Scalene Research Articles

Aberrant artery within the brachial plexus: Doppler ultrasound as a savior

Sir, Anatomical variations of the brachial plexus at the supraclavicular region are quite common, and it is important to identify such abnormalities for a successful block. The use of ultrasound to identify these variations will prevent potential adverse complications and will improve the safety and quality of the block.[1] Herewith, we report the case of an aberrant artery within the brachial plexus and the effective use of color Doppler ultrasound for the identification of the artery. A 28-year-old, male patient, a case of malunited fracture of right both bone forearms was posted for open reduction and internal fixation. Preoperative investigations and vitals were within the normal limits. In the operation theater, after attaching all standard monitors, preprocedural ultrasound was done in two-dimensional mode, and an abnormal structure was noticed within the plexus [Figure 1]. Subsequent color Doppler revealed that it was a blood vessel [Figure 2a] and a spectral Doppler also confirmed that it was an artery, but we could not identify its origin [Figure 2b]. After taking all precautions to treat local anesthetic systemic toxicity, brachial plexus block under ultrasound guidance was performed using linear probe by in-plane technique. Needle was inserted from lateral to medial direction, and the tip was placed above the artery. After confirming negative aspiration, injection bupivacaine 0.5% 10 ml was injected. The needle was then redirected below the artery, and the rest of the local anesthetic was injected (10 ml of injection bupivacaine 0.5%). A successful block was confirmed by the complete anesthesia of the upper limb, and the rest of the intraoperative period remained uneventful. Postprocedure, a scan on the other side (left) did not reveal any such aberrant vessel inside the brachial plexus.Figure 1: Two-dimensional image of brachial plexus in the supraclavicular a b region, with aberrant vessel inside the plexus. BP: Brachial plexus, SA: Subclavian artery, AA: Aberrant artery, ASM: Anterior scalenus muscle, MSM: Middle scalenus muscleFigure 2: (a) Color Doppler image of the brachial plexus with aberrant vessel and (b) Spectral Doppler view of the aberrant artery inside the brachial plexusSupraclavicular brachial plexus block under ultrasound guidance offers added advantages such as better anatomical interpretation, precise needle location, and avoidance of intravascular and intraneural injection.[2] Interpretation requires not only careful anatomical orientation, but also precise image optimization, the recognition of artifact, and the ability to distinguish nerves from the tendons, muscle, and vessels. It is important to note that not all circular hypoechoic structures seen on transverse scanning are nerves. Cadaveric studies have shown that vascular structures can be found within the brachial plexus in around 90% of general population, and the most common vessels include aberrant subclavian artery, dorsal scapular artery, and transverse cervical artery.[3] As these variations can compromise the success and safety of supraclavicular technique, we believe that careful preprocedural scanning, especially using color Doppler, is important to differentiate between vascular structures and nerves. Small noncompressible vessels can mimic proximal nerve roots during gray-scale ultrasound evaluations, making color Doppler imperative when sonographically evaluating the brachial plexus.[4] Hence, in addition to standard gray-scale imaging, color Doppler imaging should be done as a routine before selecting the optimal needle path and location of anesthetic placement, to reduce the possibility of inadvertent vascular injury or intravascular anesthetic deposition. Spectral waveforms obtained with Doppler ultrasonography of small arteries will show triphasic pattern but with a less diastolic flow as seen in our case.[5] Although we could not trace the origin and course of the vessel in our case, appreciation of such vessel within the brachial plexus by Doppler ultrasound enabled us to advance and place the needle tip close to the nerve without puncturing the vessel. Before attempting block in such cases, it is also equally important to take all standard precautions to treat local anesthetic systemic toxicity, as this complication may still occur with the use of ultrasound guidance.[6] Thus, in addition to standard imaging, anesthesiologists should consider preprocedural color Doppler to identify the presence of any abnormal vessel inside the plexus for a safe and successful block. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A Case of Kirschner’s Wire Migrating into the Scalenus Anterior Muscle following Right Clavicular Osteosynthesis

A Case of Kirschner’s Wire Migrating into the Scalenus Anterior Muscle following Right Clavicular Osteosynthesis

Treatment of scalene muscles with the Ergon technique can lead to greater improvement in hip abduction range of motion than local hip adductor treatment: a study on deep front line connectivity.

