Transient Brachial Plexus Palsy Research Articles

Lumbar spine instrumented fusion surgery under spinal anaesthesia versus general anaesthesia-A retrospective study of 239 cases

ObjectiveConventionally spinal surgeries are done under general anaesthesia (GA). Plenty of literature is available on lumbar spine non-instrumented surgeries under spinal anaesthesia (SA) but handful of literature is there on lumbar spinal instrumented fusion surgeries under SA. We retrospectively analysed the data of 131 patients operated under SA and 108 patients under GA. Aim of the study was to evaluate the safety, advantages and disadvantages of doing lumbar spine instrumented fusion surgeries under SA.In time of COVID-19 pandemic, aerosol generating procedure like intubation, can be avoided if lumbar spine instrumented fusion surgeries are performed under SA. Methods239 patients aged between 20 and 79 years operated from January 2014 to December 2019 were included in this study. Indications for surgery were lumbar canal stenosis, degenerative or lytic spondylolisthesis. They underwent L4-L5 or L5-S1 fusion surgeries either TLIF or pedicle screw fixation postero lateral fusion (PLF) and decompression. Out of 239 patients,131 were operated under SA and 108 patients under GA. Heart rate, mean arterial pressure (MAP), blood loss, operating room time, post-op pain relief and need of analgesics, cost of surgery and anaesthesia related complications were analysed. ResultsThe study found significantly less blood loss (p<.05), less OR time, better post-op analgesia and lesser incidence of nausea and vomiting in SA (8.4%) than GA (29.6%). We observed average 10% cost reduction in SA. This study did not find any prone position related complication in regional anaesthesia but one transient brachial plexus palsy and one post-op shoulder pain in GA group. ConclusionSA is a safe alternative to GA for lumbar spine instrumented fusion surgery with significant less blood loss, OR time, better post-op analgesia, average 10% overall cost reduction and no reported prone-position related complications.

A Sequential Approach to the Management of Posterior Glenoid Defects in RSA: Angulated BIO Versus Multiple Bioresorbable Pinning-Assisted Structural Bone-Grafting.

Background:Large posterior glenoid defects pose problems in reverse shoulder arthroplasty (RSA). We have adopted a sequential approach to the management of posterior glenoid defects using asymmetrical reaming, the placement of a ring graft around the central peg (bony-increased offset, or BIO), or structural bone-grafting, depending on the amount of glenoid retroversion. Furthermore, we have devised multiple bioresorbable pinning (MBP)-assisted bone-grafting, in which as many bioresorbable pins as required are inserted, from whichever aspects of the graft necessary, to achieve initial stability.Methods:We reviewed 52 shoulders with posterior glenoid defects undergoing RSA between 2014 and 2019 (mean follow-up, 4.8 years; range, 2 to 6 years). Twenty (38.5%) of the shoulders had glenoid retroversion of <15° and were treated by asymmetrical reaming (Group A), 19 (36.5%) of the shoulders had retroversion of ≥15° to <30° and were treated with asymmetrical reaming combined with angulated ring graft around the central peg (Group B), and 13 (25.0%) of the shoulders had retroversion of ≥30° and were treated with MBP-assisted bone-grafting (Group C).Results:Mean version correction was 10.6° ± 4.3° in Group A, 20.7° ± 8.8° in Group B, and 33.8° ± 9.6° in Group C. The mean postoperative active anterior elevation was 138.3° ± 12.3°, 128.3° ± 12.3°, and 126.5° ± 15.3° in the 3 groups, respectively. The mean postoperative Constant score was 66.8 ± 14.6, 62.2 ± 13.5, and 61.7 ± 16.7, respectively. The mean preoperative active anterior elevation was significantly higher in Group A than in Group C (p = 0.037). The full or partial graft-incorporation rate (≥25% of original size) was 89.5% in Group B and 100% in Group C. One glenoid fracture and 1 case of transient brachial plexus palsy occurred in Group B (10.5%), and 1 acromion fracture and 2 cases of transient brachial plexus palsy occurred in Group C (23.1%).Conclusions:The results of the present sequential approach to management of posterior glenoid defects by the 3 modalities were acceptable. The present MBP-assisted bone-grafting procedure is an effective treatment for cases of shoulder arthropathy with severe posterior glenoid defects. Angulated ring grafting around the central peg may yield equally acceptable results, although its graft-incorporation rate requires further follow-up.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Functional improvement in patients with Sprengel's deformity following Modified Green's procedure and simplified clavicle osteotomy-a study of forty cases.

