Left Brachial Plexus Research Articles

An unusual case of hearing loss in a patient with neurofibromatosis type 1

A man of Afro-Caribbean background was diagnosed with eurofibromatosis type 1 (NF1) aged 21 years, on the basis of afe-au-lait spots, cutaneous neurofibromas and axillary freckling, ithout a family history. He had mild cognitive impairment conistent with NF1. In his twenties, he had removal of neurofibromas rom the left brachial plexus, right hemithorax and left sciatic erve. He presented to our neurofibromatosis service at the age of 32 ears, with numbness, weakness and clumsiness in the left arm, nd heaviness in the legs. Examination demonstrated right-sided pper motor signs in upper and lower limbs and a diminished eft triceps jerk. Magnetic resonance imaging of the cervical spine

Neoplastic brachial plexopathy detected by ultrasonography in a patient with chronic cervicobrachialgia

We report here a case of neoplastic brachial plexopathy detected by musculoskeletal ultrasonography in a patient with chronic cervicobrachialgia. A 71-year-old man presented at Gülhane Military Medical Academy, Turkish Armed Forces Rehabilitation Center, Ankara, Turkey with a one-year history of cervicobrachial pain radiating to the left arm and numbness in the medial aspect of the left arm and hand. He could not tolerate magnetic resonance imaging because his pain was exacerbated by cervical extension. Radiographs of his chest and cervical spine were normal. Ultrasound examination of the left brachial plexus revealed segmental fusiform swelling, suggestive for a compressing lesion. Magnetic resonance imaging of the brachial plexus performed under general anaesthesia revealed a left apical lung tumour (Pancoast) infiltrating the brachial plexus. Clinicians should consider neoplastic brachial plexopathy, which is an uncommon diagnosis, when evaluating patients with unrelenting and severe cervicobrachialgia. Musculoskeletal ultrasonography can be beneficial for examining brachial plexus lesions.

Transfer of a Motor Fascicle From the Ulnar Nerve to the Branch of the Radial Nerve Destined to the Long Head of the Triceps for Restoration of Elbow Extension in Brachial Plexus Surgery

Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks. Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases. The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.

Superficial Siderosis of the Central Nervous System

Superficial siderosis of the central nervous system (CNS) is a rare entity characterized by the deposition of hemosiderin in the leptomeninges. In most cases it is caused by chronic and recurrent bleeding into the subarachnoid space as a subclinical form and for long periods of time. The cases described in the literature are associated with tumors, aneurysms, arteriovenous malformations, changes in post-surgical, traumatic cervical and brachial plexus injuries. However, the cause of bleeding is unclear in 40-50% of cases. This report describes the case of a 38-year-old man with a history of trauma with a complete lesion of the left brachial plexus. The patient presented progressively worsening gait imbalance, bilateral deafness, tinnitus and memory loss over two years. Neurological examination disclosed bilateral hearing loss, left upper limb plegia with atrophy of muscle mass, spastic paraparesis with pyramidal signs and gait ataxia. The analytical/genetic study was consistent with hereditary hemochromatosis. In addition to typical findings of siderosis, MR disclosed pseudomeningocele while CT angiography and angiography revealed an aneurysm of the internal carotid artery. Although rare, we should be aware of superficial siderosis especially in imaging studies in patients with deafness or ataxia and in those with lesions of the brachial plexus. The imaging signals are subtle and can easily go unrecognized. The radiological investigation must be extensive to find the primary cause.

