Left Brachial Plexus Research Articles

Diffusion-tensor magnetic resonance imaging in patients with consequences of obstetric brachial plexus palsy

BACKGROUND: Diffusion-tensor magnetic resonance imaging allows visualizing the conductive pathways of the brain and spinal cord and assessing their structure and integrity and has found wide application in practical medicine. Currently, brachial plexus diffusion-tensor magnetic resonance imaging is not a routine research technique, and very few studies have described its use in children and adolescents. AIM: This study aimed to evaluate the possibility of brachial plexus diffusion-tensor magnetic resonance imaging application in pediatric patients with obstetric brachial plexus palsy sequelae and identify correlations between the diffusion-tensor magnetic resonance imaging parameters of brachial plexus and parameters of electrophysiological study of the upper extremities in these patients. MATERIALS AND METHODS: A complex examination of 50 patients was performed. The main group included 30 patients aged 6–17 years, with contractures and secondary deformities of the bones of the shoulder girdle and upper limbs caused by unilateral obstetric brachial plexus palsy. The control group included 20 patients aged 7–17 (10.1 ± 2.1) years without clinical signs, and anamnestic data indicated the presence of damage to the brachial plexus and peripheral nerves of the upper limbs. RESULTS: No significant differences in diffusion-tensor magnetic resonance imaging parameters of the right and left brachial plexus were found in the control group. Significant differences in fractional anisotropy of the C5–C8 tracts on the side of the damaged brachial plexus were detected compared with those on the side of the undamaged brachial plexus. On the side of the injured brachial plexus, nonlinear correlations were found between the fractional anisotropy of the tracts of the spinal nerve and its branches and the amplitude of sensory responses from the sensory nerve, which originated from the anterior branches of this spinal nerve, and between the volume of the branches of the tracts of the spinal nerve and the amplitude of соmpound motor responses from the muscles, which were innervated by the anterior branches of this spinal nerve. CONCLUSIONS: Diffusion-tensor magnetic resonance imaging allows for the evaluation of the structural changes in the SNs that participate in the formation of the brachial plexus. The results can be used for further studies of diffusion-tensor magnetic resonance imaging of brachial plexuses in various pathologies in pediatric patients.

An unusual case of hoarseness of voice after left supraclavicular brachial plexus block

Supraclavicular brachial plexus block (SBPB) is a commonly used regional anesthetic technique for upper limb surgeries in orthopaedic patients. It provides intraoperative anesthesia and postoperative analgesia. SBPB can be administered using either a landmark approach or ultrasound guidance (USG). The use of ultrasound has reduced the complications associated with the block by providing excellent real-time visualization of the pleura, vessels, and plexus in relation to needle insertion. However, complications can still arise even with USG-guided block if a large volume of local anesthetics is used. In fact, a large volume is not necessary when performing USG-guided blocks.We report a case of a 25-year-old male who presented with hoarseness of voice after receiving a USG-guided supraclavicular block (left side) due to recurrent laryngeal nerve (RLN) block. While RLN block is more common in interscalene blocks, it is a rare complication in SBPB, with very few reported cases of hoarseness of voice due to RLN block after SBPB.

Long-term and transient body representation plasticity after left brachial plexus avulsion

Long-term and transient body representation plasticity after left brachial plexus avulsion

Resting-state brain network remodeling after different nerve reconstruction surgeries: a functional magnetic resonance imaging study in brachial plexus injury rats.

