Brachial Plexus Traction Research Articles

Сравнительный анализ ближайших результатов хирургического лечения пациентов с закрытыми тракционными повреждениями плечевого сплетения

Brachial plexus traction injury is common and is an important socioeconomic issue with surgical outcomes being essential for neurosurgery, neurology, trauma, orthopaedic and rehabilitation specialists. The objective was to compare short-term surgical outcomes in patients with closed brachial plexus traction injuries. Material and methods The study involved 61 patients with closed brachial plexus traction injuries who were divided into two homogeneous groups according to sex, age and severity of neurological deficit. Patients of Group I (n = 33) underwent microsurgical neurolysis as a surgical treatment and patients of Group II (n = 28) underwent microsurgical neurolysis in combination with single-level electrical stimulation. Clinical and functional status of the upper limb was assessed in dynamics using scales and electrophysiological monitoring. Results Short-term results of surgical treatment were significantly better in Group II compared to Group I. Discussion A more apparent recovery of the upper limb function was observed in patients of Group II that indicated advantages of microsurgical neurolysis in combination with electrical stimulation to repair closed brachial plexus traction injuries. Conclusion The combination of microsurgical neurolysis and single-level electrical stimulation improves short-term surgical outcomes of patients with closed brachial plexus traction injuries due to a faster pain relief in the postoperative period and positive dynamics in clinical and electrophysiological parameters.

Early supraclavicular nerve grafting is superior to late Oberlin transfer in non-flail adult brachial plexus traction lesions

Early supraclavicular nerve grafting is superior to late Oberlin transfer in non-flail adult brachial plexus traction lesions

Diagnostic accuracy of imaging studies for diagnosing root avulsions in post-traumatic upper brachial plexus traction injuries in adults.

There is no consensus about which type of imaging study, computed tomography myelography (CTM) or magnetic resonance imaging (MRI), provides better information concerning root avulsion in adult brachial plexus injuries. Patients with upper brachial plexus traumatic injuries underwent both CTM and MRI and surgical exploration. The imaging studies were analyzed by two independent radiologists and the data were compared with the intraoperative findings. The statistical analysis was based on dichotomous classification of the nerve roots (normal or altered). The interobserver agreement was assessed using Cohen's Kappa. The accuracy of CTM and MRI in comparison with the intraoperative findings was evaluated using the same methodology. Fifty-two adult patients were included. CTM tended to yield slightly higher percentages of alterations than MRI The interobserver agreement was better on CTM than on MRI for all nerve roots: C5, 0.9960 (strong) vs. 0.145 (poor); C6, 0.970 (strong) vs. 0.788 (substantial); C7, 0.969 (strong) vs. 0.848 (strong). The accuracy regarding the intraoperative findings was also higher on CTM (moderate, kappa 0.40-0.59) than on MRI (minimal, kappa 0.20-0.39) for all nerve roots. Accordingly, the overall percentage concordance (both normal or both altered) was superior in the CTM evaluation (approx. 70-75% vs. 60-65%). CTM was superior for both sensitivity and specificity at all nerve roots. CTM had greater interobserver agreement and higher diagnostic accuracy than MRI in adult patients with root avulsions due to brachial plexus injury.

Commentary: Viable C5 and C6 Proximal Stumps Use in Reconstructive Surgery of the Adult Brachial Plexus Traction Injuries

Commentary: Viable C5 and C6 Proximal Stumps Use in Reconstructive Surgery of the Adult Brachial Plexus Traction Injuries

Viable C5 and C6 Proximal Stump Use in Reconstructive Surgery of the Adult Brachial Plexus Traction Injuries.

In patients with only upper (C5, C6) brachial plexus palsy (BPP), the pooled international data strongly favor nerve transfers over nerve grafts. In patients with complete BPP, some authors favor nerve grafts for the restoration of priority functions whenever there is a viable proximal stump. To evaluate functional recovery in cases of upper and complete BPP where only direct graft repair from viable proximal stumps was performed. The study included 36 patients (24 with complete BPP and 12 with only upper BPP) operated on over a 15-yr period. In all cases, direct graft repair from C5 to the musculocutaneous and the axillary nerve was performed. In cases with complete BPP, additional procedures included either direct graft repair from C6 to the radial nerve and the medial pectoral nerve or the dorsal scapular nerve transfer to the branch for the long head of the triceps. The use of C5 proximal stump grafts (in both complete and upper BPP) resulted in satisfactory elbow flexion in 26 patients (72.2%) and satisfactory shoulder abduction in 22 patients (61.1%). The use of C6 proximal stump grafts in patients with complete BPP resulted in satisfactory elbow extension in 5 (50%) and satisfactory shoulder adduction in another 5 (50%) patients. Although nerve transfers generally enable better restoration of priority functions, in cases of infraganglionary injuries, especially in shorter defects, it is also necessary to consider direct graft repair, or at least its combination with nerve transfers, as a potentially beneficial treatment modality.

