Restoration of Elbow Flexion in Patients With Complete Traumatic and Obstetric Brachial Plexus Injury After Functional Free Gracilis Muscle Transfer: Our Experience and Management

PubMed Central

Boutros, Sean G.; Somasundaram, Chandra

2017-01-01

Background: Functional free gracilis muscle transfer is an operative procedure for elbow reconstruction in patients with complete brachial plexus nerve and avulsion injuries and in delayed or prolonged nerve denervation, as well as in patients with inadequate upper extremity function after primary nerve reconstruction. Methods: We retrospectively reviewed our patient records and identified 24 patients with complete brachial plexus nerve injury (13 obstetric, 11 males and 2 females; 11 traumatic, 9 males and 2 females) whose affected arm and shoulder were totally paralyzed and their voluntary elbow flexion or the biceps function was poor preoperatively (mean M0-1/5 in MRC grade). These patients had undergone the functional free gracilis muscle transfer procedure at our clinic since 2005. Results: Ninety-two percent of all patients showed recovery and improvement. Successful free gracilis muscle transfer is defined as antigravity biceps muscle strength of M3-4/5 and higher, which was observed in 16 (8 obstetric and 8 traumatic) of our 24 patients (67%) in this study at least 1 year after functional free gracilis muscle transfer. This is statistically significant (P < .000001) in comparison with their mean preoperative score (M0-1/5). There was no improvement in motor level of the biceps muscle (M0/5) in 2 patients (1 from each group). The donor site of these 24 patients showed no deficit in motor and sensory functions. Conclusions: Taken together, a significant number (92%) of patients in both obstetric and traumatic brachial plexus injury groups had recovery and improvement and most of these patients (64%) achieved antigravity and elbow flexion at least 1 year after free gracilis muscle transfer at our clinic. PMID:29213347

Finger movement at birth in brachial plexus birth palsy

PubMed Central

Nath, Rahul K; Benyahia, Mohamed; Somasundaram, Chandra

2013-01-01

AIM: To investigate whether the finger movement at birth is a better predictor of the brachial plexus birth injury. METHODS: We conducted a retrospective study reviewing pre-surgical records of 87 patients with residual obstetric brachial plexus palsy in study 1. Posterior subluxation of the humeral head (PHHA), and glenoid retroversion were measured from computed tomography or Magnetic resonance imaging, and correlated with the finger movement at birth. The study 2 consisted of 141 obstetric brachial plexus injury patients, who underwent primary surgeries and/or secondary surgery at the Texas Nerve and Paralysis Institute. Information regarding finger movement was obtained from the patient’s parent or guardian during the initial evaluation. RESULTS: Among 87 patients, 9 (10.3%) patients who lacked finger movement at birth had a PHHA > 40%, and glenoid retroversion < -12°, whereas only 1 patient (1.1%) with finger movement had a PHHA > 40%, and retroversion < -8° in study 1. The improvement in glenohumeral deformity (PHHA, 31.8% ± 14.3%; and glenoid retroversion 22.0° ± 15.0°) was significantly higher in patients, who have not had any primary surgeries and had finger movement at birth (group 1), when compared to those patients, who had primary surgeries (nerve and muscle surgeries), and lacked finger movement at birth (group 2), (PHHA 10.7% ± 15.8%; Version -8.0° ± 8.4°, P = 0.005 and P = 0.030, respectively) in study 2. No finger movement at birth was observed in 55% of the patients in this study group. CONCLUSION: Posterior subluxation and glenoid retroversion measurements indicated significantly severe shoulder deformities in children with finger movement at birth, in comparison with those lacked finger movement. However, the improvement after triangle tilt surgery was higher in patients who had finger movement at birth. PMID:23362472

Perinatal brachial plexus palsy

PubMed Central

Andersen, John; Watt, Joe; Olson, Jaret; Van Aerde, John

2006-01-01

BACKGROUND Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births. OBJECTIVES To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions. METHODS A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included ‘brachial plexus’, ‘brachial plexus neuropathy’, ‘brachial plexus injury’, ‘birth injury’ and ‘paralysis, obstetric’. RESULTS There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm

Changes in Spinal Cord Architecture after Brachial Plexus Injury in the Newborn

ERIC Educational Resources Information Center

Korak, Klaus J.; Tam, Siu Lin; Gordon, Tessa; Frey, Manfred; Aszmann, Oskar C.

2004-01-01

Obstetric brachial plexus palsy is a devastating birth injury. While many children recover spontaneously, 20-25% are left with a permanent impairment of the affected limb. So far, concepts of pathology and recovery have focused on the injury of the peripheral nerve. Proximal nerve injury at birth, however, leads to massive injury-induced…

Shoulder Arthroplasty for Sequelae of Obstetrical Brachial Plexus Injury.

PubMed

Werthel, Jean-David; Schoch, Bradley; Frankle, Mark; Cofield, Robert; Elhassan, Bassem T

2018-03-29

Shoulder arthroplasty following obstetrical brachial plexus injury (OBPI) is technically challenging because glenoid morphology, muscle balance, and humeral version are substantially altered compared with the neurologically intact shoulder. The purpose of this study is to report the outcome of shoulder arthroplasty in a group of patients with end-stage arthritis secondary to OBPI. Seven patients with OBPI and secondary glenohumeral arthritis were treated with shoulder arthroplasty between 1976 and 2014. Two underwent hemiarthroplasty (HA), 2 underwent total shoulder arthroplasty (TSA), and 3 underwent reverse shoulder arthroplasty (RSA). One HA was lost to follow-up and was excluded. The remaining 6 patients (mean age, 62.5 years old at the time of surgery) were followed for a minimum of 2 years (mean, 7.5 years; range, 2-13 years) Outcome measures included pain, range of motion, and postoperative modified Neer ratings. Pain improved in all shoulders. Mean forward flexion was unchanged. No shoulders treated with HA/TSA regained forward elevation above 90°, compared with 1 out of the 3 RSAs. External rotation improved from a mean of -10° to 20°. Active internal rotation decreased from L1 to L5. Immediate postoperative radiographs showed either severe posterior or posterosuperior subluxation in all 3 patients treated with nonconstrained implants. Shoulder arthroplasty is an acceptable option to relieve pain in patients with symptomatic shoulder arthritis as a sequel of OBPI. However, range of motion improvements are not expected. Therapeutic V. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Clinical research of comprehensive rehabilitation in treating brachial plexus injury patients.

PubMed

Zhou, Jun-Ming; Gu, Yu-Dong; Xu, Xiao-Jun; Zhang, Shen-Yu; Zhao, Xin

2012-07-01

Brachial plexus injury is one of the difficult medical problems in the world. The aim of this study was to observe the clinical therapeutic effect of comprehensive rehabilitation in treating dysfunction after brachial plexus injury. Forty-three cases of dysfunction after brachial plexus injury were divided into two groups randomly. The treatment group, which totaled 21 patients (including 14 cases of total brachial plexus injury and seven cases of branch brachial plexus injury), was treated with comprehensive rehabilitation including transcutaneous electrical nerve stimulation, mid-frequency electrotherapy, Tuina therapy, and occupational therapy. The control group, which totaled 22 patients (including 16 cases of total brachial plexus injury and six cases of branch brachial plexus injury), was treated with home-based electrical nerve stimulation and occupational therapy. Each course was of 30 days duration and the patients received four courses totally. After four courses, the rehabilitation effect was evaluated according to the brachial plexus function evaluation standard and electromyogram (EMG) assessment. In the treatment group, there was significant difference in the scores of brachial plexus function pre- and post-treatment (P < 0.01) in both "total" and "branch" injury. The scores of two "total injury" groups had statistical differences (P < 0.01), while the scores of two "branch injury" groups had statistical differences (P < 0.05) after four courses. EMG suggested that the appearance of regeneration potentials of the recipient nerves in the treatment group was earlier than the control group and had significant differences (P < 0.05). Comprehensive rehabilitation was more effective in treating dysfunction after brachial plexus injury than nonintegrated rehabilitation.

[Complications in brachial plexus surgery].

PubMed

Martínez, Fernando; Pinazzo, Samantha; Moragues, Rodrigo; Suarez, Elizabeth

2015-01-01

Although traumatic brachial plexus injuries are relatively rare in trauma patients, their effects on the functionality of the upper limb can be very disabling. The authors' objective was to assess the complications in a series of patients operated for brachial plexus injuries. This was a retrospective evaluation of patients operated on by the authors between August 2009 and March 2013. We performed 36 surgeries on 33 patients. The incidence of complications was 27.7%. Of these, only 1 (2.7%) was considered serious and associated with the procedure (iatrogenic injury of brachial artery). There was another serious complication (hypoxia in patients with airway injury) but it was not directly related to the surgical procedure. All other complications were considered minor (wound dehiscence, hematoma, infection). There was no mortality in our series. The complications in our series are similar to those reported in the literature. Serious complications (vascular, neural) are rare and represent less than 5% in all the different series. Given the rate of surgical complications and the poor functional perspective for a brachial plexus injury without surgery, we believe that surgery should be the treatment of choice. Copyright © 2013 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.

Risk factors for clavicle fracture concurrent with brachial plexus injury.

PubMed

Karahanoglu, Ertugrul; Kasapoglu, Taner; Ozdemirci, Safak; Fadıloglu, Erdem; Akyol, Aysegul; Demirdag, Erhan; Yalvac, E Serdar; Kandemir, N Omer

2016-04-01

The aim of this study was to evaluate the risk factors for clavicle fracture concurrent with brachial plexus injuries. A retrospective study was conducted at a tertiary centre. The hospital records of 62,288 vaginal deliveries were evaluated retrospectively. There were 35 cases of brachial plexus injury. Of these patients, nine had brachial plexus injuries with clavicle fracture and 26 without clavicle fracture. The analysed risk factors for clavicle fracture concurrent with brachial plexus injury were gestational diabetes, labour induction and augmentation, prolonged second stage of labour, estimated foetal weight above 4000 g, birth weight above 4000 g, risky working hours, and the requirement of manoeuvres to free the impacted shoulder from behind the symphysis pubis. Labour augmentation with oxytocin increased the risk of clavicle fracture in cases of brachial plexus injury (OR 6.67; 95% CI 1.26-35.03). A birth weight higher than 4000 g also increased the risk of clavicle fracture. Risky working hours, gestational diabetes, estimated foetal weight higher than 4000 g, and requirement of shoulder dystocia manoeuvres did not increase the risk of clavicle fracture. Labour augmentation and actual birth weight higher than 4000 g were identified as risk factors for clavicle fracture in cases of brachial plexus injury.

Concepts of nerve regeneration and repair applied to brachial plexus reconstruction.

PubMed

Bertelli, Jayme Augusto; Ghizoni, Marcos Flávio

2006-01-01

Brachial plexus injury is a serious condition that usually affects young adults. Progress in brachial plexus repair is intimately related to peripheral nerve surgery, and depends on clinical and experimental studies. We review the rat brachial plexus as an experimental model, together with its behavioral evaluation. Techniques to repair nerves, such as neurolysis, nerve coaptation, nerve grafting, nerve transfer, fascicular transfer, direct muscle neurotization, and end-to-side neurorraphy, are discussed in light of the authors' experimental studies. Intradural repair of the brachial plexus by graft implants into the spinal cord and motor rootlet transfer offer new possibilities in brachial plexus reconstruction. The clinical experience of intradural repair is presented. Surgical planning in root rupture or avulsion is proposed. In total avulsion, the authors are in favor of the reconstruction of thoraco-brachial and abdomino-antebrachial grasping, and on the transfer of the brachialis muscle to the wrist extensors if it is reinnervated. Surgical treatment of painful conditions and new drugs are also discussed.