JOURNAL/nrgr/04.03/01300535-202505000-00031/figure1/v/2024-07-28T173839Z/r/image-tiff Distinct brain remodeling has been found after different nerve reconstruction strategies, including motor representation of the affected limb. However, differences among reconstruction strategies at the brain network level have not been elucidated. This study aimed to explore intra-network changes related to altered peripheral neural pathways after different nerve reconstruction surgeries, including nerve repair, end-to-end nerve transfer, and end-to-side nerve transfer. Sprague-Dawley rats underwent complete left brachial plexus transection and were divided into four equal groups of eight: no nerve repair, grafted nerve repair, phrenic nerve end-to-end transfer, and end-to-side transfer with a graft sutured to the anterior upper trunk. Resting-state brain functional magnetic resonance imaging was obtained 7 months after surgery. The independent component analysis algorithm was utilized to identify group-level network components of interest and extract resting-state functional connectivity values of each voxel within the component. Alterations in intra-network resting-state functional connectivity were compared among the groups. Target muscle reinnervation was assessed by behavioral observation (elbow flexion) and electromyography. The results showed that alterations in the sensorimotor and interoception networks were mostly related to changes in the peripheral neural pathway. Nerve repair was related to enhanced connectivity within the sensorimotor network, while end-to-side nerve transfer might be more beneficial for restoring control over the affected limb by the original motor representation. The thalamic-cortical pathway was enhanced within the interoception network after nerve repair and end-to-end nerve transfer. Brain areas related to cognition and emotion were enhanced after end-to-side nerve transfer. Our study revealed important brain networks related to different nerve reconstructions. These networks may be potential targets for enhancing motor recovery.

Melanoma metastasis to the brachial plexus and median nerve. A rare clinical case

Melanoma is a malignant neuroectodermal tumor arising from skin pigment cells (melanocytes). Distant metastases and damage to the nervous system occur mainly at the later stages of disease. However, primary tumor may not be verified despite distant metastases in some cases. We present a patient with metastatic melanoma to the left median nerve and brachial plexus without clear primary lesion. This case describes surgical treatment of melanoma metastasis followed by median neuropathy.

Hemi-diaphragmatic paralysis

Introduction: Diaphragmatic paralysis (DP) involving the phrenic nerve is related to brachial plexus injury in 80–90% of the cases. Other causes include iatrogenic procedure involving the cardiopulmonary area. It causes respiratory distress which can be severe requiring prolonged need for respiratory support. Recovery can be spontaneous, typically by the first 6–12 months of life though some infants may require surgical intervention if no improvement in DP is noted by 1–2 months of life in the setting of compromised quality of life. Case Report: We present a preterm infant, 31 completed weeks of gestational age, birth weight 1440 g born via emergency C-section due to preterm labor in breech presentation. During delivery, the patient suffered a left brachial plexus injury with phrenic nerve involvement. He developed respiratory distress requiring endotracheal intubation and mechanical ventilation. His clinical course involved multiple failed extubation attempts. Chest X-ray (CXR) and chest fluoroscopy confirmed the diagnosis of left hemi-diaphragmatic paralysis. The patient had a prolonged respiratory support course but was finally weaned to room air by three months of age. Conclusion: Preterm infants can sustain perinatal brachial plexus injury like term or near-term infants in the setting of a traumatic birth irrespective of birth weight. The time and indications for conservative (non-surgical) versus surgical intervention remains debatable. Each case should be tailored to the child’s severity of injury and quality of life and growth. Clinical recovery can occur even with considerable persistence weakness on radiography or chest ultrasound.

A Rare Pathology of a Child Rescued from the Rubble in the Kahramanmaraş Earthquake: Left Brachial Plexus Injury and Diaphragmatic Paralysis

The primary destructive effect of earthquakes is sudden devastating trauma. A healthy seven-year-old male was rescued after 35 hours under the rubble in Kahramanmaraş earthquake. CPR was performed at the scene, he was intubated and transferred to a nearest pediatric intensive care unit. He was followed in pediatric intensive care unit due to crush syndrome and lung contusion for two days and then transferred to ward. While receiving oxygen therapy at the ward, the patient was intubated due to sudden respiratory distress. Since there was no empty bed in the intensive care unit of the hospital, he was transferred to the intensive care unit of our hospital. The patient had effusion in the left hemithorax, hemorrhagic contusion in the right lung, and peri splenic fluid. The patient, who had hemodynamic instability, markedly high renal functions, widespread edema, oliguria and hematuria, received 24-hour hemodiafiltration treatment. After extubating, the patient continued to experience respiratory distress, had limited movement and weakness in the left upper extremity, and diaphragmatic elevation was identified on the left side in the chest X-ray. The patient was diagnosed with left brachial plexus injury and left diaphragmatic paralysis by thoracic ultrasound, cervical vertebrae and left brachial plexus MRI. Over time, respiratory stress was relieved and oxygen support was gradually reduced and discontinued. In conclusion, it is necessary to perform repeated neurological examinations after sedation is discontinued and to assess continued respiratory distress after extubating to detect trauma-related diaphragmatic paralysis.

