C5 Nerve Root Research Articles

Shear wave elastography evaluation of brachial plexus in multiple sclerosis.

Multiple sclerosis (MS) is a chronic neuroinflammatory disease characterized by inflammation involving the peripheral nerves. Shear wave elastography (SWE) is potentially a method of choice for detecting peripheral nerve involvement. To compare the degree of thickening and nerve elasticity of brachial plexus (BP) nerve roots and evaluate the usefulness of sonoelastography in patients with clinically diagnosed MS without brachial plexopathy. Thirty-two patients with MS and 32 controls were included in the study. Bilateral C5, C6, and C7 mean nerve root diameters, and mean elasticity values in kiloPascal (kPa) were measured in the patient and control groups. The relationship between the age, height, and weight values and nerve diameter-elasticity values of the patient and control groups was compared. The elasticity values of the C5 and C6 nerve roots were increased, and the nerve root thickness was decreased in the MS group compared to that in the control (P < 0.05). There was no difference between the C7 mean nerve root elasticity (kPa) and diameter measurements in the patient and control groups (P > 0.05). Our study showed an increase in the BP nerve root elasticity values (kPa) in patients with MS compared to that of the control group and a decrease in diameter values thought to be related to the possible chronic atrophic process. The results are consistent with the demyelinating process of the peripheral nervous system (PNS) due to MS.

Long-term Improvements of Neuroplasty and Scalene Muscle Resection in LTN-injured Winged Scapula Patients.

Background:Injuries to the long thoracic nerve, which directly branches off of the C6, C7, and C8 brachial plexus nerve roots, can cause scapular winging and affect shoulder movements. Long thoracic nerve injuries resulting from accidents, violence, or overuse can be severe lesions requiring challenging surgeries. We evaluated the long-term functional outcomes of neuroplasty and the scalene muscle resection procedures in patients with long thoracic nerve injury and winging scapula.Methods:All 15 patients who underwent scalene muscle resection with decompression and neurolysis of the long thoracic nerve in a single institution to treat winged scapula and limited shoulder movements between March 2007 and May 2020 with follow-up over 2 years were included in the study.Results:Shoulder abduction and arm flexion improved significantly to 158 ± 52 degrees and 165 ± 53 degrees from a mean of 108 ± 54 degrees and 104 ± 52 degrees (P < 0.02) over 2 years after surgery (mean 3.4 years). Overall, there was a significant reduction in the scapular winging, as assessed by estimating the decrease in the angle between the scapular plane and the posterior chest wall. The extent of the score greatly improved post-surgically from a mean of 1.2 ± 0.4 to 3.5 ± 0.9 (range 1–4; 1—severe, 2—moderate, 3—mild, and 4—minimal) (P < 0.01).Conclusion:The improvement in shoulder movements and reduced scapular winging was significant and stable over 2 years of surgery in 81% of our study patients.

Intra- and Inter-Observer Variability in Sonographic Measurement of the Cervical Nerve Roots of Healthy Volunteers

Aim: The aim of our study is to determine the normal values of mean cervical (C) nerve root diameter in millimeters (mm) in healthy volunteers and to show its relationship to age, gender, height, weight, body mass index (BMI), and the dominant hand.Material and Method: Two observers measured the mean nerve root diameter of the bilateral C5, C6, and C7 nerve of all volunteers. Before the procedure, the age, sex, height, weight, BMI, and the dominant hand of all the participants were noted. Two measurements were taken by each of the two observers without one knowing about the other’s noted values. The intraclass correlation coefficient (ICC) test was used to analyze intra-and inter-observer reliability.Results: There was no statistically significant relationship between gender and dominant hand, and mean nerve root diameter. Moreover, when we compared the mean nerve root diameter for the nerves in the right and left sides of each participant, no significant statistical differences were identified. The mean diameter of the C6 nerve root was higher than that of C7, which was higher than that of C5 on both sides (p &amp;lt; 0.001). The ICC values for intra- and inter-observer were good or excellent for all diameter measurements (ICC &amp;gt; 0.8).Conclusions: The normal range of cervical nerve root diameters should be determined to distinguish pathological conditions. In our study, the measurement of mean nerve root diameters of C5, C6, and C7 nerves is highly reproducible with excellent intra-observer and inter-observer agreement. Therefore, the measurement of nerve root diameter can be confidently performed in daily clinical practice.

