C5 Nerve Root Research Articles

105. Clinical outcomes of C2 nerve root sacrifice and the feasibility of its preservation in patients with congenital atlantoaxial instability

<h3>BACKGROUND CONTEXT</h3> Posterior C1-C2 fusion is a widely used fixation technique for atlantoaxial dislocation (AAD). The C2 ganglion is a restricting factor to easy access of C1-C2 joints, and placement of C1 lateral mass screws. Both intentional C2 nerve root sectioning as well as its preservation have been described and are still debatable. The associated complications and outcomes have been less studied, particularly in congenital AAD. <h3>PURPOSE</h3> To study clinical outcome after C2 nerve root sectioning as well as the feasibility of its preservation in AAD patients. <h3>STUDY DESIGN/SETTING</h3> Retrospective study/ tertiary care center. <h3>PATIENT SAMPLE</h3> This study included 190 patients who underwent posterior C1-C2 fusion for congenital AAD. <h3>OUTCOME MEASURES</h3> C2 nerve-related dysfunction; feasibilty of nerve root preservation. <h3>METHODS</h3> This is a retrospective study of 190 patients who underwent posterior C1-C2 fusion for congenital AAD using C1 lateral mass screws. The decision to cut or preserve C2 nerve root was dependent on preoperative radiology and intraoperative suitability of its preservation. Patients were followed-up at periodic intervals and questioned about C2 nerve-related dysfunction. <h3>RESULTS</h3> Complex C1-C2 morphology with highly deformed joints was seen in 139 patients. In 178 patients, the C2 nerve root was sectioned. Postoperative numbness, paresthesia and dysesthesia were present in 30.3%, 21.9% and 19.1% patients respectively. However, the symptoms were bothersome in none. They neither required medications nor disturbed the daily activities of patients. Noticeably, 9 patients (5.1%) developed non-healing occipital ulcers; most needed surgical intervention in the form of a flap cover/skin graft. C2 nerve root preservation is feasible with robust inferior C1 lateral mass and normal sized ganglion. In patients with C1-occipital condyle hypoplasia, highly oblique joints, incurved occiput, pseudofacets and anomalous vertebral artery, its preservation is technically difficult. <h3>CONCLUSIONS</h3> Though C2 nerve root sectioning did not disable the quality of life in many, a subset of patients was prone for neuropathic ulcers. Hence, its preservation should be attempted whenever feasible. It may be possible to preserve it in less complex anomalies/favorable anatomy. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

A Young Man With Acute-Onset Bilateral Arm Weakness After Traumatic Sciatic Neuropathy: A Clinical Vignette.

A Young Man With Acute-Onset Bilateral Arm Weakness After Traumatic Sciatic Neuropathy: A Clinical Vignette.

Diagnostic Uncertainty in Cervical Radiculopathy.

Cervical radiculopathy is defined as a pathological process affecting the cervical nerve root(s). While not an uncommon entity, this report describes a case of cervical radiculopathy in an active duty Marine with unique features to include the C5 nerve root as the primary point of injury with corresponding severe motor weakness that warranted expedited workup. This expedited workup included early referral to Neurology for nerve conduction and electromyography (EMG) studies that were ultimately diagnostic in the setting of equivocal Magnetic Resonance Imaging findings. This highlight of this case is the demonstration of the utility of EMG in cervical radiculopathy evaluation, which aided in an efficient and effective treatment course. We contend that in cases of cervical radiculopathy with a focal deficit of profound weakness with shoulder abduction and elbow flexion, obtaining nerve conduction studies and EMGs within the first 4 to 6 weeks of presentation should be viewed as essential for the long-term recovery and effective management of the injured service member, particularly when injury to the upper trunk of the brachial plexus can also account for these specific motor deficits. This report will cover a brief review of the pathophysiology, evaluation, and natural history of cervical radiculopathy with special attention paid to the timing and efficacy of EMG.

