Left Brachial Plexus Research Articles

Functioning transferred free muscle innervated by part of the vascularized ulnar nerve connecting the contralateral cervical seventh root to themedian nerve: Case report

BackgroundThe limited nerve sources available for the reconstruction and restoration of upper extremity function is the biggest obstacle in the treatment of brachial plexus injury (BPI). We used part of a transplanted vascularized ulnar nerve as a motor source of a free muscle graft.Case presentationA 21-year-old man with a left total brachial plexus injury had received surgical intercostal nerve transfer to the musculocutaneous nerve and a spinal accessory nerve transfer to the suprascapular nerve in another hospital previously. He received transplantation of a free vascularized gracilis muscle, innervated by a part of the transplanted vascularized ulnar nerve connecting the contralateral healthy cervical seventh nerve root (CC7) to the median nerve, and recovered wrist motion and sensation in the palm. At the final examination, the affected wrist could be flexed dorsally by the transplanted muscle, and touch sensation had recovered up to the base of each finger. When his left index and middle fingers were touched or scrubbed, he felt just a mild tingling pain in his right middle fingertip.ConclusionPart of the transplanted vascularized ulnar nerve connected to the contralateral healthy cervical seventh nerve root can be used successfully as a motor source and may be available in the treatment of patients with BPI with scanty motor sources.

Cervical spinal cord stimulation treatment of deafferentation pain from brachial plexus avulsion injury complicated by complex regional pain syndrome.

Brachial plexus avulsion is a rare and debilitating condition frequently associated with severe, intractable neuropathic pain. Interventional treatment modalities include dorsal root entry zone lesioning, stellate ganglion blockade, and neuromodulation such as spinal cord stimulation. We present a case of a 42-year-old woman with a traumatic left upper extremity brachial plexus avulsion injury after a motor vehicle accident and treatment of deafferentation pain complicated by complex regional pain syndrome type II. Previous unsuccessful interventions included repeated stellate ganglion blocks, transcutaneous electrical nerve stimulation, and opioid medication. After a successful trial of cervical spinal cord stimulator lead placement, she went on to an uneventful permanent implantation procedure. Spinal cord stimulation is an effective treatment for deafferentation pain and complex regional pain syndrome type II secondary to brachial plexopathy refractory to pharmacotherapy and conventional interventional attempts to modulate pain.

SU‐E‐J‐210: Thoracic Atlas Segmentation Model Based On Consensus Contours

Purpose:Generation of a thoracic segmentation atlas based on consensus contours obtained through input from individual expertsMethod and Materials:A cohort of 30 patients treated for lung disease was selected for this study. All patients had 4D‐CT studies with image segmentation based on respiration‐averaged images. For each subject, three experts delineated the eighteen agreed‐upon structures using tools available in Eclipse ver.10.0. Consensus structures were generated using CERR(4.0β2). The EM‐STAPLE method was chosen to generate the consensus contours based on published reports which state that iterative methods yield better results over analytical methods in medical imaging. Once the consensus contours were generated they were re‐imported in Eclipse for further processing and evaluation. For each structure, each expert's contour was scored against the consensus using two scoring indices: Dice similarity coefficient, DSC, and Dice‐Jaccard coefficient, DJC. Visual inspection was always performed to detect large segmentation errorsResults:The respiration‐averaged CT set proved to be adequate for all structures included in the thoracic atlas. As expected, anatomic variability between patients was larger than the variability due to the level of expertise. Across the entire cohort the smallest structure segmented was the brachial plexus with a 9.4cc (+/− 3.5) volume, while the chest wall was the largest (2933cc +/‐560). The DSC and DJC coefficients were smallest for Left Brachial Plexus 0.894 (+/−0.138) and 0.842 (+/− 0.138), respectively, while the largest were 0.992(+/−0.004) and 0.990(+/− 0.004), observed for the right lung.Conclusions:Consensus contours generated using expert input were analyzed using comparison indices and visual evaluation. With appropriate atlas selection (e.g. patient gender, arm position) a robust thoracic atlas segmentation tool can be set up and may be used in conjunction with an automatic segmentation algorithm.Project supported by Varian Medical System

Electroacupuncture attenuates neuropathic pain after brachial plexus injury.