Bilateral Brachial Plexus Home Going Catheters After Digital Amputation for Patient With Upper Extremity Digital Gangrene

Peripheral nerve catheter placement is used to control surgical pain. Performing bilateral brachial plexus block with catheters is not frequently performed; and in our case sending patient home with bilateral brachial plexus catheters has not been reported up to our knowledge. Our patient is a 57 years old male patient presented with bilateral upper extremity digital gangrene on digits 2 through 4 on both sides with no thumb involvement. The plan was to do the surgery under sequential axillary blocks. On the day of surgery a right axillary brachial plexus block was performed under ultrasound guidance using 20 ml of 0.75% ropivacaine. Patient was taken to the OR and the right fingers amputation was carried out under mild sedation without problems. Left axillary brachial plexus block was then done as the surgeon was closing the right side, two hours after the first block was performed. The left axillary block was done also under ultrasound using 20 ml of 2% mepivacaine. The brachial plexus blocks were performed in a sequential manner. Surgery was unremarkable, and patient was transferred to post anesthetic care unit in stable condition. Over that first postoperative night, the patient complained of severe pain at the surgical sites with minimal pain relief with parentral opioids. We placed bilateral brachial plexus catheters (right axillary and left infra-clavicular brachial plexus catheters). Ropivacaine 0.2% infusion was started at 7 ml per hour basal rate only with no boluses on each side. The patient was discharged home with the catheters in place after receiving the appropriate education. On discharge both catheters were connected to a single ON-Q (I-flow Corporation, Lake Forest, CA) ball pump with a 750 ml reservoir using a Y connection and were set to deliver a fixed rate of 7 ml for each catheter. The brachial plexus catheters were removed by the patient on day 5 after surgery without any difficulty. Patient's postoperative course was otherwise unremarkable. We concluded that home going catheters are very effective in pain control postoperatively and they shorten the period of hospital stay.KeywordsBrachial plexus; Home going catheters; Post-operative pain

Penetrating Abdomino-Thoracic Injuries: Report of Four Impressive, Spectacular and Representative Cases as Well as Their Challenging Surgical Management

Gunshot wounds are rare events in European countries, but stab and impalement injuries occur more frequently and are often spectacular. The aim of the study was to describe several types of penetrating abdomino-thoracic injuries as well as the appropriate surgical interventions, including complex wound management. The representative case series includes four patients with abdomino-thoracic penetrating trauma (two impalements and two stabbings), who were treated in a surgical university hospital (tertiary) centre during a 12-month period. 1. A man was impaled on a steel pipe, which entered the body above the right kidney and behind the liver through the mediastinum via the right thorax, passing the heart and aortic arch up to the left clavicle. The rod was removed via sternotomy and median laparotomy. Only the left subclavian vein required repair. Postoperatively, a residual lesion of the left brachial plexus caused temporary pneumonia. 2. A leg of a collapsing chair drilled into a woman's left foramen obturatorium and exited the body at the right anterior iliac spine. At a regional hospital, the chair leg was removed and the canal caused by gluteal penetration was excised. Exploratory laparotomy revealed peritonitis resulting from a perforated ileum. The injury was repaired with segmental resection and anastomosis. Postoperative right inguinal wound necrosis necessitated excision and vacuum-assisted closure sealing. The patient has residual paresthesia in her left leg resulting from a sacral plexus lesion. 3. During an altercation, a man was stabbed twice in the right thorax. The right pulmonary lobe, the diaphragm, and the liver dome between segment VIII and V were injured. The patient also had a large scalp avulsion at the left and right parietooccipital site and transection of the biceps muscle at the middle third of the right humerus. The chest injuries, approached via right subcostal incision and right anterior thoracotomy were managed with liver packing (two towels, removed after 2 days), suture of the diaphragm, and pleural drainage. 4. A man was stabbed in the left thorax, resulting in pneumothorax and lesions of the diaphragm and left third of the transversal colon, and the neck, resulting in lesions of the pharynx and internal jugular vein. These injuries were approached with left thoracic drainage and suture of the colon and diaphragm lesions. Subsequent right thoracotomy was required to treat right pleural empyema caused by bronchopneumonia as a consequence of blunt thoracic trauma. In addition, the patient required relaparotomy to drain an abscess within the Douglas space and Billroth II gastric resection to control recurrent Forrest-Ia bleeding. Penetrating abdomino-thoracic injuries demand immediate life-saving measures, transfer to a trauma centre, appropriate resuscitative care, prompt diagnosis, and surgical intervention by an interdisciplinary team of abdominal, vascular, and cardiac surgeons. If these measures are provided, outcomes are maximized, mortality is minimized, and permanent damage can be avoided.