Sprengel's deformity though rare is the most common congenital anomaly of the shoulder region. The aim of the study was to check the effectiveness of the modified Green's procedure with simplified clavicle osteotomy in providing significant functional and radiological improvement without neurovascular complications. Sixty-eight children of Sprengel deformity were operated by the modified Green's release. Of which forty patients (15 male, 25 female) with more than two years follow-up were evaluated retrospectively. Simplified clavicle osteotomy was done in 34 patients. Severity was graded clinically by Cavendish grading (Grade II-6, III-34) and radiologically by Rigault grading (Grade II - 35, III - 5). The average age at surgery was 5.05 years with a mean follow-up of 62 (24-145) months. The average improvement in Cavendish grade was 2.6 grades, and Rigault grading was 1.07 grades. Shoulder abduction improved by a mean of 360. There was no neurovascular complication in children who had simplified clavicle osteotomy, and one patient without clavicle osteotomy developed transient brachial plexus palsy. Other complications were wound gape, pleural tear and scapular winging. The modified Green's procedure with simplified clavicle osteotomy allows for excellent correction of function and cosmesis. We describe a simpler technique of clavicle osteotomy that is quick, safe and equally effective in preventing neurovascular complications. We also describe a surrogate clinical test to avoid potential neurological injury in the absence of neuromonitoring. To the best of our knowledge, this is the second-largest operative series of Sprengel's deformity.

Efficiency of preoperative Halo-gravity traction in severe kyphoscoliosis secondary to neurofibromatosis type Ⅰ

Objective: To evaluate the efficiency of preoperative Halo-gravity traction (HGT) in the treatment of severe kyphoscoliosis secondary to neurofibromatosis type Ⅰ (NF1). Methods: A retrospective review was conducted on patients with severe kyphoscoliosis secondary to NF1 at Department of Spinal Surgery, Drum Tower Hospital, Medical School of Nanjing University between July 2007 and May 2016. A total of 29 patients including 17 males and 12 females were finally enrolled and the age was (13.7±2.9) years. The Cobb angle of major coronal curve and global kyphosis were measured before and after HGT. The forced vital capacity (FVC)and forced expiratory volume in 1 second (FEV(1)) before and after traction were also recorded. The paired t test was used for comparison analysis. Results: The average maximum traction weight of HGT was (12.2±2.8) kg and the traction duration was (10.2±6.6) weeks. The coronal Cobb angle before HGT was (87.5±36.5)°, which improved to (68.4±25.9)° after HGT with a correction rate of (21.9±12.1)% (t=9.14, P<0.001); the average global kyphosis before HGT was (79.1±27.1)°, which improved to (59.9±19.4)° after HGT and the correction rate was (20.2±14.1)% (t=8.55, P<0.001). One patient had transient brachial plexus palsy which resolved completely after reducing the traction weight. After HGT treatment, FVC increased from (0.83±0.16) L to (0.89±0.19) L (t=1.48, P=0.12) and FEV(1) increased from (0.72±0.16) L to (0.78±0.20) L (t=0.49,P=0.63). FVC predicted and FEV(1) predicted improved from (42.9±20.1)% and (40.6±19.6)% to (46.9±20.5)% (t=0.98,P=0.33) and (43.6±25.8)% (t=1.24,P=0.22), respectively. Conclusion: Preoperative HGT in the treatment of severe kyphoscoliosis secondary to NF1 can improve spinal deformity and pulmonary function to some extent, which can further benefit the patients by improving their surgical tolerance.

