Middle Trunk Research Articles

Superior Mesenteric Vein-First Approach to Robotic Complete Mesocolic Excision for Right Colectomy: Technique and Preliminary Outcomes.

There is growing evidence supporting complete mesocolic excision as the optimal surgical approach for right-sided colon cancer to improve oncologic outcomes in comparison with conventional surgical resection. Although the feasibility of a minimally invasive approach to complete mesocolic excision has been reported, obesity has been associated with increased difficulty for finding the correct plane for dissection and delineating the vascular anatomy. We describe a novel approach with early identification of and dissection along the superior mesenteric vein during robotic complete mesocolic excision surgery, for all patients, regardless of BMI. The dissection is initiated with identification of the superior mesenteric vein as the starting point. Then, the vascular dissection is performed along the anterior superior mesenteric vein plane while observing complete mesocolic excision principles. The anterior superior mesenteric vein plane is an optimal and safe dissection plane because there are no anterior tributaries. The ileocolic vein and artery are ligated separately at their junction with the superior mesenteric vein and superior mesenteric artery. The dissection is then continued cephalad along the superior mesenteric vein, identifying additional colic arteries, including the middle colic arterial trunk as well as the venous tributaries to the superior mesenteric vein such as the gastrocolic trunk. The superior right colic vein is then ligated at the gastrocolic confluence and the middle colic vessels are ligated. After the vascular dissection is completed, the colon is then mobilized. A total of 66 patients received the "superior mesenteric vein-first" approach for robotic colectomy between 2013 and 2018, including 40.9% patients with BMI >30 kg/m. Median lymph node yield was 32 (interquartile range, 25-40). The median distance to the high vascular tie was 12 cm (interquartile range, 7-19). Median estimated blood loss was 33 mL (interquartile range, 25-50). Overall rate of grade ≥3 complications was 3.0%. Using the superior mesenteric vein-first approach, robotic complete mesocolic excision for right colectomy can be performed on patients with high or low BMI with excellent short-term oncologic outcomes and acceptable morbidity. See Video Abstract at http://links.lww.com/DCR/A960.

Anatomic Variation of the Phrenic Nerve and Brachial Plexus Encountered during 100 Supraclavicular Decompressions for Neurogenic Thoracic Outlet Syndrome with Associated Postoperative Neurologic Complications

The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P=0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P=0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P=1.0) with full recovery to normal function. Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.

A prospective study of high resolution ultrasound in brachial plexopathies – Correlation with electrophysiological measurements

ObjectivesTo evaluate the diagnostic role of ultrasound in brachial plexopathies. MethodsWe included 59 healthy subjects (HS) and 42 patients consecutively referred with clinical suspicion of brachial plexopathy from October 2015 to May 2016. Patients underwent routine electrodiagnostic testing (EDx) as reference standard and a blinded standardised ultrasound examination of the brachial plexus as index test with cross-sectional area (CSA) as the ultrasound parameter of choice. ResultsSeventeen patients were diagnosed by EDx with brachial plexopathy, ten with mononeuropathies, and ten had normal EDx. Five had a cervical radiculopathy. In 11 (64%) out of the 17 patients with EDx diagnosed plexopathy, we found at least one abnormal level on ultrasound. Six (60%) out of ten normal EDx patients had a normal ultrasound examination at all levels. Ultrasound identified the same abnormal level(s) as EDx in eight (73%) of the 11 patients who had both abnormal EDx and ultrasound results. Mean CSA was higher in the plexopathy group compared to HS at the level of the C6 root (p = .022), the middle trunk (p = .027), and the medial cord (p = .003). ConclusionUltrasound examination showed abnormalities in patients with brachial plexopathies in good agreement with EDx. SignificanceUltrasound may be an important supplement to electrodiagnostics in evaluating brachial plexopathies.