A rare case report of neurolymphomatosis with NK-T-cell lymphoma

Neurolymphomatosis (NL) is a rare entity. It is usually a manifestation of B-cell lymphoma. Here we describe a case of neurolymphomatosis in a 72 year old man who was in remission for Nasal T-cell lymphoma and presented to us with subacute onset painful mononeuritis like weakness involving all 4 limbs sequentially over a period of 4 months. he was initially treated as CIDP with steroids but later in view of progression he was evaluated further. His FDG PET-CT showed increased uptake in left brachial plexus which was confirmed by subsequent MRI neurography. He underwent biopsy of left brachial plexus and diagnosis of neurolymphomatosis was confirmed. He was treated with intravenous immunoglobulins (2 gm/kg) over 5 days with minimal improvement in his neurological symptoms, his shoulder pain improved and he could feed himself with right hand. He was offered palliative treatment in view of poor prognosis seen in neurolymphomatosis. He succumbed to the illness 3 months later.

Anatomical variations in morphology of right and left brachial plexus among black African population; a cadaveric study in western Kenya

Background: Brachial plexus (Bp) is a network of bundles of nerves of spinal cord around neck and axilla in the body formed by union of anterior primary rami of C5 to C8, and T1. Technical expertise required for clinical and surgical procedures remains challenging for the beginners. Variations may be due to trauma, irradiation, neoplasm, infection, and autoimmune inflammatory disease. The purpose of this study was to determine the difference in variation of right and left Bp of the study population. Methods: Cross sectional descriptive study was used in Maseno, Uzima and Masinde Muliro Universities anatomy laboratory to get sample size of 35male and 35 female cadavers. Chi- square test was set at a p= 0.05. Ethical consideration was observed. Results: Statistically significant difference (p=0.009) between the right and the left upper limb in the branching of musculocutaneous nerve was recorded. A total of 17.8% variations in origin and segments of Bp, majority 9.9% were from left while 7.9% from right. Highest frequency of variation occurred at the prefixed root of Bp with 8.7% occurring on left upper limb and 12.13% on right upper limb. Right upper limbs had highest incidence of variations in branching patterns of Bp at 43% whilst left had incidence of 23.5%. Highest frequency of main terminal variation was of musculocutaneous nerve at 18.6% with 13.6% occurring on right side and 5% on left side. Conclusion: Knowledge of variations is essential in evaluation of unexplained sensory and motor loss after trauma and surgical interventions to the upper limb.

Peripheral Nerve Stimulation: A New Horizon for Traumatic Brachial Plexus Injury, A Case Report

BACKGROUND: The management of traumatic brachial plexus injury is challenging. Treatment options consisting of physical therapy, pharmacologic therapy, and injection therapy often provide inadequate analgesia. Peripheral nerve stimulation (PNS) has emerged as a potential therapy for treatment of pain related to brachial plexus injury. CASE REPORT: We present a case of a 37-year-old man with painful ballistic trauma to multiple cords of the left brachial plexus refractory to medications and therapies. The patient was treated with a temporary 60-day PNS targeting the brachial plexus providing 90% improvement in pain intensity persisting 7 months postintervention. CONCLUSIONS: The case supports the efficacy of a temporary PNS system as a minimally invasive treatment option for brachial plexus injuries resulting in refractory neuropathic pain. Extended lead implantation of the temporary PNS device beyond the US Food and Drug Administration-approved 60 days may be of benefit to patients, although the potential risk of infection should be assessed and monitored. KEY WORDS: Traumatic brachial plexus injury, peripheral nerve stimulator, peripheral nerve stimulation, neuromodulation, neuropathic pain, case report

