Transient Brachial Plexus Injury Research Articles

Short-term neonatal outcomes of vacuum-assisted delivery. A case–control study

IntroductionThe purpose of this study was to assess the neonatal morbidity and mortality associated with vacuum-assisted vaginal deliveries compared to all other vaginal deliveries, and to identify the associated risk factors. Material and methodsWe conducted a retrospective case–control study in a terciary maternity hospital between 2012 and 2016, including 1802 vacuum-assisted vaginal deliveries and 2 control groups: 1802 spontaneous deliveries and 909 forceps-assisted deliveries. We considered minor complications (soft tissue trauma, cephalohaematoma, jaundice, intensive phototherapy, transient brachial plexus injury) and major complications (hypoxic-ischaemic encephalopathy, intracranial and subgaleal haemorrhage, seizures, cranial fracture, permanent brachial plexus injury), admission to the neonatal intensive care unit and death. ResultsThe risk of soft tissue trauma (aOR, 2.4; P<.001), cephalohaematoma (aOR, 5.5; P<.001), jaundice (aOR, 4.4; P<.001), intensive phototherapy (aOR, 2.1; P<.001) and transient brachial plexus injury (aOR; 2.1, P=.006) was higher in vacuum deliveries compared to spontaneous deliveries. Admission to the neonatal intensive care unit was also higher in vacuum deliveries compared to spontaneous deliveries (OR, 1.9; P=.001). When we compared vacuum with forceps deliveries, we found a higher risk of soft tissue trauma (OR, 2.1; P=.004), cephalohaematoma (OR, 2.2, P=.046) and jaundice (OR, 1.4; P=.012). Major complications were more frequent in the vacuum group comparing with the control groups, but the difference was not significant. The 2 deaths occurred in vacuum deliveries (1.1 per 1000). ConclusionThe proportion of minor neonatal complications was higher in the vacuum-assisted delivery group. Although major complications and death were also more frequent, they were uncommon, with no significant differences compared to the other groups. There are obstetrical indications for vacuum delivery, but these alert to the need to watch for potential neonatal complications.

Evaluation of Complications after Surgical Treatment of Thoracic Outlet Syndrome

BackgroundSurgical treatment of thoracic outlet syndrome (TOS) is necessary when non-surgical treatments fail. Complications of surgical procedures vary from short-term post-surgical pain to permanent disability. The outcome of TOS surgery is affected by the visibility during the operation. In this study, we have compared the complications arising during the supraclavicular and the transaxillary approaches to determine the appropriate approach for TOS surgery.MethodsIn this study, 448 patients with symptoms of TOS were assessed. The male-to-female ratio was approximately 1:4, and the mean age was 34.5 years. Overall, 102 operations were performed, including unilateral, bilateral, and reoperations, and the patients were retrospectively evaluated. Of the 102 patients, 63 underwent the supraclavicular approach, 32 underwent the transaxillary approach, and 7 underwent the transaxillary approach followed by the supraclavicular approach. Complications were evaluated over 24 months.ResultsThe prevalence of pneumothorax, hemothorax, and vessel injuries in the transaxillary and the supraclavicular approaches was equal. We found more permanent and transient brachial plexus injuries in the case of the transaxillary approach than in the case of the supraclavicular approach, but the difference was not statistically significant. Persistent pain and symptoms were significantly more common in patients who underwent the transaxillary approach (p<0.05).ConclusionThe supraclavicular approach seems to be the more effective technique of the two because it offers the surgeon better access to the brachial plexus and a direct view. This approach for a TOS operation offers a better surgical outcome and lower reoperation rates than the transaxillary method. Our results showed the supraclavicular approach to be the preferred method for TOS operations.

Shoulder dystocia in primary midwifery care in the Netherlands.

In the Netherlands, low-risk pregnancies are managed by midwives in primary care. Despite strict definitions of low risk, obstetric complications can occur. Midwives seldom encounter uncommon labour complications, but are sufficiently trained to manage these. We assessed neonatal and maternal outcome after management of shoulder dystocia in primary midwifery care. In this 2-year prospective cohort study from April 2008 to April 2010, primary-care midwives, who participated in an obstetric emergency course, reported all obstetric complications. Main outcome was neonatal and maternal outcome. In sixty-four cases of shoulder dystocia McRoberts was the first maneuver in 42/64 (65.6%) cases with a success rate of 23.8%. All-fours maneuver was most frequently used as the second maneuver (24/45; 53.3%). No neonatal mortality occurred, none of the infants suffered from hypoxic ischemic injury, two (3.1%) had transient brachial plexus injuries, two (3.1%) had fractured clavicles and one (1.6%) had a fractured humerus. Eight (12.5%) neonates were successfully resuscitated because of birth asphyxia. All infants fully recovered. In neonates with immediate adverse outcome significantly more maneuvers were used compared with those without adverse neonatal outcome (p = 0.02). Postpartum hemorrhage occurred in 2/64 (3.1%) women, deep vaginal lacerations in 2/64 (3.1%), perineal tears in 23/64 (35.9%). No anal sphincter injuries occurred. McRoberts and all-fours maneuvers are widely used by primary-care midwives in the management of shoulder dystocia. Low rates of adverse neonatal and maternal outcomes were observed in cases of shoulder dystocia up to 6 weeks postpartum.