Anatomical Entrapment of the Dorsal Scapular and Long Thoracic Nerves Secondary to Brachial Plexus Piercing Variation

Understanding and documenting anatomical variation plays a vital role for furthering the ability of a physician to diagnose, care, and treat patients. Despite the textbook definition of the typical or classical pattern of the brachial plexus as emerging between the anterior and middle scalene muscles, variants involving different patterns are becoming well documented, especially the high frequency of “piercing” variants, in which the superior and/or middle trunk of the brachial plexus courses through the belly of the anterior scalene muscle. While this variation is now widely acknowledged, it is currently unclear how these variants may influence branching patterns distally along the brachial plexus in branches such as the dorsal scapular and long thoracic nerves.This project strived to identify and quantify the types of variations (piercing and non‐piercing variants) of the brachial plexus trunks, and assess the frequency of corresponding anomalies in the dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Human cadavers used in gross anatomy courses at Midwestern University's Glendale Campus were utilized in this project to examine a total of ninety‐one cadaveric brachial plexuses (46F/45M) with the right and left sides being examined independently. In the majority of specimens (89.71%), at least one neural structure (brachial plexus, DSN, or LTN) pierced one of the scalene muscles. The most common condition for the brachial plexus was piercing the anterior scalene muscle (59.34%), while the most common piercing condition for both the DSN and LTN was through the middle scalene (41.89% and 38.1% respectively). Of the specimens with a DSN piercing pattern, 64.44% also had the brachial plexus piercing variant. Similarly, of the specimens with piercing LTNs, 72.97% also had trunk(s) of the brachial plexus piercing a scalene muscle. Thus, the anomalous brachial plexus piercing variants are associated with higher frequencies of distal nerve branches also coursing through the scalene musculature, and specifically, there is a statistically significant correlation between brachial plexus piercings and LTN piercing (p = 0.0412).Circumscapular pain is a frequent complaint in clinical practice. While numerous etiologies exist, DSN entrapment is a common underlying cause. It is well documented that the DSN courses through the scalene region as it exits the neck, where it may become entrapped between or even within adjacent scalene muscles. Similarly, compromise of the LTN can result in debilitating paralysis or paresthesia of the serratus anterior muscle, often resulting in winging of the scapula. As a primary stabilizer of the scapula, serratus anterior is crucial in maintaining the normal position of the scapula against the thoracic wall and in sustaining proper scapulohumeral function. This study demonstrated that anatomical entrapment of the DSN and LTN are both quite common, and occur in higher frequency in individuals with brachial plexus piercing variants. Additionally, individuals with these compounded neural piercing patterns may be at greater risk for nerve impingement in the cervical, pectoral, and/or scapular region.Support or Funding InformationSupport provided by Midwestern University.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Залежність компонентів надземної фітомаси ялинових деревостанів від середніх таксаційних показників у переважаючих типах лісорослинних умов Полонинського хребта Українських Карпат

На основі встановлених значень основних компонентів надземної фітомаси в абсолютно сухому стані, розрахованих та усереднених за результатами опрацювання даних польових досліджень, розроблено регресійні моделі їхньої залежності від середньої висоти, середнього діаметра та відносної повноти деревостанів з домінуванням ялини європейської в умовах вологого сугруду (С3) та вологого груду (D3). Отримані рівняння, зважаючи на значення коефіцієнтів детермінації, з достатньою точністю описують досліджувані залежності. Значення загальної надземної фітомаси деревостанів та значення її окремих компонентів в обох досліджуваних типах лісорослинних умов (ТЛУ) збільшується зі збільшенням значень відповідних таксаційних показників. У ТЛУ С3 значення фітомаси деревини стовбура у досліджуваному діапазоні середніх висот за відносної повноти збільшуються від 18,8-26,9 до 380-401 т×га-1, тоді як у ТЛУ D3 збільшення відбувається від 17,2-24,6 до 381-402 т×га-1. Різниця частки у значеннях цього показника зменшується із збільшенням середніх значень і висоти і діаметра стовбура. Фітомаса кори стовбура, деревини і кори гілок та загальна надземна фітомаса ялинових деревостанів у ТЛУ С3 мають вищі значення за однакоих значень таксаційних показників, порівняно із D3. Фітомаса деревини стовбура навпаки – має вищі значення в ТЛУ D3. Частка різниці між значеннями загальної надземної фітомаси в межах ступені висоти зменшується зі збільшенням середнього діаметра.

Ultrasound-guided subomohyoid suprascapular nerve block and phrenic nerve involvement: a cadaveric dye study

Backgrounds and objectivesThe anterior approach to the subomohyoid suprascapular (SOS) nerve is a new, technically easy and reliable regional anesthesia technique for postoperative shoulder analgesia. However, due to its proximity,...