Allodynia in Cervical Polyradiculopathy Due to Low-voltage Electrical Burn Injury: A Case Report

Neuropathic pain has been described following an electrical injury, whether as an immediate response or a late-onset sequela. There is much information on high-voltage injuries in literature due to its dramatic presentation, but limited studies on low-voltage injuries. However, low-voltage injuries can be as diverse and may have symptoms varying from minimal cutaneous involvement to full-thickness injury. Significant injuries may result from multiple factors, including prolonged duration of exposure and a higher amount of current transmitted. We illustrate an atypical presentation of a low-voltage injury in a 17-year-old female. The patient had a low voltage electrical injury with no cutaneous burn noted on the affected extremity. She initially presented with allodynia, which seemed disproportionate to the clinical findings expected in a low-voltage injury. The patient underwent an electrodiagnostic study, which showed cervical polyradiculopathy (C5, C6, C7 polyradiculopathy) and neuromusculoskeletal ultrasonology, which showed enlarged right C5 nerve root. Medical management, daily physical and occupational therapies, and psychological management, were instituted, which resulted in significant improvement of the patient’s pain level and functional status. We describe the importance of the multimodal approach (medical and rehabilitation) in managing this atypical case.

Erb’s Palsy in a Newborn Child and Clinicoanatomical Approach

Erb’s palsy is found in upper trunk of brachial plexus. C5, C6 roots join to from upper trunk. Each trunk again divides into anterior and posterior divisions. All trunks and divisions are found above the clavicle in the posterior triangle of neck. Branches from the upper trunk are suprascapular nerve and nerve to subclavius. Suprascapular nerve supplies supraspinatus and infraspinatus muscle along with it a articular trig to capsule of shoulder joint. Supraspinatus helps in initial 15 ºabduction at shoulder joint. Infraspinatus acts as lateral rotator of shoulder joint and assists subscapularis and teres minor muscles to abduct at this joint when there is contraction of middle fibers of deltoid and supraspinatus. Some fibers of C5 also give contribution to accessory phrenic nerve. Lateral cord of brachial plexus giving– musculocutaneous nerve, lateral pectoral nerve, lateral root of median nerve. Musculocutaneous nerve supplies all flexor muscles of arm like biceps brachii, brachialis, coracobrachialis. Brachialis muscle flexes the elbow joint, coracobrachialis is a weak flexor of shoulder joint and biceps brachii is a strong supinator of forearm, flexor of elbow joint only when forearm is supinated. Injury occurs in the Erb’s point found in the upper trunk of brachial plexus where there are emergence of six branches- C5 & C6 nerve roots, suprascapular nerve, nerve to subclavius, anterior and posterior division of upper trunk of the plexus. In this palsy, the arm remains medially rotated and adducted at the shoulder joint, the elbow is extended or semiflexed, forearm is pronated, and the wrist semiflexed. In this case a newborn child was found unable to flex his elbow, and abducted the arm on the right side. The limb is medially rotated, adducted in shoulder joint, semiflexion at the elbow joint and forearm pronated and wrist semiflexed. The child was kept on artificial respiratory ventilation. Plain Chest X-ray done to see if any musculoskeletal abnormality is there but no positive findings found so far. Both the clavicles and all ribs were found intact. Both domes of diaphragm were moving normally. On the other hand left sided upper limb found fully flexed at the elbow joint, supinated at forearm, abducted externally rotated at the shoulder joint and wrist extended. Moros reflex on the right side was absent but on left side it was clearly present. So, there is asymmetrical Moros reflex.