Electroacupuncture has traditionally been used to treat pain, but its effect on pain following brachial plexus injury is still unknown. In this study, rat models of an avulsion injury to the left brachial plexus root (associated with upper-limb chronic neuropathic pain) were given electroacupuncture stimulation at bilateral Quchi (LI11), Hegu (LI04), Zusanli (ST36) and Yanglingquan (GB34). After electroacupuncture therapy, chronic neuropathic pain in the rats’ upper limbs was significantly attenuated. Immunofluorescence staining showed that the expression of β-endorphins in the arcuate nucleus was significantly increased after therapy. Thus, experimental findings indicate that electroacupuncture can attenuate neuropathic pain after brachial plexus injury through upregulating β-endorphin expression.

Ultrasound-guided pulse-dose radiofrequency: treatment of neuropathic pain after brachial plexus lesion and arm revascularization.

Neuropathic pain following brachial plexus injury is a severe sequela that is difficult to treat. Pulsed radiofrequency (PRF) has been proved to reduce neuropathic pain after nerve injury, even though the underlying mechanism remains unclear. This case report describes the use of ultrasound-guided PRF to reduce neuropathic pain in a double-level upper extremity nerve injury. A 25-year-old man who sustained a complete left brachial plexus injury with cervical root avulsion came to our attention. Since 2007 the patient has suffered from neuropathic pain (NP) involving the ulnar side of the forearm, the proximal third of the forearm, and the thumb. No pain relief was obtained by means of surgery, rehabilitation, and medications. Ultrasound-guided PRF was performed on the ulnar nerve at the elbow level. The median nerve received a PRF treatment at wrist level. After the treatment, the patient reported a consistent reduction of pain in his hand. We measured a 70% reduction of pain on the VAS scale. PRF treatment allowed our patient to return to work after a period of absence enforced by severe pain. This case showed that PRF is a useful tool when pharmacological therapy is inadequate for pain control in posttraumatic neuropathic pain.

MRI of the Brachial Plexus: Modified Imaging Technique Leading to a Better Characterization of Its Anatomy and Pathology

Magnetic resonance imaging (MRI) is the imaging modality of choice for the evaluation of the brachial plexus due to its superior soft tissue resolution and multiplanar capabilities. The evaluation of the brachial plexus however represents a diagnostic challenge for the clinician and the radiologist. The imaging assessment of the brachial plexus, in particular, has been traditionally challenging due to the complexity of its anatomy, its distribution in space and due to technical factors. Herein, we describe a modified technique used in our institution for the evaluation of the brachial plexus which led to a substantial decrease in scanning time and to better visualization of all the segments of the brachial plexus from the roots to the branches, in only one or two images, facilitating therefore the understanding of the anatomy and the interpretation of the study. To our knowledge, we are the first group to describe this technique of imaging the brachial plexus. We illustrate the benefit of this modified technique with an example of a patient with a lesion in the proximal branches of the left brachial plexus that was clinically suspected but missed on conventional brachial plexus imaging for six consecutive years. In addition, we review the common and infrequent benign and malignant pathology that can affect the brachial plexus.

Brachial plexus palsy after a left-side modified radical mastectomy with immediate latissimusdorsi flap reconstruction: report of a case

Brachial plexus injury is a rare complication during operation and anesthesia; it can occur as a result of various mechanisms such as inappropriate positioning, over-abduction and stretching the upper limbs. Brachial plexus injury can cause the poor function of the upper limb before recovery, and sometimes serious injury is unable to completely recovered the function permanently. Here, we report a female breast cancer patient who sustained a left brachial plexus palsy after modified radical mastectomy with immediate breast reconstruction with latissimusdorsi flap (LDF). The patient had fully recovered with normal function of her left upper limb six months postoperation after conservative treatment.

Hemi-body port-wine stains and progressive paresis due to territorial perineuriomas

We present a case of a biopsy-proven intraneural perineurioma involving the left lumbosacral and brachial plexus with prominent hemi-body port wine stains in the associated dermatomes. The relationship between the two entities is not clear, but this case may provide a clue to understanding the etiological pathogenesis of intraneural perineurioma in the future.