Structural glenoid grafting during primary reverse total shoulder arthroplasty using humeral head autograft

Large glenoid bone defects in the setting of glenohumeral arthritis can present a challenge to the shoulder arthroplasty surgeon. The results of large structural autografting at the time of reverse total shoulder arthroplasty (RTSA) are relatively unknown. This retrospective case series describes the clinical and radiographic results of large structural autografting from the humeral head to the glenoid during primary RTSA. Of 17 patients who met inclusion criteria, 14 (82% follow-up) were evaluated postoperatively at a mean of 2.6 years (range, 2.0-5.4 years). Mean inclination correction was 19° ± 12° (range, 3°-35°). Complications occurred in 3 patients, including 1 transient brachial plexus palsy, 1 loose baseplate, and 1 dislocation treated with closed reduction. Radiographic images showed 100% of grafts incorporated. Active forward elevation improved from 80° ± 40° to 130° ± 49° (P = .028). The visual analog scale score for pain improved from 8.1 ± 1.3 to 2.5 ± 3.1 (P = .005). The Simple Shoulder Test improved from 1.8 ± 1.1 to 6.5 ± 4 (P = .012). The American Shoulder and Elbow Surgeons score improved from 22 ± 10 to 66 ± 25 (P = .012). All patients (100%) were satisfied, and all patients (93%) but 1 stated that they would undergo the procedure again if given the chance. RTSA incorporating structural grafting of the glenoid with humeral head autograft results in significant improvements in active forward elevation, pain, and function, with a low complication rate. This technique can reliably be used to achieve correction of large (up to 35°) glenoid defects with a 93% chance of baseplate survival and a 100% chance of graft incorporation in the short-term.

Sprengel Deformity

We evaluated the pathologic anatomy of the Sprengel deformity using radiographs, 3-dimensional computed tomography (3D-CT), and magnetic resonance imaging (MRI), and reviewed our results of the modified Green procedure. Between 2002 and 2009, 23 scapulae in 22 patients were treated. The average age at the time of surgery was 3.4 years (range, 1.9 to 7.1 y). The outcome of surgery was assessed on the basis of changes in shoulder abduction and the radiographic findings using Cavendish classification, Rigault classification, scapular elevation, and medialization. Preoperative appearance was classified as grade III in 13 cases and grade IV in 10 cases according to the Cavendish classification, and as grade II in 4 cases and grade III in 19 cases according to the Rigault classification. Using 3D-CT, we assessed the height to width ratio on the scapular posterior view, the superior displacement ratio and rotational difference on the trunk posterior view, and the anterior curvature of the supraspinous portion on the scapular medial view. The average follow-up postoperative period was 4.4 years (range, 2.2 to 8.7 y). Postoperatively, the shoulder abduction improved well, with a mean improvement of 63 degrees. Improvement of at least 1 Cavendish grade and 1 Rigault grade was attained in all cases. On preoperative 3D-CT, the mean height to width ratio of the affected scapula was significantly smaller than that of the contralateral scapula. There was an inverse relationship between the superior displacement ratio and the rotational difference. Anterior curvature of the supraspinous portion was seen in all cases. Omovertebral bone was found in 20 cases. MRI identified unossified omovertebral cartilage that was not evident by radiographs or CT. Transient brachial plexus palsy occurred in 2 patients, both of whom recovered within 4 months. Postoperative scapula winging and unsightly scarring were seen in 3 and 8 cases, respectively. 3D-CT and MRI were helpful in evaluating the pathologic anatomy of the deformity and in planning the surgery. The modified Green procedure provided successful functional and cosmetic results. Level IV.

