hwa Ryu
- Department of Radiology, Gyeongsang National University Changwon Hospital, Changwon
| | - Jin Il Moon
- Department of Radiology, Gyeongsang National University Changwon Hospital, Changwon
| | - Hye Jin Baek
- Department of Radiology, Gyeongsang National University Changwon Hospital, Changwon
- Gyeongsang National University School of Medicine, Jinju
| | - Soo Buem Cho
- Department of Radiology, Gyeongsang National University Changwon Hospital, Changwon
| | - Bo Hwa Choi
- Department of Radiology, Gyeongsang National University Changwon Hospital, Changwon
| | - Hyo Jung An
- Department of Pathology, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Dae Hyun Song
- Gyeongsang National University School of Medicine, Jinju
- Department of Pathology, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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15
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Gunes A, Bulut E, Uzumcugil A, Oguz KK. Brachial Plexus Ultrasound and MRI in Children with Brachial Plexus Birth Injury. AJNR Am J Neuroradiol 2018; 39:1745-1750. [PMID: 30093478 DOI: 10.3174/ajnr.a5749] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 06/25/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Brachial plexus birth injury is caused by traction on the neck during delivery and results in flaccid palsy of an upper extremity commonly involving C5-C6 nerve roots. MR imaging and MR myelography help to assess the anatomic location, extent, and severity of brachial plexus injuries which influence the long-term prognosis along with the surgical decision making. Recently, sonography has been increasingly used as the imaging modality of choice for brachial plexus injuries. The aim of this study was to assess the degree of correlation among brachial plexus sonography, MR imaging, and surgical findings in children with brachial plexus birth injury. MATERIALS AND METHODS This prospective study included 55 consecutive patients (girls/boys = 32:23; mean age, 2.1 ± 0.8 months) with brachial plexus birth injury between May 2014 and April 2017. The patients were classified according to the Narakas classification and were followed up at 4- to 6-week intervals for recovery by the Modified Mallet system and sonography without specific preparation for evaluation. All patients had MR imaging under general anesthesia. Nerve root avulsion-retraction, pseudomeningocele, and periscalene soft tissue were accepted brachial plexus injury findings on imaging. Interobserver agreement for MR imaging and the agreement between imaging and surgical findings were estimated using the κ statistic. The diagnostic accuracy of sonography and MR imaging was calculated on the basis of the standard reference, which was the surgical findings. RESULTS Forty-three patients had pre- and postganglionic injury, 12 had only postganglionic injury findings, and 47% of patients underwent an operation. On sonography, no patients had preganglionic injury, but all patients had postganglionic injury findings. For postganglionic injury, the concordance rates between imaging and the surgical findings ranged from 84% to 100%, and the diagnostic accuracy of sonography and MR imaging was 89% and 100%, respectively. For preganglionic injury, the diagnostic accuracy of MR imaging was 92%. Interobserver agreement and the agreement between imaging and the surgical findings were almost perfect for postganglionic injury (κ = 0.81-1, P < .001). CONCLUSIONS High-resolution sonography can identify and locate the postganglionic injury associated with the upper and middle trunks. The ability of sonography to evaluate pre- and the postganglionic injury associated with the lower trunk was quite limited. Sonography can be used as a complement to MR imaging; thus, the duration of the MR imaging examination and the need for sedation can be reduced by sonography.
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Affiliation(s)
- A Gunes
- From the Department of Radiology (A.G.), University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - E Bulut
- Departments of Radiology (E.B., K.K.O.)
| | - A Uzumcugil
- Orthopedics and Traumatology (A.U.), Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - K K Oguz
- Departments of Radiology (E.B., K.K.O.)
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Abstract
RATIONALE We report a 45-year-old male patient with unilateral brachial plexopathy following acute carbon monoxide (CO) intoxication. PATIENT CONCERNS The patient suddenly developed severe left upper extremity weakness and cognitive impairment after CO intoxication. DIAGNOSES He showed severe weakness in the left upper extremity and decreased cognitive function during physical examination. Whole body bone scan revealed increased radioisotope uptake in the left shoulder, suggesting rhadomyolysis. Brain magnetic resonance imaging showed high signal intensity in both globus pallidus. The electrodiagnostic finding was compatible with incomplete left total brachial plexopathy (axonopathy). INTERVENTIONS High oxygen therapy and massive intravenous normal saline infusion were administered immediately after acute CO intoxication. Since then, intensive rehabilitation treatment has been provided. OUTCOME Despite having received medical and rehabilitation treatment, the patient has not recovered severe weakness in the left upper extremity and decline in cognition. LESSONS Localized swelling in the left shoulder caused by rhabdomyolysis may be a key mechanism in developing unilateral brachial plexopathy after acute CO intoxication. The early diagnosis and treatment of rhadomyolysis might be important preventing peripheral neuropathy. An electrodiagnostic study may be helpful for diagnosis of peripheral neuropathy after CO intoxication and prediction of patient's prognosis.
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17
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Bykowski J, Aulino JM, Berger KL, Cassidy RC, Choudhri AF, Kendi AT, Kirsch CFE, Luttrull MD, Sharma A, Shetty VS, Than K, Winfree CJ, Cornelius RS. ACR Appropriateness Criteria ® Plexopathy. J Am Coll Radiol 2018; 14:S225-S233. [PMID: 28473078 DOI: 10.1016/j.jacr.2017.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 02/01/2017] [Revised: 02/01/2017] [Accepted: 02/02/2017] [Indexed: 12/17/2022]
Abstract
MRI without and with contrast is the most accurate imaging method to determine whether a process is intrinsic or extrinsic to a nerve of the brachial or lumbosacral plexus. However, there are no Current Procedural Terminology codes to correspond to imaging studies of the brachial or lumbar plexus discretely. This assessment uses "MRI of the brachial plexus" or "MRI of the lumbosacral plexus" as independent entities given that imaging acquisition for the respective plexus differs in sequences and planes compared with those of a routine neck, chest, spine, or pelvic MRI, yet acknowledges the potential variability of ordering practices across institutions. In patients unable to undergo MRI, CT offers the next highest level of anatomic evaluation. In oncologic patients, PET/CT imaging can identify the extent of tumor involvement and be beneficial to differentiate radiation plexitis from tumor recurrence but provides limited resolution of the plexus itself. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Julie Bykowski
- Principal Author and Panel Chair, UC San Diego Health, San Diego, California.