Neurolymphomatosis on F-18 FDG PET/CT and MRI Findings: A Case Report.

Neurolymphomatosis is a rare manifestation of malignant lymphoma. A 74-year-old man, in complete remission from diffuse large B cell lymphoma, presented with a loss of pain and temperature sensation in the left hemiface and left upper extremity, and motor weakness in the left upper and both lower extremities. Cerebrospinal fluid analysis and brain magnetic resonance imaging (MRI) findings were negative. Combined fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) revealed multiple linear hypermetabolic lesions along the mandibular branch of the left trigeminal nerve, left brachial plexus, right axillary nerve, right suprarenal plexus, right adrenal gland, right femoral nerve, and both sciatic nerves, which corresponded to the patient's complex neurologic symptoms. C-spine and pelvic MRI revealed diffuse thickening with enhancement in the left brachial plexus and in the proximal portion of the left sciatic nerve, but negative findings for other sites identified by FDG-PET/CT. These findings suggest that FDG-PET/CT can detect peripheral nerve infiltration by malignant lymphoma earlier than MRI. Thus, if a patient with a history of lymphoma presents with neurologic symptoms, FDG-PET/CT should be performed to evaluate neurolymphomatosis.

Morphology of Brachial Plexus and Axillary Artery in Bonobo (Pan paniscus)

A left brachial plexus and axillary artery of bonobo (Pan paniscus) were examined, and the interrelation between the brachial plexus and the axillary artery was discussed. This is the first report of the brachial plexus and the axillary artery of bonobo. The bonobo brachial plexus formed very similar pattern to that of other ape species and human. On the other hand, the branches of the bonobo axillary artery had uncommon architecture in comparison with human case. The axillary artery did not penetrate the brachial plexus and passes through all way along anterior to the brachial plexus. Only 4.9% of human forelimbs have this pattern. Moreover, the brachial artery runs through superficially anterior to branches of the brachial plexus.

Magnetic resonance neurography findings in herpetic brachial plexopathy

Brachial plexus neuritis was originally diagnosed by clinical signs and symptoms in addition to electrophysiological studies [1–5]. Therefore, initially, brachial plexopathy was misdiagnosed as a shoulder disorder, cervical radiculopathy, or myelopathy [4]. Herpes zoster brachioplexopathy is a rare complication characterized by motor weakness of the arm, which may occur in limbs affected by herpes zoster. Varicella zoster virus can induce inflammatory brachial plexopathy [1–4, 6]. It is still under-recognized by clinicians and misdiagnosis or delay in treatment can occur as a consequence. Magnetic resonance (MR) imaging studies have been attempted for diagnosis of brachial plexus disorders [6–9]. However, there are very few reports about MR neurography for zoster-induced brachial neuritis [6]. We present a 68-yearold male patient with monoparesis resulting from brachial plexopathy caused by varicella zoster virus infection and report the findings of MR neurography in this patient. A 68-year-old man noted a skin rash, vesicles, and pain in his left arm. At that time, he was not treated. Four days later, he developed weakness in his left arm and visited the emergency department at our hospital for this complaint. Upon admission, the patient had multiple erythematous crusted plaques on the left arm (Fig. 1). Neurologic examination revealed weakness of shoulder abduction (grade 2/5) and elbow flexion (grade 2/5), and the left biceps reflex was diminished. He had dysesthesia and hyperalgesia over the left C6–7 dermatomes. The level of IgG antibodies against varicella zoster virus was elevated. However, the IgM antibody level against varicella zoster was negative. We performed MR neurography of the brachial plexus with a 1.5-T MR imaging system (Gyroscan Intera, Philips Medical Systems, Netherlands) 10 days after admission. Among the MR neurography images, the coronal short tau inversion recovery (STIR, TR/TE: 3558.39/60.00, time inversion: 160 ms) image depicted edema and thickening of the superior trunk of the left brachial plexus compared to the unaffected right side (Fig. 2). MR imaging also showed denervation edema of the left supraspinatus muscle (Fig. 3). Needle electromyography showed fibrillations and positive sharp waves in the left deltoid and biceps muscles and only positive sharp waves in the left supraspinatus muscle. The patient was treated with intravenous acyclovir and physical therapy for his left arm. After discharge, he was followed in the outpatient department for 6 months. His left-arm weakness improved to grade 3. Herpes zoster brachial plexus neuritis-associated motor weakness may be due to a demyelinating process related to inflammation [1–3, 5, 6]. Inflammatory changes in the brachial plexus result in swelling and thickening of divisions or cords of the brachial plexus. MRI can demonstrate inflammatory changes in neural tissue and MR neurography can detect inflammatory changes in the brachial plexus and denervation edema of affected muscle [6–9]. Especially STIR images from MR neurography have been used for evaluation of pathological lesions of the brachial plexus such as neuralgic amyotrophy [7, 8]. In our case, we evaluated the STIR images of the brachial plexus and they D. H. Heo Y. J. Cho (&) Department of Neurosurgery, Peripheral Nerve Disorder Clinic, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, 153 Kyo-dong, Chuncheon-shi, Kangwon-do, Korea e-mail: nssur771@hallym.or.kr