Anatomical study of prefixed versus postfixed brachial plexuses in adult human cadaver.

PubMed

Guday, Edengenet; Bekele, Asegedech; Muche, Abebe

2017-05-01

The brachial plexus is usually formed by the fusion of anterior primary rami of the fifth to eighth cervical and the first thoracic spinal nerves. Variations in the formation of the brachial plexus may occur. Variations in brachial plexus anatomy are important to radiologists, surgeons and anaesthesiologists performing surgical procedures in the neck, axilla and upper limb regions. These variations may lead to deviation from the expected dermatome distribution as well as differences in the motor innervation of muscles of the upper limb. This study is aimed to describe the anatomical variations of brachial plexus in its formation among 20 Ethiopian cadavers. Observational based study was conducted by using 20 cadavers obtained from the Department of Human Anatomy at University of Gondar, Bahir Dar, Addis Ababa, Hawasa, Hayat Medical College and St Paul Hospital Millennium Medical College. Data analysis was conducted using thematic approaches. A total of 20 cadavers examined bilaterally for the formation of brachial plexus. Of the 40 sides, 30 sides (75%) were found normal, seven sides (17.5%) prefixed, three sides (7.5%) postfixed and one side of the cadaver lacks cord formation. The brachial plexus formation in most subjects is found to be normal. Among the variants, the numbers of the prefixed brachial plexuses are greater than the postfixed brachial plexuses. © 2016 Royal Australasian College of Surgeons.

Child neurology: Brachial plexus birth injury: what every neurologist needs to know.

PubMed

Pham, Christina B; Kratz, Johannes R; Jelin, Angie C; Gelfand, Amy A

2011-08-16

While most often transient, brachial plexus birth injury can cause permanent neurologic injury. The major risk factors for brachial plexus birth injury are fetal macrosomia and shoulder dystocia. The degree of injury to the brachial plexus should be determined in the neonatal nursery, as those infants with the most severe injury--root avulsion--should be referred early for surgical evaluation so that microsurgical repair of the plexus can occur by 3 months of life. Microsurgical repair options include nerve grafts and nerve transfers. All children with brachial plexus birth injury require ongoing physical and occupational therapy and close follow-up to monitor progress.

Posterior subscapular dissection: An improved approach to the brachial plexus for human anatomy students.

PubMed

Hager, Shaun; Backus, Timothy Charles; Futterman, Bennett; Solounias, Nikos; Mihlbachler, Matthew C

2014-05-01

Students of human anatomy are required to understand the brachial plexus, from the proximal roots extending from spinal nerves C5 through T1, to the distal-most branches that innervate the shoulder and upper limb. However, in human cadaver dissection labs, students are often instructed to dissect the brachial plexus using an antero-axillary approach that incompletely exposes the brachial plexus. This approach readily exposes the distal segments of the brachial plexus but exposure of proximal and posterior segments require extensive dissection of neck and shoulder structures. Therefore, the proximal and posterior segments of the brachial plexus, including the roots, trunks, divisions, posterior cord and proximally branching peripheral nerves often remain unobserved during study of the cadaveric shoulder and brachial plexus. Here we introduce a subscapular approach that exposes the entire brachial plexus, with minimal amount of dissection or destruction of surrounding structures. Lateral retraction of the scapula reveals the entire length of the brachial plexus in the subscapular space, exposing the brachial plexus roots and other proximal segments. Combining the subscapular approach with the traditional antero-axillary approach allows students to observe the cadaveric brachial plexus in its entirety. Exposure of the brachial dissection in the subscapular space requires little time and is easily incorporated into a preexisting anatomy lab curriculum without scheduling additional time for dissection. Copyright © 2014 Elsevier GmbH. All rights reserved.

Primary benign brachial plexus tumors: an experience of 115 operated cases.

PubMed

Desai, Ketan I

2012-01-01

Primary benign brachial plexus tumors are rare. They pose a great challenge to the neurosurgeon, because the majority of patients present with minimal or no neurological deficits. Radical to complete excision of the tumor with preservation of neurological function of the involved nerve is an ideal surgical treatment option with benign primary brachial plexus tumor surgery. We present a review article of our 10-year experience with primary benign brachial plexus tumors surgically treated at King Edward Memorial Hospital and P.D. Hinduja National Hospital from 2000 to 2009. The clinical presentations, radiological features, surgical strategies, and the eventual outcome following surgery are analyzed, discussed, and compared with available series in the world literature. Various difficulties and problems faced in the management of primary benign brachial plexus tumors are analyzed. Irrespective of the tumor size, the indications for surgical intervention are also discussed. The goal of our study was to optimize the treatment of patients with benign brachial plexus tumors with minimal neurological deficits. It is of paramount importance that brachial plexus tumors be managed by a peripheral nerve surgeon with expertise and experience in this field to minimize the neurological insult following surgery.

[Brachial plexus. Anesthesia and analgesia].

PubMed

Schulz-Stübner, S

2003-07-01

This review explains the different approaches to the brachial plexus (posterior cervical, interscalene, supra- and infraclavicular, and axillary) and their advantages and disadvantages (indications, contraindications, and complications) for surgery and postoperative or chronic pain management. One of the focussed areas of this review is the use of continuous catheter techniques. Information about the most commonly used local anesthetics as well as adjuncts suggested in the literature is summarized. As essential components for the success of those techniques, organizational and documentation requirements are described. In summary, regional techniques for single shot or continuous block of the brachial plexus are an efficient and safe way of providing anesthesia and analgesia for surgery or pain in the region of the shoulder, arm, or hand.

Brachial Plexus Injuries in Adults: Evaluation and Diagnostic Approach

PubMed Central

Sakellariou, Vasileios I.; Badilas, Nikolaos K.; Mazis, George A.; Stavropoulos, Nikolaos A.; Kotoulas, Helias K.; Kyriakopoulos, Stamatios; Tagkalegkas, Ioannis; Sofianos, Ioannis P.

2014-01-01

The increased incidence of motor vehicle accidents during the past century has been associated with a significant increase in brachial plexus injuries. New imaging studies are currently available for the evaluation of brachial plexus injuries. Myelography, CT myelography, and magnetic resonance imaging (MRI) are indicated in the evaluation of brachial plexus. Moreover, a series of specialized electrodiagnostic and nerve conduction studies in association with the clinical findings during the neurologic examination can provide information regarding the location of the lesion, the severity of trauma, and expected clinical outcome. Improvements in diagnostic approaches and microsurgical techniques have dramatically changed the prognosis and functional outcome of these types of injuries. PMID:24967130

Hand Sensorimotor Function in Older Children With Neonatal Brachial Plexus Palsy.

PubMed

Brown, Susan H; Wernimont, Cory W; Phillips, Lauren; Kern, Kathy L; Nelson, Virginia S; Yang, Lynda J-S

2016-03-01

Routine sensory assessments in neonatal brachial plexus palsy are infrequently performed because it is generally assumed that sensory recovery exceeds motor recovery. However, studies examining sensory function in neonatal brachial plexus palsy have produced equivocal findings. The purpose of this study was to examine hand sensorimotor function in older children with neonatal brachial plexus palsy using standard clinical and research-based measures of tactile sensibility. Seventeen children with neonatal brachial plexus palsy (mean age: 11.6 years) and 19 age-matched controls participated in the study. Functional assessments included grip force, monofilament testing, and hand dexterity (Nine-Hole Peg, Jebsen-Taylor Hand Function). Tactile spatial perception involving the discrimination of pin patterns and movement-enhanced object recognition (stereognosis) were also assessed. In the neonatal brachial plexus palsy group, significant deficits in the affected hand motor function were observed compared with the unaffected hand. Median monofilament scores were considered normal for both hands. In contrast, tactile spatial perception was impaired in the neonatal brachial plexus palsy group. This impairment was seen as deficits in both pin pattern and object recognition accuracy as well as the amount of time required to identify patterns and objects. Tactile pattern discrimination time significantly correlated with performance on both functional assessment tests (P < 0.01). This study provides evidence that tactile perception deficits may accompany motor deficits in neonatal brachial plexus palsy even when measures of tactile registration (i.e., monofilament testing) are normal. These results may reflect impaired processing of somatosensory feedback associated with reductions in goal-directed upper limb use and illustrate the importance of including a broader range of sensory assessments in neonatal brachial plexus palsy. Copyright © 2016 Elsevier Inc. All rights

Pediatric Evaluation of Disability Inventory: its application to children with obstetric brachial plexus palsy.

PubMed

Ho, Emily S; Curtis, Christine G; Clarke, Howard M

2006-02-01

A standardized method of measurement of self-care ability in children with obstetric brachial plexus palsy (OBPP) has not been universally adopted. A study was conducted to determine if the Pediatric Evaluation of Disability Inventory (PEDI) was able to discriminate between the self-care ability of children with OBPP and their peers and distinguish between those with differing severities of OBPP. The PEDI self-care domain results for 45 children with OBPP (30 without hand impairment, 15 with hand impairment) were reviewed retrospectively. The group performance of children without hand impairment was within 1 SD above the mean. The group performance of children with hand impairment was more than 2 SDs below the mean. The difference between the 2 groups was statistically significant. In this study children without hand impairment did not have a self-care activity limitation as measured by the PEDI. A deficit in self-care ability was found in those with hand impairment. The PEDI was able to differentiate between the performances of reported self-care activities of children with differing severities of OBPP; however, it was unable to discriminate between those without hand impairment and their peers. Diagnostic, Level II.

Prompt Referral in the Nonoperative Treatment of Obstetrical Brachial Plexus Injuries

PubMed Central

Aubin-Lemay, Camille; Kvann, Julie Chakriya; Retrouvey, Helene; Aldekhayel, Salah; Zadeh, Teanoosh

2017-01-01

Background: Prompt physical and occupational therapy is crucial in managing nonsurgical candidates with obstetrical brachial plexus injuries (OBPI). The objective of our study was to identify newborns suffering from nonoperative OBPI in need of a “fast-track” evaluation by a multidisciplinary team. Methods: This is a retrospective review of patients with OBPI from June 1995 to June 2015. All nonsurgical candidates (Narakas class 1) were included in the study. The Gilbert score and the Medical Research Council grading system were used to measure shoulder and elbow function, respectively. The relationship between shoulder and elbow functional outcomes and time delay to consultation was studied using analysis of variance and Welch’s tests. Various subgroups were studied based on OBPI risk factors: maternal diabetes, birth weight >4 kg, use of forceps, asphyxia, multiple comorbidities, and Apgar score at 1 and 5 minutes. Results: A total of 168 patients were included in this study. Mean follow-up time was 313.8 weeks (minimum: 52; maximum: 1072; SD: 228.1). A total of 19 patients had an Apgar scores <7 at 5 minutes. Time delay between birth and the first consult to our clinic had an impact on shoulder outcome in the subgroup of newborns with Apgar scores <7 at 5 minutes. Conclusions: The subgroup of newborns with an Apgar score <7 at 5 minutes shows improved long-term shoulder function when promptly examined by an OBPI clinic. We recommend a “fast-track” referral for this time-sensitive population. PMID:29632767

The natural history and management of brachial plexus birth palsy.

