C5 Root Research Articles

Detailed features and prognostic factors of twenty-three patients with drop finger caused by cervical radiculopathy: a retrospective multicentre study.

It has been reported that C7 and C8 nerve root impairment can cause drop finger; however, the clinical characteristics of each injured nerve root and post-operative outcomes remain unclear. This study aimed to investigate the detailed features and surgery-related prognostic factors of drop finger caused by cervical radiculopathy. We retrospectively investigated the clinical characteristics, paralysis patterns and surgery-related prognostic factors of 23 patients with drop finger caused by cervical radiculopathy who underwent posterior cervical foraminotomy. We classified paralysis into three patterns based on the fingers predominantly exhibiting extensor digitorum communis (EDC) muscle weakness: index finger side-dominant, middle and ring fingers-dominant and little finger side-dominant. The aetiologies were cervical disc hernia (CDH) in ten patients, cervical spondylotic radiculopathy (CSR) in eight and both CDH and CSR in five. The levels of the decompressed root were C7 in one patient, C8 in 11 and both C7 and C8 in 11. Scapular pain was frequently observed as the initial symptom (78%), especially in patients with only C8 nerve root disorder (91%). Drop finger recovered to a score of ≥ 3 on manual muscle testing in 17 patients; patients with the little finger side-dominant pattern tended to have poor recoveries. Patients with CDH improved significantly than those with CSR or both CDH and CSR (p < 0.05). Good surgical recovery of drop finger can be expected in patients with CDH and in those with index fingers-dominant and middle and ring fingers-dominant patterns.

Long-term functional recovery in C5-C6 avulsions treated with distal nerve transfers

ABSTRACT Background In patients suffering from traction lesions of the brachial plexus, complete C5 and/or C6 root avulsion patients with C7 root preservation are relatively uncommon occurrences, but represent excellent candidates for surgical treatment, with satisfactory results. Shoulder abduction and extra-rotation, elbow flexion and forearm supination are lost functions restorable with surgical treatment. Methods This single-center, prospective observational study involved a series of 27 young adults with C5 and/or C6 root complete avulsion and C7 preservation, which underwent surgical repair with double or triple nerve transfer. Results Patients recovered a useful elbow flexion. Electromyographic and clinical signs of biceps reinnervation were observed in each UN-MC nerve transfer. The abduction strength recovery was M5 in 10 patients, M4 in 14 patients and M3 in 3 patients. The external rotation strength recovery was M5 in 4 patients, M4 in 18 patients, M3 in 3 patients and M2 in 2 patients. The elbow flection strength was M5 in 5 patients, M4 in 15 patients and M3 in 7 patients. Elbow extension was preserved in all cases. Conclusions The concept of ‘peripheral rewiring procedures’ represents an advance in the repair of the peripheral nerve injuries. Triple nerve transfer can be nowadays considered a standard treatment for isolated C5-C6 avulsions. We report our experience with the second-biggest casuistry in the literature on patients treated with this technique. We consider our outcome concerning functional recovery to be satisfying and comparable to data reported in the literature.

Letter: Fascicular Topography of the Suprascapular Nerve in the C5 Root and Upper Trunk of the Brachial Plexus: A Microanatomic Study From a Nerve Surgeon's Perspective

Letter: Fascicular Topography of the Suprascapular Nerve in the C5 Root and Upper Trunk of the Brachial Plexus: A Microanatomic Study From a Nerve Surgeon's Perspective

A meta-analysis on the anatomical variability of the brachial plexus: Part II — Branching of the supraclavicular part