Lower Brachial Plexopathy in a Child With Henoch-Schönlein Purpura

Henoch-Schönlein purpura is characterized by nonthrombocytopenic purpura with multisystem involvement. Nervous system involvement was reported, characterized by headaches, mental-status changes, seizures, paresis, coma, or encephalopathy. Peripheral neuropathy is rarely reported. We describe a 12-year-old boy with Henoch-Schönlein purpura who presented with abdominal pain and underwent a laparatomy before the onset of palpable purpuric rash. Neuropathic findings in the left lower brachial plexus developed while he was receiving steroid treatment for gastrointestinal involvement. He responded well to intravenous pulse steroid therapy. Both sensory and motor dysfunction returned to normal after 3 months of treatment. His steroid dose was gradually withdrawn and stopped. He was symptom-free at month 12 of follow-up.

Reorganization in motor cortex after brachial plexus avulsion injury and repair with the contralateral C7 root transfer in rats

The purpose of our study was to establish the profile of cortical reorganization in whole BPAI on rats and evaluate changes of cortical reorganization after repair of the median nerve with the contralateral C7 root transfer. Forty adult SD rats underwent whole roots avulsion of left brachial plexus, among them 20 received contralateral C7 root transfer to the injured median nerve. Intracortical microstimulation was performed in primary motor cortex (M1) at intervals of 3, 5, 7, and 10 months, postoperatively. The maps of motor cortical responses were constructed. Five normal rats were used as the control. Results showed that stimulating right M1 elicited motion of left vibrissae, submaxilla, neck, back, and left hindlimb after left BPAI, among them neck representation area replaced the forelimb area throughout the reorganization process. The left forelimb representation area was found in the left motor cortex 5 months after the contralateral C7 root transfer and existed in both motor cortexes at 7th postoperative month. The left forelimb representation area was detected only in right motor cortex at 10th month, postoperatively. In conclusions, after the contralateral C7 root transfer for repair of the median nerve in BPAI, the cortical reorganization occurred in a time-dependent reorganization. The findings from this study demonstrate that brain involves in the functional recovery after BPAI and repair with nerve transfer and suggest that efforts to improve the results from nerve repair should address the peripheral nerve as well as the brain.

