Root Avulsion Research Articles

Treatment of neuropathic pain after peripheral nerve and brachial plexus traumatic injury.

Peripheral nerve and brachial plexus injuries typically cause severe impairment in the affected limb. The incidence of neuropathic pain is high, reaching up to 95% of cases, especially if cervical root avulsion has occurred. Neuropathic pain results from damage to the somatosensory system, and its progression towards chronicity depends upon disruptions affecting both the peripheral and central nervous system. Managing these painful conditions is complex and must be accomplished by a multidisciplinary team, starting with first-line pharmacological therapies like tricyclic antidepressants and calcium channel ligands, combined physical and occupational therapy, transcutaneous electrical stimulation and psychological support. For patients refractory to the initial measures, several neurosurgical options are available, including nerve decompression or reconstruction and ablative/modulatory procedures.

Berberine enhanced survival and axonal regeneration of motoneurons following spinal root avulsion and reimplantation in rats

Berberine enhanced survival and axonal regeneration of motoneurons following spinal root avulsion and reimplantation in rats

Adolf stoffel and the development of peripheral neurosurgical reconstruction for the management of paralysis: One hundred years of nerve transfer surgery

The concept of nerve transfer as an alternative solution for paralysis through rewiring a denervated motor nerve using an intact and expendable nerve branch or fascicle in proximity to the injured nerve became widely adopted as a strategy for nerve root avulsion in brachial plexus injuries. The success of the technique has encouraged clinicians to extend the indications for other complex nerve injuries, and the technique may be considered as an adjunct or replacement to nerve grafting for some proximal, high-energy, and late-presenting peripheral nerve injuries. The technique is not new. Many of the current “advances” in peripheral nerve transfer were described contemporaneously by Adolf Stoffel in 1911. He was an orthopedic surgeon working in Germany in the early 1900s. He had an interest in nerve injury reconstruction, described the functional fascicular anatomy of the peripheral nerves, developed an intraoperative nerve stimulator, and pioneered many of the techniques used today. His work was never translated from the German language and did not, therefore, receive wide acknowledgment. The aim of this study is to correct the perceived timeline of nerve transfer surgery and include the pioneering work of Adolf Stoffel.

Epigallocatechin gallate enhances the motor neuron survival and functional recovery after brachial plexus root avulsion by regulating FIG4.

The survival of motor neurons (MNs) is the key to recovery of the motor function after brachial plexus root avulsion (BPRA). (-)-epigallocatechin-3-gallate (EGCG) exerts neuroprotective roles in neurons under different pathological conditions. However, the role of EGCG in regulating motor neurons under BPRA remains to be unclear. In the present study, we investigated the functional role of EGCG both <i><i><i>in vitro</i></i></i> and <i><i><i>in vivo</i></i></i>. In an <i><i><i>in vitro</i></i></i> study, we observed that EGCG obviously increased the cell survival rate of MNs and FIG4 protein levels compared with the vehicle control, with a peak level observed at 50 µM; EGCG can also upregulate FIG4 to reduce the cell death of MNs and increase the neurite outgrowth under oxidative stress; moreover, EGCG can upregulate FIG4 to promote the functional recovery and the survival of MNs in the ventral horn in mice after BPRA. These combined results may lay the foundation for EGCG to be a novel strategy for the treatment of BPRA.

L-Theanine and NEP1-40 promote nerve regeneration and functional recovery after brachial plexus root avulsion

Brachial plexus root avulsion causes severe sequelae Treatments and prognosis face many problems, including inflammatory reaction, oxidative damage, and myelin related inhibitory effect. l-Theanine has anti-inflammatory, anti-oxidative, and neuroprotective effects. NEP1-40 competitively inhibits Nogo-66 receptor (NgR1) promotes axonal regeneration. Forty-eight Sprague-Dawley rats were randomly assigned into four groups to establish an animal model of brachial plexus root avulsion. Inflammation and oxidative damage were evaluated by spectrophotometry and motor function of the upper limbs was assessed via Terzis grooming test after modeling. Immunofluorescence and hematoxylin and eosin staining were utilized to determine the content of reactive oxygen species, activation of microglial cells, neuroprotection, and nerve regeneration. Compared with the control group, the L-Theanine + NEP1-40 group had significantly decreased myeloperoxidase, malondialdehyde, interleukin-6, reactive oxygen species, and microglial cells, significantly increased score on the Terzis grooming test, increased motor neuron content, and thickened muscle fibers, increased area, and appearance of large and clear motor endplate structures. The results of this study suggest that l-Theanine combined with NEP1-40significantly promoted nerve regeneration after brachial plexus root avulsion, and may be a potential treatment for promoting nerve regeneration. Possible mechanisms underlying these results are alleviation of oxidative damage and inflammatory responses in the injured area and antagonism of myelin inhibition.