Neonatal Brachial Plexus Paralysis: A Discussion on the Light of Literature

Neonatal Brachial Plexus Paralysis (PPBN) is defined as a brachial plexus traction or compression injury resulting from dystocic delivery. The incidence of PPBN varies from 0.42 to 5.1% per 1000 births. The lesion occurs in the expulsive period of childbirth, is most often associated with shoulder dystocia, gestational or pre-gestational diabetes and macrosomic fetuses. The lesion resulting from C5-C6 root involvement is the most frequent, affecting around 50 to 60% of the cases, and 80% of these patients have spontaneous recovery. However, around 20 to 30% of patients may develop persistent deficits, with permanent impacts on upper limb function, compromising the child's development; leading to repercussions for their families and for the health system. PPBN is usually diagnosed by clinical examination and usually does not require imaging studies. Initial treatment is conservative based on functional rehabilitation through physical therapy. Sequential physical examination will indicate patients with no recovery of shoulder movement between 3 and 6 months, who may benefit from surgical treatment. The prognosis of PPBN depends on the level (pre- or postganglionic), the extent, severity of the lesion, the speed of recovery and the quality of initial clinical management. Keywords : Obstetric Paralysis, Brachial plexus, Neonatal

Brachial Plexus Surgery - Present Limits and Perspectives

Surgery of the brachial plexus is demanding field of surgery. The most common condition in this section of neurosurgical expertise that requires surgical treatment is brachial plexus injury. Timing of the surgical treatment is of the outmost importance. Most experts recommend conservative treatment for patients who have showed spontaneous recovery within the first few week after the trauma. Surgical treatment is indicated for patients who have an associated vascular lesion and for sharp wounds, in which a nerve lesion can be expected, exploration and repair of the divided neural elements should be undertaken as soon as the patient’s condition permits. The patient with a root avulsion injury should undergo surgery within the first few months after the injury. A closed injury without evidence of root avulsion should be treated by surgery, if there is no sign of recovery within 6 months. In cases of brachial plexus traction injuries only possibility is nerve transfer. Surgical treatment consists of neurolysis, nerve grafting, nerve transfer and combination of these procedures. Goal of the treatment is achieving good shoulder and elbow control, than elbow, wrist and finger extension, and finally sensibility of the hand and the forearm. Combined use of donor nerves in reinnervation of the musculocutaneus or axillary nerves results with high rate and better quality of recovery when compared with the other modalities of nerve transfer. The use of intraplexal and contralateral plexal neurotization along with a better understanding of central-peripheral function integration may provide improved results and purposeful hand function for our patients in the future. The other, much rarer pathology are tumors of brachial plexus. Radical to complete excision of the tumor with preservation of neurological function of the involved nerve is an ideal surgical treatment option with brachial plexus tumor surgery.

Postfixed Brachial Plexus Radiculopathy Due to Thoracic Disc Herniation in a Collegiate Wrestler: A Case Report