| | | | | | - R Carter Cassidy
- UK Healthcare Spine and Total Joint Service, Lexington, Kentucky, American Academy of Orthopaedic Surgeons
| | - Asim F Choudhri
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Claudia F E Kirsch
- North Shore-Long Island Jewish Hospital, Hofstra Medical School, Hempstead, New York
| | | | - Aseem Sharma
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | | | - Khoi Than
- Oregon Health & Science University, Portland, Oregon, neurosurgical consultant
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18
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Bauer AS, Shen PY, Nidecker AE, Lee PS, James MA. Neonatal Magnetic Resonance Imaging Without Sedation Correlates With Injury Severity in Brachial Plexus Birth Palsy. J Hand Surg Am 2017; 42:335-343. [PMID: 28318741 DOI: 10.1016/j.jhsa.2017.01.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 08/24/2016] [Revised: 01/24/2017] [Accepted: 01/29/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Which infants with brachial plexus birth palsy (BPBP) should undergo microsurgical plexus reconstruction remains controversial. The current gold standard for the decision for plexus reconstruction is serial clinical examinations, but this approach obviates the possibility of early surgical treatment. We hypothesize that a new technique using 3-dimensional volumetric proton density magnetic resonance imaging (MRI) without sedation can evaluate the severity of BPBP injury earlier than serial clinical examinations. METHODS Infants were prospectively enrolled prior to 12 weeks of age and imaged using 3 Tesla MRI without sedation. Clinical scores were collected at all visits. The imaging findings were graded based on the number of injured levels and the severity of each injury, and a radiological score was calculated. All infants were followed at least until the decision for surgery was made based on clinical examination. RESULTS Nine infants completed the MRI scan and clinical follow-up. The average Toronto score at presentation was 4.4 out of 10 (range, 0-8.2); the average Active Movement Scale score was 50 out of 105 (range, 0-86). Four infants required surgery: 2 because of a flail limb and Horner syndrome and 2 owing to failure to recover antigravity elbow flexion by age 6 months. Radiological scores ranged from 0 to 18 out of a maximum score of 25. The average radiological score for those infants who required surgery was 12 (range, 6.5-18), whereas the average score for infants who did not require surgery was 3.5 (range, 0-8). CONCLUSIONS Three-dimensional proton density MRI can evaluate spinal nerve roots in infants without the need for radiation, contrast agents, or sedation. These data suggest that MRI can help determine the severity of injury earlier than clinical examination in infants with BPBP, although further study of a larger sample of infants with varying severity of disease is necessary. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Andrea S Bauer
- Department of Orthopaedic Surgery, Shriners Hospitals for Children-Northern California, Sacramento, CA.
| | - Peter Y Shen
- Division of Neuroradiology, University of California Davis Medical Center, Sacramento, CA
| | - Anna E Nidecker
- Division of Neuroradiology, University of California Davis Medical Center, Sacramento, CA
| | - Paul S Lee
- Division of Neuroradiology, University of California Davis Medical Center, Sacramento, CA
| | - Michelle A James
- Department of Orthopaedic Surgery, Shriners Hospitals for Children-Northern California, Sacramento, CA
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van de Bunt F, Pearl ML, Lee EK, Peng L, Didomenico P. Analysis of normal and dysplastic glenohumeral morphology at magnetic resonance imaging in children with neonatal brachial plexus palsy. Pediatr Radiol 2017; 47:1337-1344. [PMID: 28676895 PMCID: PMC5574959 DOI: 10.1007/s00247-017-3882-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/28/2017] [Accepted: 04/27/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Glenoid version and percentage of the humeral head anterior to the scapular line are commonly used 2-D measures to assess deformity of the glenohumeral joint of children with neonatal brachial plexus palsy. OBJECTIVE To assess whether glenoid version and percentage of the humeral head anterior to the scapular line would be altered by standardizing the measurements to the orientation of the scapula. MATERIALS AND METHODS Twenty-one bilateral magnetic resonance imaging (MRI) scans were evaluated by four reviewers. Measurements were performed on the axial image slices and again after applying 3-D reformatting. RESULTS Three-dimensional reformatting led to intrapatient corrections up to 25° for version and -30% for percentage of the humeral head anterior to the scapular line. The mean difference on the involved side between clinical and anatomical version across all subjects from all reviewers was 2.2° ± 3.9° (range: -4.5° to 11.5°). The mean difference in the percentage of the humeral head anterior to the scapular line after reformatting was -1.8% (range: -15.9% to 5.2%). CONCLUSION Measurements can differ greatly for the same child depending on technical factors of image acquisition and presentation in the clinical setting. With this study, we present a clinically accessible protocol to correct for scapular orientation from MRI data of children with neonatal brachial plexus palsy.