[Purpose] This study aimed to investigate the effects of Ergon® instrument-assisted softtissue mobilization of the upper and lower midpoints of the Deep Front Line (DFL) on hip abduction range of motion (ROM). [Participants and Methods] Forty healthy adults (29.3 ± 6.3 years; height: 175.8 ± 7.4 cm; weight: 77.2 ± 9.2 kg) were randomly divided into two groups and received a single 15-minute Ergon treatment in the upper midpoint (scalene muscles) and the lower midpoint of the DFL (hip adductors) on their dominant side. The non-dominant hip served as a control. Pre-and post-therapy active and passive hip abduction ROM at 0° and 90° flexion was examined using a goniometer. [Results] In both experimental groups, active and passive hip abduction ROM on the treated side improved significantly compared to the control side. Scalene treatment led to significantly greater improvement in active hip abduction ROM at 0° and 90° and in passive ROM at 90° compared to local hip adductor treatment. [Conclusion] The application of the Ergon technique on remote parts of the DFL may lead to a significant increase in hip abduction ROM compared to local hip adductors treatment.

Breathing retraining with chest wall mobilization improves respiratory reserve and decreases hyperactivity of accessory breathing muscles during respiratory excursions: A randomized controlled trial

The aim of this paper was to evaluate the effects of breathing retraining with chest wall mobilization on the onset of accessory breathing muscle recruitment and respiratory reserve in individuals with chronic neck pain. Thirty-two participants with non-specific chronic neck pain were randomly assigned into intervention and control groups. The intervention group received 30 minutes of breathing retraining with chest wall mobilization and the control group was assigned to rest for 30 minutes. Electromyography (EMG) of upper trapezius (UT), scalene (SC), and sternocleidomastoid (SCM) muscles were recorded during respiratory excursions by cycling for 12 minutes. Measurement of maximum voluntary ventilation (MVV), chest expansion, and pain intensity were taken during normal breathing. The immediate effects within each group and between two groups were analyzed. Significant improvement in respiratory reserve was observed in the intervention group compared to control group through prolonged EMG onset of accessory breathing muscles. Moreover, increase of MVV, chest expansion and decrease in pain intensity were observed. This research suggests that breathing patterns and chest expansion should be considered within the physical assessment of breathing retraining, and that chest wall mobilization offers clinically important improvements in patients with chronic neck pain.

Ultrasonographic diagnosis of an iatrogenic winged scapula caused by spinal accessory neuropathy combined with dorsal scapular neuropathy - a case report

Background: The most common cause of a spinal accessory nerve (SAN) lesion is iatrogenic injuries that occur during operations on the posterior cervical triangle of the neck. Dorsal scapular nerve (DSN) lesions occur rarely and are usually caused by compression of the nerve by the hypertrophic middle scalene muscle or stretching of the nerve as a result of traumatic movements. Case Presentation: We present a case with SAN and DSN lesions due to neck surgery because it is a rare case and we think it will contribute to the literature. To the best of our knowledge, this is the first presentation of a case of iatrogenic injury to both the SAN and DSN. As a result of the examination and evaluation by ultrasonography of the patient, we suspected the accompanying DSN lesion and confirmed it with electromyography (EMG) examination. Conclusion: Musculoskeletal ultrasound can be used as an assistive or alternative technique for EMG examination in the diagnosis of chronic peripheral nerve lesions by measuring muscle thickness.

The minimum local anesthetic concentration of ropivacalne for ultrasound-guided phrenic nerve block in the treatments of central hiccup