The posterior surgical treatment and outcomes of cervical spondylotic myelopathy: Why not C5 nerve root palsy occur

Aim: Cervical spondylotic myelopathy is an age-related degenerative spinal pathology. Anterior or posterior approaches are preferredfor surgical treatment. C5 palsy is a common complication after the posterior approach. The aim of our study is to describe themodified laminectomy technique, evaluate short-time surgical outcomes and comment on the C5 nerve root palsy formation.Materials and Methods: 83 patients who had been treated by modified laminectomy for cervical spondylotic myelopathy between theyears 2012 and 2017 in our clinic were undertaken in our study. We evaluated the preoperative and postoperative neurologic statusof the patients with VAS and JOA scales, complications (C5 palsy) of surgical treatment. The posterior approach was not performedat patients with a >13 degree angle of cervical curvature.Results: 61 of 83 patients were male and 22 were female. The mean age at the time of surgery was 57.8±8.3. The average JOA scalescore was 9.4±0.9 preoperatively, 10.1±.0.9 early postoperatively and 15.1±1.0 during the late postoperative follow-up. The averageangle of the cervical curvature preoperatively-postoperatively was 17.1±2.6 and 15.8±2.4 respectively. There weren’t any symptomsfor C5 nerve root palsy which is a common postoperative complication.Conclusions: The cervical posterior laminectomy, which includes en-bloc laminectomy and preserving of the facet joint capsule,allows a sufficient and safe decompression of the neural structures for cervical spondylotic myelopathy.

Schwannoma on Cervical Cervices (C2 &amp; C3): A Case Report

Background: Schwannoma is classified as a benign, encapsulated tumor, derived from the perineural cells which are classified as neural cell membranes. About 10% of Schwannomas has occurred in the head and neck and the incidence of Schwannoma arising from the Cervical C2 nerve roots is extremely rare. Aims of study: This case report aims to provide a rare case report on Schwannoma located in cervical cervices (C2&amp; C3). Case presentation: A 37-year-old female patient with a lump in the left neck for 4 years ago, the first lump appeared as a larger (increasingly large 1×1 cm) marbles with no pain in the lump but over the past 4 months the patient felt his legs and arms are weak. Patients have a history of surgical removal of tumors in the back of the neckline by the end of 2016. At first, we estimated the lump that appeared on the left neck of the patient stands alone in the sense that it was not related to the history of the first lump surgery, but when further examination, the tumor was apparently related to the lump that appeared previously who had surgery. Conclusion: The extracranial Schwannoma in the head and neck areas is a rare neoplasm. The extracranial Schwannoma case is a case that is difficult to diagnose, in addition to good clinical examination, imaging examination, such as CT scan and MRI are an indispensable way of ensuring the diagnosis of an extracranial Schwannoma.

Supplementation of Screw-Rod C1-C2 Fixation With Posterior Arch Femoral Head Allograft Strut.

Numerous C1-C2 fixation techniques exist for the treatment of atlantoaxial instability. Limitations of screw-rod and sublaminar wiring techniques include C2 nerve root sacrifice and dural injury, respectively. We present a novel technique that utilizes a femoral head allograft cut with a keyhole that rests posteriorly on the arches of C1 and C2 and straddles the C2 spinous process, secured by sutures. To offer increased fusion across C1-C2 without the passage of sublaminar wiring or interarticular arthrodesis. A total of 6 patients with atlantoaxial instability underwent C1-C2 fixation using our method from 2015 to 2016. After placement of a C1-C2 screw/rod construct, a cadaveric frozen femoral head allograft was cut into a half-dome with a keyhole and placed over the already decorticated dorsal C1 arch and C2 spinous process. Notches were created in the graft and sutures were placed in the notches and around the rods to secure it firmly in place. The femoral head's shape allowed for creation of a graft that provides excellent surface area for fusion across C1-C2. There were no intraoperative complications, including dural tears. Postoperatively, no patients had sensorimotor deficits, pain, or occipital neuralgia. 5 patients demonstrated clinical resolution of symptoms by 3 mo and radiographic (computed tomography) evidence of fusion at 1 yr. One patient had good follow-up at 1 mo but died due to complications of Alzheimer disease. The posterior arch femoral head allograft strut technique with securing sutures is a viable option for supplementing screw-rod fixation in the treatment of complex atlantoaxial instability.