Application of CUBE-STIR MRI and high-frequency ultrasound in contralateral cervical 7 nerve transfer surgery

Objective The objective of the study was to investigate the feasibility of CUBE-SITR MRI and high-frequency ultrasound for the structural imaging of the brachial plexus to exclude neoplastic brachial plexopathy or structural variation and measure the lengths of anterior and posterior divisions of the C7 nerve, providing guidelines for surgeons before contralateral cervical 7 nerve transfer. Methods A total of 30 patients with CNS and 20 with brachial plexus injury were enrolled in this retrospective study. All patients underwent brachial plexus CUBE-STIR MRI and high-frequency ultrasound, and the lengths of the anterior and posterior divisions of C7 nerve were measured before surgery. Precise length of anterior and posterior divisions of contralateral C7 nerve was measured during surgery. Results MRI-measured lengths of anterior and posterior divisions of C7 nerves were positively correlated with that measured during surgery (anterior division, r = 0.94, p < .01; posterior division, r = 0.92, p < .01). High agreement was found between MRI-measured and intra-surgery measured length of anterior and posterior divisions of C7 nerve by BLAD-ALTMAN analysis. Ultrasonography could feasibly image supraclavicular C7 nerve and recognize small variant branches derived from middle trunk of C7 nerve root, which could be dissected intra-operatively and confirmed by electromyography during the procedure of contralateral C7 nerve transfer. Conclusion CUBE-STIR MRI had advantages for the imaging of the brachial plexus and measurement of the length of root-trunk-anterior/posterior divisions of C7 nerve. The clinical role of ultrasonography may be a simple way of evaluating general condition of C7 nerve and provide guidelines for contralateral C7 nerve transfer surgery.

Endoscopic injection sclerotherapy for pediatric bleeding esophageal varices complicated by gastric vein, main portal vein, splenic mesenteric junction, and splenic vein occlusion: a case report

BackgroundEndoscopic injection sclerotherapy (EIS) is a life-saving procedure for pediatric patients with bleeding gastric varices (GV) associated with advanced liver cirrhosis and severe portal hypertension. Because of the lack of an endoscopic banding ligation device for pediatric patients, EIS is usually performed for bleeding esophageal varices (EV) in infants with congenital biliary atresia.Case presentationWe present a case of a 15-month-old female infant with type I biliary atresia with jaundice (total serum bilirubin, 22.2 mg/dL), hypoalbuminemia (serum albumin level, 2.58 g/dL), coagulopathy (prothrombin time > 20 s compared with that of a normal control), ascites, splenomegaly, portal hypertension (portal vein velocity, 3.9–5.6 cm/sec of hepatopetal flow), and repeated bleeding of the varices after receiving three doses of intravascularly administered Histoacryl 1 ampoule mixed with Lipiodol UF 8 mL in the EV. Prominent GV and EV were occluded by EIS. The sclerosing agent was also present in the main portal vein, splenic mesenteric junction, and splenic vein, causing an engorged inferior mesenteric vein. The patient underwent total hepatectomy and living donor liver transplantation (LDLT) by left lateral segment graft (segments 2, 3, and 4 of the middle hepatic vein trunk) and left portal vein graft to the recipient inferior mesenteric vein anastomosis. Portal vein stent placement via segment 4 of the portal vein stump was performed from the inferior mesenteric vein to the umbilical portion of the left portal vein. The patient is still alive and doing well after the LDLT.ConclusionsEIS is a life-saving procedure in cases involving bleeding EV complicated by gastric, main portal vein, splenic mesenteric junction, and splenic vein occlusions; hence, it should be kept in mind as a treatment for EV complications in pediatric patients.

Incidence of sub-perineural injection using a targeted intracluster supraclavicular ultrasound-guided approach in cadavers

BackgroundMulti-injection targeted intracluster injection ultrasound-guided supraclavicular brachial plexus block has been advocated to provide a faster onset of anaesthesia compared with a double injection technique. By placing the needle within clusters of hypoechoic structures, corresponding to neural tissue, this technique may increase needle trauma and the incidence of nerve injury. This study assessed the rate of sub-perineural needle placement with a single intracluster brachial plexus injection in the supraclavicular fossa of human cadavers. MethodsA single ultrasound-guided intracluster brachial plexus injection was performed bilaterally at the supraclavicular fossa on 21 lightly embalmed clinical grade cadavers. Using an in-plane technique, an echogenic needle was positioned to target the middle or lower trunk ‘cluster’, where 0.2 ml black India ink was injected. An effort was taken to avoid the hypoechoic structures with the needle tip. Tissue samples were assessed histologically by two experienced reviewers. ResultsAll 42 injections were sonographically assessed to be within the ‘main cluster’. Ink was extra-epineural in 13/41 (32%), sub-epineural but outside perineurium in 18/41 (44%), and sub-perineural in 10/41 sections (24%; 95% confidence interval, 13–41%). The histology from one injection was uninterpretable. Of the 10 sub-perineural deposits, the ink was intrafascicular in nine sections. ConclusionsWe observed a high rate of sub-perineural injection with a single intracluster injection. Thus the targeted intracluster injection supraclavicular block cannot be recommended until further evidence is available regarding the safety of this technique.