Electrophysiological Evaluation of a Patient With Chronic Erb-Duchenne Palsy (C5-C6): A Case Study

Background Erb-Duchenne palsy describes injury to the upper trunk of the brachial plexus or the C5 and C6 nerve roots. It typically occurs from a traction injury that increases the angle between the head and shoulder girdle, placing excessive strain on the cervical nerve roots and brachial plexus. Injury to the C5 and C6 nerve roots and/or upper trunk of the brachial plexus results in severe shoulder girdle weakness with preservation of the hand intrinsic muscles and some forearm motions. 2 , 9 Case Presentation A 64-year-old right-hand–dominant male was referred by his orthopaedic surgeon for electromyograhy (EMG) and nerve conduction studies (NCS) to evaluate the nerve and muscle structures in the right upper extremity prior to surgical fusion of the glenohumeral joint for chronic humeral head subluxation and shoulder instability. The patient was diagnosed with a right Erb-Duchenne palsy following a hit-and-run motor vehicle accident in 2001. Physical examination revealed muscle weakness in all muscles representative of the right C5-C6 myotomes and absent biceps brachii and brachioradialis muscle stretch reflexes. Outcome and Follow Up The clinical exam findings and electrophysiological testing evidence suggested that the patient had a chronic right C5-C6 radiculopathy affecting the right upper extremity and the right mid cervical paravertebral muscles, consistent with the referring diagnosis of Erb-Duchenne palsy. Needle EMG findings suggested little chance of further neurological recovery, so the patient underwent a right glenohumeral joint fusion to improve the stability of the right shoulder and limit glenohumeral subluxation. Discussion This case study highlights the role of a thorough neuromusculoskeletal exam in the differential diagnostic process for a patient with a right C5-C6 Erb-Duchenne palsy, and the role of EMG and NCS in distinguishing brachial plexopathy from cervical radiculopathy. Additionally, EMG and NCS provided prognostic information on potential neurological recovery, suggesting that surgical fusion was the best intervention. JOSPT Cases 2022;2(3):152–158. Epub: 21 June 2022. doi:10.2519/josptcases.2022.11174

Atlantoaxial Joint Distraction and Fusion with DTRAX Intra-Articular Cages: A Cadaveric Feasibility Study and Review of the Pertinent Literature

Atlantoaxial joint distraction is a key procedure for the treatment of selected patients affected by basilar invagination (BI). In recent years, several authors have reported various techniques of distraction and fixation of the C1-C2 joint using different types of intra-articular spacers, with or without posterior fixation. We review the pertinent literature and propose a feasibility study on the use of a new device for the distraction of the C1-C2 joint aimed to the descent of the dens out of the foramen magnum suggesting its application on selected cases of BI. The GL-DTRAX Cervical Cage-SE is a cage approved by the Food and Drug Administration for distraction and fixation of subaxial cervical spine. Five adult cadaveric specimens were dissected surgically to evaluate the feasibility of DTRAX insertion inside the C1-C2 joint through a posterior approach. The cages were uneventfully set into the C1-C2 intra-articular space of all samples without the need to sacrifice C2 nerve roots and ganglia. Postoperative cervical computed tomography scanning confirmed the correct fitting of the devices in every sample. This cadaveric study highlights the feasibility of the DTRAX cage as a C1-C2 intra-articular device producing a substantial distraction of atlantoaxial complex and suggesting a possible therapeutic role in selected cases of BI.

A Risk Calculator for the Prediction of C5 Nerve Root Palsy After Instrumented Cervical Fusion