PubMed

Buterbaugh, Kristin L; Shah, Apurva S

2016-12-01

Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging. Physical examination is also the best modality to determine candidates for microsurgical reconstruction of the brachial plexus. The key finding on physical examination that determines need for microsurgery is recovery of antigravity elbow flexion by 3-6 months of age. When indicated, both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve functional outcomes. These procedures include nerve transfers and nerve grafting in infants and secondary procedures in children, such as botulinum toxin injection, shoulder tendon transfers, and humeral derotational osteotomy.

High resolution neurography of the brachial plexus by 3 Tesla magnetic resonance imaging.

PubMed

Cejas, C; Rollán, C; Michelin, G; Nogués, M

2016-01-01

The study of the structures that make up the brachial plexus has benefited particularly from the high resolution images provided by 3T magnetic resonance scanners. The brachial plexus can have mononeuropathies or polyneuropathies. The mononeuropathies include traumatic injuries and trapping, such as occurs in thoracic outlet syndrome due to cervical ribs, prominent transverse apophyses, or tumors. The polyneuropathies include inflammatory processes, in particular chronic inflammatory demyelinating polyneuropathy, Parsonage-Turner syndrome, granulomatous diseases, and radiation neuropathy. Vascular processes affecting the brachial plexus include diabetic polyneuropathy and the vasculitides. This article reviews the anatomy of the brachial plexus and describes the technique for magnetic resonance neurography and the most common pathologic conditions that can affect the brachial plexus. Copyright © 2016 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

Tolerance of the Brachial Plexus to High-Dose Reirradiation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chen, Allen M., E-mail: achen5@kumc.edu; Yoshizaki, Taeko; Velez, Maria A.

Purpose: To study the tolerance of the brachial plexus to high doses of radiation exceeding historically accepted limits by analyzing human subjects treated with reirradiation for recurrent tumors of the head and neck. Methods and Materials: Data from 43 patients who were confirmed to have received overlapping dose to the brachial plexus after review of radiation treatment plans from the initial and reirradiation courses were used to model the tolerance of this normal tissue structure. A standardized instrument for symptoms of neuropathy believed to be related to brachial plexus injury was utilized to screen for toxicity. Cumulative dose was calculatedmore » by fusing the initial dose distributions onto the reirradiation plan, thereby creating a composite plan via deformable image registration. The median elapsed time from the initial course of radiation therapy to reirradiation was 24 months (range, 3-144 months). Results: The dominant complaints among patients with symptoms were ipsilateral pain (54%), numbness/tingling (31%), and motor weakness and/or difficulty with manual dexterity (15%). The cumulative maximum dose (Dmax) received by the brachial plexus ranged from 60.5 Gy to 150.1 Gy (median, 95.0 Gy). The cumulative mean (Dmean) dose ranged from 20.2 Gy to 111.5 Gy (median, 63.8 Gy). The 1-year freedom from brachial plexus–related neuropathy was 67% and 86% for subjects with a cumulative Dmax greater than and less than 95.0 Gy, respectively (P=.05). The 1-year complication-free rate was 66% and 87%, for those reirradiated within and after 2 years from the initial course, respectively (P=.06). Conclusion: The development of brachial plexus–related symptoms was less than expected owing to repair kinetics and to the relatively short survival of the subject population. Time-dose factors were demonstrated to be predictive of complications.« less

Brachial Plexus Injury from CT-Guided RF Ablation Under General Anesthesia

DOE Office of Scientific and Technical Information (OSTI.GOV)

Shankar, Sridhar, E-mail: shankars@ummhc.org; Sonnenberg, Eric van; Silverman, Stuart G.

2005-06-15

Brachial plexus injury in a patient under general anesthesia (GA) is not uncommon, despite careful positioning and, particularly, awareness of the possibility. The mechanism of injury is stretching and compression of the brachial plexus over a prolonged period. Positioning the patient within the computed tomography (CT) gantry for abdominal or chest procedures can simulate a surgical procedure, particularly when GA is used. The potential for brachial plexus injury is increased if the case is prolonged and the patient's arms are raised above the head to avoid CT image degradation from streak artifacts. We report a case of profound brachial plexusmore » palsy following a CT-guided radiofrequency ablation procedure under GA. Fortunately, the patient recovered completely. We emphasize the mechanism of injury and detail measures to combat this problem, such that radiologists are aware of this potentially serious complication.« less

Avulsion of the brachial plexus in a great horned owl (Bubo virginaus)

USGS Publications Warehouse

Moore, M.P.; Stauber, E.; Thomas, N.J.

1989-01-01

Avulsion of the brachial plexus was documented in a Great Horned Owl (Bubo virginianus). A fractured scapula was also present. Cause of these injuries was not known but was thought to be due to trauma. Differentiation of musculoskeletal injury from peripheral nerve damage can be difficult in raptors. Use of electromyography and motor nerve conduction velocity was helpful in demonstrating peripheral nerve involvement. A brachial plexus avulsion was suspected on the basis of clinical signs, presence of electromyographic abnormalities in all muscles supplied by the nerves of the brachial plexus and absence of median-ulnar motor nerve conduction velocities.

A novel technique for teaching the brachial plexus.

PubMed

Lefroy, Henrietta; Burdon-Bailey, Victoria; Bhangu, Aneel; Abrahams, Peter

2011-09-01

The brachial plexus has posed problems for both students and teachers throughout generations of medical education. The anatomy is intricate, and traditional pictorial representations can be difficult to understand and learn. Few innovative teaching methods have been reported. The basic anatomy of the brachial plexus is core knowledge required by medical students to aid clinical examination and diagnosis. A more detailed understanding is necessary for a variety of specialists, including surgeons, anaesthetists and radiologists. Here, we present a novel, cheap and interactive method of teaching the brachial plexus. Using coloured pipe cleaners, teachers and students can construct three-dimensional models using different colours to denote the origin and outflow of each nerve. The three-dimensional nature of the model also allows for a better understanding of certain intricacies of the plexus. Students may use these models as adjuncts for self study, didactic lectures and tutorials. Compared with traditional textbooks and whiteboards, the pipe-cleaner model was preferred by medical students, and provided a higher level of student satisfaction. This was demonstrated and analysed using student feedback forms. Our model could be incorporated into current curricula to provide an effective and enjoyable way of rapidly teaching a difficult concept. Other such novel methods for teaching complex anatomical principles should be encouraged and explored. © Blackwell Publishing Ltd 2011.

Current Concept in Adult Peripheral Nerve and Brachial Plexus Surgery.

PubMed

Rasulic, Lukas

2017-01-01

Peripheral nerve injuries and brachial plexus injuries are relatively frequent. Significance of these injuries lies in the fact that the majority of patients with these types of injuries constitute working population. Since these injuries may create disability, they present substantial socioeconomic problem nowadays. This article will present current state-of-the-art achievements of minimal invasive brachial plexus and peripheral nerve surgery. It is considered that the age of the patient, the mechanism of the injury, and the associated vascular and soft-tissue injuries are factors that primarily influence the extent of recovery of the injured nerve. The majority of patients are treated using classical open surgical approach. However, new minimally invasive open and endoscopic approaches are being developed in recent years-endoscopic carpal and cubital tunnel release, targeted minimally invasive approaches in brachial plexus surgery, endoscopic single-incision sural nerve harvesting, and there were even attempts to perform endoscopic brachial plexus surgery. The use of the commercially available nerve conduits for bridging short nerve gap has shown promising results. Multidisciplinary approach individually designed for every patient is of the utmost importance for the successful treatment of these injuries. In the future, integration of biology and nanotechnology may fabricate a new generation of nerve conduits that will allow nerve regeneration over longer nerve gaps and start new chapter in peripheral nerve surgery.

Perineural Spread of Nonmelanoma Skin Cancer to the Brachial Plexus: Identifying Anatomic Pathway(s).

PubMed

Marek, Tomas; Howe, B Matthew; Amrami, Kimberly K; Spinner, Robert J

2018-06-01

Perineural spread leading to brachial plexopathy has recently been described in cases of melanoma. The occurrence and mechanism for nonmelanoma skin cancer spread to the brachial plexus is poorly understood. A retrospective chart review of the Mayo Clinic database was conducted to identify patients with nonmelanoma skin cancer and brachial plexopathy between 2000 and 2017. Inclusion criteria were a history of nonmelanoma skin cancer, a clinical diagnosis of brachial plexopathy, imaging features of perineural spread, and a positive result of examination of a biopsy specimen showing tumor in a skin nerve. Thirty-seven patients with a history of nonmelanoma skin cancer and brachial plexopathy were identified. Inclusion criteria were fulfilled in 2 cases of cutaneous squamous cell carcinoma. One case of recurrent basal cell carcinoma with perineural spread confirmed in the brachial plexus by pathologic examination was excluded because confirmatory evidence of perineural spread from the skin to the brachial plexus was not available. Perineural spread of nonmelanoma skin cancer leading to brachial plexopathy is rare. Our 2 cases and the cases found in the literature demonstrate different entry points to the neural highway resulting in neurologic deficits. The cervical plexus serves as a hub for further spread in certain cases of perineural spread of skin cancer. Copyright © 2018 Elsevier Inc. All rights reserved.

Isolated lower brachial plexus (Klumpke) palsy with compound arm presentation: case report.

PubMed

Buchanan, Edward P; Richardson, Randal; Tse, Raymond

2013-08-01

Klumpke palsy has yet to be clearly documented in the newborn, because previous reports lack any description of the obstetrical history, clinical progression, or outcome. Based on a high incidence of breach presentation in the few clinical series that report Klumpke palsy, hyperabduction with arm overhead during delivery has been the presumed mechanism. We report a child with isolated lower brachial plexus palsy and Horner syndrome who presented at birth with a vertex compound arm presentation. Recognition of this condition and details of the clinical progression and outcome are important, because guidelines for management are currently not available. Copyright © 2013. Published by Elsevier Inc.

Palpation- and ultrasound-guided brachial plexus blockade in Hispaniolan Amazon parrots (Amazona ventralis).

PubMed

da Cunha, Anderson F; Strain, George M; Rademacher, Nathalie; Schnellbacher, Rodney; Tully, Thomas N

2013-01-01

To compare palpation-guided with ultrasound-guided brachial plexus blockade in Hispaniolan Amazon parrots. Prospective randomized experimental trial. Eighteen adult Hispaniolan Amazon parrots (Amazona ventralis) weighing 252-295 g. After induction of anesthesia with isoflurane, parrots received an injection of lidocaine (2 mg kg(-1)) in a total volume of 0.3 mL at the axillary region. The birds were randomly assigned to equal groups using either palpation or ultrasound as a guide for the brachial plexus block. Nerve evoked muscle potentials (NEMP) were used to monitor effectiveness of brachial plexus block. The palpation-guided group received the local anesthetic at the space between the pectoral muscle, triceps, and supracoracoideus aticimus muscle, at the insertion of the tendons of the caudal coracobrachial muscle, and the caudal scapulohumeral muscle. For the ultrasound-guided group, the brachial plexus and the adjacent vessels were located with B-mode ultrasonography using a 7-15 MHz linear probe. After location, an 8-5 MHz convex transducer was used to guide injections. General anesthesia was discontinued 20 minutes after lidocaine injection and the birds recovered in a padded cage. Both techniques decreased the amplitude of NEMP. Statistically significant differences in NEMP amplitudes, were observed within the ultrasound-guided group at 5, 10, 15, and 20 minutes after injection and within the palpation-guided group at 10, 15, and 20 minutes after injection. There was no statistically significant difference between the two groups. No effect on motor function, muscle relaxation or wing droop was observed after brachial plexus block. The onset of the brachial plexus block tended to be faster when ultrasonography was used. Brachial plexus injection can be performed in Hispaniolan Amazon parrots and nerve evoked muscle potentials were useful to monitor the effects on nerve conduction in this avian species. Neither technique produced an effective block at the

[Microsurgical treatment of brachial plexus injuries].