Delayed Myelopathy in Patients with Traumatic Preganglionic Brachial Plexus Avulsion Injuries

Cervical and upper thoracic nerve root avulsions are preganglionic lesions that occur after extreme traction of the brachial plexus. The tearing of the roots from the spinal cord pia leads, not only to immediate and permanent deficits, but also to delayed neurologic complications. Symptomatic myelopathy can present in a late fashion owing to chronic sequelae from the inciting traumatic event. No unifying theory has yet been provided that can explain the causes of delayed spinal cord dysfunction after preganglionic brachial plexus injury. We have proposed a collective mechanism for the development of delayed spinal cord injury. An institutional database search and a literature review were performed to find patients who had presented with delayed myelopathy after brachial plexus injury. We found 454 adult patients with traumatic brachial plexus injury and spinal cord injury from 1997 to 2018 in the institutional search. Of these patients, 74 had a delayed presentation of new myelopathic findings on physical examination that had developed ≥6 months after the initial presentation. In these 74 patients with delayed myelopathic symptoms, radiologic findings of spinal cord herniation, syringomyelia, superficial siderosis, or pathologic intradural or extradural cerebrospinal fluid collections from traumatic dural tears were present. Each of these pathologic entities was present in isolation or combination in our patient population. Four overlapping etiologies appeared to compose the primary foundation for delayed spinal cord dysfunction after brachial plexus injury. We have highlighted this continuum by providing institutional case examples and a review of the reported data.

Simultaneous Phrenic and Intercostal Nerves Transfer for Elbow Flexion and Extension in Total Brachial Plexus Root Avulsion Injury.

To report the results of restoring the elbow flexion and extension in patients with total brachial root avulsion injuries by simultaneous transfer of the phrenic nerve to the nerve to the biceps and three intercostal nerves to the nerve of the long head of the triceps. Ten patients with total brachial root avulsion injuries underwent the spinal accessory nerve transfer to the suprascapular nerve for shoulder reconstruction. Simultaneous transfer of the phrenic nerve to the nerve to the biceps via the sural nerve graft and three intercostal nerves to the nerve of the long head of the triceps was done for restoration of the elbow flexion and extension. Trunk flexion exercise program was used for all patients postoperatively. The mean follow up period was 36 months. For elbow flexion, there were two M4, seven M3, and one M1. For elbow extension, there were three M4, four M3, two M2, and one M1. No patient demonstrated a respiratory problem clinically postoperatively. The average FVC% decreased to 61% of the predicted value at 24 months after surgery. The simultaneous nerve transfer using the phrenic nerve to the nerve to the biceps and 3 intercostal nerves to the nerve of the long head of the triceps with postoperative trunk flexion exercise provide a comparable result for restoration of elbow function in total brachial plexus root avulsion injury. The patients who appear to have a respiratory problem and are unable to comply with the post-operative respiratory muscles training should be contraindicated for this simultaneous transfer.

Incidence, Presentation, and Treatment of Pediatric and Adolescent Meniscal Root Injuries.