Evaluating the spread of costoclavicular brachial plexus block: an anatomical study

Background and objectivesThe costoclavicular brachial plexus block is performed deep and posterior to the midpoint of the clavicle. There are limited data evaluating the spread of the costoclavicular brachial plexus...

Far-Lateral Transcondylar Approach to a Right Cervicomedullary Dural Arteriovenous Fistula of the Posterior Fossa.

Objectives Dural arteriovenous fistulas (DAVFs) at the cervicomedullary junction are uncommon and often accompanied by subarachnoid hemorrhage (SAH). We aim to illustrate in detail the microsurgical procedure for treating a DAVF located at the cervicomedullary junction. Design We present a two-dimensional operative video that includes clinical history, preoperative imaging, surgical strategy, still images with labels, clinical course, and postoperative imaging. Setting The microsurgery was performed at an academic medical center. Participant The patient is a 55-year-old female who presented with SAH, acute onset headache, nausea, and vomiting. Angiography demonstrated right vertebral artery vasospasm and a persistent arteriovenous shunt at the cervicomedullary junction supplied by small perforating arteries of the right vertebrobasilar junction ( Fig. 1 ). Main Outcome Measures The patient was placed in the park-bench position with the head turned to the contralateral side. A hockey stick incision was made, followed by a right-side far-lateral transcondylar approach. Indocynanine green videoangiography was performed to help identify the areas of arteriovenous shunting. Multiple clips were placed to interrupt vessels that corresponded to arterial feeders at the level of the C1 and C2 nerve root sleeves ( Fig. 2 ). The dura was closed in a water tight fashion and the posterior fossa was reconstructed with a titanium mesh. Results Postoperative imaging showed no evidence of continued arteriovenous shunting. The patient was discharged in good clinical condition with an uneventful postoperative course. Conclusion A deep understanding of the microsurgical vascular anatomy is necessary for successful occlusion of a cervicomedullary DAVF. The link to the video can be found at: https://youtu.be/-LfOcNB05BY .

Approach to the Pan-brachial Plexus Injury: Variation in Surgical Strategies among Surgeons

Background:Treatment of pan-brachial plexus injuries has evolved significantly over the past 2 decades, with refinement and introduction of new surgical techniques, particularly free functional muscle transfer. The extent to which contemporary brachial plexus surgeons utilize various techniques as part of their treatment algorithm for pan-plexus injuries and the rationale underlying these choices remain largely unknown.Methods:A case scenario was posed to 12 brachial plexus surgeons during semi-structured qualitative interviews. The case involved a young patient presenting 6 weeks after a pan-plexus injury from a motorcycle accident. Surgeons were asked to formulate a treatment plan. Inductive thematic analysis was used to identify commonalities and variation in approach to treatment.Results:For shoulder function, the majority of surgeons would graft from a viable C5 nerve root, if possible, though the chosen target varied. Two-thirds of the surgeons would address elbow flexion with nerve transfers, though half would combine this with a free functional muscle transfer to increase elbow flexion strength. Free functional muscle transfer was the technique of choice to restore finger flexion. Finger extension, intrinsic function, and sensation were not prioritized.Conclusions:Our study sheds light on current trends in the approach to pan-plexus injuries in the U.S. and identifies areas of variability that would benefit from future study. The optimal shoulder target and the role for grafting to the MCN for elbow flexion merit further investigation. The role of FFMT plays an increasingly prominent role in treatment algorithms.