Efficacy and Risk Factors, for Complications Associated with Growing Rods, in the Management of Progressive Early-Onset Scoliosis

Introduction Growing-rod spinal instrumentation systems are a valuable option for managing progressive early-onset scoliosis. However, some studies had suggested that its efficacy may be lost over a period time and could be counterbalanced by a high rate of complications. The objective of this study was to determine the efficacy and safety of growing rods for the treatment of progressive early-onset scoliosis. Materials and Methods An Institutional Review Board approved cross-sectional study was performed, including patients with early-onset scoliosis treated with growing rods between 1997 and 2012. A retrospective review of the chart and radiographic data were performed. Risk factors for complications were explored using univariate and multivariate analyses. Results Records of 35 patients were included. The mean age at implantation of the rods was 5.8 ± 2.3 years. Overall, 18 patients had a diagnosis of idiopathic scoliosis, 11 with congenital scoliosis, and 6 with neuromuscular scoliosis. The mean Cobb measurement for the preoperative major curves was 66.7 ± 14.4 (range, 42–98) degrees. After a mean of 4 ± 1.4 lengthening procedures, there was a statistically significant improvement in the coronal plane deformity to a mean of 34.9 ± 11.2 degrees ( p &lt; 0.001), resulting in an average decrease of 31.8 ± 14.6 degrees. Following complications have occurred in 11 patients (31.4%): implant failure/fracture (22.9%), surgical site infection (5.7%), and transient brachial plexus injury (2.8%). The only risk factor associated with the presentation of postoperative complications was the total number of lengthening procedures (OR = 2.79). Conclusion Growing rods are effective for reduction of the magnitude of the spinal deformities in patients with progressive early-onset scoliosis before the definite fusion. However, this treatment is related with a relatively high rate of postoperative complications. Those complications appear to be associated with the total number of lengthening procedures previous to the definitive fusion. Therefore, it is advisable to reduce the frequency of lengthening as much as needed for maintaining the correction and allow the longitudinal growing of the spine.

Complications of Transvaginal Natural Orifice Transluminal Endoscopic Surgery

To review the complications encountered in our facility and in previously published studies of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) to date. TV NOTES is currently observed with critical eyes from the surgical community, despite encouraging data to suggest improved short-term recovery and pain. All TV NOTES procedures performed in female patients between 18 and 65 years of age were included. The median follow-up was 90 days. The TV appendectomies and ventral hernia repairs were pure NOTES, through a SILS port in the vagina, whereas TV cholecystectomies were hybrid procedures with the addition of a 5-mm port in the umbilicus. A total of 102 TV NOTES procedures, including 72 TV cholecystectomies, 24 TV appendectomies, and 6 TV ventral hernia repairs, were performed. The average age was 37 years old and body mass index was 29 kg/m. Three major and 7 minor complications occurred. The first major complication was a rectal injury during a TV access port insertion. The second major complication was an omental vessel bleed after a TV cholecystectomy. The third complication was an intra-abdominal abscess after a TV appendectomy. Seven minor complications were urinary retention (4), transient brachial plexus injury, dislodgement of an intrauterine device, and vaginal granulation tissue. As techniques in TV surgery are adopted, inevitably, complications may occur due to the inherent learning curve. Laparoscopic instruments, although adaptable to TV approaches, have yet to be optimized. A high index of suspicion is necessary to identify complications and optimize outcomes for patients.