PubMed

Päzolt, H J

1986-01-01

Injuries of the brachial plexus are found to occur primarily to juvenile patients as a consequence of motorcycle accidents. While it is a severe injury, its prognosis has been substantively improved by the availability of microsurgical treatment, using long nerve transplants. Further improvement of results will be possible by early operation, a desirable objective. 44 patients with brachial palsy received treatment, including surgery in 41 cases. An account is given in this paper of intraoperative findings, surgical techniques, and results from follow-up checks. The need is underlined for long-term intensive after-care for the purpose of occupational reintegration.

Three-tesla magnetic resonance neurography of the brachial plexus in cervical radiculopathy.

PubMed

Yoshida, Takeshi; Sueyoshi, Takeshi; Suwazono, Shugo; Suehara, Masahito

2015-09-01

There have been no reports of the use of 3-Tesla magnetic resonance neurography (3T MRN) to characterize cervical radiculopathy. In particular, there are no reports of MRN of brachial plexus involvement in patients with cervical radiculopathy. We reviewed retrospectively 12 consecutive patients with cervical radiculopathy who underwent 3T MRN. The median age was 54.5 years. Eleven of 12 patients were men. The distribution of nerve-root signal abnormality was correlated with intervertebral foraminal stenosis and the presence of muscles that exhibited weakness and/or signs of denervation on electromyography. MRN abnormalities were found to extend into the distal part of the brachial plexus in 10 patients. This study demonstrates that MRN is potentially useful for diagnosis in patients with suspected cervical radiculopathy. Moreover, the finding of brachial plexus involvement on MRN may indicate a possible pathophysiological relationship between cervical radiculopathy and brachial plexopathy. © 2014 Wiley Periodicals, Inc.

Types and severity of operated supraclavicular brachial plexus injuries caused by traffic accidents.

PubMed

Kaiser, Radek; Waldauf, Petr; Haninec, Pavel

2012-07-01

Brachial plexus injuries occur in up to 5% of polytrauma cases involving motorcycle accidents and in approximately 4% of severe winter sports injuries. One of the criteria for a successful operative therapy is the type of lesion. Upper plexus palsy has the best prognosis, whereas lower plexus palsy is surgically untreatable. The aim of this study was to evaluate a group of patients with brachial plexus injury caused by traffic accidents, categorize the injuries according to type of accident, and look for correlations between type of palsy (injury) and specific accidents. A total of 441 brachial plexus reconstruction patients from our department were evaluated retrospectively(1993 to 2011). Sex, age, neurological status, and the type and cause of injury were recorded for each case. Patients with BPI caused by a traffic accident were assessed in detail. Traffic accidents were the cause of brachial plexus injury in most cases (80.7%). The most common type of injury was avulsion of upper root(s) (45.7%) followed by rupture (28.2%), complete avulsion (16.9%) and avulsion of lower root(s) (9.2%). Of the patients, 73.9% had an upper,22.7% had a complete and only 3.4% had a lower brachial plexus palsy. The main cause was motorcycle accidents(63.2%) followed by car accidents (23.5%), bicycle accidents(10.7%) and pedestrian collisions (3.1%) (p<0.001).Patients involved in car accidents had a higher percentage of lower avulsion (22.7%) and a lower percentage of upper avulsion (29.3%), whereas cyclists had a higher percentage of upper avulsion (68.6%) based on the data from the entire group of patients (p<0.001). Lower plexus palsy was significantly increased in patients after car accidents (9.3%,p<0.05). In the two main groups (car and motorcycle accidents),significantly more upper and fewer lower palsies were present. In the bicycle accident group, upper palsy was the most common (89%). Study results indicate that the most common injury was an upper plexus palsy. It was

‘Wondering and waiting’ after obstetrical brachial plexus injury: Are we underestimating the effects of the traumatic experience on the families?

PubMed Central

DeMatteo, Carol; Bain, James R; Gjertsen, Deborah; Harper, Jessica A

2014-01-01

BACKGROUND: Obstetrical brachial plexus injury (OBPI) in children can cause great distress to a family due to uncertain recovery, variability in spontaneous recovery and unclear indicators for surgery. OBJECTIVE: To investigate the impact of having a child with OBPI on the family and whether the Impact on Family Scale (IoFS) can assist in addressing family concerns. METHODS: A mixed-method (cross-sectional survey and semistructured interviews) study design was used. RESULTS: Thirty-eight families of children with OBPI completed the IoFS. Surgery significantly predicted a higher IoFS total impact score (P=0.02). No statistically significant association between the total impact score and severity or age was found, suggesting that impact on family was not dependent on these factors. Themes that emerged from the interviews included traumatic birthing experience, wondering and waiting, and experiencing surgery. CONCLUSION: All families should receive support and acknowledgement of the widespread impact of OBPI. PMID:25332647

The prognostic value of concurrent phrenic nerve palsy in newborn babies with neonatal brachial plexus palsy.

PubMed

Yoshida, Kiyoshi; Kawabata, Hidehiko

2015-06-01

To investigate the prognostic value of concurrent phrenic nerve palsy for predicting spontaneous motor recovery in neonatal brachial plexus palsy. We reviewed the records of 366 neonates with brachial plexus palsy. The clinical and follow-up data of patients with and without phrenic nerve palsy were compared. Of 366 newborn babies with neonatal brachial plexus palsy, 21 (6%) had concurrent phrenic nerve palsy. Sixteen of these neonates had upper-type palsy and 5 had total-type palsy. Poor spontaneous motor recovery was observed in 13 neonates with concurrent phrenic nerve palsy (62%) and in 129 without concurrent phrenic nerve palsy (39%). Among neonates born via vertex delivery, poor motor recovery was observed in 7 of 9 (78%) neonates with concurrent phrenic nerve palsy and 115 of 296 (39%) without concurrent phrenic nerve palsy. Concurrent phrenic nerve palsy in neonates with brachial plexus palsy has prognostic value in predicting poor spontaneous motor recovery of the brachial plexus, particularly after vertex delivery. Therapeutic IV. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Prevalence of brachial plexus injuries in patients with scapular fractures: A National Trauma Data Bank review

PubMed Central

Chamata, Edward; Mahabir, Raman; Jupiter, Daniel; Weber, Robert A

2014-01-01

BACKGROUND: Studies investigating the prevalence of brachial plexus injuries associated with scapular fractures are sparse, and are frequently limited by small sample sizes and often restricted to single-centre experience. OBJECTIVE: To determine the prevalence of brachial plexus injuries associated with scapular fractures; to determine how the prevalence varies with the region of the scapula injured; and to assess which specific nerves of the brachial plexus were involved. METHODS: The present study was a retrospective review of data from the National Trauma Data Bank over a five-year period (2007 to 2011). RESULTS: Of 68,118 patients with scapular fractures, brachial plexus injury was present in 1173 (1.72%). In patients with multiple scapular fractures, the prevalence of brachial plexus injury was 3.12%, and ranged from 1.52% to 2.22% in patients with single scapular fractures depending on the specific anatomical location of the fracture. Of the 426 injuries with detailed information on nerve injury, 208 (49%) involved the radial nerve, 113 (26.5%) the ulnar nerve, 65 (15%) the median nerve, 36 (8.5%) the axillary nerve and four (1%) the musculocutaneous nerve. CONCLUSION: The prevalence of brachial plexus injuries in patients with scapular fractures was 1.72%. The prevalence was similar across anatomical regions for single scapular fracture and was higher with multiple fractures. The largest percentage of nerve injuries were to the radial nerve. PMID:25535462

Neonatal brachial plexus palsy--management and prognostic factors.

PubMed

Yang, Lynda J-S

2014-06-01

Successful treatment of patients with neonatal brachial plexus palsy (NBPP) begins with a thorough understanding of the anatomy of the brachial plexus and of the pathophysiology of nerve injury via which the brachial plexus nerves stretched in the perinatal period manifest as a weak or paralyzed upper extremity in the newborn. NBPP can be classified by systems that can guide the prognosis and the management as these systems are based on the extent and severity of nerve injury, anatomy of nerve injury, and clinical presentation. Serial physical examinations, supplemented by a thorough maternal and perinatal history, are critical to the formulation of the treatment plan that relies upon occupational/physical therapy and rehabilitation management but may include nerve reconstruction and secondary musculoskeletal surgeries. Adjunctive imaging and electrodiagnostic studies provide additional information to guide prognosis and treatment. As research improves not only the technical aspects of NBPP treatment but also the ability to assess the activity and participation as well as body structure and function of NBPP patients, the functional outcomes for affected infants have an overall optimistic prognosis, with the majority recovering adequate functional use of the affected arm. Of importance are (i) early referral to interdisciplinary specialty clinics that can provide up-to-date advances in clinical care and (ii) increasing research/awareness of the psychosocial and patient-reported quality-of-life issues that surround the chronic disablement of NBPP. Copyright © 2014 Elsevier Inc. All rights reserved.

Correlation between ultrasound imaging, cross-sectional anatomy, and histology of the brachial plexus: a review.

PubMed

van Geffen, Geert J; Moayeri, Nizar; Bruhn, Jörgen; Scheffer, Gert J; Chan, Vincent W; Groen, Gerbrand J

2009-01-01

The anatomy of the brachial plexus is complex. To facilitate the understanding of the ultrasound appearance of the brachial plexus, we present a review of important anatomic considerations. A detailed correlation of reconstructed, cross-sectional gross anatomy and histology with ultrasound sonoanatomy is provided.

Postfixed brachial plexus radiculopathy due to thoracic disc herniation in a collegiate wrestler: a case report.

PubMed

Kuzma, Scott A; Doberstein, Scott T; Rushlow, David R

2013-01-01

To present the unique case of a collegiate wrestler with C7 neurologic symptoms due to T1-T2 disc herniation. A 23-year-old male collegiate wrestler injured his neck in a wrestling tournament match and experienced pain, weakness, and numbness in his left upper extremity. He completed that match and 1 additional match that day with mild symptoms. Evaluation by a certified athletic trainer 6 days postinjury showed radiculopathy in the C7 distribution of his left upper extremity. He was evaluated further by the team physician, a primary care physician, and a neurosurgeon. Cervical spine injury, stinger/burner, peripheral nerve injury, spinal cord injury, thoracic outlet syndrome, brachial plexus radiculopathy. The patient initially underwent nonoperative management with ice, heat, massage, electrical stimulation, shortwave diathermy, and nonsteroidal anti-inflammatory drugs without symptom resolution. Cervical spine radiographs were negative for bony pathologic conditions. Magnetic resonance imaging showed evidence of T1-T2 disc herniation. The patient underwent surgery to resolve the symptoms and enable him to participate for the remainder of the wrestling season. Whereas brachial plexus radiculopathy commonly is seen in collision sports, a postfixed brachial plexus in which the T2 nerve root has substantial contribution to the innervation of the upper extremity is a rare anatomic variation with which many health care providers are unfamiliar. The injury sustained by the wrestler appeared to be C7 radiculopathy due to a brachial plexus traction injury. However, it ultimately was diagnosed as radiculopathy due to a T1-T2 thoracic intervertebral disc herniation causing impingement of a postfixed brachial plexus and required surgical intervention. Athletic trainers and physicians need to be aware of the anatomic variations of the brachial plexus when evaluating and caring for patients with suspected brachial plexus radiculopathies.