IntroductionThe anatomy of the supraclavicular part of the brachial plexus is highly variable, therefore the aim of this study was to perform a systematic review and meta-analysis of the various origins of the long thoracic, dorsal scapular, suprascapular and subclavian nerves. Materials and methodsMajor electronic databases were searched to identify all cadaveric studies investigating the morphology of the supraclavicular part of the brachial plexus. Data on the origins of these nerves were extracted and classified. A random effects meta-analysis was performed to state the pooled prevalence estimates. ResultsA total of 26 studies, constituting a total of 1021 cases, were deemed eligible for inclusion into the meta-analysis. The usual origin of the long thoracic nerve from the C5, C6 and C7 roots was observed in 78.1% (95% CI 69.4–86.7%) of cases and 21.9% (95% CI 13.3–30.6%) had unusual origins. An accessory long thoracic nerve occurred in 0.3% (95% CI 0–0.7%) of cases. The overall prevalence of the dorsal scapular nerve arising from its usual origin the C5 root was found in 85.2% (95% CI 75.7–94.6%) of cases, while 14.8% (95% CI 5.4–24.3%) appeared abnormal. The suprascapular nerve emerged from its usual point on the superior trunk in 89.8% (95% CI 85.1–94.4%) of cases and in 10.2% (95% CI 5.6–14.9%) of cases had a variable origin. An accessory suprascapular nerve was present in 0.2% (95% CI 0–0.6%). Two possible sites of origin of the subclavian nerve were noted and the typical origin from the superior trunk was found in 98.3% (95% CI 96.3–100%) of cases and variable origin from the C5 root in 1.7% (95% CI 0–3.7%). All unusual origins of each nerve were much less common. ConclusionsThe nerves emerging from the supraclavicular part of the brachial plexus express a wide spectrum of potential origins. Based on their various origins, a new classification system for all the nerves belonging to the supraclavicular part was proposed. Knowledge of these variations and their prevalence data is important to prevent iatrogenic injuries and to state useful landmarks for interventions in the axilla.

Clinical Anatomy of Human Donor C7 Nerve Roots for Surgical Transfer in Patients with Spastic Arm Paralysis

Contralateral C7 (CC7) nerve transfer has successfully restored hand function in patients with spastic hemiplegia from chronic central nervous system injuries. However, little is known about the morphology and anatomy of the donor C7 nerve root in patients undergoing this procedure. This study quantified intraoperative measurements of donor C7 nerve roots during CC7 transfer surgery for spastic hemiplegia in patients treated at a high-volume center to describe observed anatomical variations for successful direct anastomosis. A database of images from 21 patients (2 females, 19 males) undergoing CC7 surgery was searched for photographic data that contained a standard ruler measuring donor C7 nerve root length after surgical sectioning and before transfer. Two independent observers analyzed these images and recorded C7 nerve root diameter, length, and branch lengths. Mean (SD) values of donor C7 nerve measurements were length, 53.5 (8.0) mm; diameter, 5.1 (0.9) mm; branch length following surgical sectioning, 18.3 (6.3) mm. Right-sided donor C7 nerve roots yielded significantly longer branches compared with left-sided donor C7 nerve roots (P= 0.01). Other patient factors such as age, sex, or laterality of brain injury did not influence intraoperative anatomy. We report detailed intraoperative measurements of the donor C7 root during CC7 nerve transfer for spastic hemiplegia. These findings describe existing variation in surgical C7 nerve root anatomy in patients undergoing this procedure and may serve as a general reference for the expected donor C7 length in successful direct anastomosis.

Transfer of the phrenic nerve to musculocutaneous nerve via sural nerve graft after total brachial plexus injury

A middle age male presented a right total brachial plexus injury after motorcycle fall one year ago. Subsequent electromyographic evaluation was consistent withC5, C6, C7, C8 and T1 root avulsion. The patient was submitted to a right transfer of thephrenic nerve to musculocutaneous nerve , using rural nerve graft.

Risk Analysis of Needle Injury to the Long Thoracic Nerve during Ultrasound-Guided C7 Selective Nerve Root Block.

Background and Objectives: Ultrasound (US)-guided cervical selective nerve root block (SNRB) is a widely used treatment for upper limb radicular pain. The long thoracic nerve (LTN) passes through the middle scalene muscle (MSM) at the C7 level. The needle trajectory of US-guided C7 SNRB pierces the MSM, therefore indicating a high probability of injury to the LTN. We aimed to identify the LTN and to investigate the risk of needle injury to the nerve during US-guided C7 SNRB. Materials and Methods: This retrospective observational study included 30 patients who underwent US-guided SNRB at the C7 level in a university hospital. We measured the maximal cross-sectional diameter (MCSD) of the LTN and cross-sectional area (CSA) of the C7 nerve root and assessed the injury risk of LTN during US-guided C7 SNRB by simulating the trajectory of the needle in the ultrasound image. Results: The LTN was detectable in all the cases, located inside and outside the MSM in 19 (63.3%) and 11 (36.7%) of cases, respectively. The LTN’s mean MCSD was 2.10 mm (SD 0.13), and the C7 root’s CSA was 10.78 mm2 (SD 1.05). The LTN location was within the simulated risk zone in 86.7% (26/30) of cases. Conclusion: Our findings suggest a high potential for LTN injury during US-guided C7 SNRB. The clear visualization of LTNs in the US images implies that US guidance may help avoid nerve damage and make the procedure safer. When performing US-guided C7 SNRB, physicians should take into consideration the location of the LTN.