Neuritis ossificans of the common peroneal nerve

Dear Sir: We read with interest the 2009 report by Trigkilidas et al. of an unusual case of neuritis ossificans of the common peroneal nerve treated at the historic Royal National Orthopaedic Hospital in Stanmore, UK [1]. The term “neuritis ossificans” was originally introduced by our group in 1999 [2, 3]. At least, that is what we thought at the time. The designation harked back to its striking histological similarities with heterotopic ossification and myositis ossificans, processes often associated with trauma, but occurring within nerve. Histologically similar cases had previously been published under various designations. More recent cases of so-called neuritis ossificans have been reported by others, as have been summarized by Trigkilidas [1]. However, we were recently surprised to find that the term neuritis ossificans had been introduced long ago [4]— at our very own institution, no less. It was ascribed to an entirely different lesion, one with a dire prognosis. Herein, we seek to clarify the literature with respect to the term neuritis ossificans—its history, current usage, and clinical significance. The original patient in whom the term had been applied was a 29-year-old woman who presented to Mayo Clinic in the winter of 1939. Her case was reported in 1946 by the esteemed neurologist Henry Woltman and the neurosurgeon Alfred Adson [4]. The initial clinical diagnosis was that of post-traumatic neuritis or plexitis affecting the posterior cord of the left brachial plexus. A 3-year period of incomplete improvement and stabilization followed, but her neurological status worsened over the next 4 years. Upon presentation in 1946 she had developed complete loss of left brachial plexus function and a Brown–Sequard syndrome. The radiographic findings were illustrated in the published paper and showed a large, calcified soft tissue mass in the supraclavicular region and lower cervical spine. Its appearance was suggestive of myositis ossificans. She underwent a two-stage operative procedure, the first being a cervical and upper thoracic hemilaminectomy that revealed an intraand extradural mass that extended through the left C5–C6 foramen. The spinal cord was decompressed. In the first operative note of 30 May 1946, Adson wrote:

Conduction block and impaired axonal function in tick paralysis

Tick paralysis (TP) is an uncommon disorder caused by a neurotoxin secreted by engorged female ticks. The cause of TP remains unclear, although alterations in axonal ion channel function and neuromuscular transmission have been proposed. In the present case, nerve excitability techniques, which provide information regarding axonal ion channel function, were used to elucidate the mechanism underlying weakness in a 45-year-old man who presented with weakness following a tick bite in the lateral aspect of the left axilla. Standard clinical nerve conduction studies were undertaken during the acute phase of symptoms and following clinical recovery. Nerve excitability studies were performed to investigate possible changes in ion channel properties distal to the site of conduction failure. Nerve conduction studies and electromyography suggested the possibility of a lesion involving the lower trunk of the left brachial plexus. Nerve excitability studies distal to the site of the tick bite demonstrated an abrupt increase in refractoriness, a marker of recovery from inactivation of Na(+) channels. There was normalization of both nerve conduction and nerve excitability parameters associated with clinical recovery. The alteration in refractoriness is similar to that noted in disorders involving the terminal portion of the motor nerve. The changes raise the possibility that TP may cause weakness through impairment of distal neural transmission.

F-18 2-Fluoro-2-Deoxy-Glucose Positron Emission Tomography/Computed Tomography for the Detection of Radicular and Peripheral Neurolymphomatosis

Neurolymphomatosis is an uncommon extranodal manifestation of non-Hodgkin lymphoma. It may mimic a broad variety of neurologic conditions which renders clinical diagnosis challenging. As blind nerve biopsy is invasive and may be false negative, surrogate criteria for the diagnosis of neurolymphomatosis have been proposed based on magnetic resonance imaging/computed tomography findings. However, these morphologic modalities may suffer from limited sensitivity. Recently, a few reports have been published that discuss a possible advantage of F-18 2-fluoro-2-deoxy-glucose positron emission tomography/computed tomography (F-18 FDG PET/CT) in these patients.We report the case of a 41-year-old man who presented with progressive tetraparesis and dysaesthesia, in which F-18 FDG PET/CT aided to the diagnosis of neurolymphomatosis due to a large B-cell lymphoma. The patient received chemotherapy (R-CHOP) and the neurologic symptoms were clearly regressive. Three months after the end of systemic chemotherapy the patient presented again with progressive neurologic symptoms. A second PET/CT was performed and demonstrated disease recurrence in the right testis as well as widespread neurolymphomatosis. Additional ultrasound and magnetic resonance imaging examinations were performed and confirmed infiltration of the left brachial plexus, the right femoral, and the right sciatic nerve.We present this case to support the hypothesis that F-18 FDG PET/CT is a valuable imaging modality in patients with suspected neurolymphomatosis. It allows one to accurately determine the extent of the disease in a single whole-body examination.