C5 palsy is a common postoperative complication after cervical fusion and is associated with increased health care costs and diminished quality of life. Accurate prediction of C5 palsy may allow for appropriate preoperative counseling and risk stratification. We primarily aim to develop an algorithm for the prediction of C5 palsy after instrumented cervical fusion and identify novel features for risk prediction. Additionally, we aim to build a risk calculator to provide the risk of C5 palsy. We identified adult patients who underwent instrumented cervical fusion at a tertiary care medical center between 2013 and 2020. The primary outcome was postoperative C5 palsy. We developed ensemble machine learning, standard machine learning, and logistic regression models predicting the risk of C5 palsy-assessing discrimination and calibration. Additionally, a web-based risk calculator was built with the best-performing model. A total of 1024 patients were included, with 52 cases of C5 palsy. The ensemble model was well-calibrated and demonstrated excellent discrimination with an area under the receiver-operating characteristic curve of 0.773. The following features were the most important for ensemble model performance: diabetes mellitus, bipolar disorder, C5 or C4 level, surgical approach, preoperative non-motor neurologic symptoms, degenerative disease, number of fused levels, and age. We report a risk calculator that generates patient-specific C5 palsy risk after instrumented cervical fusion. Individualized risk prediction for patients may facilitate improved preoperative patient counseling and risk stratification as well as potential intraoperative mitigating measures. This tool may also aid in addressing potentially modifiable risk factors such as diabetes and obesity.

A Cadaver Feasibility Study of Extradural Contralateral C7 Ventral Root Transfer Technique for Treating Upper Extremity Paralysis.

A total of 6 formalin-fixed cadavers were included in the cadaver feasibility study. The aim was to ascertain the anatomical feasibility of extradural contralateral C7 ventral root transfer technique by cervical posterior. Upper limb spastic hemiplegia is a common sequela after stroke. In our previous study, the authors established a method by transferring contralateral C7 dorsal and ventral roots to the corresponding C7 dorsal and ventral roots on the affected side in the cervical posterior. In the present study, six formalin-fixed cadavers were dissected to confirm the anatomical feasibility. Experimental anastomosis in cadavers was conducted. The pertinent lengths of the extradural nerve roots were measured. The tissue structures surrounding regions between the extradural CC7 nerve roots and the vertebral artery were observed. The cervical magnetic resonance imaging scans of 60 adults were used to measure the distance between the donor and recipient nerves. Experimental anastomosis showed that the distance between the donor and recipient nerves was approximately 1cm; the short segment of the sural nerve needed bridging. The distance between both exit sites of the exit of the extradural dura mater was 33.57±1.55mm. The length of the extradural CC7 ventral root was 22.00±0.98mm. The ventral distance (vd) and the dorsal distance (dd) in males were 23.98±1.72mm and 30.85±2.22mm ( P <0.05), while those in females were 23.28±1.51mm and 30.03±2.16mm, respectively. C7 vertebral transverse process, ligaments, and other soft tissues were observed between the vertebral artery and the extradural C7 nerve root. Under the premise of less trauma, our study shows that the extradural contralateral C7 ventral root transfer technique, in theory, yields better surgical results, including better recovery of motor function and complete preservation of sensory function. 5.

Selective C5 nerve root block versus combined interscalene block for clavicle surgery

Objectives: The pain sensation of the clavicle is innervated by two separate plexuses. Regional anesthesia techniques for this area are challenging and complicated. Interscalene block, superficial cervical block, or a combination of these two is commonly used for regional anesthesia in clavicle surgery. The aim of this study was to investigate the efficacy of C5 nerve root block for clavicle surgery. Methods: Patients were divided into two groups: Group C5B (patients who received C5 nerve root block + superficial cervical plexus block) and Group ISB (patients who received interscalene block + superficial cervical plexus block). Motor block was assessed by the Medical Research Council Scale for Muscle Strength, while the sensory block of the areas corresponding to the nerve trace was assessed using the pinprick and cold testing. Furthermore, ultrasound was employed to evaluate phrenic nerve paralysis. Results: There was no difference between the groups in terms of mean age. The mean age of Group ISB was higher; however, the comparison of comorbidities revealed no significant difference between the groups. This statistically significant difference was clinically insignificant. Group C5B had lower 6-hour pain at rest, lower 0, 2, 4-hour pain on movement, and less postoperative analgesic consumption. Moreover, the time to first analgesic requirement was significantly longer in Group C5B. The motor examination of the peripheral nerves showed a significant difference in Group C5B. Conclusions: We are of the opinion that C5 nerve root block can be used instead of interscalene block since it does not produce a motor block in hand movements and preserves diaphragmatic functions. C5 nerve root block may therefore be considered an alternative to conventional interscalene block for clavicle surgery.

