Poor Spontaneous Recovery Research Articles

Optimal timing of needle electromyography to diagnose lesion severity in traumatic radial nerve injury.

In patients with traumatic radial nerve injury (RNI), the chance of spontaneous recovery must be balanced against the benefits of early surgical reconstruction. We aimed to explore the time-specific value of needle electromyography (NEMG) to diagnose nerve lesion severity. In this retrospective diagnostic accuracy study at Leiden Nerve Center, patients at least 12 years of age with RNI caused by fractures or fracture treatment were included. The sensitivity and specificity of the patients' first NEMG examination were assessed, stratified by the timing after the nerve injury. The absence of motor unit potentials (MUPs) in muscles distal to the nerve lesion was considered a positive test result. Lesion severity was dichotomized to moderate injury (spontaneous Medical Research Council grade ≥3 recovery) or severe injury (poor spontaneous recovery or surgical confirmation of a mainly neurotmetic lesion). Ninety-five patients were included in our study. The sensitivity of NEMG to detect severe RNI was 75.0% (3 of 4) in the fourth, 66.7% (2 of 3) in the fifth, and 66.7% (2 of 3) in the sixth month after the nerve injury. The specificity in the first to the sixth month was 0.0% (0 of 1), 50.0% (2 of 4), 77.3% (17 of 22), 95.5% (21 of 22), 95.8% (23 of 24), and 100.0% (12 of 12), respectively. The specificity of NEMG is higher than 95% and therefore clinically relevant from the fourth month after the nerve injury onward. Absence of MUPs at this time can be considered an indication to plan nerve exploration. Moreover, the presence of MUPs on NEMG does not completely exclude the necessity for surgical reconstruction.

Postoperative Loss of Midline Function in Brachial Plexus Birth Palsy.

To identify the rate of and predictive variables for functionally limited shoulder internalrotation in postoperative patients with brachial plexus birth palsy. Records of patients with brachial plexus birth palsy who had surgery on the affected upper extremity during a 10-year period were retrospectively reviewed. Patient demographics, physical examinations, and all upper extremity procedures were recorded. Loss of midline function (LOM) was defined as a Modified Mallet Scale or Active Movement Scale (AMS) internal rotation score <3. Exclusion criteria were <1-year follow-up after the most recent procedure, insufficient documentation, or preexisting LOM. Multivariable logistic regression was performed on 3 different scenarios of candidate variables to identify those associated with LOM. All scenarios included each procedure as a candidate variable. Scenario A additionally analyzed preprocedural AMS scores. Scenario B additionally analyzed preprocedural Modified Mallet Scale scores. Scenario C isolated the surgical pathway without preprocedural examination scores. Among 172 included patients, 34 (19.8%) developed LOM. Predictive variables associated with LOM included severity of initial palsy (C5-7, odds ratio 3.6; C5-T1, odds ratio 4.9), poor recovery of upper trunk motor function before the patient's first surgery (specifically Modified Mallet Scale abduction < 4, AMS elbow flexion < 3, and AMS wrist extension < 3), and patients who ultimately required surgical glenohumeral reduction (odds ratio 3.6). Age, number of procedures, closed shoulder reduction with casting, shoulder tendon transfers, and external rotation humeral osteotomies were not predictive of LOM. Approximately 1 in every 5 patients with brachial plexus birth palsy will develop LOM after entering a surgical algorithm designed to improve shoulder external rotation. Patients with a more severe initial palsy (C5-7 or global), poor spontaneous recovery of upper trunk motor function (elbow flexion or wrist extension) before their first procedure, and those who ultimately require surgical glenohumeral joint reduction should be counseled as having a higher odds of LOM development. Therapeutic IV.

Third cranial nerve palsy and Purtscher retinopathy in a child with multiple injuries

Case reportA 4 year-old girl was referred to our hospital after have suffered a severe accident. The patient was diagnosed with complete third nerve palsy in her right eye and Purtscher retinopathy in her left eye. DiscussionPurtscher retinopathy is a rare condition. The diagnosis is made on clinical ground and its treatment is not well defined although it is believed that systemic steroids could improve the visual outcome. Traumatic third nerve palsy has a poor spontaneous recovery. The use of botulinum toxin might be useful in children to improve the recovery rate, maintaining binocularity, and avoiding amblyopia in other cases.

Parálisis del tercer nervio craneal y retinopatía de Purtscher en niña politraumatizada

Case reportA 4 year-old girl was referred to our hospital after have suffered a severe accident. The patient was diagnosed with complete third nerve palsy in her right eye and Purtscher retinopathy in her left eye. DiscussionPurtscher retinopathy is a rare condition. The diagnosis is made on clinical ground and its treatment is not well defined although it is believed that systemic steroids could improve the visual outcome. Traumatic third nerve palsy has a poor spontaneous recovery. The use of botulinum toxin might be useful in children to improve the recovery rate, maintaining binocularity, and avoiding amblyopia in other cases.