Spine and Lower Extremity Kinematics Exhibited During Running by Adolescent Idiopathic Scoliosis Patients With Spinal Fusion

Study DesignCase-controlled design; biomechanics laboratory setting. ObjectiveTo compare the spine and lower extremity kinematics displayed during high-effort running between individuals with spinal fusion surgery for adolescent idiopathic scoliosis (SF-AIS) and healthy controls (CON). Summary of Background DataIndividuals with SF-AIS often return to exercise and sports that include running. However, how these individuals produce the spinal rotations needed during high-effort running and thus compensate for the loss of spinal flexibility is not known. MethodsTen SF-AIS (posterior-approach spinal fusion; postoperative time: 2.0 ± 0.6 years; physically active) and 10 CON individuals, pair-matched for gender, age, mass, height, and level of physical activity participated. SF-AIS individuals ran on a treadmill at a self-selected submaximal speed perceived as “hard” (15/20 on Borg perceived-effort scale), and CON ran at the SF-AIS pair-matched speed. 3D motion capture system was used to generate trunk and pelvis segmental angles (trunk segments = upper trunk [C7–T8], middle trunk [T9–T12], lower trunk [L1–L5]), relative angles (relative angles between the two consecutive trunk segments), and lower extremity joint angles. The group differences between the SF-AIS and CON were assessed using one-way analysis of covariance (with running speed as the covariate) for trunk, lower extremity, and step kinematics. ResultsSF-AIS participants exhibited a significantly greater (6.1° greater) lower trunk and (6.3° greater) pelvis segmental axial rotation compared with CON during running. In addition, SF-AIS participants displayed a 9.2° less ankle plantarflexion during the support phase. There were no significant differences detected for step kinematics. ConclusionPossibly because of relearned compensatory mechanism, individuals with SF-AIS displayed similar patterns of spine, lower extremity, and step kinematics as healthy controls during high-effort running with some exceptions. Level of EvidenceLevel III.

Effect of propofol on NR2B/CaMKIIα signaling pathway in brain injury induced by hepatic ischemia-reperfusion in preadolescent mice

Objective To evaluate the effect of propofol on subunit 2B-containing N-methyl-D-aspartate receptor(NR2B)/calcium/calmodulin-dependent protein kinaseⅡ alpha (CaMKIIα) signaling pathway in brain injury induced by hepatic ischemia-reperfusion (I/R) in preadolescent mice. Methods Sixty-four healthy clean-grade C57BL/6 mice, aged 2 weeks, weighing 4-6 g, were randomized into 4 groups (n=16 each) using a random number table method: sham operation group (S group), hepatic I/R group (HI/R group), propofol control group (P group), and propofol plus hepatic I/R group (P+ HI/R group). The model of 70% liver I/R injury was established by clamping the left and middle lobe vascular trunk in anesthetized mice.Propofol 20 mg/kg was intraperitoneally injected before operation at 30 min before establishing the model in P and P+ HI/R groups.The equal volume of normal saline was given instead in P and P+ HI/R groups.Eight mice of each group were sacrificed at 6 h of reperfusion, hippocampal tissues were obtained for examination of pathological changes of hippocampal tissues and for determination of neuronal apoptosis (by TUNEL) and expression of NR2B, phosphorylated NR2B (p-NR2B), CaMKⅡα and phosphorylated CaMKⅡα (p-CaMKⅡα) (by Western blot). The remaining 8 mice in each group were used for Morris water maze test at 1 month after establishing the model.Apoptosis index was calculated. Results Compared with group S, the escape latency was significantly prolonged, the percentage of the time of staying at the original platform quadrant was decreased, the expression of p-NR2B and p-CaMKIIα was up-regulated, and apoptosis index was increased in HI/R and P+ HI/R groups (P 0.05). Compared with group HI/R, the escape latency was significantly shortened, the percentage of the time of staying at the original platform quadrant was increased, the expression of p-NR2B and p-CaMKIIα was down-regulated, and apoptosis index was decreased (P<0.05), and the pathological changes of hippocampal tissues were significantly attenuated in group P+ HI/R. Conclusion The mechanism by which propofol reduces brain injury induced by hepatic I/R may be related to inhibiting NR2B/CaMKIIα signaling pathway in preadolescent mice. Key words: Propofol; Liver; Reperfusion injury; Brain injuries; Infant; Receptors, N-methyl-D-aspartate; Calcium-calmodulin-dependent protein kinase type 2