Background:Despite the increasing incidence of sports-related knee injuries in youth athletes, few studies have reported on the diagnosis and treatment of pediatric and adolescent meniscal root injuries.Purpose:To describe traumatic posterior meniscal root injuries in a pediatric and adolescent population and compare the presentation of meniscal root injuries versus that of nonroot injuries.Study Design:Cohort study; Level of evidence, 3.Methods:A study was conducted of all knee arthroscopies performed on consecutive patients treated in a pediatric sports practice from March 2012 through February 2015. All patients who were younger than 20 years at the time of their injury and who underwent an arthroscopy with meniscal injury were included. Patients with discoid lateral meniscus, atraumatic meniscal cysts, partial-thickness meniscal root injuries (LaPrade type 1), and recurrent root tears were excluded. A comparative analysis of root and nonroot injuries was performed.Results:A total of 314 patients had surgery for meniscal injury (mean patient age, 16.0 years; range, 10.5-19.6 years). Of these patients, 58 (18.5%) posterior meniscal root injuries were identified. The root injuries were more likely to have joint line tenderness on preliminary physical examination compared with nonroot injuries (96.5% vs 58.6%, respectively; P < .001). Root injuries rarely occurred in isolation compared with nonroot meniscal tears (6.9% vs 17.6%; P = .021) and were frequently treated in combination with anterior cruciate ligament (ACL) injuries (86.2%). Lateral root injuries occurred more often in conjunction with ACL injuries compared with medial root injuries (84.8% vs 22.2%; P < .001). On review of preoperative imaging, meniscal extrusion occurred more often in root injuries than in nonroot injuries (32.8% vs 3.5%; P < .0001) and was uncommonly seen in the skeletally immature patient. Extrusion was seen more often in medial than lateral root tears (66.7% vs 21.7%; P = .008). A majority of patients (57/58) underwent transosseous suture repair of the meniscal root.Conclusion:When treating a pediatric or adolescent patient for a traumatic meniscal tear, a surgeon may expect to see a posterior meniscal root injury in as many as 1 in 6 patients. When treated for an ACL, contact, or multiligament injury or meniscal extrusion, a pediatric or adolescent patient may demonstrate a meniscal root avulsion or complex meniscal tear. These data provide practitioners with an improved ability to identify and treat meniscal root injuries that otherwise lead to rapid cartilage degeneration.

Isolated avulsion tear of the medial meniscus anterior root: A case report and a novel surgical technique

Compared to the more prevalent posterior root tears, injuries of the anterior root of meniscus have been relatively far scarcer. In this article, a case of an isolated medial meniscus anterior root avulsion tear was reported, which was successfully treated with a novel arthroscopic technique that incorporated the coronary ligament for a more anatomical repair. The significance of this report are two folds: (1) to the best of our knowledge, there has only been one such case of an isolated medial meniscus anterior root tear prior to this report; (2) the concept of incorporation of coronary ligament during the meniscus repair has never been mentioned in the literature thus far. With the use of a 3.5 mm double-loaded suture anchor, an anatomical repair was achieved as the anterior root of medial meniscus was fixated not only back to its tibial insertion inferiorly but re-attached to the coronary ligament anteriorly as well. Postoperative magnetic resonance imaging (MRI) at 3 months showed complete healing of the anterior root, and at 6 months the patient were able to resume full sports activities asymptomatically.

A Complex Component of the Nervous System: Brachial Plexus

Brachial plexopathy is a type of peripheral neuropathy. Injuries to the brachial plexus can be classified according to their severity, ranging from neuropraxia, the mildest form, to axonotmesis and neurotmesis, the most severe forms. The causes of brachial plexopathy include traumatic and non-traumatic injuries. Because the brachial plexus can sustain various types of injuries, different imaging modalities are required. Recent advances in diagnostic imaging have enabled better investigation of brachial plexopathy. This article reviews the major and most widely used imaging methods used for investigating brachial plexopathy along with newer modalities. The indications, advantages, and disadvantages of each modality are examined. The major factor in realizing the full potential of any imaging method is the knowledge of the requesting physician about the capabilities and limitations of each method. Magnetic resonance imaging (MRI) is the standard imaging modality for evaluating non-traumatic injury to the brachial plexus; however, there are several limitations to its use and, therefore, other modalities should be pursued. MR myelography should be used for traumatic meningoceles and root avulsions. MR neurography is a relatively new technique with massive potential. It is a tissue-specific modality with the ability to elicit morphological as well as pathological features of nerves. CT myelography is the gold standard for evaluating traumatic injury of the brachial plexus. Other potential uses are with tumors of the brachial plexus as well as obstetric brachial plexus palsies. Finally, sonography is addressed. With its ability to detect almost all plexopathies and the fact that it does not employ radiation and can be done in virtually every patient, it should be the baseline or, at least, the screening method for plexopathies.

Pretreatment of nerve grafts with resveratrol improves axonal regeneration following replantation surgery for nerve root avulsion injury in rats.