Presence of time-dependent diffusion in the brachial plexus.

PubMed

Mahbub, Zaid B; Peters, Andrew M; Gowland, Penny A

2018-02-01

This work describes the development of a method to measure the variation of apparent diffusion coefficient (ADC) with diffusion time (Δ) in the brachial plexus, as a potential method of probing microstructure. Diffusion-weighted MRI with body signal suppression was used to highlight the nerves from surrounding tissues, and sequence parameters were optimized for sensitivity to change with diffusion time. A porous media-restricted diffusion model based on the Latour-Mitra equation was fitted to the diffusion time-dependent ADC data from the brachial plexus nerves and cord. The ADC was observed to reduce at long diffusion times, confirming that diffusion was restricted in the nerves and cord in healthy subjects. T2 of the nerves was measured to be 80 ± 5 ms, the diffusion coefficient was found to vary from (1.5 ± 0.1) × 10 -3 mm 2 /s at a diffusion time of 18.3 ms to (1.0 ± 0.2) × 10 -3 mm 2 /s at a diffusion time of 81.3 ms. A novel method of probing restricted diffusion in the brachial plexus was developed. Resulting parameters were comparable with values obtained previously on biological systems. Magn Reson Med 79:789-795, 2018. © 2017 International Society for Magnetic Resonance in Medicine. © 2017 International Society for Magnetic Resonance in Medicine.

Brachial plexus injury management through upper extremity amputation with immediate postoperative prostheses.

PubMed

Malone, J M; Leal, J M; Underwood, J; Childers, S J

1982-02-01

Management of patients with brachial plexus injuries requires a team approach so that all aspects of their care are addressed simultaneously. This report examines elective amputation and prosthetic rehabilitation in a patient with brachial plexus avulsion of the left arm. The best possibility for good prosthetic rehabilitation is the early application of prosthetic devices with intensive occupational therapy. Using this type of approach, we have achieved significant improvement in amputation rehabilitation of upper extremity amputees treated with immediate postoperative conventional electric and myoelectric prostheses.

Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series study.

PubMed

Crofts, J F; Lenguerrand, E; Bentham, G L; Tawfik, S; Claireaux, H A; Odd, D; Fox, R; Draycott, T J

2016-01-01

To investigate management and outcomes of incidences of shoulder dystocia in the 12 years following the introduction of an obstetric emergencies training programme. Interrupted time-series study comparing management and neonatal outcome of births complicated by shoulder dystocia over three 4-year periods: (i) Pre-training (1996-99), (ii) Early training (2001-04), and (iii) Late training (2009-12). Southmead Hospital, Bristol, UK, with approximately 6000 births per annum. Infants and their mothers who experienced shoulder dystocia. A bi-monthly multi-professional 1-day intrapartum emergencies training course, that included a 30-minute practical session on shoulder dystocia management, commenced in 2000. Neonatal morbidity (brachial plexus injury, humeral fracture, clavicular fracture, 5-minute Apgar score <7) and documented management of shoulder dystocia (resolution manoeuvres performed, traction applied, head-to-body delivery interval). Compliance with national guidance improved with continued training. At least one recognised resolution manoeuvre was used in 99.8% (561/562) of cases of shoulder dystocia in the late training period, demonstrating a continued improvement from 46.3% (150/324, P < 0.001) pre-training, and 92% (241/262, P < 0.001) in the early training period. In parallel there was reduction in the brachial plexus injury at birth (24/324 [7.4%, P < 0.01], pre-training, 6/262 [2.3%] early training, and 7/562 [1.3%] late training. There are significant benefits to long-term, embedded training programmes with improvements in both management and outcomes. A decade after the introduction of training there were no cases of brachial plexus injury lasting over 12 months in 562 cases of shoulder dystocia. © 2015 Royal College of Obstetricians and Gynaecologists.

Frontal slab composite magnetic resonance neurography of the brachial plexus: implications for infraclavicular block approaches.

PubMed

Raphael, David T; McIntee, Diane; Tsuruda, Jay S; Colletti, Patrick; Tatevossian, Ray

2005-12-01

Magnetic resonance neurography (MRN) is an imaging method by which nerves can be selectively highlighted. Using commercial software, the authors explored a variety of approaches to develop a three-dimensional volume-rendered MRN image of the entire brachial plexus and used it to evaluate the accuracy of infraclavicular block approaches. With institutional review board approval, MRN of the brachial plexus was performed in 10 volunteer subjects. MRN imaging was performed on a GE 1.5-tesla magnetic resonance scanner (General Electric Healthcare Technologies, Waukesha, WI) using a phased array torso coil. Coronal STIR and T1 oblique sagittal sequences of the brachial plexus were obtained. Multiple software programs were explored for enhanced display and manipulation of the composite magnetic resonance images. The authors developed a frontal slab composite approach that allows single-frame reconstruction of a three-dimensional volume-rendered image of the entire brachial plexus. Automatic segmentation was supplemented by manual segmentation in nearly all cases. For each of three infraclavicular approaches (posteriorly directed needle below midclavicle, infracoracoid, or caudomedial to coracoid), the targeting error was measured as the distance from the MRN plexus midpoint to the approach-targeted site. Composite frontal slabs (coronal views), which are single-frame three-dimensional volume renderings from image-enhanced two-dimensional frontal view projections of the underlying coronal slices, were created. The targeting errors (mean +/- SD) for the approaches-midclavicle, infracoracoid, caudomedial to coracoid-were 0.43 +/- 0.67, 0.99 +/- 1.22, and 0.65 +/- 1.14 cm, respectively. Image-processed three-dimensional volume-rendered MNR scans, which allow visualization of the entire brachial plexus within a single composite image, have educational value in illustrating the complexity and individual variation of the plexus. Suggestions for improved guidance during

Brachial plexus palsy and shoulder dystocia: obstetric risk factors remain elusive.

PubMed

Ouzounian, Joseph G; Korst, Lisa M; Miller, David A; Lee, Richard H

2013-04-01

Shoulder dystocia (SD) and brachial plexus palsy (BPP) are complications of childbirth that can result in significant long-term sequelae. The purpose of the present study was to analyze risk factors in cases of SD and BPP. We performed a retrospective study of laboring women who delivered a singleton, term, live-born infant at the Los Angeles County + University of Southern California Medical Center from 1995 to 2004. Multivariable logistic regression models were used to analyze risk factors among SD cases with and without BPP. Of the 13,998 deliveries that met inclusion criteria, 221 (1.6%) had SD. Of these, 42 (19.0%) had BPP. After testing for association with multiple potential risk factors, including maternal demographic variables, diabetes, hypertension, prior cesarean delivery, uterine abnormalities, induction of labor, prolonged second stage (adjusted by parity and epidural use), assisted vaginal delivery, and neonatal birth weight, no statistical association of BPP with any specific risk factor was identified. In the present study, we were unable to identify any reliable risk factors for BPP among deliveries with or without SD. SD and BPP remain unpredictable complications of childbirth. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Development of a set of activities to evaluate the arm and hand function in children with obstetric brachial plexus lesion.

PubMed

Boeschoten, K H; Folmer, K B; van der Lee, J H; Nollet, F

2007-02-01

To develop an observational instrument that can be used to evaluate the quality of arm and hand skills in daily functional activities in children with obstetric brachial plexus lesion (OBPL). A set of functional activities was constructed and standardized, and the intra-observer reliability of the assessment of this set of activities was studied. Department of Occupational Therapy and Department of Rehabilitation Medicine, VU University Medical Centre. Twenty-six children with OBPL in the age range of 4 -6 years. The children were asked to perform 47 bimanual activities, which were recorded on videotape. The videotapes were scored twice by the same occupational therapist. The percentage of agreement in scoring 'hand-use', 'speed' and 'assistance' was over 80% for a substantial number of activities, indicating a strong agreement. However, in scoring 'deviations in movements and body posture' the percentage of agreement was insufficient in most activities. This set of activities has good potential for assessment of the performance of functional activities in children with OBPL. This study, however, showed a number of difficulties in observing and scoring the activities that have to be considered when developing a standardized video observation.

Brachial Plexus-Associated Neuropathy After High-Dose Radiation Therapy for Head-and-Neck Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chen, Allen M., E-mail: allen.chen@ucdmc.ucdavis.edu; Hall, William H.; Li, Judy

2012-09-01

Purpose: To identify clinical and treatment-related predictors of brachial plexus-associated neuropathies after radiation therapy for head-and-neck cancer. Methods and Materials: Three hundred thirty patients who had previously completed radiation therapy for head-and-neck cancer were prospectively screened using a standardized instrument for symptoms of neuropathy thought to be related to brachial plexus injury. All patients were disease-free at the time of screening. The median time from completion of radiation therapy was 56 months (range, 6-135 months). One-hundred fifty-five patients (47%) were treated by definitive radiation therapy, and 175 (53%) were treated postoperatively. Radiation doses ranged from 50 to 74 Gy (median,more » 66 Gy). Intensity-modulated radiation therapy was used in 62% of cases, and 133 patients (40%) received concurrent chemotherapy. Results: Forty patients (12%) reported neuropathic symptoms, with the most common being ipsilateral pain (50%), numbness/tingling (40%), motor weakness, and/or muscle atrophy (25%). When patients with <5 years of follow-up were excluded, the rate of positive symptoms increased to 22%. On univariate analysis, the following factors were significantly associated with brachial plexus symptoms: prior neck dissection (p = 0.01), concurrent chemotherapy (p = 0.01), and radiation maximum dose (p < 0.001). Cox regression analysis confirmed that both neck dissection (p < 0.001) and radiation maximum dose (p < 0.001) were independently predictive of symptoms. Conclusion: The incidence of brachial plexus-associated neuropathies after radiation therapy for head-and-neck cancer may be underreported. In view of the dose-response relationship identified, limiting radiation dose to the brachial plexus should be considered when possible.« less

Intraoperative brachial plexus injury during emergence following movement with arms restrained: a preventable complication?