Objective To determine the minimum local anesthetic concentration of ropivacalne for ultrasound-guided phrenic nerve block in the treatments of central hiccup. Methods In this experiment, sequential experimental method was used to select patients with hiccup after the operation of cerebral hemorrhage. The starting concentration of ropivacaine was 0.25%. The ratio between adjacent concentrations was 1.3. The superficial phrenic nerve on the left anterior scalene muscle of all patients were located by ultrasound. The predetermined concentration of ropiacaine 4 ml was injected. After twenty minutes, whether the injection works or not was judged by observing the symptom of all patients. If the first one is effective, the next injection dose will be decreased one concentration gradient. If the block was not effective, then 4 ml of 1.5% lidocaine will be injected at the same lateral phrenic nerve. If the block is still not effective, the next injection will be ropivacaine with increased one concentration gradient. If the hiccups still did not end, the routine drug treatment will be used. At the same time, with the approval of the patients′ family, after eight hours, we will take the right phrenic nerve block. Then this case will not be included in the data statistic. The next patient continues to use the same initial concentration ropivacaine. The effective cases were included in effective group(group A) while the cases with lidocaine supplement were divided into invalid group (group B). The drug concentration, blocking effect, median effective dose(ED50) and 95% confidence intervals (CI) were calculated according to Dixon and Brownlee methods. Results Ultrasound-guided application of ropivacaine for phrenic nerve block for central hiccup is safe, effective and requires little medication. 95%CI of ultrasound-guided phrenic nerve block for central hiccup is 0.267%-0.335%. Conclusions The minimum effective concentration of ropivacaine in the treatment of central hiccup was 0.299%. Key words: Phrenic nerve; Nerve blocking anesthesia; Hiccup; Ultrasound-guided; Ropivacaine

Sonographically guided botulinum toxin injections in patients with neurogenic thoracic outlet syndrome: correlation with surgical outcomes.

We examined the role of botulinum toxin (BTX) injections of anterior scalene (AS) and pectoralis minor (PM) muscles in patients undergoing surgery for neurogenic thoracic outlet syndrome (NTOS). We hypothesized that symptomatic improvement from BTX injections correlates with favorable long-term response to surgery for NTOS. This Health Insurance Portability and Accountability Act compliant study was approved by the institutional review board and prior informed consent requirement was waived. We retrospectively analyzed prospectively acquired data in NTOS patients who underwent sonographically guided chemodenervation of AS and PM using BTX type A followed by scalenectomy and first rib resection. Overall responses to BTX injections and surgery were recorded after each procedure. Statistical analyses were performed to determine correlation between responses to BTX injections and surgery. In 157 patients, 178 BTX injections followed by surgery were identified (114 females; mean age 38 ± 13 years). Responders and non-responders to BTX injections and surgery had similar preoperative symptom duration and age (P > 0.14). Better response to BTX injections correlated positively with better response to surgery (P = 0.003), persisting after adjustment for age, gender, and symptom duration (P = 0.03). A high proportion of responders to BTX injections also responded to surgery (positive predictive value of 99%), and BTX injections showed high specificity (90%). BTX injections were moderately sensitive (66%) and accurate (67%) to determine surgical response and had low negative predictive value (14%). Response to BTX injections correlates positively with long-term surgical outcome in subjects with NTOS, potentially playing an important role in patient management.

Respiratory muscle activity in voluntary breathing tracking tasks: Implications for the assessment of respiratory motor control

How the involuntary (bulbospinal) and voluntary (corticospinal) pathways interact in respiratory muscle control is not established. To determine the role of excitatory corticobulbar pathways in humans, studies typically compare electromyographic activity (EMG) or evoked responses in respiratory muscles during hypercapnic and voluntary tasks. Although ventilation is matched between tasks by having participants track signals of ventilation, these tasks may not result in matched respiratory muscle activity. The aim of this study was to describe respiratory muscle activity and ribcage and abdominal excursions during two different voluntary conditions, compared to hypercapnic hyperventilation. Ventilation was matched in the voluntary conditions via (i) a simple target of lung volume (‘volume tracking’) or (ii) targets of both ribcage and abdominal excursions, adjusted to end-expiratory lung volume in hypercapnic hyperventilation (‘bands tracking’). Compared to hypercapnic hyperventilation, respiratory parameters such as tidal volume were similar, but the ratio of ribcage to abdominal excursion was higher for both voluntary tasks. Inspiratory scalene and parasternal intercostal muscle activity was higher in volume tracking, but diaphragm and abdominal muscle activity showed little to no change. There were no differences in muscle activity in bands tracking for any muscle, compared to hypercapnic hyperventilation. An elevated ratio of ribcage to abdominal excursion in the bands tracking task indicates that participants could not accurately match the targets in this condition. Inspiratory muscle activity is altered in some muscles in some voluntary tasks, compared to hypercapnia. Therefore, differences in muscle activity should be considered in interpretation of studies that use these protocols to investigate respiratory muscle control.