Right Traumatic Transradial Amputation and Left Brachial Plexus Injury in a Dismounted Improvised Explosive Device Blast: A Case Report

Right Traumatic Transradial Amputation and Left Brachial Plexus Injury in a Dismounted Improvised Explosive Device Blast: A Case Report

Metastatic brachial plexopathy from breast cancer detected by 18F-FDG PET/MRI

A 62-year-old woman with history of ductal-invasive arcinoma of the left breast, treated with surgery (left astectomy and left axillary lymphadenectomy) and adjuvant hemotherapy and radiotherapy 17 years before, underwent maging for restaging due to increased serum tumor markers evels (CEA and CA 15-3) and onset of pain on the left rm. Whole-body computed tomography (CT) and other conentional imaging methods were negative. The patient even nderwent a fused 18F-FDG PET/MRI which showed some areas of ncreased 18F-FDG uptake corresponding to an abnormal thickenng of the left brachial plexus at MRI. No other areas of abnormal 8F-FDG uptake were evident in the rest of the body (Fig. 1). Based on these 18F-FDG PET/MRI findings, the patient underwent histology which demonstrated the presence of a metastatic plexopathy from breast cancer and she was addressed to chemotherapy. PET/MRI is of special interest for neuroscience, given that PET and MRI are the neuroimaging methods of choice for many clinical and scientific applications. The first clinical studies conducted have tested the performance of PET/MRI in oncology indications, neurodegenerative disorders and epilepsy, using different PET tracers.1,2 The case which we have briefly presented illustrated the usefulness of fused 18F-FDG PET/MRI in evaluating neoplastic processes involving the peripheral nerves.3 This emerging technique

The Effectiveness of Contralateral C7 Nerve Root Transfer for the Repair of Avulsed C7 Nerve Root in Total Brachial Plexus Injury: An Experimental Study in Rats

The aim of this study was to evaluate the feasibility and effectiveness of transferring the contralateral C7 root to repair avulsed C7 nerve root. Thirty rats were randomized into three groups. In group A, rats underwent whole-root avulsion of the left brachial plexus and contralateral C7 root transfer to the avulsed C7 nerve root. In group B, rats underwent whole-root avulsion and contralateral C7 root transfer to the radial nerve. In group C, rats underwent whole-root avulsion of the left brachial plexus without nerve transfer. Functional outcomes were measured by electrophysiological studies, muscle tetanus contraction force, muscle mass, and histology. Six months postoperatively, increased amplitude and shortened latency of compound muscle action potentials, larger maximum tetanic contractile tension, heavier muscle mass, and larger cross-sectional area of the muscle fibers were observed in the triceps, extensor carpi radialis brevis, and extensor digitorum in groups A and B when compared with group C (p < 0.01). There were no significant differences between group A and B (p > 0.05). Contralateral C7 nerve transfer to repair avulsed C7 nerve root was feasible and effective in this rat model. It should be considered as an option for the treatment of brachial plexus injuries.

Progressive neurolymphomatosis with cutaneous disease: Response in a patient with mycosis fungoides

Peripheral neurolymphomatosis is a rare manifestation of advanced lymphoproliferative disorders. It is often associated with B cell lymphomas and rarely with cutaneous T cell lymphomas, such as mycosis fungoides and Sézary syndrome. In this case report, we present a 78-year-old male with a long-standing history of mycosis fungoides. The patient initially presented with chronic peripheral neuropathy in an ulnar nerve distribution. After an unsuccessful ulnar nerve transposition, the ulnar nerve was re-explored and a mass consistent with diffuse lymphomatous infiltration was diagnosed. Magnetic resonance (MR) imaging of the left brachial plexus and later of the sacral plexus demonstrated diffuse thickening and peripheral nodularity in keeping with neurolymphomatosis. The patient's clinical course rapidly deteriorated thereafter and the patient succumbed to his disease. Although uncommon, neurolymphomatosis may be considered in patients with chronic peripheral neuropathy and an underlying history of a lymphoproliferative disorder. US and MR may serve as helpful non-invasive adjuncts in making the diagnosis and identifying sites for biopsy.