Ultrasound reference values of C5, C6, and C7 brachial plexus roots at the interscalene groove

The objective of this study is to estimate the reference values of the brachial plexus roots at the interscalene groove. The physical and demographic characteristics of 59 healthy adult volunteers were studied. The CSA reference values and their correlations with weight, height, age, body mass index (BMI). Fifty nine (27 males, 32 females) subjects were enrolled in the study. The mean cross sectional area of C5, C6 and C7 nerve roots were obtained. The mean CSA of the brachial plexus roots was as follows: C5 nerve root was 5.1mm2 (range 1.7-11.1 ± 1.9 SD), C6 nerve root CSA 5.8mm2 (range 1.7-12 ± 2.4 SD), and C7 nerve root 6.3 (range 1.6-19.6 ± 3.4 SD). There was a significant statistical difference between both sexes in our study. No statistical significant difference in tissue stiffness between dominant and nondominant hands. No statistical correlation was found between the CSA of the cervical nerve roots and different demographic factors. There was a positive statistical correlation between the CSA of C5 and both C6 and C7 nerve roots. Also positive significant statistical correlation was noted between the CSA of C6 and C7 nerve roots. The CSA reference values of the C5-C7 nerve roots has been determined in asymptomatic individuals and can serve as a reference when studying pathological conditions of these structures.

Biomechanical study of the C5\u2013C8 cervical extraforaminal ligaments

BackgroundThe anatomical distribution of the extraforaminal ligaments in the cervical intervertebral foramina has been well studied. However, detailed descriptions of the biomechanical characteristics of these ligaments are lacking.MethodsThe paravertebral muscles were dissected, and the extraforaminal ligaments and nerve roots were identified. The C5 and C7 or C6 and C8 cervical nerve roots on both sides were randomly selected, and a window was opened on the vertebral lamina to expose the posterior spinal nerve root segments. Five needles were placed on the nerve root and the bone structure around the intervertebral foramen; the distal end of the nerve root was then tied with silk thread, and the weights were connected across the pulley. A weight load was gradually applied to the nerve root (50 g/time, 60 times in total). At the end of the experiment, segments of the extraforaminal ligaments were selectively cut off to compare the changes in nerve root displacement.ResultsThe displacement of the C5, C6, C7, and C8 nerve roots increases with an increasing traction load, and the rate of change of nerve root displacement in the intervertebral foramen is smaller than that in the nerve root on the outside area (p < 0.05). Extraforaminal ligaments can absorb part of the pulling load of the nerve root; the C5 nerve root has the largest load range.ConclusionsCervical extraforaminal ligaments can disperse the tension load on the nerve root and play a role in protecting the nerve root. The protective effect of the C5 nerve root was the strongest, and this may anatomically explain why the C5 nerve roots are less prone to simple avulsion.

Anterolateral approach for subaxial vertebral artery decompression in the treatment of rotational occlusion syndrome: results of a personal series and technical note

ABSTRACT Objectives To report the results of a retrospective series and a technical note about the anterolateral approach for the treatment of the rotational occlusion syndrome (ROS) involving the subaxial V2 segment of the vertebral artery (VA). Methods We retrospectively reviewed the data of a cohort of patients that underwent an anterolateral approach to decompress the VA as they suffered from ROS secondary to a subaxial compression. A dynamic study with ultrasonography, CT, MRI, and catheter-based angiography were obtained in all cases. Severe symptomatology and cerebellar-brainstem strokes were indications for surgery. The anterolateral approach involved a pre-sternocleidomastoid precarotid exposure. The retro-longus colli and pre-scalenic corridors were used to access the C5-C6 and C3-C4 segment, respectively, and to perform the decompression. Results Twelve patients were treated. Recurrent drop attacks were present in all cases. Osteophytes at C5 and C6 were the most common causes of subaxial VA compression. Anterior decompression stand-alone was performed in all but 1 patient. A recurrent laryngeal nerve palsy and a numbness of the C5 nerve root were the only complications observed, both transient. A satisfactory untethering of the VA with a complete recovery was achieved in all patients, apart from those with severe infratentorial strokes. Discussion read Anterolateral approach allows for an effective and safe treatment of the ROS involving the subaxial portion of the VA. Retro-longus colli and pre-scalenic corridors, developed through a precarotid exposure, have an anatomical rationale in decreasing the risks of complications. Decompression stand-alone is adequate in almost the totality of cases.