Thoracic Outlet Syndrome: Diagnostic Accuracy of MRI

BackgroundThoracic outlet syndrome (TOS) is challenging to diagnose, as the physical findings and investigations lack sensitivity and/or specificity. Magnetic resonance imaging (MRI) with dynamic manoeuvres can rule out a tumour and detect anatomical abnormalities potentially responsible for compression. The objective of this study was to assess the sensitivity and specificity of MRI for identifying anatomical structures responsible for compression in TOS, using intra-operative findings as the diagnostic reference standard. HypothesisMRI is effective in diagnosing the source of compression in TOS, notably within the scalene triangle and at the pleural apex. MethodsWe retrospectively included 48 patients who underwent surgery for TOS after a work-up that included MRI (1.5-T, n=29 and 3-T, n=19). The MRI scans were reviewed for the study by a specialised radiologist who was unaware of the intra-operative findings. The sensitivity and specificity of MRI for diagnosing TOS were estimated using the intra-operative findings as the reference standard. ResultsMRI identified a structure potentially responsible for TOS in 34 (71%) patients; thus, the false-negative rate was 14/48 (29%). The sensitivity of MRI was 28% for compression at the suspensory ligament of the pleural dome, 81% for hypertrophy of the anterior scalene muscle, and 50% for an accessory scalene muscle. For diagnosing a cervical rib, MRI had 100% sensitivity and 100% specificity. ConclusionMRI can contribute to the diagnosis of TOS. Specificity is sufficiently high to provide guidance for planning the surgical procedure. Sensitivity, however, is too low for MRI to be useful as a screening test. MRI should be used in combination with the clinical assessment and other investigations to assist in the diagnosis of TOS. Level of evidenceIV, retrospective cohort study.

P46 Swimmer’s thoracic outlet: it doesn’t have quite the same ring as tennis elbow!

Abstract Background We present a case that was referred and seen in our chronic pain clinic, and highlight the importance of keeping an open mind about alternative diagnoses when reviewing these patients. Methods Please refer to the results section. Results A 12 year-old girl was referred with right sided neck and shoulder pain associated with occasional pins and needles. The patient was a competitive swimmer, training and competing five times a week at her peak. She did not have a history of mottling or colour change, and clinically she had full range of motion of her joints and no neurological deficit. On repeated assessments, she had reproducible pain on horizontal flexion and reduced muscle bulk of the right shoulder, although power was preserved. Functionally the patient had to reduce her participation in swimming due to pain, and found it difficult to carry or lift things, brush or wash her hair, or write for extended periods of time. Imaging with shoulder X-ray and shoulder and cervical spine MRI did not reveal a cause, and she did not have an anatomical variation such as a thoracic rib. Due to the reproducibility on swimming, an ultrasound looking at the insertion of the biceps insertion during dynamic movements was arranged and was also normal with no subluxation noted. As she failed to improve with chronic pain education, chronic pain approach to physiotherapy sessions and graded reintroduction of swimming, ultrasound angiology was arranged. This showed minor disease in the right subclavian, axillary, brachial, radial and ulnar arteries, with significant reduction in right brachial arterial flow with the patient supine, right arm in horizontal flexion and contralateral head turn. This suggested arterial thoracic outlet syndrome (TOS). All other positions resulted in no significant difference in arterial flow. TOS is traditionally broken into two categories – neurogenic and vascular, the latter can be broken down further into arterial or venous. While in adults, the vast majority (90-95%) present as neurogenic, in the paediatric population there is a higher proportion of vascular cases. This has implications, as vascular TOS can be complicated by vessel disease and thrombus formation. There are a number of case reports in which management is reported as decompression of the thoracic outlet with partial first rib resection, with or without scalene muscle resection. Consideration of hypercoagulable states is also warranted. We have referred our patient to the vascular team for an urgent review and await their assessment and feedback about management. Conclusion A proportion of patients managed with chronic pain syndrome will have an alternative explanation for their pain. In particular, if a patient has focal pain or pain that is reproducible on a particular movement or activity, consider alternate diagnoses. Conflicts of Interest The authors declare no conflicts of interest.

Neck Muscle Changes Following Long-Duration Spaceflight.