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Affiliation(s)
- Fabian van de Bunt
- VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Michael L Pearl
- Kaiser Permanente, 4760 Sunset Blvd Ste. 1213, Los Angeles, CA, 90027, USA
| | - Eric K Lee
- Kaiser Permanente, 4760 Sunset Blvd Ste. 1213, Los Angeles, CA, 90027, USA
| | - Lauren Peng
- Kaiser Permanente, 4760 Sunset Blvd Ste. 1213, Los Angeles, CA, 90027, USA
| | - Paul Didomenico
- Kaiser Permanente, 4760 Sunset Blvd Ste. 1213, Los Angeles, CA, 90027, USA
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Somashekar DK, Di Pietro MA, Joseph JR, Yang LJS, Parmar HA. Utility of ultrasound in noninvasive preoperative workup of neonatal brachial plexus palsy. Pediatr Radiol 2016; 46:695-703. [PMID: 26718200 DOI: 10.1007/s00247-015-3524-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [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: 06/10/2015] [Accepted: 11/26/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ultrasound has been utilized in the evaluation of compressive and traumatic peripheral nerve pathology. OBJECTIVE To determine whether US can provide comprehensive evaluation of the post-ganglionic brachial plexus in the setting of neonatal brachial plexus palsy and whether this information can be used to guide preoperative nerve reconstruction strategies. MATERIALS AND METHODS In this retrospective cohort study, preoperative brachial plexus ultrasonography was performed in 52 children with neonatal brachial plexus palsy who were being considered for surgery. The 33 children who had surgery compose the patient cohort. The presence and location of post-ganglionic neuromas were evaluated by US and compared to the surgical findings. US evaluation of shoulder muscle atrophy was conducted as an indirect way to assess the integrity of nerves. Finally, we correlated glenohumeral joint laxity to surgical and clinical management. RESULTS Ultrasound correctly identified 21 of 25 cases of upper trunk and middle trunk neuroma involvement (84% sensitivity for each). It was 68% sensitive and 40% specific in detection of lower trunk involvement. US identified shoulder muscle atrophy in 11 of 21 children evaluated; 8 of these 11 went on to nerve transfer procedures based upon the imaging findings. US identified 3 cases of shoulder joint laxity of the 13 children evaluated. All 3 cases were referred for orthopedic evaluation, with 1 child undergoing shoulder surgery and another requiring casting. CONCLUSION Ultrasound can provide useful preoperative evaluation of the post-ganglionic brachial plexus in children with neonatal brachial plexus palsy.
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Affiliation(s)
- Deepak K Somashekar
- Department of Radiology, Section of Pediatric Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Radiology, Section of Neuroradiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael A Di Pietro
- Department of Radiology, Section of Pediatric Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jacob R Joseph
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Hemant A Parmar
- Department of Radiology, Section of Pediatric Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Department of Radiology, Section of Neuroradiology, University of Michigan Health System, Ann Arbor, MI, USA.
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Choi JH, Choi SC, Kim DK, Sung CH, Chon JY, Hong SJ, Lee JY, Moon HS. Combined Spinal Cord Stimulation and Peripheral Nerve Stimulation for Brachial Plexopathy: A Case Report. Pain Physician 2016; 19:E459-E463. [PMID: 27008302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Brachial plexopathy usually results from an iatrogenic brachial plexus injury and can sometimes cause severe chronic pain and disability. There are a number of possible treatments for this condition, including medication, physical therapy, nerve blocks, and neuromodulation, but they are not always successful. Recently, combined spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) have been tried for various chronic pain diseases because of their different mechanisms of action.Here, we describe the case of a 54-year-old man who was diagnosed with brachial plexopathy 8 years ago. He underwent video-assisted thoracoscopic surgery to remove a superior mediastinal mass. However, his brachial plexus was damaged during the surgery. Although he had received various treatments, the pain did not improve. For the management of intractable severe pain, he underwent SCS 2 years ago, which initially reduced his pain from numeric rating scale (NRS) 10/10 to NRS 4 - 5/10, but the pain then gradually increased, reaching NRS 8/10, 6 months ago. At that time, he was refractory to other treatments, and we therefore applied PNS in combination with SCS. The PNS electrode was positioned on the radial nerve under ultrasound guidance. After combined PNS and SCS, his background pain disappeared, although a breakthrough pain (NRS 3 - 4/10) was caused intermittently by light touch. Furthermore, the patient's need for analgesics decreased, and he was satisfied with the outcome of this combined treatment. We concluded that combined SCS and PNS is a very useful treatment modality, which can stimulate the target nerve both directly and indirectly, and hence, relieve pain from brachial plexopathy.
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Affiliation(s)
- Ji Hye Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Shu Chung Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Kyu Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Choon Ho Sung
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | | | - Sung Jin Hong
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Young Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Sik Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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22
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Dale GH, Gottrup H, Andersen H. [Brachial plexopathy after breast cancer]. Ugeskr Laeger 2014; 176:V12120732. [PMID: 25497636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Neoplastic plexopathy is an unusual, but known cause of neuropathy. This is a case report of a patient, who developed brachial plexopathy years after completing treatment for breast cancer. The patient presented with pain in one arm and, subsequently, developed sensory deficits and muscle atrophy, resulting in severely impaired hand function. Repeated magnetic resonance imaging and positron emission tomography scans were necessary before the final diagnosis could be made. The case report illustrates the importance of a thorough and repeated diagnostic work-up, when metastatic cancer is a perhaps unlikely but possible cause of plexopathy.
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Affiliation(s)
- Gro Helen Dale
- Neurologisk Afdeling F, Aarhus Universitetshospital, Nørrebrogade 44, 8000 Aarhus C.
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Zhu YS, Mu NN, Zheng MJ, Zhang YC, Feng H, Cong R, Zhou XD, Chen DZ. High-resolution ultrasonography for the diagnosis of brachial plexus root lesions. Ultrasound Med Biol 2014; 40:1420-1426. [PMID: 24768481 DOI: 10.1016/j.ultrasmedbio.2014.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 01/10/2014] [Accepted: 02/08/2014] [Indexed: 06/03/2023]
Abstract
The aim of this study was to investigate the feasibility of using high-resolution ultrasonography in the diagnosis of brachial plexus (BP) root lesions. A prospective study of ultrasonographic evaluation of BP nerve roots was performed in 37 patients with BP root lesions (29 with root injuries, 8 with tumors). The pre-operative ultrasonographic findings were compared with the surgical and pathohistological findings. All C5-7 roots were detected by ultrasonography in all patients, whereas 92% (68/74) of C8 and 51% (38/74) of T1 nerve roots were visualized. Among 29 patients with BP root avulsion, partial injuries or totally interrupted BP roots were detected in all patients. Cystic masses and neuromas were detected in 16 and 23 patients, respectively. In 8 patients with BP root tumors, 8 hypo-echoic masses were detected inside or partly outside of intervertebral foramina connecting to nerve roots. Surgical exploration revealed that there were 57 BP root avulsions in 29 patients. However, 2 T1 nerve root avulsions had been missed by pre-operative ultrasonography. Pathohistology revealed that all 8 BP root tumors pre-operatively diagnosed by ultrasonography were schwannomas. High-resolution ultrasonography can provide a convenient and accurate imaging modality for quick diagnosis and location of BP root lesions.