To present the unique case of a collegiate wrestler with C7 neurologic symptoms due to T1-T2 disc herniation. A 23-year-old male collegiate wrestler injured his neck in a wrestling tournament match and experienced pain, weakness, and numbness in his left upper extremity. He completed that match and 1 additional match that day with mild symptoms. Evaluation by a certified athletic trainer 6 days postinjury showed radiculopathy in the C7 distribution of his left upper extremity. He was evaluated further by the team physician, a primary care physician, and a neurosurgeon. Cervical spine injury, stinger/burner, peripheral nerve injury, spinal cord injury, thoracic outlet syndrome, brachial plexus radiculopathy. The patient initially underwent nonoperative management with ice, heat, massage, electrical stimulation, shortwave diathermy, and nonsteroidal anti-inflammatory drugs without symptom resolution. Cervical spine radiographs were negative for bony pathologic conditions. Magnetic resonance imaging showed evidence of T1-T2 disc herniation. The patient underwent surgery to resolve the symptoms and enable him to participate for the remainder of the wrestling season. Whereas brachial plexus radiculopathy commonly is seen in collision sports, a postfixed brachial plexus in which the T2 nerve root has substantial contribution to the innervation of the upper extremity is a rare anatomic variation with which many health care providers are unfamiliar. The injury sustained by the wrestler appeared to be C7 radiculopathy due to a brachial plexus traction injury. However, it ultimately was diagnosed as radiculopathy due to a T1-T2 thoracic intervertebral disc herniation causing impingement of a postfixed brachial plexus and required surgical intervention. Athletic trainers and physicians need to be aware of the anatomic variations of the brachial plexus when evaluating and caring for patients with suspected brachial plexus radiculopathies.

Clavicle Lengthening by Distraction Osteogenesis for Congenital Clavicular Hypoplasia

Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted shoulder movement, subjective feeling of instability, and cosmetic deformity. There are no reports of clavicle lengthening by osteotomy and distraction osteogenesis (DO). This is a retrospective review of 5 patients (7 clavicles) who underwent clavicle lengthening by DO using a monolateral external fixator for clavicular hypoplasia. There were 3 males and 2 females with the mean age of 15 years (9 to 23 y) and mean follow-up of 35 months (12 to 66 mo). Preoperative diagnoses included Klippel-Feil syndrome, cleidocranial dysplasia with hemihypertrophy and torticollis, congenital myopathy and Noonans syndrome, and obstetric brachial plexus injury. Mean length gained was 31 mm (15 to 41 mm) that represents an average of 24.7% of overall bone length. Mean time in fixator was 174 days (161 to 263 d) and mean external fixation index was 56 d/cm. Two patients required internal fixation after fixator removal to consolidate union and 1 required additional internal fixation for atrophic regeneration. Mean preoperative oxford shoulder score improved from 28.5 to 41 and all patients were extremely satisfied with their result. Two patients developed pin-site infections. Clavicular lengthening by DO for congenital clavicular hypoplasia is a previously unreported technique that enables gradual correction of deformity without risking brachial plexus traction injury after acute correction. It has the potential to improve shoulder pain, function, range of movement, and cosmesis. Distraction ≥25% of overall bone length may require additional plate fixation to consolidate union. Level IV-therapeutic study.

Sympathetically mediated upper back pain after coronary artery bypass graft surgery

Sympathetically mediated upper back pain after coronary artery bypass graft surgery

Clinical findings in C5-C6 and C5-C7 root palsies with brachial plexus traction lesions

Stretch injuries of the C5-C7 roots of the brachial plexus traditionally have been associated with palsies of shoulder abduction/external rotation, elbow flexion/extension, and wrist, thumb, and finger extension. Based on current myotome maps we hypothesized that, as far as motion is concerned, palsies involving C5-C6 and C5-C7 root injuries should be similar. In 38 patients with upper-type palsies of the brachial plexus, we examined for correlations between clinical findings and root injury level, as documented by CT tomomyeloscan. Contrary to commonly held beliefs, C5-C7 root injuries were not associated with loss of extension of the elbow, wrist, thumb, or fingers, but residual hand strength was much lower with C5-C7 vs C5-C6 lesions.

Collateral branches of the brachial plexus as donors in nerve transfers

Nerve transfers in cases of directly irreparable, or high level extensive brachial plexus traction injuries are performed using a variety of donor nerves with various success but an ideal method has not been established. The purpose of this study was to analyze the results of nerve transfers in patients with traction injuries to the brachial plexus using the thoracodorsal and medial pectoral nerves as donors. This study included 40 patients with 25 procedures using the thoracodorsal nerve and 33 procedures using the medial pectoral nerve as donors for reinnervation of the musculocutaneous or axillary nerve. The results were analyzed according to the donor nerve, the age of the patient and the timing of surgery. The total rate of recovery for elbow flexion was 94.1%, for shoulder abduction 89.3%, and for shoulder external rotation 64.3%. The corresponding rates of recovery using the thoracodorsal nerve were 100%, 93.7% and 68.7%, respectively. The rates of recovery with medial pectoral nerve transfers were 90.5%, 83.3% and 58.3%, respectively. Despite the obvious differences in the rates of recovery, statistical significance was found only between the rates and quality of recovery for the musculocutaneous and axillary nerve using the thoracodorsal nerve as donor. According to our findings, nerve transfers using collateral branches of the brachial plexus in cases with upper palsy offer several advantages and yield high rate and good quality of recovery.