C7 contribution to the ulnar nerve

Introduction. Classic anatomical literature frequently describes C7 contribution to ulnar nerve (UN) formation as a casual event. However, surgical practice and dissections frequently reveal a recurrent presence of a lateral cord component of the UN. This study aimed to seek through literature to establish the frequency and degree of this contribution. Methodology. We ran a literature review searching on Pubmed, MEDLINE, Embase and Web of Science databases for ulnar nerve anatomy and described discursively the results. Results and discussion. We found 9 articles that described quantitatively and qualitatively the contribution of C7 on the formation of the UN. The prevalence described ranged from 2 to 100%, depending on the methodology used and population characteristics. When present, studies described a contribution from 9,9% to 30,4%, sending even more fibres than T1 root on average. Conclusion. The C7 root can be considered a frequent and important component of the ulnar nerve, explaining UN territory repercussions on C7 radiculopathies. This knowledge is important on surgical approaches, maybe avoiding iatrogenic lesions and negative outcomes.

Risk Factors and Prevention of C5 Palsy After Anterior Cervical Decompression and Fusion: Similarity of the Pathomechanism With That After a Posterior Approach.

This was a retrospective study. The objective of this study was to review clinical and imaging findings after anterior cervical decompression and fusion, as a basis for prevention of C5 palsy. C5 palsy is a common postoperative complication in spine surgery, but the mechanistic basis for this condition is unknown. The subjects were 239 patients with cervical myelopathy who underwent anterior cervical decompression and fusion including at C4-C5 disk level at our hospital from 2001 to 2018. Twelve of these patients (5.0%) had C5 palsy postoperatively. Clinical features and imaging findings were compared in patients with and without C5 palsy. In patients with C5 palsy, the sagittal alignment of the cervical spine was kyphotic, the width of the C5 intervertebral foramen was narrower, and the lateral decompressed line was wider beyond the medial part of the Luschka joint. Age, sex, disease, the number of fused segments, decompression width, and anterior shift of the spinal cord did not differ significantly between patients with and without C5 palsy. These results indicate that the pathomechanism of C5 palsy may be dependent on the location of the lateral decompression line, especially in patients with cervical kyphosis and a narrow C5 intervertebral foramen. Excessive lateral decompression beyond the Luchka joint might lead to C5 root kinking between the intervertebral foramen and posterior edge of vertebra. This pathomechanism may be similar in anterior and posterior approaches. To prevent C5 palsy, the medial line of the Luschka joint should be confirmed intraoperatively and decompression should be performed within the Luschka joints. Alternatively, medial foraminotomy should be used in cases needing wide decompression, such as those with massive ossification of the posterior longitudinal ligament, lateral osteophytes, and symptomatic foraminal stenosis. Level III.

Cross-sectional area reference values for peripheral nerve ultrasound in adults: A systematic review and meta-analysis-Part III: Cervical nerve roots and vagal nerve.

Measurement of the cross-sectional area (CSA) of cervical nerve roots using ultrasound is useful in the evaluation of inflammatory polyneuropathies, and measurement of CSA of the vagal nerve might give information about involvement of the autonomic nervous system. We performed a systematic review and meta-analysis of published CSA reference values for cervical nerve roots and vagal nerve. We included available-to-date nerve ultrasound studies on healthy adults and provide meta-analysis for CSA of the following nerves: cervical nerve roots C5, C6, and C7 as well as vagal nerve in the carotid sheath at the carotid bifurcation level. We report regression and correlation analyses for age, gender, height, weight, and geographic continent. We included 11 studies with 885 healthy volunteers (mean age=42.7years) and 3149 examined nerve sites. Calculated mean pooled CSA of C5 root was 5.6mm2 (95% confidence interval [CI]=4.6-6.7mm2 , n=911), of C6 root was 8.8mm2 (95% CI=7.4-10.3mm2 , n=909), of C7 root was 9.5mm2 (95% CI=8.0-10.9mm2 , n=909), and of vagal nerve was 2.2mm2 (95% CI=1.5-2.9mm2 , n=420). No heterogeneity was found across studies for any site. Subgroup analysis revealed no significant effects of age, gender, height, weight, and geographic continent on CSA for any of these nerve sites. We provide the first meta-analysis on CSA reference values for the cervical nerve roots and the vagal nerve, with no heterogeneity of reported CSA values at all nerve sites. Our data facilitate the goal of an international standardized evaluation protocol.