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Affiliation(s)
- Yong-Sheng Zhu
- Department of Ultrasonography, Xijing Hospital, Fourth Military Medical University, Xi'An, China
| | - Nan-Nan Mu
- Department of Ultrasonography, General Hospital of Jinan Military Area Command of Chinese PLA, Ji'Nan, China
| | - Min-Juan Zheng
- Department of Ultrasonography, Xijing Hospital, Fourth Military Medical University, Xi'An, China
| | - Yun-Chu Zhang
- Department of Ultrasonography, Xijing Hospital, Fourth Military Medical University, Xi'An, China
| | - Hua Feng
- Department of Ultrasonography, Xijing Hospital, Fourth Military Medical University, Xi'An, China
| | - Rui Cong
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'An, China
| | - Xiao-Dong Zhou
- Department of Ultrasonography, Xijing Hospital, Fourth Military Medical University, Xi'An, China
| | - Ding-Zhang Chen
- Department of Ultrasonography, Xijing Hospital, Fourth Military Medical University, Xi'An, China.
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Sanchez TRS, Chang J, Bauer A, Joyce NC, Patel CV. Dynamic sonographic evaluation of posterior shoulder dislocation secondary to brachial plexus birth palsy injury. J Ultrasound Med 2013; 32:1531-1534. [PMID: 23980211 DOI: 10.7863/ultra.32.9.1531] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Thomas Ray S Sanchez
- Department of Radiology, University of California, Davis, Sacramento, CA 95817 USA.
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Assunção JH, Ferreira AAN, Benegas E, Bolliger RN, Prada FS, Malavolta EA, Gracitelli MEC, Camanho GL. Humeral internal rotation osteotomy for the treatment of Erb-Duchenne-type obstetric palsy: clinical and radiographic results. Clinics (Sao Paulo) 2013; 68:928-33. [PMID: 23917655 PMCID: PMC3715036 DOI: 10.6061/clinics/2013(07)07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 03/08/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the functional and radiographic results in patients undergoing shoulder anterior soft tissue stretching in association with open reduction and internal rotation osteotomy to centralize the humeral head as a treatment for Erb-Duchenne obstetric palsy sequelae. METHOD A total of 35 patients underwent this surgical treatment, and the mean follow-up was 4.6 years. The Mallet scale was applied before and after the surgical procedure. A total of 20 patients underwent computed tomography to assess the glenoid version and humeral head subluxation. RESULTS Functional improvement was achieved, as evidenced by an increase in the Mallet scale score from 12.14 to 16.46 (p<0.001). The correction of retroversion was achieved once the glenoid version ranged from -21.4 to -12 degrees (p<0.001). The humeral head subluxation improved from 6.5 to 35.2% (p<0.001). Patients older than 6 years of age did not achieve glenohumeral joint improvement with respect to dysplastic abnormalities. CONCLUSION Internal rotation osteotomy in association with the stretching of anterior soft tissues of the shoulder in patients under the age of 7 years provided improvements in the function, retroversion, and subluxation of the glenohumeral joint.
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Affiliation(s)
- Jorge Henrique Assunção
- Department of Orthopedics and Traumatology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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26
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Abstract
The brachial plexus is related intimately to the clavicle such that injury can occur primarily and most commonly at the time of trauma through traction or it can occur secondarily, mainly owing to hypertrophic non-union with exuberant callus formation, causing compression of the plexus. The movement-dependent rearrangement of the subclavicular space is restricted with rigid internal fixation, thereby placing inappropriate pressure on the plexus from the deep hypertrophic tissue. This case highlights another cause of brachial plexopathy of which to be aware.
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Affiliation(s)
- D Thavarajah
- Department of Trauma and Orthopaedics, St Mary's Hospital, Parkhurst Road, Newport, Isle of Wight PO30 5TG, UK.
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27
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Affiliation(s)
- Kazumoto Shibuya
- Department of Neurology, Graduate School of Medicine, Chiba University, Japan
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28
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Chen DZ, Cong R, Zheng MJ, Zhu T, Coles G, Feng H, Zhou XD, Zhu YS. Differential diagnosis between pre- and postganglionic adult traumatic brachial plexus lesions by ultrasonography. Ultrasound Med Biol 2011; 37:1196-1203. [PMID: 21645961 DOI: 10.1016/j.ultrasmedbio.2011.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 04/14/2011] [Accepted: 04/26/2011] [Indexed: 05/30/2023]
Abstract
The goal of this study was to prospectively investigate the feasibility of preoperative ultrasonography evaluation in the differentiation between pre- and postganglionic traumatic brachial plexus lesions. Two expert radiologists employed ultrasonography to observe the morphology of the brachial plexus in 23 patients with suspected traumatic brachial plexus lesions and 40 healthy volunteers. The detection rate was 100% (126/126) for the C5 through C7 nerve roots and upper and middle trunks and three fascicles, 84% (106/126) for the C8 roots and the lower trunks and 64% (81/126) for T1 roots in all subjects. Surgical inspections found 58 lesions in 23 patients (40 preganglionic lesions and 18 postganglionic lesions). Ultrasonography detected most of the brachial plexus lesions (56/58) but misjudged two preganglionic and two postganglionic lesions. The rate of differentiation was 93% (52/56). This study demonstrated that ultrasonography is a useful but experience-dependent supplemental imaging technique for preoperative diagnosis of brachial plexus lesions and differentiation between pre- and postganglionic brachial plexus lesions.