Pronator Teres Reflex and the Diagnosis of C6 and C7 Radiculopathy

Objectives: Neck roots lesions are among the etiologies of cervical and arm pain. A detailed patient evaluation could assist the diagnosis, reduce imaging requests, and promote the treatment of cervical pain. We tried to estimate the value of pronator teres reflex in C6 and C7 roots irritation. Methods: The present study comprises 118 participants, including 56 patients with C6 and C7 lesions and 62 normal controls. The reliability and usefulness of this reflex in C6 and C7 roots lesions were compared to positive electromyography and imaging with magnetic resonance. Results: The sensitivity, specificity, positive predictive value, and negative predictive value for pronator teres reflex were 36.4%, 13.6%, 64.8%, and 4.6%, respectively. Discussion: This reflex can be considered an additional reflex during the physical examination for C6 and C7 nerve roots injury, but its diagnostic value for C6 and C7 radiculopathy is unreliable to be used for screening purposes.

Treatment of Odontoid Fractures in Elderly Patients Using C1/C2 Instrumented Fusion Supplemented With Bilateral Atlantoaxial Joint Spacers: A Case Series.

Spinal fractures are among the most common traumatic injuries in elderly patients, with the odontoid process being frequently affected. As this patient group usually has high rates of comorbidity and chronic diseases, a nonoperative approach may offer a reasonable solution for a favorable fracture pattern. We modified the procedure by implanting a bilateral atlantoaxial joint spacer (model DTRAX) into the joint space and review our experience utilizing this technique for the treatment of patients with a fracture of the odontoid process. A retrospective evaluation was performed on patients treated surgically for unstable traumatic fractures of the odontoid process. The stabilization was performed using a dorsal rod and screw instrumentation of the lateral mass of the atlas and the pars interarticularis of the axis. The procedure was further modified by implanting a bilateral atlantoaxial joint spacer (DTRAX) into the joint space bilaterally after the removal of the articular cartilage. Patients older than 70 years with a traumatic fracture of the odontoid process were included. Pain was assessed pre- and postoperatively using the visual analog scale (VAS). To verify fusion during follow-up, either x-ray imaging of the cervical spine or magnetic resonance imaging or computed tomography were performed. A total of 5 patients were included in our study. Four patients had an American Society of Anesthesiology score of 3 and 1 had a score of 4. The average duration of surgery was 187 ± 38.1 minutes. The average blood loss during the procedure was 340 ± 270 mL. The average radiological follow-up period was 21.2 ± 17.5 months. Preoperatively, the average VAS pain score was 2.3 ± 3.3. Postoperatively, the mean VAS decreased to 0.6 ± 0.9. The average follow-up period for pain was 27.2 ± 19 months. No patient showed neurological deficits before or after surgery. Follow-up demonstrated solid fusion in all cases. The fusion of the atlantoaxial joint with bilateral atlantoaxial joint spacers represents a suitable and feasible option for achieving high fusion rates in elderly patients with odontoid fractures. A significant percentage of patients who are treated non-operatively will experience nonunion, which may cause instability of the atlantoaxial joint. Posterior fixation with screws and rods is a treatment option, but it leaves the cartilaginous joint surface in place, which can be an impediment to the fusion process. In other cases, degenerative collapse of the C1/C2 joint can cause compression of the C2 nerve root.

