Traumatic Brachial Plexus Research Articles

Core outcomes in nerve surgery: development of a core outcome set for brachial plexus and upper extremity nerve injuries.

When considering traumatic brachial plexus and upper extremity nerve injuries, iatrogenic nerve injuries, and nontraumatic nerve injuries, brachial plexus and upper extremity nerve injuries are commonly encountered in clinical practice. Despite this, data synthesis and comparison of available studies are difficult. This is at least in part due to the lack of standardization in reporting and a lack of a core outcome set (COS). Thus, there is a need for a COS for adult brachial plexus and upper extremity nerve injuries (COS-BPUE). The objective of this study was to develop a COS-BPUE using a modified Delphi approach. A 5-stage approach was used to develop the COS-BPUE: 1) consortium development, 2) literature review to identify potential outcome measures, 3) Delphi survey to develop consensus on outcomes for inclusion, 4) Delphi survey to develop definitions, and 5) consensus meeting to finalize the COS and definitions. The study followed the Core Outcome Set-STAndards for Development (COS-STAD) recommendations. The Core Outcomes in Nerve Surgery (COINS) Consortium comprised 23 participants, all neurological surgeons, representing 13 countries. The final COS-BPUE consisted of 36 data points/outcomes covering demographic, diagnostic, patient-reported outcome, motor/sensory outcome, and complication domains. Appropriate instruments, methods of testing, and definitions were set. The consensus minimum duration of follow-up was 24 months, with the consensus optimal time points for assessment being preoperatively and 3, 6, 12, and 24 months postoperatively. The COINS Consortium developed a consensus COS and provided definitions, methods of implementation, and time points for assessment. The COS-BPUE should serve as a minimum set of data that should be collected in all future neurosurgical studies on adult brachial plexus and upper extremity nerve injuries. Incorporation of this COS should help improve consistency in reporting, data synthesis, and comparability, and should minimize outcome reporting bias.

A Colombian's Group Experience Using Contralateral C7 Nerve Transfer for Brachial Plexus Trauma

A Colombian's Group Experience Using Contralateral C7 Nerve Transfer for Brachial Plexus Trauma

Surgical Approach to Brachial Plexus Root Repair: A Case Study with Literature Review

This article presents a clinical case study of a 32-year-old patient with brachial plexus trauma following a motorcycle accident, as well as a review of the relevant literature on surgical approaches to brachial plexus root repair. The case study highlights the patient's symptoms, initial assessments, further investigations, surgical management, and post-operative results. The literature review synthesizes the main surgical approaches used in the repair of brachial plexus injuries, highlighting direct root repair techniques, nerve grafts, nerve transfers, as well as their results and complications. This study contributes to the body of knowledge on surgical options for brachial plexus injuries, highlighting the importance of post-operative rehabilitation and long- term follow-up in improving patients' functional recovery.

Nerves Transfer Procedure in Patients with Left Upper Extremities Weakness Following Gunshot Wounds: A Case Report