Extending the Indications for Primary Nerve Surgery in Obstetrical Brachial Plexus Palsy

Purpose. This study identifies a small subset of patients with obstetrical brachial plexus palsy who, while they do not meet common surgical indications, may still benefit from primary nerve surgery. Methods. Between April 2004 and April 2009, 17 patients were offered primary nerve surgery despite not meeting the standard surgical indications of the authors. The authors performed a retrospective analysis of these 17 patients using prospectively collected data. Results. This group of 17 patients were identified as having poor shoulder function at about 9 months of age despite passing the Cookie Test. Fourteen patients underwent surgical intervention and three families declined surgery. All patients in the operative group regained some active external rotation after surgery. Five patients in this group have required further interventions. Two of the three patients for whom surgery was declined have had no subsequent spontaneous improvement in active external rotation. Discussion. The commonly used indications for primary nerve surgery in obstetrical brachial plexus palsy may not adequately identify all patients who may benefit from surgical intervention. Patients who pass the Cookie Test but have poor spontaneous recovery of active shoulder movements, particularly external rotation, may still benefit from primary nerve surgery.

Changes in Electrical Perception Threshold Within the First 6 Months After Traumatic Spinal Cord Injury

Objective. To assess the reliability of the electrical perception threshold (EPT) in healthy participants and its responsiveness in patients for 6 months after traumatic spinal cord injury (SCI). Methods. The reliability of EPT measures was assessed in 15 healthy volunteers (from C3 to S2). EPT measures were assessed in 37 patients at 1, 3, and 6 months after SCI. EPT was determined in dermatomes at, above, and below the neurological level of lesion. Reliability was quantified with an intraclass correlation coefficient (ICC) and responsiveness with the standardized response mean (SRM). Dermatomes were classified as having normal or pathological sensory perception, based on both light touch (LT) and EPT testing. The percentage of agreement between LT and EPT classifications was determined. Results. The ICCs varied considerably between dermatomes (0.00 ≤ ICC ≤ 0.86). Overall, EPTs changed little within the first 6 months after SCI, resulting in small SRM values. Agreement between classifications according to EPT or LT testing varied from 30% to 100%. The least agreement was observed in the first segment below the lesion. Conclusion. Future studies must note that the reliability of EPT differs between dermatomes in healthy participants. Furthermore, at and below the level of the lesion, spontaneous recovery of sensory perception is poor within the first 6 months after SCI. Based on subgroup analyses, if a translational trial aims to improve sensory perception around the level of the lesion, sensory-incomplete tetraplegic patients could be included. These patients show poor spontaneous recovery, and the EPT may detect subtle changes in perception.

Local Intraarterial Fibrinolysis Administered in Aliquots for the Treatment of Central Retinal Artery Occlusion

Central retinal artery occlusion results in acute visual loss with poor spontaneous recovery. Current standard therapies do not alter the natural history of disease. Several open-label clinical studies using continuous infusion of thrombolytic agents have suggested that local intraarterial fibrinolysis (LIF) is efficacious in the treatment of central retinal artery occlusion. The aim is to compare the visual outcome in patients with acute central retinal artery occlusion of presumed thromboembolic etiology treated with LIF administered in aliquots with that of patients treated with standard therapy. We conducted a single-center, nonrandomized interventional study of consecutive patients with acute central retinal artery occlusion from July 1999 to July 2006. Twenty-one patients received LIF and 21 received standard therapy. Seventy-six percent of subjects in the LIF group had a visual acuity improvement of one line or more compared with 33% in the standard therapy group (P=0.012, Fisher exact). Multivariate logistic regression controlling for gender, history of prior stroke/transient ischemic attack, and history of hypercholesterolemia showed that patients who received tissue plasminogen activator were 36 times more likely to have improvement in visual acuity (P=0.0001) after adjusting for these covariates. Post hoc analysis showed that patients who received tissue plasminogen activator were 13 times more likely to have improvement in visual acuity of 3 lines or more (P=0.03) and 4.9 times more likely to have a final visual acuity of 20/200 or better (P=0.04). Two groin hematomas were documented in the LIF group. No ischemic strokes, retinal or intracerebral hemorrhages were documented. LIF administered in aliquots is associated with an improvement in visual acuity compared with standard therapy and has few side effects.

Pressure dependent stromal oedema following deep anterior lamellar keratoplasty

A 53 year old man with keratoconus and a steroid related intraocular pressure response developed acute hydrops and underwent deep anterior lamellar keratoplasty after poor spontaneous recovery of vision. Intraocular...