Foraminal Origin of the Dorsal Scapular Nerve: An Anatomical Study

Although distal dorsal scapular nerve (DSN) anatomy has been well characterized, a paucity of literature exists detailing its proximal origin. To our knowledge, this is the first study examining DSN origin and its anatomy relative to the C5 nerve root, which may help localize pathology and provide insight into timing of DSN or C5 nerve root clinical and electrophysiological recovery. Eighteen cadaveric dissections were performed using a posterior-midline approach. Calipers were used for DSN branching and course characterization with statistical analysis completed for the following measurements: DSN diameter, C5 nerve root diameter, distance of DSN branch-point from the C5 ganglion, dural edge, and posterior foraminal tubercle (intra-vs. extraforaminal origin), as well as C5 root-SC branch-point distance. Average/mean measurements (standard error) were as follows: DSN diameter: 3.7 mm (0.3 mm), C5 nerve root diameter: 6.2 mm (0.5 mm), DSN origin to C5 DRG: 12.4 mm (1.9 mm) distal, DSN origin to dural edge: 19. 6mm (1.8 mm), DSN origin to C5 root origin: 23.3 mm (2.2 mm), DSN origin to the posterior foraminal tubercle: 2.3 mm (2.5 mm) proximal/intraforaminal (first branch from C5 in all cases, and the majority [12 of 18, 67%] of DSNs originating from the C5 spinal nerve root within the foramen). The C5 nerve root contributed to the DSN in all specimens that originated from the proximal, intraforaminal, C5 nerve root in the majority of specimens. As the first C5 nerve branch, surgeon knowledge of this proximal DSN pattern will help localize lesional pathology, as well as may help monitor clinical and electrophysiological recovery.

Analysis of clinical efficacy of C3 expanded half lamina excision combined with unilateral open-door laminoplasty for multiple segmental cervical spinal cord compression syndrome

To explore the clinical efficacy of C3 expanded half lamina excision combined with unilateral open door laminoplasty for multiple segmental cervical spinal cord compression syndrome. The clinical data of 58 patients with multiple segmental cervical spinal cord compression syndrome underwent surgical treatment between September 2014 and May 2018 were retrospectively analyzed. There were 34 males and 24 females with a mean age of 64.4 years old (ranged from 46 to 78 years old). Among them, 28 cases received the surgery of C3 expanded half lamina excision combined with C4-C7 unilateral open-door laminoplasty (improvedgroup), and 30 cases received a single C3-C7 unilateral open-door laminoplasty (traditional group). Operation time, intraoperative blood loss, complications including C5 nerve root palsy and axial symptoms were compared between two groups. To evaluate the situation of the imaging indicators by measuring the space available for the spinal cord through cross sectional MRI of cervical spine at the narrowest segment of C3 (including intervertebral disc levels of C3, 4). Pre- and post-operative Japanese Orthopedic Association(JOA) score, Neck Disability Index(NDI) score, and improvement rate of neurological function, were recorded and analyzed between the two groups. All the patients were followed up for 12 to 18 months with an average of(14.5±1.8) months for improved group and (14.5±1.9) months for traditional group, and no significant difference was found between the two groups (P>0.05). There was no significant difference in intraoperative blood loss and C5 nerve root palsy between the two groups (P>0.05). The operation time (119±10) min vs (126±12) min and axial symptoms 7.1%(2/28) vs 26.6%(8/30) was significant difference between the two groups (P<0.05). Preoperative and postoperative space available for the spinal cord of C3 was (93.61±9.02) mm3 and (153.50±12.76) mm3 respectively, which was obtained obvious improvement in all patients(P<0.05). At the final follow up, JOA scores of improved group and traditional group were 14.36±1.70 and 14.03±1.82 respectively, and NDI scores were 10.36±2.55 and 12.47±3.46 respectively, there was significant difference between two groups (P<0.05). However, there was no significant difference between two groups for the improvement rate (68.36±0.12)%VS (65.01±0.12)%of neurological function(P>0.05). C3 expanded half lamina excision combined with unilateral open-door laminoplasty is an effective method to treat multiple segmental cervical spinal cord compression syndrome, for it can not only fully relieved spinal cord compression, but also achievedgood effect in preventing complications such as axial symptoms by reducing stripping of muscles from C2 spinous process.