BACKGROUND: Gunshot wounds (GSWs) to the extremities can result in damage to the neurovascular structure which results in high morbidity and loss of function. According to the Centers for Disease Control report, the incidence of non-fatal GSWs has increased in the past decade. Trauma to the brachial plexus is a type of peripheral nerve trauma that is most difficult to treat due to its complex surgical procedures. Early exploration and reconstruction of peripheral nerve trauma are still being debated to this day. However, most recommend surgical exploration when the suspicion of neurovascular trauma is very high based on clinical findings. Nerve transfer is one of the recommended methods of nerve reconstruction even in pre-ganglionic lesions. We report a case of a patient with weakness of the upper limb after a gunshot wound to his left shoulder. Based on clinical considerations and investigations, nerve transfer procedure is carried out to restore patient’s shoulder function. CASE REPORT: Male, 32 years old, working as a policeman, complained difficulty on moving his shoulder for 3 months. Patients had a history of GSWs to the left shoulder which also results in a left clavicular fracture. First aid, debridement, and fracture management were performed at Bhayangkara Hospital, Palu. Physical examination revealed winging scapula positive on his left shoulder, shoulder abduction 5/1, and hypoesthesia at left C5 level. Electromyographic examination revealed lesions on the left posterior chord and left brachial plexus. Based on clinical findings and supporting examination, we performed nerve transfers procedure from the accessory nerve to suprascapular notch. In the previous study, 63% of cases GSWs associated with nerve dysfunction. About 75% of patients with nerve palsy are associated with nerve lacerations during surgical exploration. However, many surgeons continue to recommend early exploration after GSWs to the upper extremities, especially in patients who will undergo surgical treatment for other indications. Based on this, we suggest the probable cause of brachial plexus lesions in this case resulted from gunshot wound which injures the brachial plexus or as a complication from previous procedures. Surgery that is too early can interfere with the spontaneous reinnervation process, but late surgical procedures can result in failure of reinnervation. In general, optimal time is set between 3 and 6 months after trauma. Nerve transfer is one method of reconstructing peripheral nerve lesions that can be applied to pre-ganglionic or post-ganglionic lesions. CONCLUSION: This procedure has several benefits, namely, the proximity of the donor and the recipient nerve anatomy, shorter operating time and does not require grafts. Brachial plexus trauma due to trauma or non-trauma together has an impact on the patient’s quality of life. However, advances in surgical techniques and further understanding of nerve physiology have led clinicians and patients to better outcomes. The current trend of treatment strategies for brachial plexus trauma is surgical reconstruction with the nerve transfer procedure.

Disociación escapulo-torácica y trauma cerrado de arteria vertebral: reporte de un caso.

Descripción del caso: Varón de 24 años que sufre accidente automovilístico con trauma penetrante de cuello y trauma cerrado cervico torácico izquierdo concomitante. Hallazgos clínicos: Shock hipovolémico, trauma en zona I cuello izquierdo, isquemia por trauma cerrado de vasos axilares y lesión por trauma cerrado del plexo braquial; producto de trauma de alto impacto. Sección de arteria vertebral por angiotomografia. Se diagnostica disociación escapulo-torácica y trauma de arteria vertebral. Tratamiento y resultado: Reconstrucción vascular arterio-venosa axilar, fasciotomías y abordaje no operatorio del trauma de arteria vertebral, con manejo diferido del trauma del plexo braquial. Sobrevida del paciente y su extremidad, con secuelas neurológicas mayores. Relevancia clínica: Es un caso de disociación escapulotorácica y lesión de arteria vertebral concomitante, siendo esta una asociación infrecuente y de alta morbi-mortalidad. El reconocimiento temprano de las lesiones y un abordaje multidisciplinario de este escenario de complejidad por medio de juntas quirúrgicas en varios niveles del proceso de atención, fueron determinantes para cambiar el pronóstico del paciente. Se presenta un análisis del diagnóstico, manejo y evolución; considerando el proceso de atención hospitalaria, toma consensuada de decisiones y el pronóstico en un paciente politraumatizado.

Human motor endplate remodeling after traumatic nerve injury.