Contralateral C7 to C7 nerve root transfer in reconstruction for treatment of total brachial plexus palsy: anatomical basis and preliminary clinical results.

OBJECTIVEContralateral C7 (CC7) nerve root has been used as a donor nerve for targeted neurotization in the treatment of total brachial plexus palsy (TBPP). The authors aimed to study the contribution of C7 to the innervation of specific upper-limb muscles and to explore the utility of C7 nerve root as a recipient nerve in the management of TBPP.METHODSThis was a 2-part investigation. 1) Anatomical study: the C7 nerve root was dissected and its individual branches were traced to the muscles in 5 embalmed adult cadavers bilaterally. 2) Clinical series: 6 patients with TBPP underwent CC7 nerve transfer to the middle trunk of the injured side. Outcomes were evaluated with the modified Medical Research Council scale and electromyography studies.RESULTSIn the anatomical study there were consistent and predominantly C7-derived nerve fibers in the lateral pectoral, thoracodorsal, and radial nerves. There was a minor contribution from C7 to the long thoracic nerve. The average distance from the C7 nerve root to the lateral pectoral nerve entry point of the pectoralis major was the shortest, at 10.3 ± 1.4 cm. In the clinical series the patients had been followed for a mean time of 30.8 ± 5.3 months postoperatively. At the latest follow-up, 5 of 6 patients regained M3 or higher power for shoulder adduction and elbow extension. Two patients regained M3 wrist extension. All regained some wrist and finger extension, but muscle strength was poor. Compound muscle action potentials were recorded from the pectoralis major at a mean follow-up of 6.7 ± 0.8 months; from the latissimus dorsi at 9.3 ± 1.4 months; from the triceps at 11.5 ± 1.4 months; from the wrist extensors at 17.2 ± 1.5 months; from the flexor carpi radialis at 17.0 ± 1.1 months; and from the digital extensors at 22.8 ± 2.0 months. The average sensory recovery of the index finger was S2. Transient paresthesia in the hand on the donor side, which resolved within 6 months postoperatively, was reported by all patients.CONCLUSIONSThe C7 nerve root contributes consistently to the lateral pectoral nerve, the thoracodorsal nerve, and long head of the triceps branch of the radial nerve. CC7 to C7 nerve transfer is a reconstructive option in the overall management plan for TBPP. It was safe and effective in restoring shoulder adduction and elbow extension in this patient series. However, recoveries of wrist and finger extensions are poor.

P3.01-114 Dissociation of Heart and Great Vessels for Long Tracheal Tumors and Lung Cancer Invaded Trachea: The Chinese Experience