The features of the intrafascicular structure of the thoracodorsal nerve trunk in terms of ­restoring afferent innervation in breast reconstruction

Aim. To study of anatomical and topographic features and the intrafascicular structure of the thoracodorsal nerve trunk in the brachial plexus.&#x0D; Methods. The study was performed on the brachial plexus preparations of 80 male and female corpses. Short and long branches, secondary bundles, primary trunks, spinal nerves, anterior and posterior roots of the spinal cord were layer-by-layer anatomically prepared from brachial plexus. The angles of inclination from the arising site of the thoracodorsal nerve, the topography throughout and after entering the latissimus dorsi muscle were studied. The length and thickness of the thoracodorsal nerve, including the extramuscular and intramuscular parts, were measured. After isolation and fixation of the preparations, intrafascicular dissection of the thoracodorsal nerve was performed throughout the brachial plexus, by using microsurgical instruments and a binocular magnifier.&#x0D; Results. The length of the thoracodorsal nerve consists of extramuscular and intramuscular parts and was equal to 17.9 cm, of which the extra-muscular part was three-quarters of the total length of the nerve. The nerve trunk dissection revealed that the thoracodorsal nerve consists of 14 nerve fascicles and most frequently, in 46.2% of preparations, the thoracodorsal nerve arises from the C7 nerve root. The presence of motor and sensory portions of nerve fibers in the thoracodorsal nerve was found. In 90.2% of the preparations, the motor portion was located in the posterior-lateral part of the nerve and sensory in the anterior-medial. In most cases, both the sensory and motor fascicles arose from C7, or motor fascicle from C7 and sensory from C8.&#x0D; Conclusion. The intrafascicular dissection of the thoracodorsal nerve revealed microtopography of the sensitive and motor portions of nerve fibers in the nerve and along the entire length of the brachial plexus; in breast reconstruction, after mastectomy with thoracodorsal flap for the preservation of afferent innervation, it is recommended to cross only motor fibers of the thoracodorsal nerve.

Modified C1 lateral mass screw insertion using a threaded K-wire. A technical note

Instrumented fixation of the C1-C2 motion segment is a standard surgical technique to stabilise that spinal segment. Instability at C1-C2 can arise from a number of conditions. Fixation of the C1 lateral mass usually involves dissection and exposure of the C2 nerve root and the posterior wall of the C2 lateral mass which can result in significant bleeding from the venous plexus. Whilst image guidance is increasing in accessibility, there are few public hospitals in Australia that have access to this technology. The authors describe their technique for insertion of a C1 lateral mass screw over a threaded K-wire to avoid extensive dissection of the C2 nerve root, reducing the risk of significant haemorrhage from the epidural venous plexus during the procedure. A retrospective analysis was undertaken on 18 consecutive patients who underwent C1-C2 instrumented fixation using this technique. Indications for C1-C2 instrumented fixation included traumatic injury (10 patients), failure of non-operative management of odontoid fractures (5 patients), pathological fractures of C2 (2 patients) and inflammatory conditions (1 patient). All patients underwent successful C1-C2 stabilisation using this technique. Blood loss did not exceed 400mls in any patient. There were no vertebral artery injuries and no patient experienced a neurological deterioration. The authors propose that their technique for insertion of a C1 lateral mass screw over a threaded K-wire is safe and effective with a low risk of neurological or vertebral artery injury. The technique may be considered as a slight modification of the Harm’s procedure to reduce disturbance of the adjacent venous plexus and thereby reduction in intraoperative bleeding and operative time.

Patterns of neurological deficits and recovery of postoperative C5 nerve palsy.