Treating mild gestational diabetes mellitus: a cost-effectiveness analysis

This study investigated the cost-effectiveness of treating mild gestational diabetes mellitus (GDM). A decision analytic model was built to compare treating vs not treating mild GDM. The primary outcome was the incremental cost per quality-adjusted life year (QALY). All probabilities, costs, and benefits were derived from the literature. Base case, sensitivity analyses, and a Monte Carlo simulation were performed. Treating mild GDM was more expensive, more effective, and cost-effective at $20,412 per QALY. Treatment remained cost-effective when the incremental cost to treat GDM was less than $3555 or if treatment met at least 49% of its reported efficacy at the baseline cost to treat of $1786. Treating mild GDM is cost-effective in terms of improving maternal and neonatal outcomes including decreased rates of preeclampsia, cesarean sections, macrosomia, shoulder dystocia, permanent and transient brachial plexus injury, neonatal hypoglycemia, neonatal hyperbilirubinemia, and neonatal intensive care unit admissions.

Arterial Complications of Thoracic Outlet Syndrome

Arterial complications of thoracic outlet compression have serious potential implications; however, these complications rarely appear. Between 1990 and 2006, prospectively collected data on 27 patients with arterial complications of thoracic outlet syndrome were analyzed. The causes of arterial compression were cervical rib (20 [74.1%]), abnormalities of the first thoracic rib (three [11.1%]), soft tissue anomalies (two [7.4%]), and hypertrophic callus after clavicle fracture (two [7.4%]). In all cases, a combined supraclavicular and infraclavicular approach was used. Decompression was achieved by cervical rib excision in 13 (48.1%) patients, combined cervical and first rib excision in seven (26%), and first rib excision in six (22.2%). Associated vascular procedures included resection and replacement of the subclavian artery (26 [97.3%]), one subclavian-axillary and one axillary-brachial bypass as well as 17 (63%) brachial embolectomies. The mean follow-up period was 7 years 4 months (range, 1-16 years). Two pleural entries, two transient brachial plexus injuries, and one subclavian artery rethrombosis were found. Complete resolution of symptoms with a return to full activity was noted in all cases. In surgical treatment, a combined anterior supraclavicular and infraclavicular approach is recommended as well as transbrachial embolectomy in all cases with symptoms of distal embolization.

Should axillary artery to coronary artery bypass be part of the cardiac surgeon's armamentarium?☆

The axillary artery has been used as an alternate inflow source for revascularization of the lower extremities for four decades. Since 1997, there have been several reports of axillary artery to coronary artery bypass. All cases of axillary artery to coronary artery bypass at our institution from 1997 through 2003 were reviewed. PubMed was queried for publications on this subject and all pertinent reports were reviewed. Thirty-eight patients underwent axillary artery to coronary artery bypass at our hospital. Most (34) of the operations were performed without cardiopulmonary bypass. Saphenous vein (37) or radial artery (1) grafts were placed to one or more coronary arteries from either the left (36) or right (2) axillary artery. Twenty patients underwent sternotomy, and 18 had either a left (16) or right (2) minimally invasive direct coronary artery bypass (MIDCAB) procedure performed. Most of the sternotomies were for primary myocardial revascularization and most of the MIDCABs were reoperations. There were three deaths-all from non-cardiac causes, one myocardial infarction, and one transient brachial plexus injury. Doppler ultrasound, angiographic, and clinical follow-up were limited, but graft patency has been demonstrated up to 9 years. Axillary artery to coronary artery bypass should be part of the armamentarium of surgeons who perform myocardial revascularization operations.

Positioning for the Nuss procedure: avoiding brachial plexus injury

In 1987, Nuss developed a minimally invasive technique for the treatment of pectus excavatum. The procedure has had excellent results with minimal complications. Anesthetic concerns include risks of cardiothoracic injuries, dysrythmias, pneumothorax, pleural effusions, and hemorrhage. In addition, we identified a risk of brachial plexus injury that can occur secondary to patient positioning. We report our experience with the Nuss procedure and modified patient positioning. A retrospective chart review was performed on 95 children or adolescents who underwent a Nuss procedure at the Children's Hospital in Denver, CO, USA. The first group of patients (58) was positioned with their arms extended above their heads at a 90 degrees angle at the shoulder. The second group of patients (37) was positioned in an arthroscopy sling in a neutral position utilizing a right angled suspension device attached to the operating room bed. In the first group of patients, three of 58 (5.2%) children had transient brachial plexus injuries. To date, in the second group of patients, there have been no brachial plexus injuries using the suspension device. We found that patients are at risk of transient brachial plexus injury during the Nuss procedure due to positioning of the arms. A readily available device that permits the extremity to be maintained in a neutral position but also allows intraoperative manipulation during critical aspects of the Nuss procedure eliminates transient brachial plexus palsy.

Vascular thoracic outlet syndrome.