The effects of long-duration spaceflight on crewmember neck musculature have not been adequately studied. The purpose of this study was to evaluate the changes in the neck musculature on pre-flight and post-flight magnetic resonance imaging (MRI) examinations of six crewmembers on 4- to 6-month missions equipped with the advanced resistive exercise device (aRED). The MRI images were resliced to remove variations in spinal curvature, the cross-sectional area (CSA), and muscle fat infiltration (MFI) of neck musculature at the C1-C2, C4-C5, C7-T1, and T1-T2 intervertebral disc levels were measured bilaterally. Percent changes in the neck muscle CSA and fatty infiltration following spaceflight were calculated, and mixed models were used to assess significance of these changes. Crewmembers on missions equipped with the aRED experienced an average 25.1% increase in CSA for the trapezius muscle at C6-C7, an average 11.5% increase in CSA for the semispinalis capitis muscle at C4-C5, an average 9.0% increase in CSA for the sternocleidomastoid muscle at C4-C5, and an average 23.1% increase in CSA for the rhomboid minor at T1-T2. There were no significant changes in the CSA of the levator scapulae, splenius capitis, rectus capitis posterior major, scalenus anterior, scalenus posterior, scalenus medius, longissimus capitis, or obliquus capitis inferior muscles at the locations measured. None of the muscles analyzed experienced statistically significant changes in fatty infiltration with spaceflight. Our study indicates that long-duration spaceflight conditions are associated with preservation of CSA in most neck muscles and significant increases in the CSAs of the trapezius, semispinalis capitis, sternocleidomastoid, and rhomboid minor muscles. This may indicate that cervical muscles are not subjected to the same degradative effects microgravity imparts on the majority of muscles.

Five Hundred Rib-Sparing Scalenectomies for the Treatment of Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (TOS) is no longer either controversial or disputed, but its optimal surgical management remains unclear. Most thoracic outlet decompression procedures are carried out by first rib resection, usually through a transaxillary route. A retrospective review was conducted of a prospectively maintained TOS database. Patients with neurogenic TOS associated with a cervical rib were excluded from analysis, as were patients with recurrent neurogenic TOS. All study patients satisfied a 5-point clinical diagnostic protocol and experienced a positive response to a local anesthetic scalene block. Surgical decompression included anterior, minimus, and middle scalenectomy and brachial plexus neurolysis by a supraclavicular incision and pectoralis minor tenotomy through a small vertical infraclavicular incision. No first ribs were excised. All patients completed a shortened Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) preoperatively and at 1 month, 3 months, and 6 months postoperatively; operative success was defined as 50% improvement of 6-month postoperative vs preoperative QuickDASH scores. Between 2011 and 2019, there were 500 consecutive thoracic outlet decompression procedures carried out in 448 patients. Average operative time was 1.15 hours, and hospital length of stay was 1.05 days. Major complications (serious bleeding, permanent nerve injury, infection) occurred in seven patients (1.3%). All but two (99.6%) patients improved symptomatically; using the more rigorous definition of operative success noted before, 452 (90.9%) rib-sparing neurogenic TOS operations were successful. These results suggest that adherence to a rigorous preoperative diagnostic regimen, including scalene block, ensures, at the least, that operation for neurogenic TOS can successfully be restricted to patients actually suffering from the condition; fibrotic, contracted scalene muscles are the cause of neurogenic TOS; the first rib need not be removed for successful surgical treatment of neurogenic TOS; and >90% of patients so treated can expect significant medium-term symptomatic and functional improvement.

Local and Widespread Pressure Pain Hyperalgesia Is Not Side Specific in Females with Unilateral Neck Pain that Can Be Reproduced during Passive Neck Rotation.

Current evidence for widespread hyperalgesia in non-specific neck pain (NSNP) is unclear. It is currently recommended to group NSNP patients according to pain-provoking movements. The aim of this study was to investigate local and widespread pain sensitivity in females with unilateral NSNP that is reproducible during passive neck rotation compared with matched controls, and to compare the side specific effect of pain location on pressure pain sensitivity among females with unilateral NSNP. Thirty-six females with unilateral NSNP evoked during passive ipsilateral (n = 20) or contralateral (n = 16) rotation toward the painful side were compared with 20 controls. Participants reported their pain intensity at rest and during passive neck rotation and completed the Neck Disability Index. Pressure pain thresholds (PPTs) were assessed bilaterally over the anterior scalene; the sternocleidomastoid; the levator scapulae; lateral to the spinous process of C6; the median, ulnar, and radial nerves; and the tibialis anterior. The ANOVA revealed lower PPTs in females with unilateral NSNP compared with the controls (all at p < 0.001), but no differences were found between the sides, nor was there any Group × side interaction. Among females with NSNP, those with higher pain intensity during ipsilateral rotation toward the painful side showed lower PPTs over the anterior scalene, median nerve, ulnar nerve, and tibialis anterior (all, p < 0.05) than females with higher pain intensity during contralateral rotation toward the painful side. These findings demonstrated bilateral local and widespread pressure pain hyperalgesia in females with unilateral NSNP that was reproducible during passive neck rotation compared with controls. There was no side specific effect of pain location on PPTs among females with unilateral NSNP.