Paresis of the C5 nerve is a well-recognized complication of cervical spine surgery. Numerous studies have investigated its incidence and possible causes, but the specific pattern and character of neurological deficits, time course, and relationship to preoperative cord signal changes remain incompletely understood. Records of patients undergoing cervical decompressive surgery for spondylosis, disc herniation, or ossification of the longitudinal ligament, including the C4-5 level, were reviewed from a 15-year period, identifying C5 palsy cases. Data collected included age, sex, diabetes and smoking statuses, body mass index, surgical levels, approach, presence of increased cord signal intensity, and modified Japanese Orthopaedic Association (mJOA) scores. Narrative descriptions of the patterns and findings on neurological examination were reviewed, and complications were noted. The minimum follow-up requirement for the study was 12 months. Of 642 patients who underwent cervical decompressive surgery, 18 developed C5 palsy (2.8%). The incidence was significantly lower following anterior surgery (6 of 441 [1.4%]) compared with that following cervical laminectomy and fusion (12 of 201 [6.0%]) (p < 0.001). There were 10 men and 8 women whose mean age was 66.7 years (range 54-76 years). The mean preoperative mJOA score of 11.4 improved to 15.6 at the latest follow-up examination. There were no differences between those with and without C5 palsy with regard to sex, age, number of levels treated, or pre- or postoperative mJOA score. Fifteen patients with palsy (83%) had signal changes/myelomalacia on preoperative T2-weighted imaging, compared with 436 of 624 (70%) patients without palsy; however, looking specifically at the C4-5 level, signal change/myelomalacia was present in 12 of 18 (67%) patients with C5 palsy, significantly higher than in the 149 of 624 (24%) patients without palsy (p < 0.00003). Paresis was unilateral in 16 (89%) and bilateral in 2 (11%) patients. All had deltoid weakness, but 15 (83%) exhibited new biceps weakness, 8 (44%) had triceps weakness, and 2 (11%) had hand intrinsic muscle weakness. The mean time until onset of palsy was 4.6 days (range 2-14 days). Two patients (11%) complained of shoulder pain preceding weakness; 3 patients (17%) had sensory loss. Recovery to grade 4/5 deltoid strength occurred in 89% of the patients. No patient had intraoperative loss of somatosensory or motor evoked potentials or abnormal intraoperative C5 electromyography activity. Postoperative C5 nerve root dysfunction appears in a delayed fashion, is predominantly a motor deficit, and weakness is frequently appreciated in the biceps and triceps muscles in addition to the deltoid muscle. Preoperative cord signal change/myelomalacia at C4-5 was a significant risk factor. No patient had a detectable deficit in the immediate postoperative period or changes in intraoperative neuromonitoring status. Neurological recovery to at least that of grade 4/5 occurred in nearly 90% of the patients.

Comparison of Two Bone Grafting Techniques Applied During Posterior C1-C2 Screw-Rod Fixation and Fusion for Treating Reducible Atlantoaxial Dislocation

Several bone grafting techniques for posterior atlantoaxial arthrodesis have been reported. The techniques of placing a cancellous morselized bone graft (MBG) on decorticated surfaces of the atlantoaxial complex and securing a structural iliac bone graft (SBG) between C1 and C2 have been used widely. The aim of the present study was to compare the outcomes of these 2 bone grafting techniques for atlantoaxial arthrodesis. The data from 64 patients with reducible atlantoaxial dislocation treated using posterior C1-C2 screw-rod fixation and fusion were retrospectively reviewed. The MBG technique had been used in 32 patients and the SBG technique in 32 patients. The time required for bone fusion was recorded. The outcomes were evaluated using the Japanese Orthopaedic Association scale score, Neck Disability Index, visual analog scale (VAS) score for neck pain, patient satisfaction, and neck stiffness and compared between the 2 groups. The donor site complications were also compared, and donor site pain was assessed using a VAS. At the final follow-up, the bone fusion rate was 100% in both groups. No significant differences were found in the bone fusion time or donor site pain between the 2 groups (P > 0.05). Postoperatively, The Japanese Orthopaedic Association scale scores, Neck Disability Index, and VAS score for neck pain had improved significantly within both groups (P < 0.05), with no statistically significant differences between the 2 groups (P > 0.05). Additionally, no differences were found between the 2 groups in patient satisfaction and neck stiffness postoperatively (P > 0.05). The MBG and SBG techniques were both effective for atlantoaxial arthrodesis, with the advantages of reducing the potential risk of catastrophic bleeding of the epidural venous plexus and C2 nerve root injury.