Diagnosis and treatment of rib fracture during spontaneous vaginal delivery

Progress of labor in multiparous women usually is not accompanied with risk of any kind of birth trauma. We report a very rare case of rib fracture in a neonate during vaginal delivery in the 39/40 week of gestation. The expulsion started spontaneously without any manipulation from the obstetrician. Live male newborn was delivered 4650 g. in weight, 55 cm long, with head circumference of 39 cm, Apgar score 9. The child was immediately examined by the neonatologist. Crepitations were palpable over the left hemithorax, and auscultatory on the left side inspiratory cracks. Finding was suspicious for rib fracture on the left side posteriorly and brachial plexus palsy, while other findings were normal. X-ray finding was inconclusive, but suspicious for fracture of the 4th, 5th, and 6th left rib posteriorly, without dislocation of bone fragments. There were no signs of pneumothorax. Dorsal position of the newborn was considered sufficient, accompanied with analgetics. X-ray was scheduled in a week because formation of the calus would be the only objective sign of previous rib fracture. On the control X-ray fracture lines were clearly visible on the 3rd, 4th, 5th 6th and 7th rib posteriorly, without dislocation of bone fragments with initial calus formation. The child was discharged from hospital in good condition after two weeks, for further outpatient care. With timely diagnostics of this very rare intrapartal fracture, adequate treatment, dorsal position and close control of clinical condition of the newborn, serious and potentially life threatening complications can be avoided.

Clinical observation of peripheral nerve injury in 2 patients with cancer after radiotherapy

Aim of the studyThis study aims to analyze the clinical manifestations and sequelae of peripheral nerve radiation damage of two cases of cancer patients after radiotherapy at the corresponding sites in clinical practice and to summarize experiences and lesions in order to provide a reference for future tumor radiotherapy.Material and methodsSome data of two cases of patients, such as doses of radiotherapy, clinical manifestations and damage occurrence time, were collected and examinations were conducted to define diagnosis. Afterwards, therapies and follow-up were conducted.ResultsCase 1 (rectal cancer) was diagnosed as mild left lower extremity nerve damage. After the symptomatic treatment, the disease condition was improved, and there was no tumor recurrence sign. Case 2 (breast cancer) was diagnosed as left brachial plexus damage, and left upper extremity movement function was lost completely. While the analgesic treatment was conducted, anti-tumor relevant treatments were being carried out.ConclusionsRadiotherapy can cause different extents of radioactive nerve damage. In practice, it is necessary to constantly improve the radiotherapy technology level and actively prevent the occurrence of complications. Once symptoms appear, the diagnosis and treatment should be conducted as early as possible in order to avoid aggravating damage to cause dysfunction and cause lifetime pain to patients.

Effects of brachial plexus amputation on the calcitonin gene related peptide content and the spasmodic muscles in foreleg

Objective To study the relationship between the calcitonin gene related peptide (CGRP) content in brachial plexus and spasmodic muscles.Methods The 16 Wistar rats with right cerebral cortex injury were diveded into 2 groups (8 rats in each group):the experiment group was given brachial plexus amputation,and the control group received no-treatment.The CGRP in brachial plexus was examined by using immunohistochemical method and the biceps musele tension was evaluated by electrophysiology measurement at 20th day after sympathectomy.Meanwhile,the nerve symptom was observed and spasm of flexion elbow muscles on the left foreleg after sympathectomy was assessed.Results The CGRP in left brachial plexus was significantly higher in experiment group [(7122.58 ± 1697.72) μm2] than in control group [(6613.96 ± 1433.59) μm2] (P ＜ 0.05),and spasm of the limbs was alleviated after sympathectomy.Conclusion The treatment mechanism of brachial plexus amputation for myospasm resulting from cerebrum injury may be related to the increase in the local content of CGRP. Key words: Brachial plexus; Calcitonin gene related peptide; Muscular tone

Pulsed radiofrequency treatment within brachial plexus for the management of intractable neoplastic plexopathic pain

We report on the use of pulsed radiofrequency (RF) within the plexus for the management of intractable pain in three patients with metastatic or invasive plexopathy. The patients were a 38-year-old woman with a history of breast cancer 6years earlier whose computed tomography (CT) scans revealed a mass lesion at the infraclavicular part of the right brachial plexus, a 68-year-old man diagnosed with advanced lung cancer whose CT scans revealed a bone metastasis in the right humerus invading the axillary region of the right brachial plexus, and a 67-year-old woman diagnosed with advanced lung cancer whose CT scans revealed a bone metastasis in the left humerus invading the axillary region of the left brachial plexus. Ultrasound-guided pulsed RF was performed within the interscalene brachial plexus. During the follow-up period, their intractable pain was moderately controlled.