The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib ( n = 16), soft tissue anomalies ( n = 12), and scar tissue after clavicle fracture ( n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia ( n = 11), transient ischemic attack (TIA) ( n = 1), and claudication or vasomotor phenomena during the arm hyperabduction ( n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision ( n = 12), combined cervical and first rib excision ( n = 4), and first rib excision ( n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.

Cervical Spine and Brachial Plexus Injuries

Great care is required in managing cervical spine and brachial plexus injuries. Athletes who suffer one or more burners (transient brachial plexus injuries) may return to contact activity when they are asymptomatic and neurologically normal and have full cervical motion. A vertebra displaced horizontally more than 3.5 mm or rotated more than 11° is an absolute contraindication to contact sports. Cervical cord neurapraxia is generally benign, but patients should be counseled about the probability of recurrence, depending on the spinal canal/vertebral body ratio. Unresolved spear tackler's spine is an absolute contraindication to collision sports, as are axial-load teardrop fracture and cervical spine fusion of more than three levels. Spinal cord resuscitation can include blood pressure maintenance and timely methylprednisolone.

Induction of labor versus expectant management in macrosomia: A randomized study

Macrosomia at term is associated with increased maternal and neonatal morbidity, including a higher rate of cesarean delivery and shoulder dystocia. Induction of labor has been suggested as a means to prevent further weight gain and improve outcome. The aim of this study was to determine whether or not induction of labor in these cases improves maternal and neonatal outcome. Patients at term with an ultrasonic fetal weight estimation of 4000-4500 g were prospectively randomized into two groups: induction of labor (group D and expectant management (group II). Patients with diabetes, a previous cesarean delivery, or nonvertex presentation were excluded. Outcome variables included mode of delivery, arterial cord pH, presence of shoulder dystocia, brachial plexus injury, clavicular fracture, cephalohematoma, and intraventricular hemorrhage. Of 273 patients who were eligible for the study, 134 were randomized to group I and 139 to group II. Parity, gestational age, and fetal weight estimation were similar in the two groups. The neonates of group II patients were significantly heavier (4132.8 +/- 347.4 versus 4062.8 +/- 306.9 g; P = .024). The rate of cesarean delivery was 19.4% in group I and 21.6% in group II patients (not significant [NS]). Cord pH was similar in both groups. Shoulder dystocia was diagnosed in five group I and six group II patients (NS). None developed brachial plexus injury. There were two cases of mild, transient brachial plexus injury in group II patients without documented shoulder dystocia. Mild intraventricular hemorrhage was diagnosed in three of 44 group I and two of 31 group II neonates evaluated (NS). In this prospective, randomized study, induction of labor for suspected macrosomia at term did not decrease the rate of cesarean delivery or reduce neonatal morbidity. Ultrasonic estimation of fetal weight between 4000 and 4500 g should not be considered an indication for induction of labor.

Transcatheter Closure of Atrial Septal Defects

Transcatheter closure of atrial septal defects using a double-umbrella (clamshell) device can now be performed during an overnight hospital stay with little morbidity and no mortality. The initial 2-yr experience with anesthetic care for the procedure was collected and subsequently analyzed. Primary anesthetic care was given in 118 cases and urgent anesthetic intervention was required in another four cases. Anesthesia with spontaneous ventilation in patients with unprotected airways using intravenous ketamine and midazolam (average cumulative doses 1.4 and 0.17 mg.kg-1.h-1, respectively) was used in 93 cases (77%); mean maximum PaCO2 value was 41 +/- 6 mm Hg. In 29 patients (23%) tracheal intubation and muscle paralysis were used to facilitate control of airway and ventilation. Anesthetic-related complications occurred in three patients: ventilatory compromise developed in two patients in the spontaneous ventilation group and one patient experienced awareness during endotracheal anesthesia with paralysis. Procedural complications that altered anesthetic management were more frequent, including embolization of the clamshell device requiring surgical retrieval in two of six embolizations, intracardiac air embolization (four cases), tricuspid regurgitation (one case), device malplacement requiring late operation (one case), and transient brachial plexus injury (three cases). Anesthesia for transcatheter atrial septal defect closure allows precise device placement, prompt control of hemodynamic complications, and transesophageal echocardiographic monitoring of device placement. Although general anesthesia with spontaneous ventilation using ketamine and midazolam was usually safe and effective, tracheal intubation for control of airway and ventilation was sometimes necessary for safety and for optimal operating conditions. Familiarity with transcatheter closure techniques and close communication with the catheterization team is essential to minimize and treat associated complications.(ABSTRACT TRUNCATED AT 250 WORDS)