Nerve transfers using collateral branches of the brachial plexus as donors in patients with upper palsy—thirty years’ experience

Nerve transfers in cases of directly irreparable or high-level extensive brachial plexus traction injuries have been done using a variety of donor nerves with various success, but an ideal method has not been established. The purpose of this study is to analyze the results of nerve transfers using the thoracodorsal and medial pectoral nerves as donors in patients with upper palsy. This retrospective study included 40 patients with 29 procedures using the thoracodorsal nerve and 33 procedures using the medial pectoral nerve as donors for reinnervation of the musculocutaneous or axillary nerve. Both nerves were used simultaneously in 22 of these patients. The thoracodorsal nerve was transferred in 13 patients to the musculocutaneous nerve and in nine patients to the axillary nerve. The medial pectoral nerve was transferred in nine patients to the musculocutaneous nerve and in 13 patients to the axillary nerve. The results were analyzed according to the donor nerve, the age of the patient, and the timing of surgery. The total rate of recovery for elbow flexion was 94.1%, for shoulder abduction 89.3%, and for shoulder external rotation 64.3%. The corresponding rates of recovery using the thoracodorsal nerve were 100, 93.7, and 68.7%, respectively. The rates of recovery with medial pectoral nerve transfers were 90.5, 83.3, and 58.3%, respectively. Despite the obvious differences in the rates of recovery, statistical significance was found only between the rates and quality of recovery for the musculocutaneous and axillary nerve using the thoracodorsal nerve as donor. According to our findings, nerve transfers using collateral branches of the brachial plexus in cases with upper palsy offer several advantages and yield high rate and good quality of recovery.

Transaxillary Approach for Thoracic Outlet Syndrome: Results of Surgery

Thoracic outlet syndrome (TOS) is one of the most complicated diseases in thoracic surgery with regard to both diagnosis and treatment. Surgical removal of the first rib and cervical rib, if present, has been suggested as the treatment of choice in patients who do not benefit from physiotherapy. In this retrospective study, our surgical experience with TOS and the management of surgical complications are presented. A total of 109 cases with the diagnosis of TOS were operated on between January 1995 and April 2010. Ninety-five of the cases were females (87.2 %) and 14 (12.8 %) were males with a mean age of 35.7 (16-58). A total of 131 operations were performed, of which 21 were bilateral and one was a recurrent operation. The diagnosis was neurogenic TOS in 107 (98.2 %) and vascular TOS in two (1.8 %) patients. All neurogenic TOS operations were performed via the transaxillary route. A posterior thoracoplasty approach was used for recurrent TOS in one case. A total of 23 (21.1 %) cases had a cervical rib. Fibromuscular bands were observed in 68 (62.3 %) cases. The rates for favorable and poor surgical outcome were 125 (95.4 %) and 6 (4.6 %), respectively. The most common complication was apical pneumothorax in 32 (24.6 %) cases, followed by wound infection in four (3 %), lymphatic leak, axillary hematoma and mild brachial plexus traction palsy in one (0.8 %) case. Mortality was not observed. In our experience the exposure provided by the transaxillary approach is safe and superior to that offered by other approaches as it allows a wide range of surgical applications such as first rib resection, cervical rib resection and resection of fibrotic bands.

Pain and brachial plexus lesions: evaluation of initial outcomes after reconstructive microsurgery and validation of a new pain severity scale