Replantation of the avulsed nerve root has been proposed for the treatment of severe brachial plexus injury for several decades. However, due to the complexity of the technique and limited functional improvement, practical applications are yet to be implemented. In the present study, we investigated the effect of pretreatment with resveratrol on nerve autografts used for replantation surgery in a rat model of nerve root avulsion. Resveratrol pretreatment was performed using an explant culture technique. Two surgical procedures were performed. During the first surgery, Sprague-Dawley rats were subjected to left C6 nerve root avulsion, and nerves were harvested for autografting. The harvested grafts were explant-cultured for 1 week. A second procedure was performed to replant the C6 nerve root using the explant-cultured nerve graft 1 week after the first procedure. Histological and immunohistochemical analyses were performed 8 weeks after the second procedure. We first compared findings between explant-cultured nerve grafts and fresh nerve grafts, following which we compared findings between explant-cultured grafts pretreated with and without resveratrol. Changes induced within nerve grafts by 1 week of explant culture with or without resveratrol were investigated in vitro. There was no significant difference in outcomes between 1 week-explant-cultured and fresh nerve grafts. Addition of resveratrol to the explant culture medium resulted in a significant increase in the number and myelin thickness of regenerated axons, and in the number of regenerating motor neurons in the C6 spinal cord segment. In vitro analyses revealed that nerve grafts pretreated with resveratrol exhibited significant increases in glial cell line-derived neurotrophic factor (GDNF) expression and the number of dedifferentiated Schwann cells. Resveratrol may promote axonal regeneration following replantation surgery for the treatment of nerve root avulsion injury; however, further studies are required to verify these findings in humans.

Is Pseudomeningocele an Absolute Sign of Root Avulsion Brachial Plexus Injury?

The finding of pseudomeningocele from cervical myelogram is widely accepted as a pathognomonic sign for diagnosing root avulsion in brachial plexus injury. In general, motor power in this setting should be absent. However, in clinical practice, we observed that motor power in some patients was still preserved. The objective of this study is to evaluate the accuracy of pseudomeningocele from cervical myelogram for predicting root avulsion in brachial plexus injury. We retrospectively reviewed 201 patients with brachial plexus injury from 2007-2011. Four patients were excluded due to open wound injury. Motor power of the key muscle of each nerve root was evaluated by skilled hand surgeons. All cervical myelogram was interpreted by radiologists. Sensitivities, specificities, positive predictive values and negative predictive values were calculated with 95% confidence interval. Thirty and 29% of pseudomeningocele occurred at C7 and C8 level, respectively. The sensitivity of pseudomeningocele of each root from C5 to T1 was low (range, 10-62%). The specificity was high only at C5 (91%) and T1 (96.2%). Over 20% of patients with pseudomeningocele at C6-8 levels had some motor function. The initial muscle power of these patients was M1 or M2 and 70% of them recovered to at least M3 at the final follow-up. Pseudomeningocele is not an absolute sign for diagnosing of root avulsion in brachial plexus injury due to its high false positive rate when compared with preoperative motor function of each root. Careful examination of the key muscle of each root is extremely crucial to prevent unnecessary operation on that cervical nerve root.

EMG characteristics of the external anal sphincter guarding reflex and effects of a unilateral ventral root avulsion injury in rhesus macaques ( Macaca mulatta).