201 Management of an unusual presentation of spontaneous intracranial hypotension (SIH)

A 49-year-old woman presented with 9 months of progressive cognitive decline and somnolence. In the last few weeks she developed right hand tremor, unsteadiness and urinary incontinence, which improved after lying flat. There was no headache. Examination findings included vertical gaze restriction, hypomimia, right-sided rest tremor, rigidity and bradykinesia, globally brisk reflexes and an unsteady gait. She scored 50/100 on the Addenbrooke’s Cognitive Examination.Brain MRI showed features consistent with intracranial hypotension with marked ‘brain sag’ but standard imaging did not identify the site of the leak. Two blind blood patches were followed by only transient symptomatic improvement. Initial Digital Subtraction Myelogram (DSM) was non-diagnostic, but repeat DSM identified a leak at C6–7 with an irregular diverticulum/CSF-venous fistula.A CT-guided fibrin patch injected at C6/7 resulted in transient improvement. Finally, a neurosurgical procedure was performed to coagulate the venous plexus adjacent to the C7 nerve root. This effected a dramatic and sustained improvement in her cognitive and motor symptoms.SIH is a treatable cause of cognitive decline and parkinsonism. DSM is a novel approach to localising CSF leaks. This is the first reported cognitive presentation of SIH where identification of a CSF leak with DSM led to successful surgical treatment.saamir.mohideen@nhs.net

098 Guillain Barré syndrome (GBS) – like presentation as a first clinical manifestation of non-Hodgkin’s lymphoma

A variety of peripheral nerve disorders can be seen in association with lymphomas. We present a case of a 68-year-old female who presented with ten days history of rapid onset ascending paresthesias followed by unsteadiness. Neurological examination was remarkable for truncal ataxia with wide-based gait, large fiber sensory impairment (proprioception/vibration). There was some evidence of autonomic instability given labile blood pressure and tachycardia. MRI head and spine were unremarkable, as was the CSF. She was initially treated as acute ataxic variant of GBS with IVIG; however, there was continued clinical deterioration. Electrophysiology three weeks after symptom onset showed minimally delayed F waves, with normal sensory and motor NCS. Nerve Ultrasound revealed pronounced enlargement of C6 nerve root which was confirmed later with MRI of brachial plexus showing thickening and some enhancement of roots and trunks. Subsequent CT CAP and PET scan showed mediastinal, hilar and supraclavicular lymphadenopathy, though no PET uptake in the region of dorsal root ganglion. Biopsy of the right supra- clavicular node was consistent with an anaplastic large cell lymphoma.Atypical presentations of acute neuropathy can be attributed to GBS; however, they should include evalu- ation of a paraneoplastic process which can have similar acute presentations. This case also demonstrates the importance of nerve ultrasound which can be significantly abnormal in sensory neuronopathy with relatively normal electrophysiological testing.s_hasan_s@yahoo.com

Intraforaminal cervical gas cyst with vacuum disc treated by anterior cervical discectomy and fusion: illustrative case.

BACKGROUNDThe authors report an extremely rare presentation of a patient with an intraforaminal cervical gas cyst with radiculopathy. The patient’s condition was refractory to conservative treatment, and he was treated by anterior cervical discectomy and fusion (ACDF). Several intraspinal gas cysts with lumbar disc herniation have been treated surgically. However, no cases of intraforaminal cervical gas requiring ACDF have been reported.OBSERVATIONSA 70-year-old male patient presented with right-sided neck and shoulder pain, aggravating in the supine position. Cervical radiography showed vacuum disc phenomenon at C4–5, and multiplanar computed tomography showed intraforaminal gas along the right C5 nerve root. The patient experienced severe pain with impaired sleep and daytime fatigue. After confirming C5 radiculopathy using an echo-guided technique using ultrasonography guidance, the authors performed C4–5 ACDF. Postoperatively, the patient’s neck and shoulder pain disappeared immediately. There was no recurrence at the 2-year follow-up.LESSONSThis is the first case report of an intraspinal cervical gas cyst with radiculopathy treated by ACDF surgery. The vacuum disc had been implicated as the genesis of the intraforaminal cervical gas cyst, leading to radiculopathy. ACDF surgery provides favorable outcomes in cases of intraspinal gas refractory to conservative therapy.

Ultrasonographic evaluation reveals thinning of cervical nerve roots and peripheral nerves in spinal and bulbar muscular atrophy.