Endoscopic Posterior Approach for Cervicothoracic and Upper Thoracic Foraminotomies: 2-Dimensional Operative Video

Lower cervical and cervicothoracic radiculopathies can be challenging to treat through an anterior approach in patients with short-statured necks. With unilateral pathology, a posterior foraminotomy affords preservation of motion and avoids risks to anterior structures; yet, traditional open or even tubular retractor-based open systems are associated with postoperative muscle pain. Endoscopic approaches reduce muscle retraction and resection and are associated with shorter recovery time. This video demonstrates the endoscopic technique for performing cervicothoracic and thoracic foraminotomies. We present the case of a patient with severe left-hand weakness, particularly in grasp and hand intrinsic muscles. The differential diagnosis included a combined median and ulnar neuropathy, lower trunk plexopathy, medial cord plexopathy, thoracic outlet syndrome, and combined C8 and T1 radiculopathies. Imaging did not show brachial plexus pathology; instead, severe foraminal narrowing at the C8 and T1 roots was noted. We performed a fully endoscopic approach to decompress 2 levels of foraminal stenosis on the left side. Because the levels were adjacent, we operated through a single incision. Recovery of motor-evoked potentials to the abductor pollicis brevis was identified intraoperatively. The patient consented to the procedure and publication.

Transferência nervosa da raiz de C4 para C5 em lesões do plexo braquial. Estudo anatômico e descrição de técnica cirúrgica

Objective This is an anatomical study of C4 and C5 roots for nerve transfers in upper brachial plexus injuries, with surgical technique demonstration. Methods Fifteen brachial plexuses from both male and female cadavers were dissected. Morphological features of C4 and C5 roots were recorded and analyzed, followed by a neurotization simulation. Results In all dissections, C4 and C5 roots morphological features allowed their mobilization and neurotization with no need for a nerve graft. The surgical technique spared important regional nerve branches. Conclusion Based on these data, we conclude that C4-C5 nerve transfers are feasible and result in no additional neurological deficit in upper brachial plexus injuries.

Surgical Reconstruction of Isolated Upper Trunk Brachial Plexus Birth Injuries in the Presence of an Avulsed C5 or C6 Nerve Root.

Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk. We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment. Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement. In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Reconstruction of Isolated Upper Trunk Brachial Plexus Birth Injuries in the Presence of an Avulsed C5 or C6 Nerve Root.

Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk. We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment. Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement. In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Variations in the Anatomy of Spinal Accessory Nerve and its Landmarks for Identification in Neck Dissection: A Clinical Study

To assess the anatomy of the spinal accessory nerve (SAN), its variations and the landmark of level II B lymph nodes. Prospective study included 50 patients from 2016 to 2018.The predictor variables were drawn from demographic details of the patients; SAN was analyzed intraoperatively with the parameters like the nerve relationship with the IJV, SCM muscle, contributions of cervical plexus and a new parameter of length from midpoint of clavicle to entry of nerve in the trapezius muscle in the lower part of neck which was studied for the first time and forms the prime identification landmark to preserve the nerve. Outcome variables were details of anatomic variations and branches and utility of these landmarks in prevention of nerve injury. Sample consisted of 38 (76%) male and 12 (24%) female patients. The SAN with respect to the IJV was dorsal in 42% patients and ventral in58%. In 54% cases, SAN gave a branch to the SCM without penetrating the muscle and in 46% gave a branch to the SCM penetrating the muscle. SAN received contributions from the C2 root of the cervical plexus in 68%, both C2 and C3 in 54% and C3 in 50% cases. Mean length from measurements recorded between mid-line of clavicle to insertion of SAN to trapezius muscle and entry of SAN into trapezius muscle was 59mm with variations recorded in gender and short/long neck. The result of this study suggests that parameters used are simple clinical tools for identification of the SAN and its variations resulting in no nerve injury. It is prudent for the surgeon to have knowledge of sound anatomical landmarks with the variations in the SAN course which avoids morbidity and improves the quality of life.