Efficacy of preoperative Halo-femoral traction in the treatment of rigid idiopathic scoliosis

To evaluate the efficacy of preoperative Halo-femoral traction in the treatment of rigid idiopathic scoliosis. Sixteen patients with rigid idiopathic scoliosis treated with Halo-femoral traction before posterior spine fusion from July 2003 through May 2006 were studied retrospectively. There were 4 male and 12 female, with a mean age of 16 years (range, 12-20 years). The coronal Cobb angles of coronal major curve and the thoracic kyphosis (T(5)-T(12)) were 111 degrees and 64 degrees, respectively. All the patients underwent preoperative Halo-femoral traction. After the maximum weight traction for 2-3 weeks, a posterior instrumentation and fusion was performed. The correction rate of coronal major curve on preoperative side bending film, on supine film after Halo-femoral traction and after surgery was compared. The maximum traction weight averaged 19 kg. All patients had an at least 12-month follow-up. One patient experienced transient brachial plexus palsy and complete recovery was achieved after reducing the traction weight. No neurologic complication, death and respiratory failure occurred after surgery. In comparison to the correction rate of 18.7% on preoperative side bending film, the correction rate of coronal major curve after Halo-femoral traction increased by 13.2% (P < 0.05). The postoperative correction rate of coronal major curve and thoracic kyphosis was 48.6% and 51.9%, respectively. At the final follow-up, the coronal and sagittal correction loss averaged 2.0% and 5.8%, respectively. Preoperative Halo-femoral traction combined with intraoperative posterior spinal release can significantly enhance the correction rate for rigid idiopathic scoliosis. However, the traction complications should be worthy of vigilance.

Deep dopamine extravasation injury: a case report

We report the case of a 3-month-old girl with Down's syndrome, who sustained a deep and massive extravasation of dopamine, resulting in segmented, full-thickness skin necrosis and transient brachial plexus palsy of her left upper extremity. The patient was managed conservatively, including wound care, de-bridement of necrotic tissue, secondary wound healing and intensive physical therapy. The patient showed a satisfactory outcome with complete secondary closure of her wounds and full brachial plexus recovery after 1 year of follow-up. The mechanism of action of dopamine in the deep soft tissue, the difficulties of an adequate diagnosis of a deep dopamine extravasation and alternative treatments are presented in this article.

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.

A Comparison of Shoulder Dystocia-Associated Transient and Permanent Brachial Plexus Palsies

In Brief OBJECTIVE To estimate differences between shoulder dystocia-associated transient and permanent brachial plexus palsies. METHODS We performed a retrospective case-control analysis from national birth injury and shoulder dystocia databases. Study patients had permanent brachial plexus palsy and had been entered into a national birth injury registry. Cases of Erb or Klumpke palsy with documented neonatal neuromuscular deficits persisting beyond at least 1 year of life were classified as permanent. Cases of transient brachial plexus palsy were obtained from a shoulder dystocia database. Non-shoulder dystocia–related cases of brachial plexus palsy were excluded from analysis. Cases of permanent brachial plexus palsy (n = 49) were matched 1:1 with cases of transient brachial plexus palsy. RESULTS Transient brachial plexus palsy cases had a higher incidence of diabetes mellitus than those with permanent brachial plexus palsy (34.7% versus 10.2%, odds ratio [OR] 4.68, 95% confidence interval [CI] 1.42, 16.32). Patients with permanent brachial plexus palsies had a higher mean birth weight (4519 ± 94.3 g versus 4143.6 ± 56.5 g, P < .001) and a greater frequency of birth weight greater than 4500 grams (38.8% versus 16.3%, OR, 0.31, 95% CI 0.11, 0.87). There were, however, no statistically significant differences between the two groups with respect to multiple antepartum, intrapartum, and delivery outcome measures. CONCLUSION Transient and permanent brachial plexus palsies are not associated with significant differences for most antepartum and intrapartum characteristics. Transient and permanent brachial plexus palsies were not associated with significant differences for most antepartum and intrapartum characteristics.