Ultrasonography (US) is a noninvasive and patient-friendly tool for the evaluation of peripheral nerves. In motor neuron diseases, amyotrophic lateral sclerosis (ALS) has been reported to show the atrophy of peripheral nerves on US. However, the US findings are still unclear in spinal and bulbar muscular atrophy (SBMA), an adult-onset lower motor neuron disease caused by an abnormal CAG repeat expansion in the androgen receptor gene. We prospectively recruited and evaluated 11 patients with genetically confirmed SBMA and 9 patients with ALS diagnosed according to the revised El Escorial ALS criteria or the Awaji electrodiagnostic criteria. The C5-C7 cervical nerve roots and the median and ulnar nerves were evaluated ultrasonographically. The cross-sectional areas (CSAs) of the C6 and C7 nerve roots, the median nerve in the upper arm and forearm, and the ulnar nerve in the upper arm were smaller in patients with SBMA than those in patients with ALS (p < 0.05), whereas the CSAs of the C5 nerve root and the ulnar nerve in the forearm were not smaller. US showed that the peripheral nerves in patients with SBMA were thinner than those in patients with ALS despite similar degrees of weakness and motor neuron loss. Possible causes include additional sensory nerve involvement and longer disease duration in patients with SBMA than those in patients with ALS.

Q&amp;A: Rating Brachial Plexus Injury

QUESTION: How do I assess impairment for a patient with a brachial plexus injury involving the middle and lower trunks but not the upper trunk?ANSWER: Rating impairment for a brachial plexus injury using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, is straightforward. Table 15-20, Brachial Plexus Impairment: Upper Extremity Impairments (6th ed, 434-435), lists impairments for the entire brachial plexus, as well as upper, middle, and lower trunks individually, each in different rows. If both middle and lower trunks were injured, each would be rated, and the upper limb impairments combined per instructions number 8 and 13 on page 481.The classic anatomic description of the brachial plexus describes the C5 through T1 nerve roots as contributing to the plexus, with the middle trunk composed of just the C7 nerve root, while the lower trunk is formed by the fusion of the C8 and T1 nerve roots. However, this “classic plexus” is found in only 37% to 77% of cadaver dissections.1 The two most common anatomic anomalies are “prefixed” and “postfixed” plexi. In a prefixed plexus, the C4 nerve root has a substantial contribution, while the T1 nerve root has minimal or no contribution to the plexus. In a postfixed plexus, there is minimal or no C5 contribution to the plexus and a substantial T2 nerve root contribution. Thus, standard charts of the nerve root contributing to individual peripheral nerves or trunks of the plexus may not correspond to an individual patient's anatomy.Assuming C7 supplies sensation to the middle finger and C8 and T1 to the little finger and ulnar forearm, rating sensory deficit without obvious duplication is more straightforward.Rating the motor deficit is more complex. No nerve to a single muscle leaves either the middle or lower trunk of the classic plexus. Hence, one cannot determine whether the injury does or does not involve the trunk by involvement or sparing that nerve, respectively. Normal paraspinal muscles on needle electromyography (EMG) with clear denervation in limb muscles helps localize the lesion as distal to the nerve root division into anterior and posterior primary rami. Stimulating proximal to the plexus at the level of individual nerve root during nerve conduction testing is challenging and rarely done. Magnetic resonance imaging (MRI) may not clarify the level of injury. However, in cases of open trauma with immediate surgery to repair vascular damage, the operative report may accurately describe the extent of any concomitant brachial plexus injury.Because most muscles are innervated by more than one nerve root—a fail-safe redundancy in the case of injury—residual weakness in any one muscle may be from injury to the lower trunk, middle trunk, or both. Hence, it is wise to rate the severity of the motor loss on physical examination by assuming any one muscle is innervated by nerves derived from only one trunk.For example, the triceps is classically described as innervated by the C7, C8, and partially by the T1 nerve roots. If the triceps has grade 3/5 weakness on examination, and if that is considered middle trunk weakness when rating the middle trunk, and lower trunk weakness when rating the lower trunk, the motor deficit rating will be duplicative (rating the same weakness twice).Similarly, classic innervation charts show C7 and C8 contributing to the flexor carpi ulnaris, flexor digitorum profundus, abductor digiti minimi, first dorsal interosseous, extensor digitorum communis, and extensor carpi ulnaris. Logically weakness in these muscles should be attributed to and rated as either middle or lower trunk motor deficits, but not both.Brachial plexus injuries are uncommon, and it takes considerable time and thought to thoroughly examine and correctly rate the residuals.