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Affiliation(s)
- Ding-Zhang Chen
- Department of Ultrasound, Xijing Hospital, Fourth Military Medical University Xi'an, China
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29
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Qamar SR, Akram MH, Niazi PHK. Relationship of length of transverse process of seventh cervical vertebra with positive nerve conduction studies in cases of brachialgia. J PAK MED ASSOC 2011; 61:429-432. [PMID: 22204171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To determine the association between length of transverse process of seventh cervical vertebrae on plain x-ray cervical spine AP-view and nerve conduction studies of respective patients having brachialgia. METHODS The study was carried out at Department of Radiology, Military Hospital Rawalpindi in collaboration with Armed Forces Institute of Rehabilitation Medicine (AFIRM) Rawalpindi from January 2004 to December 2004. A total of 160 adult subjects were enrolled in this study including 80 volunteers with no history of brachialgia. Eighty subjects suffered from brachialgia and were documented to have abnormal nerve conduction studies/Electromyography referred from AFIRM Rawalpindi. X-ray cervical spine AP-view of all patients was taken. Relative risk (RR) was calculated to determine the association. RESULTS Eighty percent (64 out of 80) patients with brachialgia and documented abnormal nerve conduction studies had prominent transverse process of seventh cervical vertebrae on x-ray cervical spine AP-view. RR for developing brachialgia was 2.64 and association was statistically significant. CONCLUSION X-ray cervical spine AP-view is a simple, quick and tolerable method of measuring transverse process of seventh cervical vertebra. This can predict which individuals are more likely to develop brachialgia.
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30
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Martinoli C, Valle M, Malattia C, Beatrice Damasio M, Tagliafico A. Paediatric musculoskeletal US beyond the hip joint. Pediatr Radiol 2011; 41 Suppl 1:S113-24. [PMID: 21523581 DOI: 10.1007/s00247-011-2037-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 01/14/2011] [Indexed: 12/14/2022]
Abstract
US is a technique particularly suited to the investigation of musculoskeletal disorders in children and adolescents. This review paper describes a range of clinical settings beyond the hip joint where US has a significant role to play, including sports injuries, infectious diseases, inflammatory and degenerative conditions, congenital and developmental disorders, acute trauma of bone and joints, and peripheral nerve injuries. In some circumstances, US can be regarded as the most effective means of diagnostic imaging, whereas in other instances, it is an alternative or supplement to other more comprehensive imaging modalities, like MRI and CT. Although MRI offers superior soft-tissue contrast resolution, US is low-cost, non-invasive and has higher spatial resolution and real-time capability for the assessment of musculoskeletal structures during joint movement and stress manoeuvres.
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Affiliation(s)
- Carlo Martinoli
- Radiologia-DISC, Università di Genova, Largo Rosanna Benzi 8, 16132 Genoa, Italy.
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Abstract
AIM The purpose of this study was to evaluate long-term shoulder functional outcomes from a triangle tilt procedure on obstetric patients, who initially presented with medial rotation contracture and scapular deformity secondary to obstetric brachial plexus injury. METHODS We retrospectively studied long-term outcomes both functionally and anatomically in 61 patients (age ranging from 2 to 12 years). Functional movements were evaluated and scored using a modified Mallet scale at different time intervals: preoperatively, 1 year and 2 year following triangle tilt surgery. Shoulder anatomy was examined on radiologic images to evaluate the severity of shoulder deformities preoperatively and anatomical improvement after the surgery. RESULTS All shoulder functional movements were significantly improved at 1 and 2 year follow-ups. Functional improvements were maintained in shoulder abduction, external rotation and hand-to-mouth movements beyond the first year, and continued in hand-to-neck and hand-to-spine movements past 2 years. Remarkable glenohumeral remodeling or reservation of glenoid congruence was observed in all patients over a mean time of 27 months postoperatively. CONCLUSION The triangle tilt procedure, which addresses scapular and glenohumeral joint abnormalities characteristic of Erb's palsy, improves shoulder functional movements and anatomical structure in patients over the long-term.
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Affiliation(s)
- Rahul K Nath
- Texas Nerve and Paralysis Institute, Houston, USA.
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33
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Affiliation(s)
- Takashi Irioka
- Department of Neurology, Yokosuka Kyosai Hospital, Kanagawa, Japan.
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Abstract
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.
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Affiliation(s)
- M H Tan
- Department of Surgery, Royal Victoria Hospital, Belfast, UK
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35
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Vathana T, Rust S, Mills J, Wilkes D, Browne R, Carter PR, Ezaki M. Intraobserver and interobserver reliability of two ultrasound measures of humeral head position in infants with neonatal brachial plexus palsy. J Bone Joint Surg Am 2007; 89:1710-5. [PMID: 17671008 DOI: 10.2106/jbjs.f.01263] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ultrasonographic evaluation of the hip in infants is considered both reliable and reproducible in the diagnosis of developmental dysplasia of the hip. Ultrasonographic evaluation of the shoulder in infants has been reported as a valuable diagnostic aid in dysplastic development following neonatal brachial plexus palsy. To our knowledge, there has been no study of the intraobserver reproducibility and interobserver reliability of sonography of the shoulder in infants with and without suspected posterior shoulder dislocation. METHODS Two identical but randomly ordered sets of the same deidentified sonographic images of shoulders in infants were given to radiologists, pediatric orthopaedists and orthopaedic residents, and fellows with varying degrees of experience in the evaluation of shoulder pathology in infants, who measured the position of the humeral head relative to the axis of the scapula. Intraobserver reproducibility and interobserver reliability of the measurements were assessed. RESULTS For the position of the humeral head with respect to the glenoid in both normal and abnormal conditions, the Pearson correlation coefficient for intraobserver reproducibility was 0.91 and the intraclass correlation coefficient for interobserver reliability was 0.875. For estimating the percentage of the humeral head posterior to the axis of the scapula, the Pearson correlation was 0.85 and the intraclass correlation coefficient was 0.77. CONCLUSIONS Ultrasonographic examination of the shoulder in infants to assess for the position of the humeral head with respect to the scapula showed high intraobserver reproducibility and interobserver reliability. It is recommended as a reliable technique for evaluating shoulder position in infants with neonatal brachial plexus palsy.