Radiological and Electrophysiological Detection of Nerve Roots Avulsion in Patients with Birth-Related Brachial Plexus Paralysis

Obstetrical trauma is one of the most common causes of traction injuries of the brachial plexus, with incidence varying between one and two per 1000 live births. This incidence remains stable despite improvement in obstetrical care because of increasing mean birth weight. The majority of the patients with obstetrical brachial plexus palsy recover spontaneously after conservative treatment, without any or with minor functional deficit. The rest of the children require microsurgical treatment, which recently, with the introduction of interposition nerve grafting and neurotization techniques, has significantly improved the prognosis of these patients. Outcomes of surgical treatment depend on the severity and localization of the brachial plexus lesion and also on the timing of surgery. The results of early microsurgical brachial plexus interventions are superior to late brachial plexus reconstructions or following secondary procedures dealing with established joint contractures and bone deformities. Root avulsion is the most severe type of obstetrical brachial plexus lesion, usually found following use of extreme force during a complicated delivery. Presence of an avulsion lesion implies devastating paralysis without possibility for spontaneous recovery, as well as associated spread of the traction force to neighboring spinal nerves or trunks. Therefore, clinical signs of root avulsion such as Horner sign and phrenic nerve palsy are considered strong indicators for brachial plexus exploration and reconstruction. However, the absence of these signs does not rule out root avulsion. Thus, poor spontaneous recovery necessitates accurate diagnostic between preganglionic and postganglionic lesions of the brachial plexus. Postganglionic lesions occur distally to the dorsal root ganglion at the level of the spinal nerve, trunks, or cords. Continuity usually can be restored with nerve repair or interposition nerve grafting. Preganglionic lesions occur proximal to the dorsal root ganglion, with irreversible loss of the original source of nerve fibers. Preganglionic lesions were once considered inoperable, but the use of neurotization procedures from other plexus donors or the use of extraplexus donor nerves has allowed the return of rewarding degree of function.1,2,3,4 Radiological studies such as cervical myelography, computed tomography myelography (CTM) and preoperative electrophysiological testing are commonly used in an effort to correctly pinpoint the brachial plexus lesion. However, there are some controversies regarding the place of all these methods in diagnostic of obstetrical brachial plexus lesions. Cervical myelography can indicate a sign that has a strong association with root avulsions; however, the signs can exist without root avulsion. Furthermore, large, contrast-enhancing pseudomeningoceles expanding along the cervical spine can overlap adjacent normal roots. The CTM allows more accurate assessment of the root and rootlets, but delineation of a level of avulsion on axial slides can be difficult because of discrepancy between the location of root exit zones from spinal cord segments and that of respective intervertebral foramina. The electrophysiology in obstetric brachial plexus lesions differs essentially from one in older patients. The electromyelography (EMG) in obstetric palsy is far too optimistic compared with the clinical picture.5 Others consider EMG unreliable and excluded it from their protocol for examination of the children with obstetrical brachial plexus paralysis, but some still use it with the condition that studies must be done by experienced electromyographer, and results must be interpreted expertly.6 This study was undertaken to determine the diagnostic value of plain myelography, CTM, and preoperative electrophysiology in patients with obstetrical brachial plexus paralysis. Data obtained from these studies will be correlated with intraoperative diagnosis on the basis of operative findings following exploration of these lesions, intraoperative electrostimulation, and histological studies of nerve biopsies.

THE PROGNOSTIC VALUE OF CONCURRENT HORNER'S SYNDROME IN TOTAL OBSTETRIC BRACHIAL PLEXUS INJURY

The prognostic value of concurrent Horner's syndrome in infants with total birth palsy was investigated. The records of 48 cases with total palsy were reviewed. Poor spontaneous return of the motor function of the limb was found for both with and without concurrent Horner's syndrome. Fisher's exact test ( P=0.02) indicated that the presence of concurrent Horner's syndrome is a significant prognostic factor for poor spontaneous recovery of the limb.

Obstetric Brachial Plexus Palsy

Objectives: to describe my research into and conclusions about obstetric brachial plexus palsy with special emphasis on aspects that would be of interest to obstetricians.Materials and Methods: based on an extensive literature review as well as on the research I was involved in concerning birth palsy, the following points are investigated: classification of the types of traumatic birth palsy, risk factors, congenital and intra-uterine palsies, evaluation, prognostic factors for spontaneous recovery and surgery for obstetric paralysis.Results: infants with birth palsy should be assessed by a multidisciplinary team. Traumatic brachial plexus injury is classified into four types: Erb’s, total, Klumpke’s and intermediate palsies. Each type is associated with a specific intrapartum force and each has a specific clinical presentation. Risk factors for birth palsy include fetal macrosomia, shoulder dystocia, maternal short stature, gestational diabetes, vaginal breech delivery, instrumental delivery and a previous history of giving birth to a baby with birth palsy. The hand surgeon is frequently involved in the medico-legal assessment of birth palsy cases and, hence, it is important to realize that paralysis of the limb in the newborn is not always due to traumatic delivery. Other causes of paralysis include: congenital aplasia of the roots of the brachial plexus, congenital varicella, cerebral palsy, intra-uterine nerve compression by the umbilical cord or amniotic bands, “Deformation Syndrome“ and “intra-uterine mal-adaptation palsy”. Infants with birth palsy should be evaluated at regular intervals by the hand surgeon and have continuous physiotherapy exercises. The most important factor that indicates good spontaneous recovery is early clinical improvement of limb function. Infants with poor spontaneous recovery will benefit from surgical exploration and reconstruction of the brachial plexus.Conclusion: obstetric brachial plexus palsy has become a subject of interest in the surgical literature because of advances in microsurgery and nerve reconstruction. This has led to several published papers on the topic dealing with the re-classification of the types of palsy, its risk factors, aetiology, evaluation, prognosis and new concepts of surgical intervention.