Extensor/flexor ratio of neck muscle strength and electromyographic activity of individuals with migraine: a cross-sectional study.

Neck pain is considered a common characteristic of migraine attacks. The relationship between neck pain and migraine can be explained by central sensitization of the trigeminocervical complex, where superior cervical afferents and the trigeminal nerve converge. However, few studies have evaluated motor control of cervical muscles in individuals with migraine. Thus, the purpose of the present study was to determine the extensor/flexor ratio of neck muscle strength and electromyographic activity during a test of maximal voluntary isometric contraction and craniocervical flexion in individuals with migraine and individuals without history of migraine or other headaches. Fifty-two women with the disease and 52 women with neither a history of migraine nor neck pain, between 18 and 55years old, were included in the study. The electromyographic activities of the sternocleidomastoid, anterior scalene, splenius capitis, and upper trapezius muscles were evaluated during a test of maximal voluntary isometric contraction and craniocervical flexion. The migraine group presented lower flexor muscle strength and a higher extensor/flexor muscle strength ratio than the control group. In addition, the migraine group showed a reduced electromyographic extensor/flexor muscle ratio during maximal voluntary isometric contraction in flexion. The results demonstrated worse performance in the craniocervical flexion test of the migraine group and a lower electromyographic ratio of extensor/flexor neck muscles in the last stage of the test. Altogether, the migraine group presented an imbalance in cervical muscles verified not only during force production, but also during muscle activity. These slides can be retrieved under Electronic Supplementary Material.

Acute Effects of Inspiratory Loads and Interfaces on Breathing Pattern and Activity of Respiratory Muscles in Healthy Subjects.

ObjectivesThe aim of this study was to evaluate the acute effects of different inspiratory loads and different interfaces on the breathing pattern and activity of the respiratory muscles.MethodsTwenty healthy adults were recruited and assigned to two groups (20 and 40% of the Maximal Inspiratory Pressure) by way of randomized crossover allocation. Subjects were evaluated during quiet breathing, breathing against inspiratory load, and recovery. The measurements were repeated using two different interfaces (nasal and oral). Chest wall volumes and respiratory muscle activity were assessed with optoelectronic plethysmography and surface electromyography, respectively.ResultsDuring the application of inspiratory load, significant changes were observed in the respiratory rate (p < 0.04), inspiratory time (p < 0.02), minute ventilation (p < 0.04), tidal volume (p < 0.01), end-inspiratory volume (p < 0.04), end-expiratory volume (p < 0.03), and in the activity of the scalene, sternocleiomastoid, and parasternal portion of the intercostal muscles (RMS values, p < 0.01) when compared to quiet breathing, regardless of the load level or the interface applied. Inspiratory load application yielded significant differences between using nasal and oral interfaces with an increase in the tidal volume (p < 0.01), end-inspiratory volume (p < 0.01), and electrical activity of the scalene and sternocleiomastoid muscles (p < 0.01) seen with using the nasal interface.ConclusionThe addition of an inspiratory load has a significant effect on the breathing pattern and respiratory muscle electrical activity, and the effects are greater when the nasal interface is applied.