Current management of traumatic peripheral nerve injuries is variable with operative decisions based on assumptions that irreversible degeneration of the human motor endplate (MEP) follows prolonged denervation and precludes reinnervation. However, the mechanism and time course of MEP changes after human peripheral nerve injury have not been investigated. Consequently, there are no objective measures by which to determine the probability of spontaneous recovery and the optimal timing of surgical intervention. To improve guidance for such decisions, the aim of this study was to characterize morphological changes at the human MEP following traumatic nerve injury. A prospective cohort (here analyzed retrospectively) of 18 patients with traumatic brachial plexus and axillary nerve injuries underwent biopsy of denervated muscles from the upper extremity from 3 days to 6 years after injury. Muscle specimens were processed for H & E staining and immunohistochemistry, with visualization via confocal and two-photon excitation microscopy. Immunohistochemical analysis demonstrated varying degrees of fragmentation and acetylcholine receptor dispersion in denervated muscles. Comparison of denervated muscles at different times postinjury revealed progressively increasing degeneration. Linear regression analysis of 3D reconstructions revealed significant linear decreases in MEP volume (R = -0.92, R2 = 0.85, p = 0.001) and surface area (R = -0.75, R2 = 0.56, p = 0.032) as deltoid muscle denervation time increased. Surprisingly, innervated and structurally intact MEPs persisted in denervated muscle specimens from multiple patients 6 or more months after nerve injury, including 2 patients who had presented > 3 years after nerve injury. This study details novel and critically important data about the morphology and temporal sequence of events involved in human MEP degradation after traumatic nerve injuries. Surprisingly, human MEPs not only persisted, but also retained their structures beyond the assumed 6-month window for therapeutic surgical intervention based on previous clinical studies. Preoperative muscle biopsy in patients being considered for nerve transfer may be a useful prognostic tool to determine MEP viability in denervated muscle, with surviving MEPs also being targets for adjuvant therapy.

Infraspinatus muscle palsy involving suprascapular nerve, brachial plexus or cervical roots related to inflammatory or mechanical causes: Experience of 114 cases

ObjectivesTo report a large series of neurogenic infraspinatus muscle (ISM) palsy, in order to improve knowledge of diagnosis, diverse etiologies and care management. MethodsClinical and electrodiagnostic (EDX) data for 114 cases of ISM palsy were collected over a 21-year period. Cases were attributed to 4 clinical conditions: (1) isolated suprascapular nerve mononeuropathy (n=48), (2) multiple mononeuropathies (n=33), (3) plexus lesions (n=17), and (4) cervical radiculopathy (n=16). These were related to 2 mechanisms: inflammatory (dysimmune) and mechanical. ResultsGroup 1 cases were younger, had the most severe ISM palsies, were mostly related to inflammatory lesions (81%) such as neuralgic amyotrophy (NA), and frequently had delayed diagnosis because disability was mild. Group 2 cases were all related to inflammatory lesions and had slightly less severe ISM palsies that were frequently hidden by winged scapula. In groups 3 and 4, ISM palsies were milder and all cases were related to mechanical lesions such as brachial plexus trauma or C4-C5-C6 radiculopathy. In these cases, deltoid and ISM palsies were equal in frequency and severity whereas biceps brachii impairment was less frequent and much milder. Deltoid palsy frequently appeared predominant as compared with ISM palsy, because upper limb elevation palsy was more disabling than external rotation palsy. ConclusionsISM palsy is a rare condition, often under-diagnosed and misidentified. The 4 main conditions of ISM palsy may be recognized by careful clinical, EDX and other examinations when necessary. Analysis of the present series highlights some clinical and EDX points that should help non-specialist and even specialist clinicians who are faced with this rare condition, to distinguish mechanical and inflammatory causes, and thus adapt patient management accordingly.

English

English

Ultrasound imaging of brachial plexus trauma in gunshot injury.

Brachial plexus trauma related to gunshot (GS) injury requires early examination and characterization to ensure appropriate treatment. Magnetic resonance imaging (MRI) may be contraindicated when there are metal fragments in a patient's body. Ultrasound (US) may present an alternative to imaging GS-related brachial plexus injury. Three patients with GS-related brachial plexus injury who underwent US imaging evaluation at our institution were identified. A retrospective review of the patients' medical records was performed. US characterization of nerve abnormalities after GS injury to the brachial plexus was in agreement with electrodiagnostic and intraoperative findings. Information from the US reports was useful in preparation for brachial plexus reconstruction surgery. As such, US has unique utility when MRI cannot be performed. US imaging can provide useful characterization of the brachial plexus after GS injury when performed by an experienced operator. Muscle Nerve 59:707-711, 2019.