A case-control study:the clinical efficacy of total laminectomy with lateral mass screw fixation and single open-door laminoplasty for cervical spinal cord injury without fracture and dislocation

To compare the clinical effects of total laminectomy with lateral mass screw fixation and single open-door laminoplasty in the treatment of cervical spinal cord injury without fracture and dislocation. The clinical data of 75 patients with cervical spinal cord injury without fracture and dislocation treated from December 2014 to April 2020 were retrospectively analyzed, including 65 males and 10 females, aged from 33 to 83 years old with an average of (60.1±11.4) years. According to surgical method, the patients were divided into observation group (36 cases) and control group (39 cases). The observation group was treated with C3-C6 single open-door laminoplasty. In the control group, the C3-C6 whole lamina was opened by "uncovering", and the lateral mass screw was fixed and fused. The general conditions including operation time, intraoperative blood loss, hospital stay and complications such as axial pain, cerebrospinal fluid leakage, postoperative C5 nerve palsy were recorded. Visual analogue scale(VAS), Nurick pain scale, Japanese Orthopaedic Association(JOA) scores and American Spinal Injury Association(AISA) injury scale were used to evaluate the improvement of clinical symptoms and related functional recovery 12 months after operation. There were no statistically significant differences in operation time, intraoperative blood loss and hospital stay between two groups(P>0.05). There were statistically significant differences in JOA, VAS, ASIA and Nurick scores of the all patients between 12 months after surgery and before surgery (P<0.05), and there was no significant difference between groups. There was significant difference in the incidence of C5 nerve root palsy and axial pain between two groups(P<0.05), but there was no significant difference in the complications of cerebrospinal fluid leakage between two groups (P>0.05). Total laminectomy with lateral mass screw fixation and single open-door laminoplasty in treating cervical spinal cord injury without fracture and dislocation can obtain satisfactory results in restoring nerve function, alleviating pain and improving daily behavior, but single open-door laminoplasty has the advantages of less trauma and low incidence of complications.

An electroencephalography-based human-machine interface combined with contralateral C7 transfer in the treatment of brachial plexus injury.

Transferring the contralateral C7 nerve root to the median or radial nerve has become an important means of repairing brachial plexus nerve injury. However, outcomes have been disappointing. Electroencephalography (EEG)-based human-machine interfaces have achieved promising results in promoting neurological recovery by controlling a distal exoskeleton to perform functional limb exercises early after nerve injury, which maintains target muscle activity and promotes the neurological rehabilitation effect. This review summarizes the progress of research in EEG-based human-machine interface combined with contralateral C7 transfer repair of brachial plexus nerve injury. Nerve transfer may result in loss of nerve function in the donor area, so only nerves with minimal impact on the donor area, such as the C7 nerve, should be selected as the donor. Single tendon transfer does not fully restore optimal joint function, so multiple functions often need to be reestablished simultaneously. Compared with traditional manual rehabilitation, EEG-based human-machine interfaces have the potential to maximize patient initiative and promote nerve regeneration and cortical remodeling, which facilitates neurological recovery. In the early stages of brachial plexus injury treatment, the use of an EEG-based human-machine interface combined with contralateral C7 transfer can facilitate postoperative neurological recovery by making full use of the brain’s computational capabilities and actively controlling functional exercise with the aid of external machinery. It can also prevent disuse atrophy of muscles and target organs and maintain neuromuscular junction effectiveness. Promoting cortical remodeling is also particularly important for neurological recovery after contralateral C7 transfer. Future studies are needed to investigate the mechanism by which early movement delays neuromuscular junction damage and promotes cortical remodeling. Understanding this mechanism should help guide the development of neurological rehabilitation strategies for patients with brachial plexus injury.