The external anal sphincter (EAS) is important for the maintenance of bowel continence and may be compromised by a variety of neuropathic conditions. However, large animal models for the study of EAS functions have been sparse. The EAS guarding reflex was examined by electromyography (EMG) in neurologically intact rhesus macaques ( n = 6) and at 4-6 wk after a unilateral EAS denervation from an L6-S3 ventral root avulsion (VRA) injury ( n = 6). Baseline EAS EMG recordings were quiescent in all subjects, and evoked responses showed an initial large-amplitude EMG activity, which gradually returned to baseline within 1-2 min. At 4-6 wk postoperatively, the EAS guarding reflex showed a significantly reduced EMG response duration of 47 ± 15 s and area under the curve (AUC) of 0.198 ± 0.097 mV·s compared with the corresponding evoked EAS EMG duration of 102 ± 19 s and AUC of 0.803 ± 0.225 mV·s ( P < 0.05) in the control group. Detailed time- and frequency-domain analysis of the evoked EAS EMG responses for the first 40 s showed no difference between groups for the maximum amplitude but a significant decrease for the mean amplitude across the study period and an early AUC reduction for the first 10 s in the VRA injury group. Time-frequency analysis and power spectrum plots indicated decreased intensity and a narrower midrange of frequencies in the VRA injury group. We conclude that the EAS guarding reflex in rhesus macaques shows characteristic EMG features in control subjects and signs of partial target denervation after a unilateral L6-S3 VRA injury. NEW & NOTEWORTHY The external anal sphincter guarding reflex showed initial large-amplitude peaks and a gradual return to a quiescent baseline after a rectal probe stimulus in rhesus macaques. At 4-6 wk after a unilateral ventral root avulsion (VRA) injury, the electromyography duration, mean amplitude, and area under the curve measurements were decreased. Time-frequency analysis and power spectrum plots indicated decreased intensity and a narrowed midrange of frequencies in the VRA injury cohort.

Sensory Outcome in Children Following Microsurgery for Brachial Plexus Birth Injury.

Studies are limited on sensory outcome in children with brachial plexus birth injury (BPBI). The purpose of this research was to evaluate the sensory function of the hand in children with BPBI who had microsurgical reconstruction of the brachial plexus. The sensory thresholds of children with upper and total plexus injury were evaluated with the Weinstein Enhanced Sensory Test and a test of stereognosis. A total of 63 children participated (aged 10.92 ± 3.29 years), 24 (38%) of whom had abnormal sensory thresholds in the affected hand. Only 4 children had loss of protective sensation or higher thresholds. These 4 measurements were all identified in the territory of the superficial branch of the radial nerve. Twelve children with upper plexus (43%) and 12 (34%) with total plexus injury had sensory impairment in the affected hand. These proportions were not statistically different. Of all children evaluated, 18 (29%) had a lower stereognosis score in the affected hand compared with the unaffected hand. The proportions of children with impairment in stereognosis in the upper plexus group (n= 5; 18%) versus the total plexus group (n= 13; 37%) were not statistically different. Age at the time of assessment, sex, upper versus total plexus injury, number of root avulsions, subjective report of altered sensation, and Faces Pain Scale-Revised score were not related to sensory impairment in the affected hand. Sensory recovery in BPBI after microsurgical reconstruction in children with total plexus injury who had reconstruction of the lower trunk had the potential to achieve sensory recovery similar to their upper plexus counterparts. A large proportion of children achieve normal sensory outcome, and those who had deficits had mild impairments. Prognostic IV.

Meniscal Root Tears: Current Concepts Review.

Meniscal root tears are defined as radial tears located within 1 cm from the meniscal attachment or a bony root avulsion. This injury is biomechanically comparable to a total meniscectomy, leading to compromised hoop stresses resulting in decreased tibiofemoral contact area and increased contact pressures in the involved compartment. These changes are detrimental to the articular cartilage and ultimately lead to the development of early osteoarthritis. Surgical repair is the treatment of choice in patients without significant osteoarthritis (Outerbridge grades 3 or 4). Root repairs have been reported to improve clinical outcomes, decrease meniscal extrusion and slow the onset of degenerative changes. Here we describe the anatomy, biomechanics, clinical evaluation, treatment methods, outcomes, and post-operative rehabilitation for posterior meniscal root tears.

ATG5 overexpression is neuroprotective and attenuates cytoskeletal and vesicle-trafficking alterations in axotomized motoneurons

Injured neurons should engage endogenous mechanisms of self-protection to limit neurodegeneration. Enhancing efficacy of these mechanisms or correcting dysfunctional pathways may be a successful strategy for inducing neuroprotection. Spinal motoneurons retrogradely degenerate after proximal axotomy due to mechanical detachment (avulsion) of the nerve roots, and this limits recovery of nervous system function in patients after this type of trauma. In a previously reported proteomic analysis, we demonstrated that autophagy is a key endogenous mechanism that may allow motoneuron survival and regeneration after distal axotomy and suture of the nerve. Herein, we show that autophagy flux is dysfunctional or blocked in degenerated motoneurons after root avulsion. We also found that there were abnormalities in anterograde/retrograde motor proteins, key secretory pathway factors, and lysosome function. Further, LAMP1 protein was missorted and underglycosylated as well as the proton pump v-ATPase. In vitro modeling revealed how sequential disruptions in these systems likely lead to neurodegeneration. In vivo, we observed that cytoskeletal alterations, induced by a single injection of nocodazole, were sufficient to promote neurodegeneration of avulsed motoneurons. Besides, only pre-treatment with rapamycin, but not post-treatment, neuroprotected after nerve root avulsion. In agreement, overexpressing ATG5 in injured motoneurons led to neuroprotection and attenuation of cytoskeletal and trafficking-related abnormalities. These discoveries serve as proof of concept for autophagy-target therapy to halting the progression of neurodegenerative processes.