Major surgical strategies of the upper and middle trunks of adult brachial plexus injury by Erb­ — Duchenne palsy type

Objective — to increase the effectiveness of surgical treatment of patients with injury to the upper and middle trunks of the brachial plexus based on the comprehensive involvement of compensatory regenerative mechanisms by applying original neurotic, autoplastic, long‑term electrostimulation and orthopedic correction of the upper limb function.Methods and subjects. The analysis of the results of surgical treatment of 64 patients with brachial plexus trauma, accompanied by detachment or injury of the C5—C7 spinal nerves, upper and middle trunks, or their anterior and posterior portions, was performed. For the reconstruction of the structures of the shoulder plexus and its long branches, the technique of nerve autoplasty and the method of neurotication were most often used. In the cases of maintaining the anatomical integrity of damaged structures of the brachial plexus, which was manifested during the course of neurology, especially in cases of positive intraoperative diagnostics, the technique of long‑term electrostimulation of damaged structures in the postoperative period was used with the help of domestic electrostimulation systems Ney C 3M (Ukraine).Results. 86.7 % of cases showed good recovery (4 points or higher on 86.7 % MRCS) of the shoulder abduction and elbow flexion with no dependence on applied surgical procedure (whether grafting or nerve transfer). Chronic invasive electrical stimulation of the anatomically preserved structures of the adult brachial plexus led to significant improvement of the shoulder abduction and elbow flexion in 53.9 % of cases.Conclusions. In the absence of signs of regeneration during restorative conservative therapy for two months in cases of damages of the upper and middle trunk of the brachial plexus in the type of Erb­ — Duchenne paralysis, surgical treatment with the maximum full involvement of compensatory and regenerative properties of the nervous system through the application of original techniques of neuroticisation, long‑term electrostimulation and orthopedic correction of the function of the upper limb. Neuroticisation of the structures of the upper trunk of the brachial plexus in all cases gave satisfactory restoration of flexion in the elbow and shoulder removal.

Postop QOL assessment following surgical intervention for total BPI

Traumatic total brachial plexus injury (TTBPI) is a severe and disabling form of injury. Reconstructive modalities are complex and outcomes are variable. This is mainly because of the multitude of functions lost and relative scarcity of donor nerves to reconstruct these functions. As a result, there are several different opinions and ideologies on TTBPI. Several papers report the functional outcomes of nerve transfers and free muscle transfers (FMT). Only few papers report retrospectively on the quality of life recovery. There are no studies which compare pre and postoperative objective and subjective parameters of quality of life. We conducted a prospective comparative study of functional outcome and quality of life (QoL) measures of patients with TTBPI, before and after surgical treatment. The three current representative treatment modalities for elbow with/without finger function used were: double free muscle transfer (DFMT), single muscle transfer (SMT), and intercostal to musculocutaneous nerve transfers (NT).

Qué hacer en el trauma del plexo braquial. Conceptos actuales

órgano de divulgación oficial de la División de Ciencias de la Salud de la Universidad del Norte (Barranquilla, Colombia). Publica artículos originales, revisiones, descripción de casos clínicos y artículos especiales que se consideren del ámbito de la revista en medicina clínica y ciencias biomédicas