Left brachial plexopathy after prone positioning with COVID-19: a case series

Prone positioning is a strategy shown to reduce mortality in patients who are mechanically ventilated for acute respiratory distress syndrome and has been used in the COVID-19 pandemic. It is not, however, without complications. Barotrauma, pressure sores, ventilator associated pneumonia and peripheral nerve injuries have all been implicated as complications of prone positioning. There have also been several reports of brachial plexopathy in patients who have undergone prolonged mechanical ventilation with prone positioning. Patient characteristics including body weight index, degree of critical illness, and suboptimal prolonged positioning have all been suggested as possible contributing factors, although, there has been less discussion concerning the action of rolling patients, and how it may contribute to the development of injuries. We describe 3 cases of left brachial plexus injury in patients who were consistently rolled on their left sides. Patients presented with isolated left upper extremity weakness without any structural etiology found on imaging. Electrodiagnostic studies subsequently confirmed a left brachial plexopathy in each of the cases. We suggest that the action of proning patients may contribute to injury. This observation has not yet been suggested in the literature, and carries clinical relevance, as greater attention and meticulous care may need to be employed when moving these individuals.

Altered Neural Pathways and Related Brain Remodeling: A Rat Study Using Different Nerve Reconstructions.

Function recovery is related to cortical plasticity. The brain remodeling patterns induced by alterations in peripheral nerve pathways with different nerve reconstructions are unknown. To explore brain remodeling patterns related to alterations in peripheral neural pathways after different nerve reconstruction surgeries. Twenty-four female Sprague-Dawley rats underwent complete left brachial plexus nerve transection, together with the following interventions: no nerve repair (n = 8), grafted nerve repair (n = 8), and phrenic nerve transfer (n = 8). Resting-state functional MR images of brain were acquired at the end of seventh month postsurgery. Amplitude of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), and functional connectivity (FC) were compared among 3 groups. Behavioral observation and electromyography assessed nerve regeneration. Compared with brachial plexus injury group, ALFF and ReHo of left entorhinal cortex decreased in nerve repair and nerve transfer groups. The nerve transfer group showed increased ALFF and ReHo than nerve repair group in left caudate putamen, right accumbens nucleus shell (AcbSh), and right somatosensory cortex. The FC between right somatosensory cortex and bilateral piriform cortices and bilateral somatosensory cortices increased in nerve repair group than brachial plexus injury and nerve transfer groups. The nerve transfer group showed increased FC between right somatosensory cortex and areas including left corpus callosum, left retrosplenial cortex, right parietal association cortex, and right dorsolateral thalamus than nerve repair group. Entorhinal cortex is a key brain area in recovery of limb function after nerve reconstruction. Nerve transfer related brain remodeling mainly involved contralateral sensorimotor areas, facilitating directional "shifting" of motor representation.

Interobserver Agreement among Multiple Generalists is Comparable to that of Recognized Experts: Prospective Acceptability Benchmarks from the C3RO Crowdsourced Initiative

<h3>Purpose/Objective(s)</h3> Contouring Collaborative for Consensus in Radiation Oncology (C3RO) is a public crowdsourced challenge engaging radiation oncologists across various expertise levels in cloud-based image-segmentation. A challenge in artificial intelligence (AI) development is the relative paucity of multi-expert observer datasets sufficiently large to train deep learning; consequently, we sought to characterize whether aggregate segmentations generated from large numbers of generalists could meet or exceed expert interobserver agreement, the current "gold standard." <h3>Materials/Methods</h3> Participants who contoured at least one region of interest (ROI) for the C3RO breast or sarcoma challenge were identified as generalist or recognized expert. Cohort-specific ROIs were combined into single simultaneous truth and performance level estimation (STAPLE) consensus segmentations. STAPLE_generalist ROIs were evaluated against STAPLE_expert contours using Dice Similarity Coefficient (DSC). The expert interobserver DSC (IODSC_expert) (i.e., pairwise median DSC across experts) was calculated as a performance acceptability threshold between STAPLE_generalist and STAPLE_expert. To determine the number of generalists required to match the IODSC_expert for each ROI, a single STAPLE_bootstrap consensus contour was generated for a 10-fold random-bootstrap using a variable number of generalists (between 2-25) and then compared to the IODSC_expert. <h3>Results</h3> The breast challenge yielded contours from 124 generalists and 8 experts. The DSC for STAPLE_generalist versus STAPLE_expert were higher than their respective expert IODSC_expert for all ROIs, including the axilla (STAPLE_generalist/IODSC_expert, 0.86/0.68), chest wall (0.91/0.67), heart (0.97/0.9), supraclavicular nodes (0.77/0.57), internal mammary nodes (0.66/0.46), left brachial plexus (0.46/0.2), and left anterior descending artery (0.62/0.32). The sarcoma case had contours from 61 generalists and 4 experts. The DSC between STAPLE_generalist and STAPLE_expert were higher than their respective IODSC_expert for GTV (0.97/0.94) and CTV (0.76/0.69), but not genitalia (0.60/0.66). The theoretical minimum number of generalist segmentation needed to cross the IODSC_expert acceptability threshold ranged between 2-4 for breast and 2-5 for sarcoma ROIs. <h3>Conclusion</h3> Multi-generalist-generated consensus ROIs met or exceeded expert-derived acceptability thresholds. Analyses suggest that 5+ generalists could potentially generate consensus ROIs with DSC performance approximating an individual expert, suggesting multi-generalist segmentations as a feasible AI input. Future research will explore whether these observations are site-specific and/or generalizable to more granular surface metrics.