Triple Monitoring May Avoid Intraneural Injection during Interscalene Brachial Plexus Block for Arthroscopic Shoulder Surgery: A Prospective Preliminary Study.

Nerve injury is a feared complication of peripheral nerve blockade. The aim of this study was to test the effectiveness of a triple monitoring (TM), i.e., a combination of ultrasound (US), nerve stimulation (NS) and opening injection pressure (OIP) during interscalene brachial plexus block (IBPB) for surgery of the shoulder. Sixty patients undergoing IBPB for shoulder arthroscopy received TM. BSmart®, an inline injection device connected to a 10 mL syringe, was used to detect OIP during IBPB. Nerve stimulation was set to 0.5 mA to rule out any motor response, and if OIP was below 15 PSI, 10 mL of local anaesthetic was injected under US guidance between the C5 and C6 roots. The main outcome was the ability of TM to detect a needle–nerve contact. Other outcomes including the duration of IBPB; pain during injection; postoperative neurologic dysfunction. Triple monitoring revealed needle–nerve contact in 33 patients (55%). In 18 patients, NS evoked motor responses despite first control with US; in a further 15 patients, BSmart® detected an OIP higher than 15 PSI, despite the absence of motor response to NS. Mean duration of IBPB was 67.2 ± 5.3 seconds; neither pain during injection nor postoperative neurologic dysfunctions were detected. Clinical follow up excluded the presence of postoperative neuropathies. Triple monitoring showed to be a useful and feasible tool while performing IBPB for arthroscopic shoulder surgery. Future studies will be needed to confirm our findings.

Cervical decompressive laminectomy and lateral mass screw-rod arthrodesis: surgical experience and analytical review of 4120 consecutive screws

Background Cervical decompressive laminectomy with lateral mass arthrodesis is a common neurosurgical procedure used to address a variety of cervical spine pathologies. Purpose This study aimed to determine the safety and efficacy of this neurosurgical procedure using the Anderson–Sekhon technique for screw trajectory. Methods The study retrospectively reviewed all clinical and radiological indicators for patients who underwent lateral mass arthrodesis between December 2005 and December 2017. All patients underwent polyaxial screw-rod implants using the Anderson–Sekhon technique for screw trajectory. It additionally reported all intra- and post-operative complications, along with short- and long-term outcomes for these patients. The follow-up period ranged from 2 months to 10 years. Results The study evaluated 695 patients who received a total of 4120 lateral mass screws. This is considered the largest reported case series up to date. No patients had neuro-vascular injuries. The main complications included 51 (7.3%) cases of screw malposition, as when the screw had breached either of foramen transversarium, neural foramen, or the facet joint; 39 (5.6%) cases of lateral mass breakdown; 29 (4.2%) cases of C5 root pain which has subsided overtime; 22 (3.2%) of incidental durotomy; and 18 (2.6%) cases of postoperative wound infection. There were only 3 cases of screw pullout leading to a stability rate of 99.5%. Most cases demonstrated very good to excellent outcomes on both short- and long-term follow-up. Conclusions Cervical decompressive laminectomy with lateral mass arthrodesis is a safe and effective technique for the management of different cervical spine pathologies, which results in favourable short- and long-term outcomes.

Preoperative electrophysiologic assessment of C5-innervated muscles in predicting C5 palsy after posterior cervical decompression.