The length limit of tracheal resection is less than five centimeters. Up to know, there is no any report about resection of more than five centimeters for tracheal tumors. We created a new technique and successfully remove 124 tracheal tumors more than 5 cm in length and 52 lung cancer invaded trachea through dissociation heart and great vessels. Here, we report the results of 176 patients surgically treated in series. All patients were given general anesthesia and single cavity endotracheal intubation. After thoracotomy, the right pericardium was totally excised, the heart, inferior vena cava, superior vena cava, ascending aorta and innominate artery were dissociated. Then, thoracic trachea, left and right main bronchus were dissociated; the proximal and distal end of trachea, or left and right main bronchus, or left main bronchus and right middle trunk bronchus were cut off. Fallowing, the distal end of trachea was anastomosed to the proximal end of trachea, or anastomosed to the left and right main bronchus, or anastomosed to the left main bronchus and right middle trunk bronchus with 3-0 micro Joe lines. Finally, the pulmonary artery sleeve reconstruction was performed, and resection and reconstruction of SVC was performed. There were 124 patients with tracheal tumor over than 5cm in length and 52 patients with lung cancer invaded trachea. The length of trachea tumor was 5.5 cm to 10.9 cm. 5 tracheal tumor involved SVC and combined with SVCS. The trachea length invaded by the cancer was 4.5cm-7.0cm in the 52 patients with lung cancer. Of the 52 cases, 10 cancer invaded right main pulmonary artery, 22 cancer involved right main pulmonary artery and SVC. The operative procedures included: (1) resection and reconstruction of trachea, or combined with carina in 124 cases, and combined with resection and reconstruction of SVC in 5 cases in the tracheal tumor group; (2) Sleeve right upper lobectomy combined with resection and reconstruction of trachea and carina in 52 cases, combined with sleeve pulmonary artery in 10 cases, combined with sleeve pulmonary artery, and resection and reconstruction of SVC in 32 cases of lung cancer group. There were 5 operative death in this series. The 1-, 3-, 5- and 10-year survival were 71.2%, 54.3%, 33.1% and 22.5%. We pioneered a new technique and treated 124 tracheal tumor more than 5 cm in length and 52 lung cancer invaded trachea in the world.

Major surgical strategies of the upper and middle trunks of adult brachial plexus injury by Erb­ — Duchenne palsy type

Objective — to increase the effectiveness of surgical treatment of patients with injury to the upper and middle trunks of the brachial plexus based on the comprehensive involvement of compensatory regenerative mechanisms by applying original neurotic, autoplastic, long‑term electrostimulation and orthopedic correction of the upper limb function.Methods and subjects. The analysis of the results of surgical treatment of 64 patients with brachial plexus trauma, accompanied by detachment or injury of the C5—C7 spinal nerves, upper and middle trunks, or their anterior and posterior portions, was performed. For the reconstruction of the structures of the shoulder plexus and its long branches, the technique of nerve autoplasty and the method of neurotication were most often used. In the cases of maintaining the anatomical integrity of damaged structures of the brachial plexus, which was manifested during the course of neurology, especially in cases of positive intraoperative diagnostics, the technique of long‑term electrostimulation of damaged structures in the postoperative period was used with the help of domestic electrostimulation systems Ney C 3M (Ukraine).Results. 86.7 % of cases showed good recovery (4 points or higher on 86.7 % MRCS) of the shoulder abduction and elbow flexion with no dependence on applied surgical procedure (whether grafting or nerve transfer). Chronic invasive electrical stimulation of the anatomically preserved structures of the adult brachial plexus led to significant improvement of the shoulder abduction and elbow flexion in 53.9 % of cases.Conclusions. In the absence of signs of regeneration during restorative conservative therapy for two months in cases of damages of the upper and middle trunk of the brachial plexus in the type of Erb­ — Duchenne paralysis, surgical treatment with the maximum full involvement of compensatory and regenerative properties of the nervous system through the application of original techniques of neuroticisation, long‑term electrostimulation and orthopedic correction of the function of the upper limb. Neuroticisation of the structures of the upper trunk of the brachial plexus in all cases gave satisfactory restoration of flexion in the elbow and shoulder removal.

A clinical study on the pain following brachial plexus injury and its correlative factors

Objective To evaluate the characteristic and correlative factors of pain following traumatic brachial plexus injury and the impact of surgery on pain. Methods This study was a prospective, self-controlled study. Each enrolled patient was asked to respond to the revised short form McGill pain (SF-MPQ-2) and neuropathic pain symptom inventory (NPSI) questionnaire before and after surgery. Multiple factors analysis on pain was carried out and the effect of surgery on pain was evaluated. Results The total number of the study was 100 patients. Both of the SF-MPQ-2 38.33±30.38 and NPSI 15.62±14.84 scores after surgery were significantly lower than those before surgery SF-MPQ-2 50.13±36.55; NPSI 20.24±16.84. The highest score appeared in affective descriptors of the four subscales in SF-MPQ-2 and the score of paresthesia was the highest in the 5 divisions of NPSI, no matter before or after surgery. The postoperative scores of deep pain, evoked pain and paresthesia were significantly lower than the preoperative scores. Preoperative pain was related to whether nerve continuity existed or not (SF-MPQ-2: r=-0.2198, P=0.0280; NPSI: r=-0.2322, P=0.0201). The postoperative SF-MPQ-2 and NPSI scores were significantly lower than preoperative scores in motorcycle accident and weight dropping groups. The SF-MPQ-2 and NPSI scores were the highest in global brachial plexus injury group before and after operation. The SF-MPQ-2 and NPSI scores in global brachial plexus injury group or upper and middle trunks injury group after surgery were significantly lower than those before surgery. The postoperative SF-MPQ-2 and NPSI scores in nerve transfer or neurolysis group were significantly lower than preoperative scores. Conclusion In the study, according to SF-MPQ-2 and NPSI evaluation, affective descriptors and paresthesia accounted for the largest proportion in pain expression. Nerve transfer or neurolysis might have a positive effect on prognosis of neuropathic pain for traumatic brachial plexus injury. Surgery might relieve deep pain and evoked pain and paresthesia. Key words: Brachial plexus; Prospective studies; Neuropathic pain; SF-MPQ-2; NPSI