Magnetic resonance imaging for detecting root avulsions in traumatic adult brachial plexus injuries: protocol for a systematic review of diagnostic accuracy

BackgroundAdult brachial plexus injuries (BPI) are becoming more common. The reconstruction and prognosis of pre-ganglionic injuries (root avulsions) are different to other types of BPI injury. Preoperative magnetic resonance imaging (MRI) is being used to identify root avulsions, but the evidence from studies of its diagnostic accuracy are conflicting. Therefore, a systematic review is needed to address uncertainty about the accuracy of MRI and to guide future research.MethodsWe will conduct a systematic search of electronic databases alongside reference tracking. We will include studies of adults with traumatic BPI which report the accuracy of preoperative MRI (index test) against surgical exploration of the roots of the brachial plexus (reference standard) for detecting either of the two target conditions (any root avulsion or any pseudomeningocoele as a surrogate marker of root avulsion). We will exclude case reports, articles considering bilateral injuries and studies where the number of true positives, false positives, false negatives and true negatives cannot be derived. The methodological quality of the included studies will be assessed using a tailored version of the QUADAS-2 tool. Where possible, a bivariate model will be used for meta-analysis to obtain summary sensitivities and specificities for both target conditions. We will investigate heterogeneity in the performance of MRI according to field strength and the risk of bias if data permits.DiscussionThis review will summarise the current diagnostic accuracy of MRI for adult BPI, identify shortcomings and gaps in the literature and so help to guide future research.Systematic review registrationPROSPERO CRD42016049702.

SIRT1 activation with neuroheal is neuroprotective but SIRT2 inhibition with AK7 is detrimental for disconnected motoneurons

Sirtuin 1 (SIRT1) activity is neuroprotective, and we have recently demonstrated its role in the retrograde degenerative process in motoneurons (MNs) in the spinal cord of rats after peripheral nerve root avulsion (RA) injury. SIRT2 has been suggested to exert effects opposite those of SIRT1; however, its roles in neurodegeneration and neuron response after nerve injury remain unclear. Here we compared the neuroprotective potentials of SIRT1 activation and SIRT2 inhibition in a mouse model of hypoglossal nerve axotomy. This injury induced a reduction of around half MN population within the hypoglossal nucleus by a non-apoptotic neurodegenerative process triggered by endoplasmic reticulum (ER) stress that resulted in activation of the unfolded protein response mediated by IRE1α and XBP1 by 21 days post injury. Both SIRT1 activation with NeuroHeal and SIRT2 inhibition with AK7 protected NSC-34 motor neuron-like cells against ER stress in vitro. In agreement with the in vitro results, NeuroHeal treatment or SIRT1 overexpression was neuroprotective of axotomized hypoglossal MNs in a transgenic mouse model. In contrast, AK7 treatment or SIRT2 genetic depletion in mice inhibited damaged MN survival. To resolve the in vitro/in vivo discrepancies, we used an organotypic spinal cord culture system that preserves glial cells. In this system, AK7 treatment of ER-stressed organotypic cultures was detrimental for MNs and increased microglial nuclear factor-κB and the consequent transcription of cytotoxic pro-inflammatory factors similarly. The results highlight the importance of glial cells in determining the neuroprotective impact of any treatment.