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Affiliation(s)
- Torpon Vathana
- Texas Scottish Rite Hospital for Children, Dallas, Texas 75219, USA
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36
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Mullins GM, O'Sullivan SS, Neligan A, Daly S, Galvin RJ, Sweeney BJ, McNamara B. Non-traumatic brachial plexopathies, clinical, radiological and neurophysiological findings from a tertiary centre. Clin Neurol Neurosurg 2007; 109:661-6. [PMID: 17624660 DOI: 10.1016/j.clineuro.2007.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 05/15/2007] [Accepted: 05/16/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To establish the clinical characteristics, aetiology, neuro-physiological characteristics, imaging findings and other investigations in a cohort of patients with non-traumatic brachial plexopathy (BP). METHODS A 3-year retrospective study of patients with non-traumatic BP identified by electromyography (EMG) and nerve conduction studies (NCS). Clinical information was retrieved from patients' medical charts. RESULTS Twenty-five patients were identified. Causes of BP included neuralgic amyotrophy (NA) (48%), neoplastic (16%), radiation (8%), post infectious (12%), obstetric (4%), rucksack injury (4%), thoracic outlet syndrome (4%) and iatrogenic (4%). Patients with NA presented acutely in 50%. The onset was subacute in all others. Outcome was better for patients with NA. All patients with neoplastic disease had a previous history of cancer. MRI was abnormal in 3/16 patients (18.8%). PET scanning diagnosed metastatic plexopathy in two cases. CONCLUSIONS NA was the most common cause of BP in our cohort and was associated with a more favourable outcome. The authors note potentially discriminating clinical characteristics in our population that aid in the assessment of patients with brachial plexopathies. We advise NCS and EMG be performed in all patients with suspected plexopathy. Imaging studies are useful in selected patients.
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Affiliation(s)
- G M Mullins
- Department of Neurology Cork University Hospital, Ireland.
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MESH Headings
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biopsy, Needle
- Brachial Plexus Neuropathies/diagnostic imaging
- Brachial Plexus Neuropathies/etiology
- Brachial Plexus Neuropathies/radiotherapy
- Diagnosis, Differential
- Follow-Up Studies
- Humans
- Immunohistochemistry
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/diagnosis
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/pathology
- Male
- Neoplasm Recurrence, Local/diagnosis
- Neoplasm Recurrence, Local/diagnostic imaging
- Neoplasm Recurrence, Local/radiotherapy
- Positron-Emission Tomography
- Tomography, X-Ray Computed
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Affiliation(s)
- Li-Yuan Bai
- Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
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Abstract
While most obstetric brachial plexus palsy patients recover arm and hand function, the residual nerve weakness leads to muscle imbalances about the shoulder which may cause bony deformities. In this paper we describe abnormalities in the developing scapula and the glenohumeral joint. We introduce a classification for the deformity which we term Scapular Hypoplasia, Elevation and Rotation. Multiple anatomic parameters were measured in bilateral CT images and three-dimensional CT reconstruction of the shoulder girdle of 30 obstetric brachial plexus palsy patients (age range 10 months–10.6 years). The affected scapulae were found to be hypoplastic by an average of 14% while the ratio of the height to the width of the body of scapula (excluding acromion) were not significantly changed, the acromion was significantly elongated by an average of 19%. These parameters as well as subluxation of the humeral head (average 14%) and downward rotation in the scapular plane were found to correlate with the area of scapula visible over the clavicle. This finding provides a classification tool for diagnosis and objective evaluation of the bony deformity and its severity in obstetric brachial plexus palsy patients.
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Affiliation(s)
- Rahul K Nath
- Texas Nerve and Paralysis Institute, 2201 W. Holcombe Blvd., Ste. 225, Houston, TX 77030, USA.
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Unlü MC, Kesmezacar H, Akgün I. [Brachial plexus neuropathy (stinger syndrome) occurring in a patient with shoulder laxity]. Acta Orthop Traumatol Turc 2007; 41:74-9. [PMID: 17483641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The stinger syndrome is a common neuropathy caused by traction or compression of the brachial plexus. In general, it is seen in young adults involved in sport activities and a major contact trauma is the rule. An 11-year-old boy with bilateral glenohumeral joint laxity had pain in the left shoulder, numbness and decreased strength in the left arm that developed after striking against a wall while running, with the left shoulder in extension and the neck in minimal lateral flexion to the contralateral side. Physical examination showed extreme anteroinferior passive translocation of the humeral head in neutral rotation and a positive sulcus sign in the left shoulder. The diagnosis was made as brachial plexus neuropathy (stinger syndrome) resulting from traction trauma and shoulder joint laxity and a shoulder-arm brace was applied. After two weeks, atrophy was detected in the right deltoid, supraspinatus, and infraspinatus muscles, and active and passive motion exercises of the shoulder were initiated. At the end of three months, he achieved normal range of motion of the shoulder and muscle strength.
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40
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Bertelli JA, Ghizoni MF. Use of clinical signs and computed tomography myelography findings in detecting and excluding nerve root avulsion in complete brachial plexus palsy. J Neurosurg 2006; 105:835-42. [PMID: 17405253 DOI: 10.3171/jns.2006.105.6.835] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of this study was to investigate the usefulness of preoperative evaluation based on clinical testing and computed tomography (CT) myelography in differentiating root rupture (that is, graftable root) from root avulsion in total brachial plexus palsy.