PubMed Central

Chandler, Mark H; DiMatteo, Laura; Hasenboehler, Erik A; Temple, Michael

2007-01-01

Background Despite considerable analysis and preventive strategies, brachial plexus injuries remain fairly common in the perioperative setting. These injuries range from brief periods of numbness or discomfort in the immediate postoperative period to, in rare cases, profound, prolonged losses of sensation and function. We present a case of an orthopedic surgery patient who suffered a brachial plexus injury while under anesthesia after trying to sit upright with his arms restrained. Case presentation After the uneventful placement of an intramedullary tibial nail, an 18 year old patient tried to sit upright with his arms restrained while still under the influence of anesthesia. In the immediate postoperative period, the patient complained of a profound loss of sensation in his left arm and an inability to flex his left elbow, suppinate his arm, or abduct and rotate his shoulder. Neurological examination and subsequent studies revealed a C5-6 brachial plexus injury. The patient underwent range of motion physical therapy and, over the next three months, regained the full function and sensation of his left arm. Conclusion Restraining arms during general anesthesia to prevent injury remains a wise practice. However, to avoid injuring the brachial plexus while the arms are restrained, extra caution must be used to prevent unexpected patient movement and to ensure gentle emergence. PMID:18271944

Scapular deformity in obstetric brachial plexus palsy and the Hueter-Volkmann law; a retrospective study

PubMed Central

2013-01-01

Background The Hueter-Volkmann law describes growth principles around joints and joint deformation. It states that decreased stress leads to increased growth and that excessive stress leads to growth retardation. Aim of this study was to test the possible results of this principle by measuring the effect of dorsal humeral head subluxation on scapular growth in children with Obstetrical Brachial Plexus Lesions (OBPL). According to the Hueter-Volkmann law, subluxation should result in decrease of growth of the dorsal length of the scapula (by increased dorsal pressure) and increase of the ventral length (decreased pressure). Methods 58 children (mean age 20 months, range 1-88 month) with unilateral OBPL and good quality MRI of both shoulders were included. On MRI, humeral head subluxation, joint deformation, and ventral and dorsal scapular lengths were measured. Data were expressed as a ratio of the normal side. Results In affected scapulas both ventral and dorsal side were smaller compared to the normal side. Reduction of growth on the affected side was more marked on the dorsal side than on the ventral side (6.5 mm respectively 4.5 mm, p < 0.001). The balance of growth reduction as expressed by the ratio of ventral and dorsal length was strongly related to subluxation (R2 = 0.33, p < 0.001) and age (R2 = 0.19, p < 0.001). Conclusions The Hueter-Volkmann law is incompletely active in subluxated shoulders in OBPL. Dorsal subluxation indeed leads to decrease of growth of the dorsal length of the scapula. However, decreased stress did not lead to increased growth of the ventral length of the scapula. PMID:23522350

Brachial plexus injury mimicking a spinal-cord injury

PubMed Central

Macyszyn, Luke J.; Gonzalez-Giraldo, Ernesto; Aversano, Michael; Heuer, Gregory G.; Zager, Eric L.; Schuster, James M.

2010-01-01

Objective: High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis. Clinical presentation: A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department. Intervention: Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion. Conclusion: Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury. PMID:22956928

Phrenic nerve transfer to the musculocutaneous nerve for the repair of brachial plexus injury: electrophysiological characteristics

PubMed Central

Liu, Ying; Xu, Xun-cheng; Zou, Yi; Li, Su-rong; Zhang, Bin; Wang, Yue

2015-01-01

Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we performed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduction function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regenerated potentials first appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering ‘excellent’ and ‘good’ muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The functional recovery of a transplanted nerve can be dynamically observed after the surgery. PMID:25883637

Phrenic nerve transfer to the musculocutaneous nerve for the repair of brachial plexus injury: electrophysiological characteristics.

PubMed

Liu, Ying; Xu, Xun-Cheng; Zou, Yi; Li, Su-Rong; Zhang, Bin; Wang, Yue

2015-02-01

Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we performed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduction function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regenerated potentials first appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering 'excellent' and 'good' muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The functional recovery of a transplanted nerve can be dynamically observed after the surgery.

[Pattern of paralysis and reconstructive operations after traumatic brachial plexus lesions].

PubMed

Rühmann, O; Schmolke, S; Carls, J; Wirth, C J

2002-12-01

The aim of this study was to evaluate persistent patterns of paralysis after traumatic brachial plexus lesions. As a result, consecutive reconstructive operations according to our differential therapy concept are presented. Between 04/1994 and 12/2000 in 104 patients with brachial plexus palsy, the grade of muscle power of the affected upper extremities was evaluated prospectively. The neuromuscular patterns of defect showed, in most cases, insufficient muscle power grades of 0-2 for the deltoid muscle (90%), supraspinatus muscle (82%), infraspinatus muscle (93%), elbow flexors (67% to 77%), hand and finger extensors (69% to 71%), and the abductor and extensors of the thumb (67% to 70%). In corresponding frequency, the following operations were performed between 04/1994 and 06/2002: shoulder arthrodesis (n 26), trapezius transfer (n 80), rotation osteotomy of humerus (n 10), triceps to biceps transposition (n 11), transposition of forearm flexors or extensors/Steindler operation (n 12), latissimus transfer (n 7), pectoralis transfer (n 1), teres major transfer (n 1), transposition of forearm flexors to the tendons of extensor digitorum (n 19) and of the extensor pollicis longus (n 9), and wrist arthrodesis (n 5). On malfunction of muscles following brachial plexus lesions, taking into account the individual neuromuscular defect, passive joint function, and bony deformities, different procedures such as muscle transposition, arthrodesis, and corrective osteotomy can be performed to improve function of the upper extremity.

Restoration of shoulder motion using single- versus dual-nerve repair in obstetrical brachial plexus injury.

PubMed

Azzi, Alain Joe; AlNaeem, Hassan; Aubin-Lemay, Camille; Kvann, Julie Chakriya; Alam, Peter; Retrouvey, Helene; Aldekhayel, Salah; Zadeh, Teanoosh

2018-05-01

OBJECTIVE The purpose of this study was to compare shoulder abduction and external rotation (ER) after single-nerve repair of the upper trunk alone versus dual-nerve repair of both the upper trunk and the suprascapular nerve. METHODS A retrospective chart review of a single surgeon's experience repairing obstetrical brachial plexus injuries between June 1995 and June 2015 was performed. Eight patients underwent repair of the upper trunk alone, and 10 patients underwent repair of the upper trunk and the suprascapular nerve. Shoulder abduction and ER ranges of motion (ROMs) (in degrees) were recorded preoperatively and postoperatively. Postoperative ROM and the difference in ROM gained after surgery were compared by independent t-test analysis. RESULTS The mean follow-up time was 161.4 weeks (range 62-514 weeks, SD 124.0 weeks). The mean patient age at the time of surgery was 31.3 weeks (range 19.9-47.0 weeks, SD 6.9 weeks). The mean postoperative shoulder abduction ROMs were 145.0° (range 85°-180°, SD 39.4°) after single-nerve repair and 134.0° (range 90°-180°, SD 30.3°) after dual-nerve repair (p = 0.51). The mean postoperative shoulder ER ROMs were 67.5° (range 10°-95°, SD 28.8°) after single-nerve repair and 72.0° (range 10°-95°, SD 31.3°) after dual-nerve repair (p = 0.76). CONCLUSIONS The authors found no difference in shoulder abduction and ER between patients who underwent single-nerve repair of the upper trunk alone and those who underwent dual-nerve repair of both the upper trunk and the suprascapular nerve.

Neurotization of elements of the brachial plexus.

PubMed

Friedman, A H

1991-01-01

Satisfactory therapy for an avulsion injury of the brachial plexus has yet to be described. Dorsal root entry zone lesions will usually mitigate the searing pain which is so disabling in some of these patients. Neurotization procedures are effective in restoring limited function to these patients. The most useful isolated movement of the upper extremity is elbow flexion, which is thus the primary target of neurotization procedures. Intercostal nerves and elements of the cervical plexus are the most commonly used donor nerves for neurotization procedures. From our experience and from a review of the literature, it appears that these procedures will be successful in approximately 50% of cases. It must be stressed that before performing a nerve transfer, the surgeon must be certain that the patient is not a candidate for a simple nerve graft.

Addition of dexmedetomidine to bupivacaine in supraclavicular brachial plexus block.

PubMed

Aksu, Recep; Bicer, Cihangir

2017-06-26

Research is ongoing to determine the lowest dose of local anesthetics in brachial plexus block that provides adequate anesthesia and postoperative analgesia and reduces complications related to local anesthetics. Patients 18-65 years of age who underwent upper limb surgery and who received ultrasound-guided supraclavicular brachial plexus block at the Erciyes University Faculty of Medicine Hospital between February 2014 and January 2015 were included in the study (n=50). Supraclavicular brachial plexus blocks were performed on Group B cases by adding 30 ml 0.33% bupivacaine and on Group BD cases by adding 15 ml 0.33% bupivacaine and 1 µg / kg dexmedetomidine. Block success was evaluated by the onset and block duration of motor and sensory block and the duration of analgesia. The block success of Group B and Group BD was 92.6% and 89.3%, respectively (P = 1.000). Onset time of sensory block, degree of sensory block, duration of sensory block, onset time of motor block, degree of motor block and duration of motor block were similar in both groups in the intergroup comparison (P > 0.05). Duration of analgesia and the operative conditions of groups were similar (P > 0.05). In the implementation of ultrasound-guided supraclavicular brachial plexus block, block success, sensory and motor block and analgesia duration were similar for patients anaesthetized with 30 ml of bupivacaine in comparison with dexmedetomidine+bupivacaine (when the bupivacaine dose was reduced by 50% by the addition of the adjuvant).

The Prevalence, Rate of Progression, and Treatment of Elbow Flexion Contracture in Children with Brachial Plexus Birth Palsy

PubMed Central

Sheffler, Lindsey C.; Lattanza, Lisa; Hagar, Yolanda; Bagley, Anita; James, Michelle A.

2012-01-01

Background: Elbow flexion contracture is a well-known complication of brachial plexus birth palsy that adversely affects upper-extremity function. The prevalence, risk factors, and rate of progression of elbow flexion contracture associated with brachial plexus birth palsy have not been established, and the effectiveness of nonoperative treatment involving nighttime splinting or serial casting has not been well studied. Methods: The medical records of 319 patients with brachial plexus birth palsy who had been seen at our institution between 1992 and 2009 were retrospectively reviewed to identify patients with an elbow flexion contracture (≥10°). The chi-square test for trend and the Kaplan-Meier estimator were used to evaluate risk factors for contracture, including age, sex, and the extent of brachial plexus involvement. Longitudinal models were used to estimate the rate of contracture progression and the effectiveness of nonoperative treatment. Results: An elbow flexion contracture was present in 48% (152) of the patients with brachial plexus birth palsy. The median age of onset was 5.1 years (range, 0.25 to 14.8 years). The contracture was ≥30° in 36% (fifty-four) of these 152 patients and was accompanied by a documented radial head dislocation in 6% (nine). The prevalence of contracture increased with increasing age (p < 0.001) but was not significantly associated with sex or with the extent of brachial plexus involvement. The magnitude of the contracture increased by 4.4% per year before treatment (p < 0.01). The magnitude of the contracture decreased by 31% when casting was performed (p < 0.01) but thereafter increased again at the same rate of 4.4% per year. The magnitude of the contracture did not improve when splinting was performed but the rate of increase thereafter decreased to <0.1% per year (p = 0.04). Conclusions: The prevalence of elbow flexion contracture in children with brachial plexus birth palsy may be greater than clinicians perceive

Sup-ER orthosis: an innovative treatment for infants with birth related brachial plexus injury.

PubMed

Durlacher, Kim M; Bellows, Doria; Verchere, Cynthia

2014-01-01

Impairments in active and passive range of upper extremity supination and shoulder external rotation are common sequelae for children with delayed recovery from birth related brachial plexus injury. Orthotic intervention may complement traditional treatment strategies commonly employed in the newborn period. These authors describe their custom fabricated orthosis designed to balance shoulder growth and muscular function, and improve prognosis of long term functional outcomes for children with birth related brachial plexus injury. - Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor. Copyright © 2014 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.