Evaluating a Personalized Deep-Learning-Based Auto-Segmentation Method for CBCT-Based Adaptive Radiotherapy

<h3>Purpose/Objective(s)</h3> Online adaptive radiotherapy (ART) requires accurate and efficient auto-segmentation of target volumes and organs-at-risk (OARs) in mostly cone-beam computed tomography (CBCT) images. Propagating expert-drawn contours from the pre-treatment planning CT (pCT) through traditional or deep learning (DL) based deformable image registration (DIR) can achieve improved results in many situations. Typical DL-based DIR models are population based, that is, trained with a dataset for a population of patients, so they tend to average their result to the data distribution rather than individualizing to a single patient. We previously proposed a method, test-time optimization (TTO), that can individualize DL-based DIR model to each patient to improve DIR accuracy. In this work, we evaluated the accuracy and efficiency of auto-segmentation results from our proposed DIR method. <h3>Materials/Methods</h3> We used 39 patients with head and neck squamous cell carcinoma for evaluation. Each patient has a pCT with manual contours and two fractions of CBCT with manual contours. 17 structures that are either critical OARs or have large anatomical changes during radiotherapy courses were selected. These structures were: left brachial plexus, right brachial plexus, brainstem, oral cavity, constrictor, esophagus, nodal gross tumor volume, larynx, mandible, left masseter, right masseter, posterior arytenoid-cricoid space, left parotid gland, right parotid gland, left submandibular gland, right submandibular gland, and spinal cord. Dice similarity coefficient (DSC) and 95% Hausdorff Distance (HD95) were calculated between auto-segmentation and manual segmentation for each structure. All the auto-segmentation methods tested in this experiment are based on DIR methods including our proposed individualized DIR models and traditional DIR models. To get individualized DIR model for each patient, TTO was applied where a pre-trained population DIR model was fine-tuned on each patient separately. The auto-segmentation accuracy and the time cost for DIR model individualization were studied. <h3>Results</h3> The average DSC and HD95 of the auto-segmentation by individualized DIR models is 0.85 and 2.33mm respectively over 17 selected OARs and a target of 39 patients, which performs better than traditional DIR methods. The average time for deriving the individualized DIR model is approximately 3.6 minutes. <h3>Conclusion</h3> The proposed TTO method is well-suited for online ART and can boost segmentation accuracy for DL-based DIR models, especially for outlier patients where traditional DIR methods fail.

Experience in the use of prolonged analgesic peripheral nerve blocks as part of multimodal analgesia regimens in the treatment of patients with gunshot wounds of the limbs