Shoulder depression should be avoided during anterior cervical surgery to reduce postoperative C5 nerve root palsy – a prospective multicentric cohort study with 1,244 patients

Shoulder depression should be avoided during anterior cervical surgery to reduce postoperative C5 nerve root palsy – a prospective multicentric cohort study with 1,244 patients

Modified Clavipectoral Fascial Plane Block to The Rescue: Polytrauma Patient with Brachial Plexus Injury Undergoing Awake Clavicle Surgery

Modified Clavipectoral Fascial Plane Block to The Rescue: Polytrauma Patient with Brachial Plexus Injury Undergoing Awake Clavicle Surgery

Cervical Transdural Discectomy with Laminoplasty for the Treatment of Multi-segment Cervical Spinal Stenosis Accompanied with Cervical Disc Herniation: Technical Note and Clinical Outcome.

ObjectiveTo describe the surgical technique of cervical transdural discectomy with laminoplasty (CTDL) for the treatment of multi‐segment cervical spinal stenosis (CSS) accompanied with cervical disc herniation (CDH) and investigate its surgical outcomes and complications.MethodsThis was a clinical study. Between 2012 and 2018, 31 patients (13 males and 18 females) with multi‐segment CSS (over two cervical segments) accompanied with huge CDH and underwent CTDL were enrolled in this study. The details of CTDL technique with general anesthesia was described by the authors. The average follow‐up period of patients was 65.03 months (range from 24 to 126 months). Perioperative parameters such as age, sex, operative level, operative time, estimated blood loss, ambulation time, and operative complications were recorded. The results of clinical metrics such as the visual analog scale (VAS) and Japanese Orthopaedic Association (JOA) scores in the preoperative and during the follow‐up period were obtained and used to evaluate clinical outcomes. Radiographic improvement was evaluated by the compression ratio, sagittal maximum spinal cord compression (SMSCC), and cervical range of motion (ROM). The preoperative and postoperative follow‐up parameters (VAS, JOA, Compression ratio, SMSCC, and ROM) were assessed with paired t test. A P‐value <0.05 was considered statistically significant.ResultsIn the study, the mean age of the 31 patients was 55.23 ± 10.97 years. The mean operative time was 192.45 ± 24.17 min (ranging from 150 to 245 min), and intraoperative blood loss was 322.58 ± 129.00 mL (ranging from 150 to 600 mL). The VAS neck pain was improved significantly over the follow‐up period (P < 0.05, respectively). The VAS arm pain improved significantly from 6.26 ± 0.93 preoperatively to 1.74 ± 0.63 at 24 months postoperatively (P < 0.001). There was no significant difference in improvement of VAS arm pain between 24 months postoperatively and final follow‐up (P = 0.180). Compared with preoperative JOA score, JOA score was significantly improved at 24 months postoperatively (14.79 ± 1.84 vs 9.66 ± 2.81, P < 0.001). Meanwhile, there were no statistically significant differences between the final follow‐up and the postoperative JOA scores (15.08 ± 1.71 vs 14.79 ± 1.84, P = 0.051). Postoperative patients showed significantly higher index of compression ratio (58.30 ± 8.51 vs 27.17 ± 3.89, P < 0.001) and lower SMSCC (25.12 ± 5.67 vs 33.66 ± 5.38, P < 0.001). In addition, there was no significant difference between preoperative and postoperative cervical ROM (P = 0.740). One patient observed postoperative symptom of C6 nerve root injury, which was resolved within 24 months after the surgery; meanwhile, the neurological monitoring also reflected the intraoperative stretching of the C6 nerve root. Two cases involved postoperative cerebrospinal fluid (CSF) leakage which may have been related to laceration of dura mater.ConclusionsThis study suggested that CTDL technique could acquire satisfactory surgical outcomes for patients with multi‐segment CSS accompanied with CDH, but the surgical indications of the patients need to be selected strictly.