The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy.

PubMed

Curtis, Christine; Stephens, Derek; Clarke, Howard M; Andrews, David

2002-05-01

Newborns with peripheral nerve lesions involving the upper extremity are difficult to evaluate. The reliability of the Active Movement Scale (AMS), a tool for assessing motor function in infants with obstetrical brachial plexus palsy (OBPP), was examined in 2 complementary studies. Part A was an interrater reliability study in which 63 infants younger than 1 year with OBPP were independently evaluated by 2 physical therapists using the AMS. The scores were compared for reliability and controlled for chance agreement by using kappa statistics. Overall kappa analysis of the 15 tested movements showed a moderate strength of score agreement (kappa = 0.51). Quadratic-weighted kappa (kappa(quad)) statistics showed that 8 of the 15 movements tested were in the highest strength of agreement category (kappa(quad) = 0.81-1.00). Five movements showed substantial agreement (kappa(quad) = 0.61-0.80), and 2 movements had moderate agreement (kappa(quad) = 0.41- 0.60). The overall kappa(quad) was 0.89. Part B was a variability study designed to examine the dispersion of scores when infants with OBPP were evaluated with the AMS by multiple raters. Ten pediatric physical therapists with varying degrees of experience using the scale attended a 1(1/2)-hour instructional workshop on administration of the tool for infants with OBPP. A chain-block study design was used to obtain 30 assessments of 10 infants by 10 raters. A 2-way analysis of variance indicated that the variability of scores due to rater factors was low compared with the variability due to patient factors and that variation in scores due to rater experience was minimal. The results of part A indicate that the AMS is a reliable tool for the assessment of infants with OBPP when raters familiar with the scale are compared. The results of part B suggest that, with minimal training, raters with a range of experience using the AMS are able to reliably evaluate infants with upper-extremity paralysis.

Cost analysis of brachial plexus injuries: variability of compensation by insurance companies before and after surgery.

PubMed

Felici, N; Zaami, S; Ciancolini, G; Marinelli, E; Tagliente, D; Cannatà, C

2014-04-01

Traumatic paralysis of the brachial plexus is an extremely disabling pathology. The type of trauma most frequently suffered by this group of patients is due to motorcycle injuries. It therefore affects a population of young patients. In the majority of cases, these patients receive compensation for permanent damage from insurance companies. Surgery of the brachial plexus enables various forms of functional recovery, depending on the number of roots of the brachial plexus involved in the injury. The aim of this study is to compare the functional deficit and the extent of the related compensation before and after surgical intervention, and to evaluate the saving in economic terms (understood as the cost of compensation paid by insurance companies) obtainable through surgical intervention. The authors analysed the functional recovery obtained through surgery in 134 patients divided into 4 groups on the basis of the number of injured roots. The levels of compensation payable to the patient before surgical intervention, and 3 years after, were then compared. The results showed that the saving obtainable through surgical treatment of brachial plexus injuries may exceed 65% of the economic value of the compensation that would have been attributable to the same patients if they had not undergone surgical treatment. © Georg Thieme Verlag KG Stuttgart · New York.

Dose–Volume Modeling of Brachial Plexus-Associated Neuropathy After Radiation Therapy for Head-and-Neck Cancer: Findings From a Prospective Screening Protocol

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chen, Allen M., E-mail: amchen@mednet.ucla.edu; Wang, Pin-Chieh; Daly, Megan E.

2014-03-15

Purpose: Data from a prospective screening protocol administered for patients previously irradiated for head-and-neck cancer was analyzed to identify dosimetric predictors of brachial plexus-associated neuropathy. Methods and Materials: Three hundred fifty-two patients who had previously completed radiation therapy for squamous cell carcinoma of the head and neck were prospectively screened from August 2007 to April 2013 using a standardized self-administered instrument for symptoms of neuropathy thought to be related to brachial plexus injury. All patients were disease-free at the time of screening. The median time from radiation therapy was 40 months (range, 6-111 months). A total of 177 patients (50%)more » underwent neck dissection. Two hundred twenty-one patients (63%) received concurrent chemotherapy. Results: Fifty-one patients (14%) reported brachial plexus-related neuropathic symptoms with the most common being ipsilateral pain (50%), numbness/tingling (40%), and motor weakness and/or muscle atrophy (25%). The 3- and 5-year estimates of freedom from brachial plexus-associated neuropathy were 86% and 81%, respectively. Clinical/pathological N3 disease (P<.001) and maximum radiation dose to the ipsilateral brachial plexus (P=.01) were significantly associated with neuropathic symptoms. Cox regression analysis revealed significant dose–volume effects for brachial plexus-associated neuropathy. The volume of the ipsilateral brachial plexus receiving >70 Gy (V70) predicted for symptoms, with the incidence increasing with V70 >10% (P<.001). A correlation was also observed for the volume receiving >74 Gy (V74) among patients treated without neck dissection, with a cutoff of 4% predictive of symptoms (P=.038). Conclusions: Dose–volume guidelines were developed for radiation planning that may limit brachial plexus-related neuropathies.« less

Acute repair of traumatic pan-brachial plexus injury: technical considerations and approaches.

PubMed

Abou-Al-Shaar, Hussam; Karsy, Michael; Ravindra, Vijay; Joyce, Evan; Mahan, Mark A

2018-01-01

Particularly challenging after complete brachial plexus avulsion is reestablishing effective hand function, due to limited neurological donors to reanimate the arm. Acute repair of avulsion injuries may enable reinnervation strategies for achieving hand function. This patient presented with pan-brachial plexus injury. Given its irreparable nature, the authors recommended multistage reconstruction, including contralateral C-7 transfer for hand function, multiple intercostal nerves for shoulder/triceps function, shoulder fusion, and spinal accessory nerve-to-musculocutaneous nerve transfer for elbow flexion. The video demonstrates distal contraction from electrical stimulation of the avulsed roots. Single neurorrhaphy of the contralateral C-7 transfer was performed along with a retrosternocleidomastoid approach. The video can be found here: https://youtu.be/GMPfno8sK0U .

Subscapularis slide correction of the shoulder internal rotation contracture after brachial plexus birth injury: technique and outcomes.

PubMed

Immerman, Igor; Valencia, Herbert; DiTaranto, Patricia; DelSole, Edward M; Glait, Sergio; Price, Andrew E; Grossman, John A I

2013-03-01

Internal rotation contracture is the most common shoulder deformity in patients with brachial plexus birth injury. The purpose of this investigation is to describe the indications, technique, and results of the subscapularis slide procedure. The technique involves the release of the subscapularis muscle origin off the scapula, with preservation of anterior shoulder structures. A standard postoperative protocol is used in all patients and includes a modified shoulder spica with the shoulder held in 60 degrees of external rotation and 30 degrees of abduction, aggressive occupational and physical therapy, and subsequent shoulder manipulation under anesthesia with botulinum toxin injections as needed. Seventy-one patients at 2 institutions treated with subscapularis slide between 1997 and 2010, with minimum follow-up of 39.2 months, were identified. Patients were divided into 5 groups based on the index procedure performed: subscapularis slide alone (group 1); subscapularis slide with a simultaneous microsurgical reconstruction (group 2); primary microsurgical brachial plexus reconstruction followed later by a subscapularis slide (group 3); primary microsurgical brachial plexus reconstruction followed later by a subscapularis slide combined with tendon transfers for shoulder external rotation (group 4); and subscapularis slide with simultaneous tendon transfers, with no prior brachial plexus surgery (group 5). Full passive external rotation equivalent to the contralateral side was achieved in the operating room in all cases. No cases resulted in anterior instability or internal rotation deficit. Internal rotation contracture of the shoulder after brachial plexus birth injury can be effectively managed with the technique of subscapularis slide.

Rehabilitation program for children with brachial plexus and peripheral nerve injury.

PubMed

Ramos, L E; Zell, J P

2000-03-01

An aggressive and integrated physical and occupational therapy program is essential in the treatment of congenital brachial plexus injuries and other severe upper extremity nerve injuries. This article addresses the evaluation, identification of needs, establishment of goals, and the approaches to rehabilitation treatment for patients with brachial plexus palsy and other peripheral nerve injuries. Rehabilitative therapy can preserve and build on gains made possible by medical or surgical interventions; however, therapy is vital to these children regardless of whether surgery is indicated. The therapist uses a problem-solving approach to evaluate the patient and select appropriate occupational and physical therapy treatment modalities. Therapy is continually adjusted based on each child's unique needs. An understanding of the therapy principles aids in making appropriate referrals and prescriptions, and helps to coordinate care between the therapist, pediatrician, neurologist, and surgeon.

Hand Function in Children with an Upper Brachial Plexus Birth Injury: Results of the Nine-Hole Peg Test

ERIC Educational Resources Information Center

Immerman, Igor; Alfonso, Daniel T.; Ramos, Lorna E.; Grossman, Leslie A.; Alfonso, Israel; Ditaranto, Patricia; Grossman, John A. I.

2012-01-01

Aim: The aim of this study was to evaluate hand function in children with Erb upper brachial plexus palsy. Method: Hand function was evaluated in 25 children (eight males; 17 females) with a diagnosed upper (C5/C6) brachial plexus birth injury. Of these children, 22 had undergone primary nerve reconstruction and 13 of the 25 had undergone…

Outcome following nonoperative treatment of brachial plexus birth injuries.

PubMed

DiTaranto, Patricia; Campagna, Liliana; Price, Andrew E; Grossman, John A I

2004-02-01

Ninety-one infants who sustained a brachial plexus birth injury were treated with only physical and occupational therapy. The children were evaluated at 3-month intervals and followed for a minimum of 2 years. Sixty-three children with an upper or upper-middle plexus injury recovered good to excellent shoulder and hand function. In all of these children, critical marker muscles recovered M4 by 6 months of age. Twelve infants sustained a global palsy, with critical marker muscles remaining at M0-M1 at 6 months, resulting in a useless extremity. Sixteen infants with upper and upper-middle plexus injuries failed to recover greater than M1-M2 deltoid and biceps by 6 months, resulting in a very poor final outcome. These data provide useful guidelines for selection of infants for surgical reconstruction to improve ultimate outcome.

Axillary Brachial Plexus Blockade for the Reflex Sympathetic Dystrophy Syndrome.

ERIC Educational Resources Information Center

Ribbers, G. M.; Geurts, A. C. H.; Rijken, R. A. J.; Kerkkamp, H. E. M.

1997-01-01

Reflex sympathetic dystrophy syndrome (RSD) is a neurogenic pain syndrome characterized by pain, vasomotor and dystrophic changes, and often motor impairments. This study evaluated the effectiveness of brachial plexus blockade with local anaesthetic drugs as a treatment for this condition. Three patients responded well; three did not. (DB)

Brachial Plexus in the Pampas Fox (Lycalopex gymnocercus): a Descriptive and Comparative Analysis.

