Brachial Plexus Traction Research Articles

Sonography of Brachial Plexus Traction Injuries

Our purpose was to evaluate the feasibility of sonography in identifying nerve abnormalities in patients with traction injury of the brachial plexus. Sonography of the brachial plexus was technically feasible, although the entire brachial plexus could not be evaluated. Sonography appears to be a useful bedside imaging technique for assessing brachial plexus injury. The potential of sonography as a complementary diagnostic tool in the evaluation of these patients warrants further investigation.

Regional modulation of primary motor cortex after peripheral nerve injury: a functional magnetic resonance imaging study

To map dynamic changes of primary motor cortex after total brachial plexus traction injury by using functional magnetic resonance imaging, and to explore underlying probable mechanisms. Five patients with total traumatic root avulsions of the brachial plexus underwent varied kinds of nerve transfer to restore partially shoulder or elbow function. Four of them (cases 1, 3, 4, 5) accepted the first fMRI examination prior to surgery treatment, and four of them (cases 2, 3, 4, 5) accepted second or third or fourth fMRI follow-up re-examinations after surgery treatment. Maps of neuronal activation within the motor cortex were generated for both hands in each patient by using BOLD-fMRI and the cluster size and position were recorded. The motor tasks consisted of simple hand grasping of both hands respectively. Patients with paralytic hand were asked to complete task under "virtual" condition. The cluster size and intensity as well as location of motor activation within the primary motor cortex of the affected hand generated were compared with those of unaffected hand generated as reference in single subject, and the resultant maps of follow-up re-examinations were also compared with those of the prior examinations. All patients' unaffected hand movement generated strong signal change within the contralateral primary motor cortex. In contrast, the clusters generated by affected hand showed very small and lower intensity than usual (2 cases) or could not be induced (2 case) in the first examination that prior to surgery treatment and seemed larger gradually in the following re-examination with time increasing. Peripheral nerve injury can produced significant changes in the motor cortex of human brain. fMRI is a valuable tool to evaluate neural plasticity in motor cortex after peripheral nerve injury.

Motor root conduction block in traumatic brachial plexopathy

A 31-year old man sustained severe left brachial plexus traction injury. Electrical stimulation demonstrated multilevel motor root conduction block, which reversed after a 4-month period. Motor root conduction studies are useful diagnostic and prognostic adjuncts in the management of brachial plexopathy.

Evaluation of suprascapular nerve neurotization after nerve grafting or transfer in the treatment of brachial plexus traction lesions

Object The aim of this retrospective study was to evaluate the restoration of shoulder function by means of supra-scapular nerve neurotization in adult patients with proximal C-5 and C-6 lesions due to a severe brachial plexus traction injury (BPTI). The primary goal of brachial plexus reconstructive surgery was to restore the biceps muscle function and, secondarily, to reanimate shoulder function. Methods Suprascapular nerve neurotization was performed by grafting the C-5 nerve in 24 patients and by accessory or hypoglossal nerve transfer in 29 patients. Additional neurotization involving the axillary nerve could be performed in 18 patients. Postoperative needle electromyography studies of the supraspinatus, infraspinatus, and deltoid muscles showed signs of reinnervation in most patients; however, active glenohumeral shoulder function recovery was poor. In nine (17%) of 53 patients supraspinatus muscle strength was Medical Research Council (MRC) Grade 3 or 4 and in four (8%) infraspinatus muscle power was Grade 3 or 4. In 18 patients in whom deltoid muscle reinnervation was attempted, MRC Grade 3 or 4 function was demonstrated in two (11%). In the overall group, eight patients (15%) exhibited glenohumeral abduction with a mean of 44 ± 17° (standard deviation [SD]) (median 45°) and four patients (8%) exhibited glenohumeral exorotation with a mean of 48 ± 24° (SD) (median 53°). In only three patients (6%) were both functions regained. Conclusions The reanimation of shoulder function in patients with proximal C-5 and C-6 BPTIs following supra-scapular nerve neurotization is disappointingly low.