S113. Intraoperative recording of somatosensory evoked potentials from both peripheral median nerve and proximal upper trunk to assess C5, C6 brachial plexus injury

The prognosis of reconstructive surgery for brachial plexus injuries is related to the localisation of injury, whether the damage exists primarily in the brachial plexus, the spinal nerves distal to the dorsal root ganglia, or at the point of connection with the spinal cord (Jones, 1980). The use of somatosensory evoked potentials (SSEP) to monitor upper extremity nerves during surgery is becoming more accepted as a valid and useful technique to minimize intraoperative nerve injuries (Son et al., 2017). When SEP recording is used in an operating theater, it is valuable for evaluating proximal root lesions (Sugioka, 1984). We present a case illustrating the benefit of utilizing both SSEP from peripheral median nerve (MN) and from brachial plexus lateral cord (LC) and upper trunk (UT) for conducting the surgery procedure. Neurosurgeons decided to do nerve transfer, distal spinal accessory nerve to suprascapular nerve and ulnar nerve branch to musculocutaneous (MC) nerve, as it was found that the lesion might correspond to C5, C6 roots avulsion instead of nerve graft for the initially suspected lateral cord injury. EMG test before surgery and intraoperative muscle MEP mapping technique and SSEP from MN, LC, anterior division of the upper trunk (ADUT) and UT in a 66-year-old patient with total left forearm flexion and shoulder abduction paralysis after motorbike accident occurred 4 months earlier. SSEP protocols (4.1 Hz stimulus rate and 300 sweeps) were already installed in the IONM NIM-eclipse Medtronic device. We used subdermal paired electrodes for MN stimulation and two hooked monopolar electrodes for proximal stimulation (LC, ADUT and UT). The peripheral nerve distal SSEP and proximal brachial plexus SSEP were recorded from spinal Cs2-Fpz, inion-Fpz and C4’-Fpz channels. For muscle MEP and raw EMG were used paired subdermal electrodes in deltoid, biceps, EDC, APB and ADM muscles. EMG: 3 weeks after the accident and 4 days before surgery showed acute denervation in myotomes corresponding to C5, C6 root levels. SNAP of ulnar, median and radial nerves were present. Intraoperatively, muscle MEP did not show responses from LC to biceps and from posterior cord to deltoid muscle. SSEP from MN showed delayed N13 at 23 ms and P(N)20 at 27 ms. SSEP from LC showed N13 at 15 ms and P20 at 20 ms. From ADUT and from the UT SSEP was obtained at cervical level but not from the cortex. At this moment we added another channel Fpz-inion. The UT SSEP was absent in inion-Fpz, C4‘-Fpz while peripheral MN SSEP showed responses at three C2 spinal, inion and cortex levels. We proved the sensory-motor dysfunction of the ADUT, UT and proximally to the site of connection with the spinal cord, both with muscle MEP mapping and SSEP absence (ADUT and UT) at cortical level and neurosurgeons decided to perform a nerve transfer instead of a nerve graft. This report demonstrates a case in which IONM was useful in identifying the lesion site during brachial plexus surgery.

Root avulsion and para-root tear of the posterolateral meniscus: repair versus untreated

Background: This study aimed to assess the outcomes of repairing posterolateral meniscal (PLM) root avulsion and para-root tear in association with anterior cruciate ligament (ACL) reconstruction and compare with those whose PLM tear was left untreated. Methods: Patients with PLM root avulsion or para-root tear accompanying ACL tear were evaluated for eligibility. Group A was composed of patients whose ACL tears were reconstructed without any lateral meniscal repair (33 patients) from 2006-2009. From 2009-2012, patients had ACL reconstruction and additional PLM repair (group B: 40 patients). Both groups were evaluated for knee stability (Lachman test), return to previous level of sports activity, subjective International Knee Documentation Committee form (S-IKDC) and Lysholm knee scores (LKS). Results: Functional results (IKDS and LKS) at 12 and 24-month follow-up were similar between the two groups (all P&gt;0.05). Eight patients (24%) in group A, and two patients (5%) in group B were unable to achieve the previous sports activity level (P=0.036). Return to previous sports activity level was significantly better in group B. Short-term (34.5 mo) and mid-term (73.5 mo) functional results of group A patients were compared, and it was demonstrated that IKDC (84.5±4) and LKS (87.7±3) scores were decreased significantly (P&lt;0.0001). Conclusions: Functional outcomes of repairing PLM root avulsion and para-root tear with those whose PLM tear was left untreated are similar in short-term follow-up; however, as the time passes, the sports activity level and mid-term subjective outcomes may worsen in patients whose PLM tear was left untreated.