Brachial plexus doses in locoregional radiotherapy for breast cancer

Background: Brachial plexopathy is a known issue following axillary radiotherapy in locally advanced breast cancer (LABC). We attempted to adapt Radiation Therapy Oncology Group (RTOG) guidelines on brachial plexus (BP) contouring (head and neck cancer) to breast cancer patients receiving post-mastectomy locoregional radiotherapy (LRRT), to determine (I) feasibility of identifying BP in the treatment position for breast cancer, and (II) radiation therapy dose received by BP with respect to the planned dose. Methods: Planning computed tomography (CT) sets (non-contrast) of 10 LABC patients, who had undergone mastectomy and subsequently completed LRRT including posterior axillary boost, were retrieved. Treatment included chest wall irradiation [50 gray (Gy) in 25 fractions, 6–10 Mega-electronVolt (MeV) electrons, 80–100% isodose], and supraclavicular and axillary RT with an anterior photon field [6 megavolts (MVs), 40 Gy in 20 fractions] and a posterior axillary field (6 MVs, 10 Gy in 5 fractions). Vertebral bodies C5–T1, anterior and middle scalene muscles (MS) were contoured and used as guide to identify probable location of BP. Results: Ten LABC patients received LRRT (50 Gy). Mean ipsilateral BP volume was 13.8 cc. Medians of maximum and mean BP doses were 54.65 and 36.62 Gy, respectively. Mean global dose maximum of the respective plans was 58.83 Gy. Mean BP volume receiving >50 Gy was 27.81% (range, 13.01–51.80%). Conclusions: BP contouring in LABC radiotherapy is feasible, with uncertainty in regions of altered anatomy (C5–6, shoulder). The maximum BP doses always exceeded prescribed dose, and although lower than tolerance dose (66 Gy) should be evaluated to reduce adverse events’ risk. This study establishes the feasibility of following RTOG guidelines for BP contouring even in altered treatment position in breast cancer radiotherapy planned on non-contrast CT scans. BP dose maxima in conventional radiotherapy planning are nearly 18–20% higher than prescription isodoses. Albeit safe in conventional terms, the risk of high doses leading to increased risk of plexopathy warrants consideration especially with regard to relation to tumor boost volumes as well as when using hypofractionated regimens which may be less forgiving for late effects.

Anatomical entrapment of the dorsal scapular and long thoracic nerves, secondary to brachial plexus piercing variation.

Circumscapular pain is a frequent complaint in clinical practice. The dorsal scapular and long thoracic nerves course through the neck, where they may become entrapped between or within adjacent scalene muscles. Additionally, a high frequency of brachial plexus "piercing" variants have recently been documented, and it is unclear how they influence branching patterns distally along the brachial plexus. In the project reported here we strived to identify and quantify variations in dorsal scapular nerve and long thoracic nerve secondary to brachial plexus piercing variation. Ninety brachial plexuses from human cadavers (45 female/45male) were evaluated to identify nerve branching patterns, specifically piercing versus non-piercing variants in the brachial plexus roots and nerves. Anatomical entrapment of the dorsal scapular nerve and long thoracic nerve was found in high frequencies (60.8% and 44.6%, respectively). Anomalous brachial plexus piercing variants were associated with higher frequencies of distal nerve branches also coursing through the scalene musculature, and there was a statistically significant correlation between brachial plexus and long thoracic nerve piercings (p = 0.027). Anatomical entrapment of nerves within scalene musculature is common and may be causative factors for idiopathic circumscapular pain, dorsalgia, and dysfunction of scapulohumeral rhythm. This study revealed a link between anatomical arrangement of the brachial plexus and occurrence of long thoracic nerve entrapment, which may lead to a series of cascading neurologic effects in which affected individuals may suffer from increased incidence of thoracic outlet syndrome and long thoracic nerve entrapment resulting in additional symptoms of interscapular pain and compromised shoulder mobility.

Immediate effects of cervical mobilisations on neck muscle activity during active neck movements in patients with non-specific neck pain. A double blind placebo controlled trial

BackgroundCervical mobilisations are used to treat people with neck pain but their mechanisms of action are unclear. One theorised reason for induced analgesia is effect on neck muscle activity. ObjectivesTo assess the effects of cervical mobilisations on muscle activity during active neck movements and whether changes in muscle activity are associated with changes in symptoms. DesignDouble-blind randomised placebo controlled trial. SettingPrimary care. Participants40 patients (aged 19 to 80 years, 24 female) with non-specific neck pain. InterventionsOne session of cervical mobilisations or motionless manual contact (placebo).Main outcome measures: sternocleidomastoid (SCM), scalene (SCA), upper trapezius (UT) and erector spinae (ES) surface electromyography (SEMG) during active neck flexion, extension, side flexion and rotation was measured immediately before and after the intervention. Patients were classified as responders according to change in symptoms assessed using the Global Rating of Change Scale (GROC). ResultsCompared with placebo, patients receiving mobilisation showed an increase in contralateral UT and ES SEMG during rotation and contralateral and ipsilateral SCM, SCA and UT during side flexion (P<0.05), however changes were mostly associated with an increase in range and speed of movement. The only association with GROC was increased (5%) SEMG in the contralateral SCM during side flexion in the mobilisation group (P=0.013). ConclusionCervical mobilisations caused increased neck SEMG, mostly due to increased movement range and speed. Change in muscle activity is unlikely to be a major mechanism of action of cervical mobilisations in symptomatic improvement with physiological neck movements. (ClinicalTrials.gov record number: 2016/066). Clinical Trials RegistryClinicalTrials.gov record number: 2016/066.