Nerve transfer in brachial plexus traction injuries

The aim of this study was to analyze the results of nerve transfer to the musculocutaneous and axillary nerves, using some technical modalities such as intercostal, spinal accessory or intraplexal transfer, and on the basis of the results to try to clarify the most common controversies concerning these operations. The study included 82 patients with brachial plexus traction injuries, who were operated on using various techniques of nerve transfer. The follow-up period was at least two years. The analysis of biceps and deltoid muscles recovery was performed according to the type of the donor nerve. The corresponding rates of recovery for the musculocutaneous and axillary nerves were 46.7% and 68.1% in intercostal nerve transfer, 71.4% and 75% in accessory nerve transfer, 93.1% and 88.8% in nerve transfer of the brachial plexus collateral branches, and 55.5% and 60% in classical intraplexal nerve transfer, respectively. Comparative statistical analysis demonstrated significantly better final outcome and quality of recovery in regional nerve transfers in comparison to the other methods. Our findings suggest that nerve transfer of collateral branches, where possible, (such as in cases with upper or extended upper brachial plexus palsy) might be a method of choice, offering better results and quality of recovery.

Nerve transfer in brachial plexus injuries--comparative analysis of surgical procedures

Nerve transfer is the only possibility for nerve repair in cases of the brachial plexus traction injuries with spinal roots avulsion. From 1980. until 2000. in Institute of Neurosurgery, Clinical Center of Serbia, nerve transfer has been performed in 127(79%) of 159 patients with traction injuries of brachial plexus, i.e., 204 reinnervation procedures has been performed using different donor nerves. We achieved good or satisfactory arm abduction and full range or satisfactory elbow flexion through reinnervation of the axillary and musculocutaneous nerve using different donor nerves in 143 of 204 reinnervations, which presents general rate of useful functional recovery in 70.1% of cases. Mean values of the rate of useful functional recovery in individual modalities of nerve transfer in our series are 50.1% for intercostal and/or spinal accessory nerve transfer, 64.5% for plexo-plexal nerve transfer, 81.7% for regional nerve transfer, and 87.1% for combine nerve transfer.

Surgical treatment of brachial plexus traction injuries in children, excluding obstetric palsy.

Traumatic brachial plexus injuries in children, excluding birth palsy, are seldom reported. In this study, we report on 11 cases operated upon between 1995-1998, and followed for at least 30 months. All patients were males with an average age of 11 years (range, 3-16 years). The denervation time averaged 3.8 months (range, 1-8 months). Eight patients had two or more root avulsions; two had additional severe infraclavicular injuries. In total, 6 grafting and 25 extraplexal neurotization procedures were used. Donor nerves included the intercostal nerves, phrenic nerve, spinal accessory nerve, and contralateral C7 root. Elbow flexion was restored in all but 2 cases. Shoulder abduction varied from 30-90 degrees, according to the method of reconstruction. Triceps recovered in 2 cases and finger and wrist extensors in 1 case. Wrist and finger flexion was obtained in 1 case. Sensory recovery in the palm reached S2/S2+. Harvesting the phrenic nerve and the contralateral C7 root resulted in no residual morbidity. Compared to adults, children have a higher incidence of root avulsion, no deafferentiation pain, a higher incidence of associated skeletal injuries, and the same recovery rate of elbow and shoulder functions following plexus reconstruction, but recovery is faster. Given the frequency of root avulsions, neurotization is often required.

In situ strain and stress of nerve conduction blocking in the brachial plexus

The objective of the present study was to determine the in situ strain and stress of nerve conduction blocking in the brachial plexus. The measurement of the in situ tension stress inducing functional failure of the brachial plexus consisted of two steps. Step I (in vivo): The brachial plexus of the rabbit was stretched laterally until electrophysiological conduction blocking occurred. The distance between two dye marks placed on the lower trunk was simultaneously recorded using a video dimensional analyzer system. Step II (in vitro): The lower trunk that was removed was loaded again, and the nerve tension was recorded. The load at complete conduction blocking was determined by a load–elongation curve. The results showed that when the in situ nerve strain reached 8.1±0.5%, the compound muscle action potential was not evoked. The in situ load and stress were 2.5±0.4 N and 0.89±0.14 MPa, respectively, at complete conduction blocking. These findings should be helpful in understanding the mechanism of brachial plexus traction injury.