Peripheral nerve lesions usually are associated with neuropathic pain. In the present paper, we describe a simple scale to quantify pain after brachial plexus injuries and apply this scale to a series of patients to determine initial outcomes after reconstructive surgery. Fifty-one patients with traumatic brachial plexus avulsion injuries were treated over the period of one calendar year at one center by the same surgical team. Of these, 28 patients who were available for follow-up reported some degree of neuropathic pain radiating towards the hand or forearm and underwent reconstructive microsurgery and direct pain management, including trunk and nerve neurolysis and repair. A special pain severity rating scale was developed and used to assess patients' pain before and after surgery, over a minimum follow-up of 6 months. An independent researcher, not part of the surgical team, performed all pre- and postoperative evaluations. Of the 28 patients with brachial plexus traction injuries who met eligibility criteria, 93% were male, and most were young (mean age, 27.6 years). The mean preoperative severity of pain using our scale was 30.9 out of a maximum of 37 (± 0.76 SD), which fell to a mean of 6.9 (± 0.68 SD) 6 months post-procedure. On average, pain declined by 78% across the whole series, a decline that was statistically significant (p < .001). Subset analysis revealed similar improvements across all the different parameters of pain. We have designed and tested a simple and reliable method by which to quantify neuropathic pain after traumatic brachial plexus injuries. Initial surgical treatment of the paralysis--including nerve, trunk and root reconstruction, and neurolysis--comprises an effective means by which to initially treat neuropathic pain. Ablative or neuromodulative procedures, like dorsal root entry zone, should be reserved for refractory cases.

Brachial Plexus Traction Injury: Quantification of Sensory Abnormalities

Stretch injury to the brachial plexus may occur following traumatic flexion-extension of the cervical spine often seen in motor vehicle accidents or falls. Radiologic and conventional nerve conduction studies are negative in many cases. The present study was undertaken in an attempt to simplify, standardize, and quantify the positive and negative sensory abnormalities that are most often seen during the clinical examination. Quantitation of thresholds for thermal detection and pain, vibration, pressure pain and elevated arm stress test was performed in a series of 38 patients with the clinical picture of brachial plexus traction injury as well as a group of age and sex matched control subjects. Significant decreases in all evoked pain thresholds, except for heat pain, along with increases in sensory detection thresholds were found in the patient group compared with controls. Quantification of sensory findings may greatly facilitate and substantiate the diagnosis of this type of injury. The data are consistent with the hypothesis that brachial plexus traction injury causes dysfunction of small sensory fiber systems and results in a form of neuropathic pain.

93. The significance of neurophysiological examinations in preoperative evaluation of brachial plexus traction injuries

93. The significance of neurophysiological examinations in preoperative evaluation of brachial plexus traction injuries

An unusual presentation of whiplash injury: long thoracic and spinal accessory nerve injury

Whiplash injuries from motor vehicle accidents are very common. The usual presentation and course of this condition normally results in resolution of symptoms within a few weeks. Brachial plexus traction injuries without any bone or joint lesion of the cervical spine have been reported before. We report a case where a gentleman was involved in a rear end vehicle collision, sustained a whiplash injury and was later found to have a long thoracic nerve palsy and spinal accessory nerve palsy. Although isolated injuries of both nerves following a whiplash injury have been reported, combined injury of the two nerves following a whiplash injury is very uncommon and is being reported for the first time.

Percutaneous Implantation of a Brachial Plexus Electrode for Management of Pain Syndrome Caused by a Traction Injury

Introduction. Intractable pain in the affected arm is a common sequel to severe traction lesions of the brachial plexus. Its management presents a challenge. Existing interventional therapies are not effective for the intractable pain from brachial plexus traction lesions, in the long term. Spinal cord stimulation is indicated for the relief of pain following peripheral nerve injury, but has its limitations and, in the UK, is restricted only to specialized centers. Peripheral neuromodulation is widely practiced noninvasively as transcutaneous electrical nerve stimulation and more recently, both as external neuromodulation and, invasively, using a surgical procedure with restricted indications. Methods. We report here a single case report of the successful management of intractable pain of uncertain pathology following traction injury of the shoulder and brachial plexus with the percutaneous implantation of a permanent stimulating electrode via a stimulating needle to the brachial plexus using the posterior route at the interscalene level. Results. Stimulation of the brachial plexus in this one patient has resulted in excellent pain control and unexpected beneficial sensory and motor changes in the arm of the patient. Conclusions. We cautiously conclude that percutaneous implantation of a stimulating electrode to the brachial plexus via a stimulating needle is a relatively simple procedure when compared to surgical implantation and, as shown in our case, very effective.

Sonography of brachial plexus traction injuries: Haber HP, Sinis N, Haerle M, Scaller H. AJR Am J Roentgenol 2006;186:1787–91

Sonography of brachial plexus traction injuries: Haber HP, Sinis N, Haerle M, Scaller H. AJR Am J Roentgenol 2006;186:1787–91