The use of regional analgesic techniques as part of multimodal analgesia regimens provides better control of acute pain. Effective anesthesia is one of the key tasks in the treatment of the wounded at all stages of medical care.&#x0D; Three clinical cases of the use of prolonged regional analgesic blockades as part of a multimodal analgesia regimen in the treatment of patients with gunshot wounds of the extremities are presented. Catheterizations of the perineural space of the peripheral nerves were performed using ultrasound imaging.&#x0D; Clinical case 1 - a patient with a gunshot shrapnel through wound of the left tibia with gunshot comminuted fractures of both bones of the lower third of the left tibia and the upper third of the fibula of the left tibia, was admitted two days after the injury. Performed catheterization of the perineural space of the left sciatic nerve in the popliteal fossa, constant infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. A satisfactory analgesic effect was observed, narcotic analgesics were not prescribed.&#x0D; Clinical case 2 - a patient with a gunshot shrapnel through wound of the left shoulder with a gunshot comminuted fracture of the left humerus in the middle third and with damage to the neurovascular bundle, was admitted more than 6 weeks after the injury. Performed catheterization of the perineural space of the left brachial plexus interscalene access, continuous infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. However, in the absence of complaints of soreness at the fracture sites and postoperative wounds, the patient began to be disturbed by neuropathic pain.Satisfactory analgesic effect was observed sporadically, narcotic analgesics were prescribed. On the second day of observation, dislocation of the catheter was detected.Considering that the patient was more concerned about pain in the distal part of the limb, catheterization of the perineural space of the left brachial plexus was performed by supraclavicular access, and a constant infusion of 0.25 % bupivacaine solution was started at a rate of 5 ml per hour using a perfusor. Satisfactory analgesic effect was observed sporadically, narcotic analgesics were prescribed.&#x0D; Clinical case 3 - a patient with a gunshot shrapnel through wound of the left thigh with a gunshot comminuted fracture of the left femur in the lower third and with damage to the popliteal artery, was admitted three weeks after the injury. Performed paravertebral catheterization of the left lumbar plexus, constant infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. In combination with oral analgesic adjuvants (effect on neuropathic pain), a satisfactory analgesic effect was observed without the prescription of narcotic analgesics.After repeated surgical treatment with the installation of the VAC-system on the posterior surface of the thigh, an unsatisfactory effect of non-opiate analgesia was observed, and narcotic analgesics were additionally prescribed.

Extramedullary relapse of acute myeloid leukemia in brachial plexus after allogeneic stem cell transplantation: a case report

BackgroundAllogeneic hematopoietic stem cell transplantation is a potentially curative treatment for acute myeloid leukemia. However, extramedullary relapse of acute myeloid leukemia can occur after hematopoietic stem cell transplantation, causing treatment failure. Extramedullary relapse rarely involves the peripheral nerves, and it is not influenced by the effect of the graft on leukemia.Case presentationWe report a case of extramedullary relapse of acute myeloid leukemia in the brachial plexus of a 41-year-old woman treated with allogeneic hematopoietic stem cell transplantation (HSCT). Complete hematological remission was confirmed by bone marrow examination 1 month after HSCT, and she developed no major complications immediately after HSCT. The immunosuppressant was discontinued 5 months later. However, 2 weeks after immunosuppressant withdrawal, the patient developed left arm pain and paresthesia, with subsequent development of a mass in the left brachial plexus. She was initially diagnosed with brachial plexus neuropathy because of concomitant graft-versus-host disease. Despite the administration of immunosuppressive agents, the mass continued to enlarge. The biopsy of the lesion revealed leukemic relapse. Thus, the patient was diagnosed with extramedullary relapse and underwent radiotherapy, resulting in tumor shrinkage.ConclusionExtramedullary relapse should be considered a differential diagnosis in post-transplant patients with leukemia presenting with paresthesia.

Nerve Injury and Regeneration after Neurolysis: Ethanol Alone versus Ethanol with Brachytherapy in Rabbits

PurposeThis study aimed to prove the hypothesis that neurolysis based on ethanol injection in combination with iodine-125 (125I) radioactive seed implantation could prolong the nerve regeneration time compared with that based on ethanol injection alone. The grade of nerve injury was assessed for both methods. Materials and MethodsTwenty female rabbits (mean weight, 2.8 kg ± 0.2) were randomly assigned to group A (neurolysis of the left brachial plexus nerve based on ethanol injection in combination with 125I radioactive seed implantation, n = 10) and group B (neurolysis using ethanol injection alone, n = 10). The right brachial plexus nerve was used as a control. Injury and regeneration of the brachial plexus nerve were analyzed using electromyography. Statistical tests were performed using the Mann-Whitney U test and repeated-measures analysis of variance. The results were verified with histopathological examinations. ResultsThe overall postprocedural amplitude was significantly lower in group A than in group B (P = .01), particularly in the second month after the procedure (P = .036). However, no statistical difference in latency was observed between the 2 groups (P = .103). Histopathological examination of both groups revealed Sunderland third-degree peripheral nerve injury (PNI), which was mainly characterized by axonal disintegration. The degree of nerve regeneration was significantly lower in group A than in group B. ConclusionsNeurolysis based on ethanol injection in combination with 125I radioactive seed implantation can prolong the nerve regeneration time compared with that based on ethanol injection alone, although both methods resulted in Sunderland third-degree PNI.