Restoration of upper arm function in traction injuries to the brachial plexus.

Restoration of upper arm function presents the main priority in nerve repair of brachial plexus traction injuries. The results are predominantly influenced by the level and extent of injury, and the type of surgical procedure. The purpose of this study is to evaluate influence of these factors on final outcome. Study included 91 surgically treated patients, including 71 patients with avulsions of one or more spinal nerve roots and 20 with peripheral traction injuries. We performed 120 nerve transfers, 25 nerve graftings and 29 neurolyses on different nerve elements depending on the type of nerve damage. Analysis of motor recovery for elbow flexion and arm abduction, isolated or in combination, was done. Recovery of elbow flexion was obtained in 75% nerve transfers, and in 68,7% nerve graftings in peripheral traction injuries. Recovery of arm abduction was obtained in 78,5% nerve transfers, and in 44,4% nerve graftings in peripheral traction injuries. Neurolysis was successful in all cases. Generally, the quality of recovery was better for the musculocutaneous nerve. Useful global upper arm function was obtained in 49,3% of patients with avulsion of spinal nerve roots, and in 55% of patients with peripheral traction injuries. Regarding upper arm function the prognosis of surgically treated patients with traction injuries to the brachial plexus is generally similar in cases with central or peripheral level of injury. However, nerve transfers of collateral branches seem to be superior to nerve grafting and may be another possibility for repair in cases with extensive nerve gaps.

Long-term Follow-up and Patient Satisfaction after Surgery for Thoracic Outlet Syndrome

The purpose of this study was to review the long-term outcomes, particularly patient satisfaction, of patients surgically treated for thoracic outlet syndrome (TOS). All patients who had undergone surgery for TOS at the University of Iowa Hospitals and Clinics between 1988 and 1999 were reviewed. A retrospective chart review of 29 patients (36 operations) was performed. In addition, 20 (69%) of the patients were able to be contacted for a phone survey. There was no operative mortality. Specific neurologic complications occurred in 4/36 operations (11%) including one brachial plexus traction palsy, two phrenic nerve palsies, and one long thoracic nerve palsy. All nerve palsies were either mild or temporary. Mean follow-up was 4 years. On phone survey, 80% of the patients were actively employed. Twenty-seven percent reported that they had an excellent result, 58% reported they had a good result, 8% reported that they had a fair result, and 8% had a poor result. If they had it to do over again, 85% of the patients would have the same surgery again for relief of TOS.

Peripheral nerve injuries during cardiac surgery: risk factors, diagnosis, prognosis, and prevention.

Neuropathies involving the brachial plexus, phrenic, recurrent laryngeal, and saphenous nerves, as well as the sympathetic chain are complications of cardiac surgery. The reported frequency of nerve injuries varies from 1.5% to 24% for the brachial plexus and 10% to 60",,6 for the phrenic nerve (1-5). Neuropathies of the recurrent laryngeal, lower limb (saphenous) nerves, and the sympathetic chain are less frequent.