English

We report the case of a 29-year-old woman previously treated for breast cancer who presented 3 years later with pain weakness and burning sensation in the left upper limb of one month duration. Electroneuromyography showed reduced sensory nerve action potential (SNAP) amplitude and reduced conduction velocity in left median nerve sensory conduction, Magnetic resonance imaging (MRI) of brachial plexus revealed nodular thickening of trunks and cords of left brachial plexus, suggesting metastasis. Ultrasonography guided fine needle aspiration cytology confirmed the presence of metastatic ductal cell carcinomatous deposits. Brachial plexopathy due to metastases from breast cancer is a rare entity, and should be kept in mind while evaluating patients with breast cancer.

Respiratory distress in a one‐month‐old child suffering brachial plexus palsy

This paper describes a one-month-old girl presenting with respiratory and growth failure due to diaphragmatic paralysis associated with left brachial plexus palsy after forceps delivery. Despite continuous positive pressure ventilation and nasogastric feeding, the situation did not improve and a laparoscopic diaphragmatic plication had to be performed. When dealing with a child born with brachial plexus palsy, one must think of this possible association and if necessary proceed to the complementary radiological examinations. The treatment must avoid complications like feeding difficulties and failure to thrive, respiratory infections or atelectasis. It includes intensive support and a good evaluation of the prognosis of the lesion to decide the best moment for a surgical therapy.

Transfer of a flexor digitorum superficialis motor branch for wrist extension reconstruction in C5–C8 root injuries of the brachial plexus: A case series

In brachial plexus injuries, though nerve transfers and root grafts have improved the results for shoulder and elbow reconstruction, wrist extension has received little attention. We operated on three young patients with C5-C8 root injuries of the left brachial plexus, each operated upon within 6 months of trauma. For wrist extension reconstruction, we transferred a proximal branch of the flexor digitorum superficialis to the motor branch of the extensor carpi radialis brevis. Twenty-four months after surgery, all patients recovered some degree of active wrist motion, from full flexion to near neutral. Independent control of finger flexion and wrist extension was not observed. In C5-C8 root injuries of the brachial plexus, transfer of a flexor digitorum superficialis motor branch to the extensor carpi radialis brevis produces limited recovery.

Cervical Extradural “En-Plaque” Meningioma

Spinal meningiomas with concurrent extradural localization and "en-plaque" growth are exceptional, with only five reported cases in the literature. We report another case and discuss the peculiar diagnostic and surgical features of this very unusual pattern of growth. A 74-year-old woman was observed because of a rapidly progressive tetraparesis, more marked in the left arm. Magnetic resonance imaging depicted an inhomogeneously enhancing tumor of the cervical spine, extending from C4 to T1, with diffuse dural enhancement and extension into the left brachial plexus roots. At operation by laminotomy from C4 to C7 a firm posterior extradural tumor arising from the dura was resected; however, the diffusely infiltrated dura could not be removed. Histology was in favor of a transitional meningioma (WHO I). Postoperatively, irradiation to the operative field with 50 Gy was performed. At follow-up, 18 months after surgery, clinical improvement to moderate tetraparesis was evidenced. Spinal extradural "en-plaque" meningiomas have been mainly reported in women and at the cervical region, and show extension to many spinal levels as well as diffuse dural infiltration. Preoperatively, they may be differentiated from spinal metastases and lymphomas because of the presence of a "dural tail" sign and calcifications. The surgical resection is mainly limited to the posterior and lateral extradural tumor component, whereas the whole invaded dura is very difficult to resect, mainly in cases with circumferential infiltration. This results in a high rate of tumor recurrence.