Brachial Plexus Ultrasound and MRI in Children with Brachial Plexus Birth Injury.

Brachial plexus birth injury is caused by traction on the neck during delivery and results in flaccid palsy of an upper extremity commonly involving C5-C6 nerve roots. MR imaging and MR myelography help to assess the anatomic location, extent, and severity of brachial plexus injuries which influence the long-term prognosis along with the surgical decision making. Recently, sonography has been increasingly used as the imaging modality of choice for brachial plexus injuries. The aim of this study was to assess the degree of correlation among brachial plexus sonography, MR imaging, and surgical findings in children with brachial plexus birth injury. This prospective study included 55 consecutive patients (girls/boys = 32:23; mean age, 2.1 ± 0.8 months) with brachial plexus birth injury between May 2014 and April 2017. The patients were classified according to the Narakas classification and were followed up at 4- to 6-week intervals for recovery by the Modified Mallet system and sonography without specific preparation for evaluation. All patients had MR imaging under general anesthesia. Nerve root avulsion-retraction, pseudomeningocele, and periscalene soft tissue were accepted brachial plexus injury findings on imaging. Interobserver agreement for MR imaging and the agreement between imaging and surgical findings were estimated using the κ statistic. The diagnostic accuracy of sonography and MR imaging was calculated on the basis of the standard reference, which was the surgical findings. Forty-three patients had pre- and postganglionic injury, 12 had only postganglionic injury findings, and 47% of patients underwent an operation. On sonography, no patients had preganglionic injury, but all patients had postganglionic injury findings. For postganglionic injury, the concordance rates between imaging and the surgical findings ranged from 84% to 100%, and the diagnostic accuracy of sonography and MR imaging was 89% and 100%, respectively. For preganglionic injury, the diagnostic accuracy of MR imaging was 92%. Interobserver agreement and the agreement between imaging and the surgical findings were almost perfect for postganglionic injury (κ = 0.81-1, P < .001). High-resolution sonography can identify and locate the postganglionic injury associated with the upper and middle trunks. The ability of sonography to evaluate pre- and the postganglionic injury associated with the lower trunk was quite limited. Sonography can be used as a complement to MR imaging; thus, the duration of the MR imaging examination and the need for sedation can be reduced by sonography.

Estudo anatômico da origem e da área de inervação que formam o plexo braquial de macaco-prego (Sapajus libidinosus)

We studied, and herein describe, the anatomy of the brachial plexus in the Sapajus libidinosus, a New World primate species. The study of origin and distribution of the nerves that form the brachial plexus of primates contributes to the body of knowledge of veterinary functional anatomy, and can have important ramifications to clinical, surgical, and anesthetic procedures, as well as to the understanding of injuries in these species. We found that the brachial plexus of Sapajus libidinosus is composed of neural fibers originating from the union of the dorsal and ventral roots of the cervical vertebral segments C5 to C8 and thoracic T1. These fibers then are organized in four main trunks, with a subdivision in the middle trunk. We concluded that the origins, trajectories and territory of innervation of the nerve trunks of the brachial plexus of Sapajus libidinosus are similar to those of other primates, with some variations occurring in the course.