Functional reorganization in the brain afar contralateral C7 transfer to the median nerve

Objective To investigate changes in brain function zones following contralateral Co transfer and its possible mechanisms, and provide scientific bases for clinical measurements to improve functional recovery after such nerve transfer. Methods Experiment al group: 6 adult male patients with left brachial plexus total avulsions who underwent contralateral G7 transfer and had recovered M3 or above muscle power of wrist flexors and finger flexors on the injured side under volitional vigorous healthy shoulder (right side) adduction. Control group:6 healthy male adults whose motor task was w adduct the right shoulder. Positron Emission tomography (PET) techniques were applied to acquire scans of the brain for analysis. Results PEI scans showed excitation mainly in the left hemisphere upon right shoulder adduction in the control group. In the experimental group, in addition to excitation in the left hemisphere, right shoulder adduction resulted in excitation in the right frontal lobe and apical lobe, including SMI and SMA, with simultaneous subcortical area activation. Conclusion Functional imaging evidences of transhemispheric plasticity in adult brain were obtained. The cortical areas involved in functional reorganization were delineated. The hypothesis that the brain may try to restore control of an injured limb to its original cortical areas after nerve transfer was put forth. Key words: Nerve transfer; Brachial plexus; Neuronal plasticity; Somatosensory cortex

Neurologic complications in liver transplantation.

A retrospective review is presented of neurologic complications in our first 143 consecutive adult patients (208 liver transplants in 143 adults and 18 children) undergoing liver transplantation. Nineteen (13.2%) of the 143 patients developed neurologic complications in the postoperative period. Immunosuppression was initiated intraoperatively with steroids with the addition of azathioprine on Day 1 and cyclosporine, adjusted by RIA to a level of 400-600 ng/ml, on Day 2 post-transplantation. Azathioprine is discontinued in the third month. Fourteen of the 19 patients (73.6%) presented with CNS complications characterized by: diffuse multifactorial encephalopathy (5 patients); leukoencephalopathy (2 patients) which required temporary (1 case) or permanent (1 case) discontinuation of cyclosporine A; hemorrhage (in 2 cases due to arterial hypertension and coagulopathy and another due to unknown causes); ischemic/anoxic injury secondary to cardiorespiratory arrest (2 patients) or arteriothrombosis (1 patient); and myelopathy (1 patient) due to vertebral compression (T10-T11) secondary to osteoporosis. The diagnostic studies most often employed were computed tomographic (CT) (85.7%) and electroencephalography (EEG) (42.8%). Five of 19 patients (26.3%) suffered peripheral nervous system (PNS) complications: 1 patient with reversible Claude-Bernard-Horner Syndrome caused by central venous catheterization during anesthesia; 2 patients with peroneal nerve palsy due to compression below the knees by operating room table supports; 1 patient with an irreversible lesion of the right recurrent laryngeal nerve secondary to prolonged intubation and central venous catheterization; and 1 patient with a reversible lesion of the left brachial plexus secondary to inadvertant hyperextension of the upper extremity on the O.R. table due to the need for dialysis and catheterization of the axillary vein for veno-venous bypass.(ABSTRACT TRUNCATED AT 250 WORDS)

Restoration of elbow flexion after brachial plexus injury by free functional rectus femoris muscle transfer