Methods
Thirty-two patients with total brachial plexus palsy were clinically tested for the presence of phrenic nerve palsy, supraclavicular Tinel sign, shoulder protraction, Bernard–Horner syndrome, and hand pain. The patients underwent CT myelography and then underwent surgery. The combination of a positive Tinel sign and a positive shoulder protraction test accurately predicted the presence of a graftable root in 93.7% of the cases. A 96.8% rate of accuracy was attained if the results of the CT myelography were considered together with the clinical signs. The presence of Bernard–Horner syndrome and hand pain accurately indicated avulsion of the lower roots in 93.7% of the patients. Computed tomography myelography accurately predicted the condition of the lower roots in 100% of the cases. Total avulsion injury was observed in five cases (16%). The lower roots were avulsed in 94% of the cases. The C-5 and C-6 roots were grafted 40 times, and a suitable root stump for grafting lay in a retroscalenic position in 18 (45%) of the 40 cases.
Conclusions
Preoperative assessment based on clinical examination and CT myelography allowed correct surgical planning in more than 90% of the cases.
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Affiliation(s)
- Jayme Augusto Bertelli
- Department of Neurosurgery, Nossa Senhora da Conceição Hospital, Tubarão, Santa Catarina, Brazil.
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41
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Abstract
Anterior shoulder dislocations are one of the most common problems seen in an emergency department. Doubtless, immediate reduction is necessary for treatment, a procedure that is extremely rarely accompanied by complications. In these cases early diagnosis and treatment may be limb saving. We report a case with rupture of the arteria subscapularis following reduction of an anterior shoulder dislocation with formation of an axillary hematoma and consecutive paresis of the plexus brachialis. Interdisciplinary operative revision was necessary to remove the hematoma, stop the hemorrhage and for neurolysis of the plexus brachialis. Treatment resulted in a speedy recovery of the patient. Gentle reduction of a dislocated shoulder is a prerequisite for a low complication rate. Contrast-enhanced computed tomography facilitated diagnosis of the hematoma and identification of the bleeding vessel.
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Affiliation(s)
- H Schmal
- Department für Orthopädie und Traumatologie, Albert-Ludwigs-Universität, Freiburg.
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42
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Luthra K, Shah S, Purandare N, Medhi S, Rangarajan V, Samuel AM. F-18 FDG PET-CT Appearance of Metastatic Brachial Plexopathy in a Case of Carcinoma of the Breast. Clin Nucl Med 2006; 31:432-4. [PMID: 16785819 DOI: 10.1097/01.rlu.0000223116.30927.48] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
MESH Headings
- Brachial Plexus/diagnostic imaging
- Brachial Plexus/metabolism
- Brachial Plexus/pathology
- Brachial Plexus Neuropathies/diagnostic imaging
- Brachial Plexus Neuropathies/metabolism
- Brachial Plexus Neuropathies/pathology
- Breast Neoplasms/drug therapy
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Ductal, Breast/surgery
- Chemotherapy, Adjuvant
- Cicatrix/diagnostic imaging
- Combined Modality Therapy
- Diagnosis, Differential
- Female
- Fibrosis
- Fluorodeoxyglucose F18/pharmacokinetics
- Humans
- Mastectomy
- Middle Aged
- Peripheral Nervous System Neoplasms/diagnostic imaging
- Peripheral Nervous System Neoplasms/metabolism
- Peripheral Nervous System Neoplasms/pathology
- Peripheral Nervous System Neoplasms/secondary
- Positron-Emission Tomography
- Radiation Injuries/diagnostic imaging
- Radiopharmaceuticals/pharmacokinetics
- Radiotherapy, Adjuvant
- Tomography, X-Ray Computed
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Affiliation(s)
- Karuna Luthra
- Bio-Imaging Unit (PET-CT Facility), Tata Memorial Hospital, Mumbai, India.
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43
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Abstract
BACKGROUND Derotational humeral osteotomies have been used in older children with brachial plexus birth palsy and glenohumeral joint deformity to place the upper extremity in a more functional position. The purpose of this study was to determine the effects of these procedures on shoulder function and joint morphology. METHODS Forty-three patients underwent a derotational humeral osteotomy for functional impairment in the setting of internal rotation contracture and/or glenohumeral joint deformity at our institution from 1996 to 2004. Osteotomies were performed proximal to the deltoid insertion and were stabilized with plate-and-screw fixation. The average age of the patients at the time of surgery was 7.6 years (range, 2.3 to 17.0 years). Shoulder function was graded according to the modified Mallet classification system. Glenohumeral deformity was graded according to the classification scheme of Waters et al. The results for twenty-seven patients who were followed for a minimum of two years (average, 3.7 years) are reported. RESULTS The average amount of external rotation achieved with osteotomy was 64 degrees (range, 35 degrees to 90 degrees). The mean aggregate Mallet classification score improved from 13 to 18 points (p < 0.01). The mean Mallet classification scores for the individual elements similarly demonstrated improvement following osteotomy, with the greatest gains in hand-to-mouth, hand-to-neck, and external rotation motions. The mean classification of the glenohumeral deformity was type IV preoperatively and postoperatively, signifying the persistence of glenohumeral dysplasia. There were no nonunions. One patient required a revision osteotomy for inadequate initial correction. One patient sustained a humeral fracture distal to the plate fixation because of sports-related trauma. CONCLUSIONS Derotational humeral osteotomy improves shoulder function in patients with brachial plexus birth palsy, internal rotation contracture, and/or advanced glenohumeral joint deformity. This osteotomy provides an attractive treatment option for patients with brachial plexus birth palsy who have advanced glenohumeral dysplasia precluding soft-tissue releases and tendon transfers.
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Affiliation(s)
- Peter M Waters
- Department of Orthopaedic Surgery, Children's Hospital, 300 Longwood Avenue, Hunn 2, Boston, MA 02115, USA.