Results of Nerve Transfers to the Musculocutaneous and Axillary Nerves

Nerve transfers in cases of brachial plexus traction injuries with avulsion of spinal nerve roots or irreparable proximal lesions of spinal nerves have been attempted using a variety of donor nerves. The purpose of this study was to analyze the results of nerve transfers to the musculocutaneous and axillary nerves, using collateral branches of the brachial plexus, upper intercostal nerves, or the accessory nerve. This study included 62 patients with brachial plexus traction injuries who were surgically treated using various nerve transfer techniques. The follow-up periods were at least 3 years. Analysis of motor recovery was performed according to the type of donor nerve, the age of the patient, and the timing of surgery. The rates of recovery for the musculocutaneous and axillary nerves were 50% and 63.2% with intercostal nerve transfers, 65% and 75% with accessory nerve transfers, and 90.4% and 86.9% with nerve transfers of collateral branches, respectively. Despite the obviously better outcomes with the latter technique, a significant difference was found only in comparison with intercostal nerve transfers for the musculocutaneous nerve (P = 0.007). With respect to the quality of recovery, we found a significant difference between the latter type and the other two types of nerve transfers only for the musculocutaneous nerve (P = 0.027 for intercostal nerve transfers and P = 0.05 for accessory nerve transfers). There was no significant difference in results obtained using the thoracodorsal and medial pectoral nerves as donors. Our findings suggest that nerve transfer of collateral branches when possible, such as in cases involving upper brachial plexus palsy, may be the method of choice, yielding better results.

Correlation between histopathological findings in C-5 and C-6 nerve stumps and motor recovery following nerve grafting for repair of brachial plexus injury.

Proximal spinal nerve stumps were used as donor sites for grafts to repair brachial plexus traction lesions. The quality of the stumps was assessed histologically, and its correlation with the strength attained in the target muscle was studied. Four histopathological parameters in frozen tissue sections of 31 C-5 or C-6 nerve stumps were examined by a neuropathologist. The total quantity of myelin was compared with normal values. Also, thick myelinated fibers, fibrosis, and misdirected axons were assessed. Stumps embedded in plastic were used in a morphometric study of myelinated fiber profiles. The fiber density, mean size, and size distribution in five donor stumps were determined; three normal C-5 spinal nerves obtained at autopsy served as controls. Finally, the relative area occupied by fiber profiles and interspace was computed. Linear regression was used as a multivariate analysis, adjusting the outcome of surgical repair for effects of age, interval between trauma and surgery, and graft length. Histopathological examination showed that the total quantity of myelin in donor stumps used for biceps muscle reinnervation was considerably reduced. On morphometric examination the fiber density did not differ significantly between stumps obtained in patients and control stumps obtained at autopsy. However, a significant reduction of the area occupied by myelinated fibers was measured: from 46% in controls to 13% in patients (p < 0.0001). Likewise, a significant reduction was found in the mean fiber size: from 7.4 microm in controls to 3.7 microm in patients (p < 0.0001). The relationship between the myelin quantity in the proximal stump and the grade of biceps muscle recovery was statistically significant (p = 0.02). From the 95% confidence interval it was concluded that the estimated effect of a mean increase of myelinated fibers by 25% almost equals an increase in recovery of one point on the Medical Research Council scale (grade range 0-5). Both histopathological and morphometric examination showed a reduction of the quantity of myelin in C-5 or C-6 stumps used as donor sites for grafts. The amount of myelin is significantly correlated with biceps muscle function after nerve grafting. Because it is possible to assess the quantity of myelin by intraoperative examination of frozen sections, this correlation is potentially useful in the decision-making process of whether to use stumps for grafting or to use nerve transfer procedures to restore biceps muscle function.

Traction injuries of the brachial plexus: signal intensity changes of the posterior cervical paraspinal muscles on MRI.

Our goal was to evaluate MR signal intensity change of the posterior cervical paraspinal muscles in brachial plexus traction injuries to determine the value of this finding in the diagnosis of nerve root avulsion. MR images of 11 consecutive patients, 7 with nerve root avulsion and 4 without nerve root avulsion, were retrospectively analyzed, focusing on the signal intensity of the paraspinal muscles. Among the seven patients with nerve root avulsion, T2- or T2*-weighted MR images showed increased signal intensity in the deep posterior paraspinal muscles in five and traumatic meningocele in four. The signal intensity of the posterior paraspinal muscles was normal in all patients without nerve root injuries. MR signal intensity change in the deep posterior cervical paraspinal muscles is related to denervation and suggests the presence of nerve root avulsion.