A 22-year-old patient sustained a complex injury of the left brachial plexus. Primary brachial plexus reconstruction did not lead to any functional recovery. Twenty-six months later, the patient showed an upper brachial plexus palsy, which precluded the possibility for a latissimus dorsi muscle transfer. To re-establish elbow flexion, a free myocutaneous neurovascular rectus femoris flap, harvested from the left thigh, was neurotised to the accessory nerve using a sural nerve graft. Ten months after the free functional rectus femoris transfer, early electromyographic results were detected, and 7 months later, strong reinnervation signs occurred. Due to dissatisfaction with the aesthetic results including an impression in the left shoulder and pectoral region, two silicon implants were inserted 41 months after rectus femoris muscle transfer. A few hours after the operation, the patient experienced palsy of the transplanted muscle. The silicon implants were removed immediately. Initial recovery of muscle function was detected by electromyography 4 months later and complete reinnervation was observed 8 years postoperative. Elbow flexion was rated M4, and the patient had no functional donor-site morbidity. The authors conclude that free rectus femoris muscle transfer offers excellent results when effort is put into postoperative rehabilitation with extensive training programs.

A new anatomical technique to investigate nerves by imagery

We describe a novel post mortem technique that makes it possible to visualise the nerve structure of the brachial plexus using imaging. We dissected in situ the brachial plexus of a cadaver preserved by formaldehyde. A preparation composed of a mixture of baryte powder, water and colorant, was applied to all sides of the brachial plexus and blood vessels of the region under study. A high resolution CT scan was performed. With the aid of Mimics (Materialise) software, segmentation of all the nerve and vascular structures on each of the 650 slices obtained was performed. The Mimics software then compiled all the slices to generate a 3-dimensional STL image. The image obtained was printed with a stereolythography printer, to produce a plastic model representing part of the cervico-thoracic spinal cord, the ribs, sternum, scapula, humerus, and clavicle, with the left brachial plexus and the subclavian, axillary and brachial veins and arteries. This technique has the potential for a wide range of uses: for teaching anatomy, to improve teaching of medical techniques, 3-dimensional modelisation of other nerve structures. The advantage is that the model obtained is a faithful and realistic reproduction.

Brachial plexus neuritis following HPV vaccination

We present a 19-year-old girl who developed a left brachial plexus neuritis following vaccination with a quadrivalent human papillomavirus (HPV) vaccine. Post-vaccination brachial plexus neuritis is a rare event. Nevertheless, this first case warrants careful attention in view of the large vaccination campaigns in young adolescents being launched all over the world.

The changes of glutamic acid and NMDA receptors in motor cortex after contralateral C7 transfer

Objective To explore the changes of glutamic acid and NMDA receptor expression in motor cortex following contralateral C7 transfer. Methods Total root avulsion of the left brachial plexus and transfer of the right C7 nerve root to the left median nerve via ulnar nerve graft was established in a rat model. Recovery of median nerve function was monitored with electrophysiologic examination at various postoperative intervals. Representation of the injured forepaw was mapped using intracortical microstimulation (ICMS). According to the ICMS results, brain samples were harvested for determination of glutamic acid and NMDA receptors (NR1、 NR2A、NR2B)in motor cortex by immuno-histochemical assay. Results After the surgery recovery of flexor digitorum profundus was indicated by decrease in compound muscle action potential (CAMP) latency and increase in CMAP amplitude over time. At 4 months, median nerve representation region of the affected forelimb appeared in the ipsilateral motor cortex in 3 rats and upregulation of NR1 was observed in both hemispheres of all rats from the operative groups. The NR1 expression showed significant change in the normal and operative groups. Meanwhile, NR1 expression in the right cortex was significantly higher than that in the left cortex. At 7 months, both hemispheres of cortex activated the injured forepaw in 4 rats. There was a significant increase in NB2A expression in the right motor cortex in the operative groups and NR2A expression in rats following contralateral C7 transfer was significantly higher than that in the rats from the other operative groups. At 10 months, the contralateral motor cortex exclusively controlled the injured forepaw and the expression of NR2A was still up-regulated. NR2A expression in rats following contralateral C7 transfer was still significantly higher than that in the rats from the other operative groups. Conclusion Transhemispheric functional reorganization of the motor cortex is confirmed in rats following contralateral C7 transfer. NR1 plays an important role in the primary cortical plasticity and NR2A is needed to continue this reorganization in later stage. Key words: Brachial plexus; Nerve transfer; Glutamic acid; Functional reorganization; NMDA receptors