Upper Extremity Monoplegia following Prone Surrender Position for Spinal Surgery.

Background Secondary peripheral nerve injuries remain a significant perioperative problem due to patient positioning and contribute to reduced patient quality of life and exacerbated professional liability. Comorbidities and concomitant lesions can further elicit these injuries in patients undergoing spinal surgeries. Case Presentation We report a case of a 70-year-old male polytrauma patient presenting with a left first-rib fracture and an adjacent hematoma around the brachial plexus without preoperative deficits. Subsequent to a lumbar spinal fusion in the prone position, he developed a postoperative left upper extremity monoplegia. The postoperative magnetic resonance imaging revealed an enhanced asymmetric signal in the trunks and cords of the left brachial plexus. He progressively improved with rehabilitation, a year after the initial presentation, with a residual wrist drop. Conclusions Pan brachial plexus monoplegia, following spine surgery, is rare and under-reported pathology. To minimize the occurrence of this rare morbidity, appropriate considerations in preoperative evaluation and counseling, patient positioning, intraoperative anesthetic, and electrophysiological monitoring should be performed. We emphasize an unreported risk factor in polytrauma patients, predisposing this rare injury that is associated with prone spinal surgery positioning, SEPs being an extremely sensitive test intraoperatively and highlight the importance of counseling patients and families to the possibility of this rare occurrence.

Brachial Plexus Injury and Musculocutaneous Nerve Palsy During Prone Positioning in a Patient With COVID-19

Prone positioning is crucial in the respiratory management of patients with acute respiratory distress syndrome (ARDS) and reduces mortality. However, this may be complicated by compression-related peripheral nerve injury. We report the case of a male in his 80s with obesity admitted to the intensive care unit (ICU) with COVID-19 pneumonia who developed brachial plexus disorder in the right upper extremity and musculocutaneous neuropathy in the left. The patient’s cough, dyspnea, and fatigue did not improve; therefore, he was intubated and placed in the prone position for one week. The patient complained of bilateral upper limb weakness on regaining consciousness. We diagnosed left musculocutaneous nerve palsy and right brachial plexus palsy based on physical findings and needle electromyography (EMG). Physical therapy was initiated, including joint range-of-motion exercises focused on preventing contractures in the extremities and active assistive exercises. Motor impairment improved, and the patient was discharged from the rehabilitation center.

Referred Somatic Hyperalgesia Mediates Cardiac Regulation by the Activation of Sympathetic Nerves in a Rat Model of Myocardial Ischemia.

Myocardial ischemia (MI) causes somatic referred pain and sympathetic hyperactivity, and the role of sensory inputs from referred areas in cardiac function and sympathetic hyperactivity remain unclear. Here, in a rat model, we showed that MI not only led to referred mechanical hypersensitivity on the forelimbs and upper back, but also elicited sympathetic sprouting in the skin of the referred area and C8-T6 dorsal root ganglia, and increased cardiac sympathetic tone, indicating sympathetic-sensory coupling. Moreover, intensifying referred hyperalgesic inputs with noxious mechanical, thermal, and electro-stimulation (ES) of the forearm augmented sympathetic hyperactivity and regulated cardiac function, whereas deafferentation of the left brachial plexus diminished sympathoexcitation. Intradermal injection of the α2 adrenoceptor (α2AR) antagonist yohimbine and agonist dexmedetomidine in the forearm attenuated the cardiac adjustment by ES. Overall, these findings suggest that sensory inputs from the referred pain area contribute to cardiac functional adjustment via peripheral α2AR-mediated sympathetic-sensory coupling.