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44
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Beekman R, van den Berg LH, Franssen H, Visser LH, van Asseldonk JTH, Wokke JHJ. Ultrasonography shows extensive nerve enlargements in multifocal motor neuropathy. Neurology 2006; 65:305-7. [PMID: 16043806 DOI: 10.1212/01.wnl.0000169179.67764.30] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Using ultrasonography we found multiple sites with nerve enlargement along the course of the brachial plexus, median, ulnar, and radial nerves in the majority of 21 patients with multifocal motor neuropathy. Sonography and electrophysiologic studies showed more abnormalities than expected on purely clinical grounds. Moreover, sonography revealed nerve enlargement without clinical or electrophysiologic abnormalities.
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Affiliation(s)
- R Beekman
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre, Utrecht, The Netherlands.
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45
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Abstract
Five dogs with unilateral thoracic limb lameness, neurologic deficits, muscle atrophy, and pain, or a combination of these signs, were examined using ultrasonograghy. Large, hypoechoic tubular masses that displaced vessels and destroyed the normal architecture were found in each dog. The affected axilla of each patient was then imaged with computed tomography or magnetic resonance to fully assess the extent of the masses. We describe the use of ultrasound in screening patients for brachial plexus tumors.
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Affiliation(s)
- Scott Rose
- School of Veterinary Medicine, Surgical and Radiological Sciences, 2112 Tupper Hall, Davis, CA 95616, USA
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46
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Senthilvel E, Curran A, Collins C, Rawluk D. Radiology quiz case 4. Schwannoma of the brachial plexus. Arch Otolaryngol Head Neck Surg 2005; 131:924, 928. [PMID: 16230603 DOI: 10.1001/archotol.131.10.924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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47
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Abstract
Pseudoaneurysms of the subclavian artery are rarities. Due to their close relationship to the brachial plexus in the shoulder girdle, delayed lesions of the brachial plexus are possible. We report a case of a subclavian pseudoaneurysm following fracture of the clavicle, and the endovascular treatment using a balloon-expandable stent-graft.
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Affiliation(s)
- F Schellhammer
- Department or Radiology and Nuclear Medicine, St. Katharinen Hospital Frechen, Germany.
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48
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Alfonso I, Papazian O, Shuhaiber H, Yaylali I, Grossman JAI. Intrauterine shoulder weakness and obstetric brachial plexus palsy. Pediatr Neurol 2004; 31:225-7. [PMID: 15351026 DOI: 10.1016/j.pediatrneurol.2004.02.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Accepted: 02/09/2004] [Indexed: 10/26/2022]
Abstract
Obstetrical brachial plexus injury occurs when the forces preventing the stretch of the brachial plexus are overcome by the forces stretching it. This report describes an 8-day-old male delivered by uncomplicated cesarean section with right obstetrical brachial plexus palsy and congenital arm atrophy. The patient had a history of decreased right arm movement detected by fetal ultrasound at 18 to 20 weeks of gestation. The purpose of this article is to report that stretching of brachial plexus at birth sufficient to produce a plexus injury may occur in a patient with a vulnerable plexus even in the absence of traction during delivery.
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Affiliation(s)
- Israel Alfonso
- Brachial Plexus Palsy Program, Department of Neurology, Miami Children's Hospital, Florida 33155, USA
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49
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Haberbeck Modesto MA. Anatomic and functional digital subtraction periangioneurography of the brachial plexus, its terminal branches, and the carotid sheath. Neuroimaging Clin N Am 2004; 14:87-92, viii. [PMID: 15177258 DOI: 10.1016/j.nic.2004.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Correct localization of perineural compressions and adhesions is essential for effective pain relief in the use of local anesthetics, anti-inflammatory drugs, and neurolytic agents for lysis of adhesion by hydraulic distention, blunt dissection, or formal surgery. This article presents a method of entering and navigating the neurovascular sheath of the brachial plexus, the perinueral space of its terminal branches, and the carotid sheath using a catheter/guidewire system for imaging, testing motor function, administering pharmaceuticals, and lysing adhesions.
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Affiliation(s)
- Marco A Haberbeck Modesto
- NIDI-Neurociências, Diagnostic and Therapeutic Neuroradiology, Celso Ramos Medical Center, Rua Dom Joaquim 849/885, Primero Andar, Florianópolis/SC CEP 88015-310, Brazil.
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50
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Carlstedt T, Anand P, Htut M, Misra P, Svensson M. Restoration of hand function and so called “breathing arm” after intraspinal repair of C5–T1 brachial plexus avulsion injury. Neurosurg Focus 2004; 16:E7. [PMID: 15174827 DOI: 10.3171/foc.2004.16.5.8] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This 9-year-old boy sustained a complete right-sided C5–T1 brachial plexus avulsion injury in a motorcycle accident. He underwent surgery 4 weeks after the accident. The motor-related nerve roots in all parts of the avulsed brachial plexus were reconnected to the spinal cord by reimplantation of peripheral nerve grafts. Recovery in the proximal part of the arm started 8 to 10 months later. Motor function was restored throughout the arm and also in the intrinsic muscles of the hand by 2 years postoperatively. The initial severe excruciating pain, typical after nerve root avulsions, disappeared completely with motor recovery. The authors observed good recruitment of regenerated motor units in all parts of the arm, but there were cocontractions. Transcranial magnetic stimulation produced response in all muscles, with prolonged latency and smaller amplitude compared with the intact side. There was inspiration-evoked muscle activity in proximal arm muscles—that is, the so-called “breathing arm” phenomenon. The issues of nerve regeneration after intraspinal reimplantation in a young individual, as well as plasticity and associated pain, are discussed.
To the best of the authors' knowledge, the present case demonstrates, for the first time, that spinal cord surgery can restore hand function after a complete brachial plexus avulsion injury.
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Affiliation(s)
- Thomas Carlstedt
- The Periphery Nerve Injury Unit, The Royal National Orthopaedic Hospital, Stanmore, United Kingdom.
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