Brachial plexus injury in multitraumatized patients

The majority of patients presenting with a brachial plexus traction injury suffer from multisystem trauma. The consequences are discussed. Occlusion of the axillary artery is an associated lesion which rarely produces ischaemia of the upper limb. Repair may preferentially be carried out together with elective plexus reconstructive surgery.

Surgical repair of brachial plexus injury

This preliminary report surveys the authors' experience in the treatment of 66 patients with brachial plexus traction injuries. The results of nerve reconstructive surgery obtained in 44 patients with a follow-up of at least 2 years were disappointing; on average, 10% of upper limb function was added. The role of several factors involved in this type of injury and the major draw-backs of treatment are discussed in combination with future possibilities. Current techniques of neurotizations are presented in one case.

Nerve transfer in brachial plexus traction injuries

Brachial plexus palsy due to traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Nerve transfer is the only possibility for repair in cases of spinal nerve-root avulsion. This technique was analyzed in 37 patients with 64 reinnervation procedures of the musculocutaneous and/or axillary nerve using upper intercostal, spinal accessory, and regional nerves as donors. The most favorable results, with an 83.8% overall rate of useful functional recovery, were obtained in patients with upper brachial plexus palsy in which regional donor nerves, such as the medial pectoral, thoracodorsal, long thoracic, and subscapular nerves, had been used. The overall rates of recovery for the spinal accessory and upper intercostal nerves were 64.3% and 55.5%, respectively, which are significantly lower. The authors evaluate the results of nerve transfer and analyze different donor nerves as factors influencing the prognosis of surgical repair.

Brachial Plexus Traction Injuries

Brachial plexus traction injuries most frequently occur following acute flexion or extension of the neck. The symptomatology following this injury may be defined clearly into the anatomic patterns of upper trunk, lower trunk, posterior cord, medial cord, and lateral cord radiations. This injury is the most common cause of the neurogenic form of thoracic outlet syndrome and is frequently seen in conjunction with cervical spine disease as well as peripheral entrapment syndromes of the ulnar, radial, and medial nerves.

Experimental traction injuries of ventral spinal nerve roots. A scanning electron microscopic study.

The aims of this experimental scanning electron microscopic study were to identify the levels at which cervical ventral nerve roots, or the rootlets by which they are attached to the spinal cord, rupture under traction and to document the resulting damage. This information would provide the basis of a rationale for repairing rootlet avulsions which may follow brachial plexus traction injuries in man and which cause severe impairment of upper limb function. Traction was applied to C4 to T1 ventral roots until rupture occurred, in 10 freshly fixed and three living anaesthetized Wistar albino rats and in one human post-mortem specimen. Rupture occurred at the rootlet-cord junction in 80% of cases. Most individual myelinated fibres broke at the central-peripheral nervous system (CNS-PNS) transitional node which, in the cervical region, lies at the bottom of an endoneurial invagination surrounding each fibre and extending deep to the cord surface. Fibre rupture at more distal levels occurred internodally, and a length of axon commonly protruded well beyond the level of sheath rupture. Some sheaths broke cleanly across but the torn surfaces of others tapered, perhaps because of rupture at Schmidt-Lanterman incisures. The cellular and connective tissue rootlet sheaths ruptured where they were continuous with the pia mater. Ruptured fixed and unfixed tissues were ultrastructurally similar. It is clear from the findings of this study that regeneration would take place entirely in a PNS environment. The endoneurial invaginations would ensure that sprouts emerging from transitional nodes would be guided distally into rootlets surgically apposed to the torn transitional zone.

Clinical Diagnosis, Testing, and Electromyographic Study in Brachial Plexus Traction Injuries

A system for evaluation of patients with brachial plexus injury is based on careful observation, including the patient's history and a physical examination, a radiographic assessment, and electrodiagnosis. The clinical history and physical examination remain the cornerstone of this evaluation and their documentation is vital. Traction injuries, wherein there is a possibility of root avulsion, were examined myelographically and electromyographically at one month. Although they must be considered, the limitations of these methods of evaluation do not vitiate their usefulness. Modification of the evaluation procedures should be made according to the requirements imposed by specific causal agents and circumstances.