To investigate the feasibility of both needle electromyography (EMG) and proximal nerve conduction studies (NCS) in predicting C5 palsy after posterior cervical decompression. This study included 192 patients with cervical myelopathy undergoing laminoplasty or laminectomy. Preoperatively, all patients accepted bilateral needle EMG detection and proximal NCS that consisted of supramaximally stimulating Erb's point and recording compound muscle action potential (CMAP) from bilateral deltoid. In the present study, 11 (11/192, 5.7%) patients developed unilateral C5 palsy after operation, and more patients with C5 palsy showed abnormal spontaneous activity in C5-innervated muscles compared to those without C5 palsy (8/11 vs. 16/181, p < 0.05). The sensitivity and specificity of spontaneous activity in C5-innervated muscles in predicting postoperative C5 palsy were 72.7% and 91.2%, respectively. Furthermore, there were significant left-to-right differences of deltoid CMAP amplitudes between the patients with and without C5 palsy (p < 0.05), and this measurement was also demonstrated to be useful for distinguishing patients with C5 palsy from cases without C5 palsy by receiver operating characteristic (ROC) curve analysis (cut-off value: 2.1mV, sensitivity: 63.6%; specificity: 95.0%). In addition, the sensitivity and specificity of a series application of these two measurements were 63.6% and 100.0%, respectively. The findings of this study support the hypothesis that pre-existing progressive C5 root injury may be a risk factor for C5 palsy after posterior cervical decompression. Clinically, the estimation of NCS and needle EMG in C5-innervated muscles may provide additional useful information for predicting C5 palsy after cervical spinal surgery. Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Pearls and Pitfalls of Phrenic Nerve Transfer for Shoulder Reconstruction in Brachial Plexus Injury.

Objectives The purpose of this study was to report the functional outcomes of phrenic nerve transfer (PNT) to suprascapular nerve (SSN) for shoulder reconstruction in brachial plexus injury (BPI) patients with total and C5–8 palsies, and its pulmonary complications. Methods Forty-four out of 127 BPI patients with total and C5–8 palsies who underwent PNT to SSN for shoulder reconstruction were evaluated for functional outcomes in comparison with other types of nerve transfers. Their pulmonary function was analyzed using vital capacity in the percentage of predicted value and Hugh-Jones (HJ) breathless classification. The predisposing factors to develop pulmonary complications in those patients were examined as well. Results PNT to SSN provided a better shoulder range of motion significantly as compared with nerve transfer from C5 root and contralateral C7. The results between PNT and spinal accessory nerve transfer to SSN were comparable in all directions of shoulder motions. There were no significant respiratory symptoms in majority of the patients including six patients who were classified into grade 2 HJ breathlessness grading. Two predisposing factors for poorer pulmonary performance were identified, which were age and body mass index, with cut-off values of younger than 32 years old and less than 23, respectively. Conclusions PNT to SSN can be a reliable reconstructive procedure in restoration of shoulder function in BPI patients with total or C5–8 palsy. The postoperative pulmonary complications can be prevented with vigilant patient selection.

Electrophysiological Diagnostic Certainty in Spinal Nerve Root Entrapment

Objective: Evaluation of sensitivity of different electrophysiological parameters among Egyptians with clinically spinal nerve entrapment. Methods: 100 spinal nerve entrapment patients and 41 healthy control. Exclusion; diabetes mellitus, renal, hepatic, endocrine disorder, other nerve involvements. Patients subjected to: Demographic data, detailed neurological history, examination. EDX; NCS, H-reflex, F-wave, Dermatomal Sensory Evoked Potential (DSEP), EMG. Normal cervical DSEP latency and same side Inter-root latency difference was calculated. Values more than 1.57 were considered abnormal. Results: Mean age 49.6 ± 10.6. sensory pattern 87%, motor pattern 9%, sensorimotor patterns 4%. Single nerve root (56%), highest C7 root (25%) (.44%. Multiple nerve root; highest C6,C7 (20.5%). No significant pattern difference among single versus multiple roots. Among single root: 91.9% sensory, 6.9% motor, 1.7% sensorimotor. Within multiple roots; sensory (81.8%), motor (11.4%), sensorimotor 6.8%. Positive DSEP; 98.2% sensory and all motor/sensoriomotor, all cervical and 93.8% lumbosacral patients. Cervical Latency normal/pathological: C5 l 18.68 ± 3.5/27.84 ± 4.02. C6: 22.18 ± 1.6)/26.38 ± 2.8. C7; 21.01 ± 1.8./25.6 ± 2.04. C8: 21.93 ± 1.7/5.93 ± 2.5. Significant difference between normal vs pathological latency. Positive F-wave; 57.5% sensory, 80%motor, 83.3%, sensorimotor. Abnormal H-reflex in patients with S1 root manifestations. Abnormal EMG: motor, sensorimotor and 54.2% sensory patterns. Conclusion: Commonest presentation is sensory. H-reflex is highly sensitive among S1 patients. DSEP is highly sensitive among sensory patterns. Sensitivity of F-wave is low among sensory, higher with motor/sensorimotor, with two segments accuracy. EMG is highly sensitive in motor but less with sensory pattern.