Evaluation of the efficacy of ropivacaine injection in the anterior and middle scalene muscles guided by ultrasonography in the treatment of Thoracic Outlet Syndrome.

A clinical, placebo-controlled, randomized, double-blind trial with two parallel groups. to evaluate the efficacy of ropivacaine injection in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome (TOS) compared to cutaneous pressure. 38 patients, 19 in the control group (skin pressure in each belly of the anterior and middle scalene muscles) and 19 in the intervention group (ropivacaine). Subjects with a diagnosis of Nonspecific Thoracic Outlet Syndrome, pain in upper limbs and/or neck, with no radiculopathy or neurological involvement of the limb affected due to compressive or encephalic root causes were included. The primary endpoint was functionality, evaluated by the Disabilities of the Arm, Shoulder, and Hand - DASH scale validated for use in Brasil. The time of the evaluations were T0 = before the intervention; T1 = immediately after; T2 = 1 week; T3 = 4 weeks; T4 = 12 weeks; for T1, the DASH scale was not applied. Concerning the DASH scale, it is possible to affirm with statistical significance (p> 0.05) that the intervention group presented an improvement of functionality at four weeks, which was maintained by the 12th week. In practical terms, we concluded that a 0.375% injection of ropivacaine at doses of 2.5 ml in each belly of the anterior and middle scalene muscles, guided by ultrasonography, in the treatment of Nonspecific Thoracic Outlet Syndrome helps to improve function.

First Rib Stress Fracture in Overhead Throwing Athletes

Objectives:First-rib stress fractures as a potential cause for non-specific atraumatic chronic shoulder pain in adolescent athletes. However, etiology on throwing athletes with first rib fracture have not been still unknown. The purpose of this retrospective study was to investigate characteristic clinical features and radiographic findings of patients with the first rib fracture in overhead throwing athletes.Methods:Twenty-four cases of first rib stress fracture in 23 players were studied retrospectively. We reviewed clinical features, including age, initial symptom, sports, activity related to pain, method of diagnose, method of treatment, and final follow-up.Results:We found characteristic clinical features as follows; 16.8 years (13-25), 19 dominant side injury and 5 non-dominant injury, an acute increase in pain while swinging the bat (9 cases) or pitching the ball (6 cases). Sixteen cases presented with posterior shoulder, inferior or medial border of the scapula, upper thoracic back pain. The current study showed 17 healing on average 3.8 month after conservative treatment and 7 nonunion of throwing athlete with the first rib stress fracture, (69.6%, 30.4%, respectively). Analysis on radiographs and CT revealed that the first rib stress fractures were classified into 3 types depends on direction and portion of fracture lines: Groove type, fracture line along with the subclavian artery groove; Intrascalene type, fracture line inside the middle scalene muscle insertion; and Posterior type, fracture beside to the costovertebral articulation (Figure 1 a-c). A 3-dimensional CT angiography showed that fracture line in the Groove type was consistent with the subclavian artery and fracture line in the Intrascalene type was different to the subclavian artery (Figure 2 a-f).We found 2 symptomatic cases and they had the first rib resection cause of thoracic outlet syndrome. We calculated percent availability of the first rib based on the measurements of 2 different observers. Percent availability of the shoulder and cervical spine radiographs were 46% and 97%, respectively. The Cohen’s kappa coefficient and percent agreement of the shoulder and cervical spine were 0.87, 89.4% and 0.80, 99.0%, respectively.Conclusion:We should consider the first rib stress fracture when teenage overhead athletes have posterior shoulder pain and acute onset while swinging the bat or pitching the ball. An anteroposterior radiograph of the cervical spine was available for initial diagnose. Although 70% of the patients would heal in 3 months with conservative treatments, some patients may have a symptom like thoracic outlet syndrome.