Segmental architecture of the spinal accessory nerve

Nicolas de Tribolet, MD Editor-in-Chief Acta Neurochirurgica The spinal accessory nerve has become a workhorse for brachial plexus reconstruction following traumatic peripheral nerve injury. It is frequently used as an extraplexal motor donor for transfer to injured nerves, including the suprascapular nerve, musculocutaneous nerve, and others [1, 10]. The spinal accessory nerve’s large motor fiber content [3] and infrequent injury from brachial plexus trauma [2] has yielded a high success rate for these transfers [9, 11]. The concept of nerve transfers for peripheral nerve injuries has been extended to apply to spinal cord injury patients [4]— transferring supralesional nerves into infralesional nerves to enable cortical control of the targeted muscle. A 36-year-old man presented to our clinic for consideration of reconstructive surgery for a high cervical cord injury from a surfing accident 14 years previously. His injury consisted of cervical fractures from C1 through C6, with burst fracture and dislocation of C4 and C5. His current lowest level of function was C4 (ASIA impairment scale A); his motor exam consisted of full strength shoulder shrug bilaterally, but without motor control of any muscle of the left upper extremity. On the right he had weak 4/5 (MRC scale) shoulder abduction and 2/5 external rotation, 3/5 pectoralis major muscle, 4/5 elbow flexion, and trace flexor carpi radialis contraction. Our goals were to identify transferable nerves to achieve elbow flexion on the left; the only donor source would be the spinal accessory nerve. Needle EMG was performed to assess for evidence of denervation of the trapezius muscle that would indicate fewer healthy axons for transfer. Very mild chronic denervation was observed in the middle trapezius, whereas there was moderate chronic denervation in the lower trapezius, including polyphasic potentials, rapid firing, and large motor unit potentials (Fig. 1). The pattern of denervation suggested correlation with his spinal cord injury: an MRI demonstrated near-total loss of spinal cord parenchyma from mid-cervical three to rostral cervical six vertebral bodies which form the C4 through C6 nerves. A segmental pattern of innervation of the trapezius muscle has not been previously defined. Several animal models have shown consistent innervation of the trapezius muscle by the C1–C7 spinal cord segments [5], with the predominant innervation deriving from C2–C6 [6, 8, 12]. The bilateral EMG findings suggest to us that the trapezius muscle is segmentally innervated, with rostral muscle coordinated by rostral cervical spinal segments and caudal muscle coordinated by caudal cervical spinal segments. The salient message, along with the previously undetected pattern of innervation, is that the concepts of nerve transfers for brachial plexus injury cannot be uniformly applied to nerve transfers for spinal cord injury. Although the spinal accessory nerve is a cranial nerve by its dural exit, it is a spinal nerve by origin of its motor neuron pool [7]. This segmental architecture is susceptible to high cervical spine injury, reducing the ability of the spinal accessory nerve to serve as a source for transfer of healthy motor neurons. Preoperative electrodiagnostic evaluation of the quality of the innervation of the trapezius muscle is essential for consideration of the M. A. Mahan (*) Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013, USA e-mail: Neuropub@dignityhealth.org

Right Traumatic Transradial Amputation and Left Brachial Plexus Injury in a Dismounted Improvised Explosive Device Blast: A Case Report

Right Traumatic Transradial Amputation and Left Brachial Plexus Injury in a Dismounted Improvised Explosive Device Blast: A Case Report

Phrenic Nerve Palsy Associated With Brachial Plexus Avulsion in a Pediatric Patient With Multitrauma

Although brachial plexus injury occurring during multitrauma is frequent in adults, it is rarely observed in childhood. The most common cause of pediatric traumatic brachial palsy is motor vehicle accidents followed by pedestrian struck. Generally, phrenic nerve palsy accompanying brachial plexus trauma is observed in 10% to 20% of cases, but it is overlooked because unilateral injuries are frequently asymptomatic. Severe unilateral phrenic nerve palsy accompanying brachial plexus avulsion is very rare. Here, we present a pediatric case of unilateral phrenic nerve palsy associated with respiratory distress and brachial plexus avulsion due to multitrauma.