Evaluation of clinical efficacy on interscalene injections by ultrasound-guided for neurogenic thoracic outlet syndrome and ultrasonic observation

Neurogenic Thoracic Outlet Syndrome (nTOS) is a clinical diagnosis that describes the symptomatic manifestation of the compression of brachial plexus. The objective of this study is to evaluate the therapeutic effects of interscalene injections by ultrasound-guided for nTOS and observe the ultrasonic characteristics of brachial plexus and their surroundings. Thirty suspect patients with nTOS were received tow stages treatments. First stage, all patients were received one-week conventional therapies, that included analgesics treatment and psychological treatment; after that, the patients were given drug discontinuance 3 days. Then patients were got into the second stage, that were treated with interscalene injections by ultrasound-guided ( Fig. 1 ). The changes of Vsiual Analogue Scale (VAS) scores before and after 2 stages treatment were recorded. At the interscalne level, the sonography and anatomic variations of the brachial plexus, superior and middle scalene muscles were observed ( Fig. 2 ). Before treatment the VAS sores were (8.25 ± 1.53), after 2 weeks of treatment,the VAS sores were(2.57 ± 1.06),comparisons of these tow VAS scores, there were significant differences ( P < 0.05). At the interscalene level, the brachial plexus were identified in the transverse view as round to oval hypoechoic structures, anterior and middle scalene muscles showed hyperechoic structures ( Fig. 3 ). There were 16 patients whose three trunks of the brachial plexus passed through between the anterior and middle scalene muscles, accounted for 53.33% of the total; 10 patients’ superior trunks of the brachial plexus pierced the anterior scalene muscle, their middle trunks and lower trunks passed through between the anterior and middle scalene muscles, accounted for 33.33% of the total; 4 patients’ superior and middle trunks pierced the anterior scalene muscle, their lower trunks passed through between the anterior and middle scalene muscles, accounted for 13.33% of the total. Accurate positioning of interscalene injections by ultrasound-guided for the treatment of nTOS could have certain efficacy. There are variations in the brachial plexus crossing the scalene triangle.

Coupling Effect of Morphology and Mechanical Properties Contributes to the Tribological Behaviors of Snake Scales

It is known that the tribological behaviors of snake skins are contributed by the synergistic action of multiple factors, such as surface morphology and mechanical properties, which has inspired fabrication of scale-like surface textures in recent years. However, the coupling effect and mechanism remain to be elucidated. In this work, the morphology and mechanical properties of the scales from different body sections (leading body half, middle trunk and tailing body half) and positions (dorsal, lateral and ventral) of Boa constrictor and Eryx tataricus were characterized and compared to investigate the corresponding effects on the tribological behaviors and to probe the possible coupling mechanism. The morphological characterizations of scanning electron microscopy and atomic force microscopy revealed significant differences between the two species that the scales from Boa constrictor are rougher in general. The mechanical properties measured by nanoindentation corroboratively demonstrated substantial differences in elastic modulus and hardness. Interestingly, the ventral scales with lower surface roughness, together with relatively larger elastic modulus and hardness, manifest higher friction coefficients. A “double-crossed” hypothesis was proposed to explain the observed coupling effect of morphology and mechanical properties on friction, which may afford valuable insights for the design of bionic surface with desirable tribological performance.

A complex scalenus muscle variant: Case report

During dissection in a first year dental gross anatomy laboratory, we identified an unusual, complex muscle variant in the left posterior triangle of an 87 year‐old, Caucasian female cadaver. This consisted of the left anterior scalene divided longitudinally into two approximately equal ‘heads', superficial and deep, with the fifth and sixth cervical nerve roots passing between them, along with a small but substantial muscle bundle passing between and attaching to portions of the anterior and middle scalene muscles. This extra muscle bundle passed antero‐medially from the middle of the anterior surface of the middle scalene, to attach inferiorly on the superficial aspect of the deep head of the anterior scalene. This ‘bridging’ muscle also passed anterior to and in contact with the middle trunk (C7) of the brachial plexus. The left subclavian artery was observed to pass as expected between the anterior scalene (both superficial and deep heads) and middle scalene insertions. Scalene muscle anatomy and neurovascular relationships on the right side were observed to be normal. Amidst the numerous reports of morphological variations in scalene muscles, particularly in association with the clinical anatomy of thoracic outlet syndrome, myofascial pain, and upper brachial plexopathies, we were unable to find any accounts of a similar complex scalene muscle variant. Most certainly, our specimen did not fit the accepted morphological descriptions of ‘scalenus anticus', scalenus minimus, or Sibson's muscle variants. Although we had no available clinical records, the muscular variations we described were arranged in configurations that other investigators have recognized as contributing to compression of brachial plexus roots associated with thoracic outlet syndrome.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.