The clinical research of restoring the global upper limber function in traumatic total brachial plexus avulsion injuries

Objective To observe the outcomes of the modified multiple nerve transfer s combined with the late hand function reconstruction to restore the active pick-up function of the paralyzed upper extremity in patients with total brachial plexus avulsion injuries (TBPAI).Methods 33 patients suffered with TBPAI firstly underwent multiple nerve transfers,which including accessory nerve transfers to neurotize the suprascapular nerve to recover the shoulder abduction,contralateral C7 (CC7) nerve transfers via the modified pre-spinal route with direct coaptation to restore lower trunk function and the musculocutaneous nerve was also neurotized by the transferred CC7 nerve via a cutaneous nerve graft to restore the function of elbow flexion,as well as the phrenic nerve transfers to neurotize the posterior division of lower trunk to restore the function of elbow and finger extension.The patients with muscle recovery were selected to perform the hand function reconstruction at the second stage for restoring the active pick-up function.The patients were chosen as followcriterias:the degree of shoulder abduction attained 30°or more,the motor power of elbow,wrist,and finger flexion attained grade M4 or more,elbow and finger extension attained M3 or more.The methods of hand function reconstruction included wrist fusion and flexor carpal ulnaris opponensplasty,in addition to palmar capsulodesis of the metacarpophalangeal joint.Results The mean follow up was 41±7.7 (range,36-73 months) after the first procedure of multiple nerve transfers,the muscle strength of elbow and finger and wrist flexion attained M 4 as well as the elbow and finger extension achieved M3 or more in 10 patients,all of 10 patients achieved 40°-80°shoulder abduction.8 out of 10 patients had performed the second surgical procedure for hand functional reconstruction.6 of them had successfully recovered the active pick-up function.Conclusions The newly designed procedure of multiple nerve transfers could effectively restore the function of shoulder abduction,elbow,wrist,and finger flexion,as well as elbows and finger extension in patients with TBPAI,combined with the hand functional reconstruction,active pick-up function could be successfully reconstructed. Key words: Brachial plexus; Wounds and injuries; Spinal nerves; Phrenic nerve; Nerve transfer

Re: Dolan RT, Butler JS, Murphy SM, Hynes D, Cronin KJ. Health-related quality of life and functional outcomes following nerve transfers for traumatic upper brachial plexus injuries. J Hand Surg Eur. 2012, 37: 642-51

Re: Dolan RT, Butler JS, Murphy SM, Hynes D, Cronin KJ. Health-related quality of life and functional outcomes following nerve transfers for traumatic upper brachial plexus injuries. J Hand Surg Eur. 2012, 37: 642-51

Brachial plexus trauma: the morbidity of hemidiaphragmatic paralysis

Phrenic nerve palsy has previously been associated with brachial plexus root avulsion; severe unilateral phrenic nerve injury is not uncommonly associated with brachial plexus injury. Brachial plexus injuries can be...

Magnetic stimulation of the radial nerve in dogs and cats with brachial plexus trauma: A report of 53 cases

Brachial plexus trauma is a common clinical entity in small animal practice and prognostic indicators are essential early in the course of the disease. Magnetic stimulation of the radial nerve and consequent recording of the magnetic motor evoked potential (MMEP) was examined in 36 dogs and 17 cats with unilateral brachial plexus trauma. Absence of deep pain perception (DPP), ipsilateral loss of panniculus reflex, partial Horner’s syndrome and a poor response to MMEP were related to the clinical outcome in 29 of the dogs and 13 of the cats. For all animals, a significant difference was found in MMEP between the normal and the affected limb. Absence of DPP and unilateral loss of the panniculus reflex were indicative of an unsuccessful outcome in dogs. Additionally, the inability to evoke a MMEP was associated with an unsuccessful outcome in all animals. It was concluded that magnetic stimulation of the radial nerve in dogs and cats with brachial plexus trauma may provide an additional diagnostic and prognostic tool.

Giant cervical pseudomeningocoele following brachial plexus trauma

We report an unusual case of a young man with a traumatic brachial plexus injury who presented with a large right-sided neck swelling 1 month after trauma. Clinical and diagnostic evaluations revealed a giant cervical pseudomeningocoele with meningitis and hydrocephalus. Following treatment for meningitis, the patient underwent ventriculoperitoneal shunt, which produced total resolution of the pseudomeningocoele. The management is discussed.