PubMed

de Souza Junior, Paulo; da Cruz de Carvalho, Natan; de Mattos, Karine; Abidu Figueiredo, Marcelo; Luiz Quagliatto Santos, André

2017-03-01

Twenty thoracic limbs of ten Lycalopex gymnocercus were dissected to describe origin and distribution of the nerves forming brachial plexuses. The brachial plexus resulted from the connections between the ventral branches of the last three cervical nerves (C6, C7, and C8) and first thoracic nerve (T1). These branches connected the suprascapular, subscapular, axillary, musculocutaneous, radial, median and ulnar nerves to the intrinsic musculature and connected the brachiocephalic, thoracodorsal, lateral thoracic, long thoracic, cranial pectoral and caudal pectoral nerves to the extrinsic musculature. The C7 ventral branches contribute most to the formation of the nerves (62.7%), followed by C8 (58.8%), T1 (40.0%) and C6 (24.6%). Of the 260 nerves dissected, 69.2% resulted from a combination of two or three branches, while only 30.8% originated from a single branch. The origin and innervation area of the pampas fox brachial plexus, in comparison with other domestic and wild species, were most similar to the domestic dog and wild canids from the neotropics. The results of this study can serve as a base for comparative morphofunctional analysis involving this species and development of nerve block techniques. Anat Rec, 300:537-548, 2017. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Phrenic Nerve Transfer for Reconstruction of Elbow Extension in Severe Brachial Plexus Injuries.

PubMed

Flores, Leandro P; Socolovsky, Mariano

2016-09-01

Background Restoring elbow extension is an important objective to pursue when repairing the brachial plexus in patients with a flail arm. Based upon the good results obtained using the phrenic nerve to restore elbow flexion and shoulder stability, we hypothesized that this nerve could also be employed to reconstruct elbow extension in patients with severe brachial plexus injuries. Methods A retrospective study of 10 patients in which the phrenic nerve targeted the radial nerve (7 patients) or the branch to the long head of the triceps (3 patients) as a surgical strategy for reconstruction of the brachial plexus. Results The mean postoperative follow-up time was 34 months. At final follow-up, elbow extension graded as M4 was measured in three patients, Medical Research Council MRC M3 in five patients, and M2 in one patient, while one patient experienced no measurable recovery (M0). No patient complained or demonstrated any signs of respiratory insufficiency postoperatively. Conclusions The phrenic nerve is a reliable donor for reanimation of elbow extension in such cases, and the branch to the long head of the triceps should be considered as a better target for the nerve transfer. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Diagnosis and treatment of the hemiplegic patient with brachial plexus injury.

PubMed

Meredith, J; Taft, G; Kaplan, P

1981-10-01

Brachial plexus injury was observed as a complication in 5 of 12 hemiplegic patients admitted over a 5-week period to an inpatient unit of the Rehabilitation Institute of Chicago. These patients exhibited unusual patterns of muscle atrophy and return of function in the impaired upper extremity. Occupational therapists may play an important part in the diagnosis and treatment of this complication of hemiplegia by promptly recognizing its subtle clinical signs and instituting appropriate therapy. Electromyography may be recommended to confirm this diagnosis. The treatment of choice is to maintain correct positioning of the limb both day and night, to use facilitation techniques for specific muscles in order to prevent atrophy, and to maintain passive range of motion as much as possible. Prevention of brachial plexus injury depends largely on the education of patient, family, and staff as to the potential hazards to a frail extremity that has no protective responses.

Ultrasound guided therapeutic injections of the cervical spine and brachial plexus.

PubMed

Cormick, Wes

2014-02-01

Introduction : Recent applications in ultrasound imaging include ultrasound assessment and ultrasound guided therapeutic injections of the spine and brachial plexus. Discussion : Ultrasound is an ideal modality for these regions as it allows accurate safe and quick injection of single or multiple sites. It has the added advantages of lack of ionising radiation, and can be done without requiring large expensive radiology equipment. Conclusion : Brachial plexus pathology may be present in patients presenting for shoulder symptoms where very little is found at imaging the shoulder. It is important to understand the anatomy and normal variants that may exist to be able to recognise when pathology is present. When pathology is demonstrated it is easy to do a trial of therapy with ultrasound guided injection of steroid around the nerve lesion. This review will outline the normal anatomy and variants and common pathology, which can be amenable to ultrasound guided injection of steroid.

Shoulder function and anatomy in complete obstetric brachial plexus palsy: long-term improvement after triangle tilt surgery

PubMed Central

Karicherla, Priyanka; Mahmooduddin, Faiz

2010-01-01

Purpose Untreated complete obstetric brachial plexus injury (COBPI) usually results in limited spontaneous recovery of shoulder function. Older methods used to treat COBPI have had questionable success, with very few studies being published. The purpose of the current study was to examine the results of triangle tilt surgery on shoulder function and development in COBPI individuals. Methods This study was conducted as a retrospective chart review. Inclusion criteria were COBPI patients that had undergone the triangle tilt procedure from 2005 to 2009 and were between the ages of 9 months and 12 years. COBPI was defined as permanent injury to all five nerve roots (C5–T1), with significant degradation in development and function of the hand. Twenty-five patients with a mean age of 5 (0.75–12) years were followed up clinically for more than 2 years. Results The triangle tilt procedure resulted in demonstrable clinical enhancements with appreciable improvements in shoulder function, glenoid version, and humeral head congruity. There was a significant increase in the overall Mallet score (2.4 points, p < 0.0001) following surgical correction in patients that were followed up for more than 2 years. Conclusions The results of this study demonstrate that COBPI patients who develop SHEAR and medial rotation contracture deformities can benefit from the triangle tilt surgery, which improves shoulder function and anatomy across a range of pediatric ages. Despite these patients presenting late for surgery in general (5 years), significant improvements were observed in their glenohumeral (GH) dysplasia and their ability to perform shoulder and arm movements following surgery. PMID:20473676

The results of supraclavicular brachial plexus neurolysis (without first rib resection) in management of post-traumatic "thoracic outlet syndrome".

PubMed

Dellon, A L

1993-01-01

This study evaluated the effectiveness of a supraclavicular brachial plexus neurolysis, without a first rib resection, in relieving the symptom complex traditionally termed "thoracic outlet syndrome." The hypothesis to be tested was that patients with a history of trauma may sustain stretch-type injury and subsequent scarring in and about the brachial plexus which is left untreated during transaxillary first rib resection. This prospective study included 14 patients who each had a neurolysis of the five roots and three trunks of the brachial plexus, plus an anterior scalenectomy through a supraclavicular approach. The results were determined on 11 patients with a mean follow-up of 26.4 months. The results of surgery were five excellent (45 percent), five good (45 percent) and one who failed to improve (10 percent). It is concluded that, with a history of trauma, the symptom complex commonly referred to as "thoracic outlet syndrome" may be primarily due to entrapment of the brachial plexus at sites proximal to the interval between the first rib and the clavicle. It is suggested that: 1) the term "brachial plexus compression" best describes the syndrome without directing the surgeon to remove any one specific anatomic structure and 2) the supraclavicular approach permits excellent surgical exposure of the compressed neurovascular structures. An unexpected observation was the formation of the lower trunk from C8 and T1 proximal to the first rib in the majority of these patients.

Brachial plexus assessment with three-dimensional isotropic resolution fast spin echo MRI: comparison with conventional MRI at 3.0 T

PubMed Central

Tagliafico, A; Succio, G; Neumaier, C E; Baio, G; Serafini, G; Ghidara, M; Calabrese, M; Martinoli, C

2012-01-01

Objective The purpose of our study was to determine whether a three-dimensional (3D) isotropic resolution fast spin echo sequence (FSE-cube) has similar image quality and diagnostic performance to a routine MRI protocol for brachial plexus evaluation in volunteers and symptomatic patients at 3.0 T. Institutional review board approval and written informed consent were guaranteed. Methods In this prospective study FSE-cube was added to the standard brachial plexus examination protocol in eight patients (mean age, 50.2 years) with brachial plexus pathologies and in six volunteers (mean age, 54 years). Nerve visibility, tissue contrast, edge sharpness, image blurring, motion artefact and acquisition time were calculated for FSE-cube sequences and for the standard protocol on a standardised five-point scale. The visibility of brachial plexus nerve and surrounding tissues at four levels (roots, interscalene area, costoclavicular space and axillary level) was assessed. Results Image quality and nerve visibility did not significantly differ between FSE-cube and the standard protocol (p>0.05). Acquisition time was statistically and clinically significantly shorter with FSE-cube (p<0.05). Pathological findings were seen equally well with FSE-cube and the standard protocol. Conclusion 3D FSE-cube provided similar image quality in a shorter acquisition time and enabled excellent visualisation of brachial plexus anatomy and pathology in any orientation, regardless of the original scanning plane. PMID:21343321

Successful outcome of modified quad surgical procedure in preteen and teen patients with brachial plexus birth palsy.

PubMed

Nath, Rahul K; Somasundaram, Chandra

2012-01-01

To evaluate the outcome of modified Quad procedure in preteen and teen patients with brachial plexus birth palsy. We have previously demonstrated a significant improvement in shoulder abduction, resulting from the modified Quad procedure in children (mean age 2.5 years; range, 0.5-9 years) with obstetric brachial plexus injury. We describe in this report the outcome of 16 patients (6 girls and 10 boys; 7 preteen and 9 teen) who have undergone the modified Quad procedure for the correction of the shoulder function, specifically abduction. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and axillary nerve decompression and neurolysis (the modified Quad procedure). Mean age of these patients at surgery was 13.5 years (range, 10.1-17.9 years). The mean preoperative total Mallet score was 14.8 (range, 10-20), and active abduction was 84° (range, 20°-140°). At a mean follow-up of 1.5 years, the mean postoperative total Mallet score increased to 19.7 (range, 13-25, P < .0001), and the mean active abduction improved to 132° (range, 40°-180°, P < .0003). The modified Quad procedure greatly improves not only the active abduction but also other shoulder functions in preteen and teen patients, as this outcome is the combined result of decompression and neurolysis of the axillary nerve and the release of the contracted internal rotators of the shoulder.

Prevalence of Neuropathic Pain in Patients with Traumatic Brachial Plexus Injury: A Multicenter Prospective Hospital-Based Study.

PubMed

Ciaramitaro, Palma; Padua, Luca; Devigili, Grazia; Rota, Eugenia; Tamburin, Stefano; Eleopra, Roberto; Cruccu, Giorgio; Truini, Andrea

2017-12-01

Prevalence and clinical characteristics of neuropathic pain due to traumatic brachial plexus injury. Observational epidemiological study. Hospital-based multicenter study. One hundred seven prospectively enrolled patients with brachial plexus injury. All the patients underwent clinical examination and neurophysiological testing for a definitive diagnosis of the brachial plexus lesion. The DN4 questionnaire was used to identify neuropathic pain, and the Neuropathic Pain Symptom Inventory (NPSI) to evaluate the different symptoms of neuropathic pain. The SF36 questionnaire and the Beck Depression Inventory (BDI) were used to assess quality of life and mood disturbances in patients with neuropathic pain. Of the 107 enrolled patients, 74 had pain (69%); neuropathic pain, as assessed by means of the DN4, was identified in 60 (56%) of these patients. According to the NPSI, the most frequent and severe pain type was the spontaneous burning pain. Clinical and neurophysiological findings showed that pain is unrelated to age but is associated with the severity of peripheral nerve damage. The SF36 questionnaire and BDI showed that neuropathic pain impairs quality of life and causes depression. Our study provides information on the prevalence, characteristics, and variables associated with neuropathic pain due to traumatic brachial plexus injuries that might provide a basis for improving the clinical management of this condition. © 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Comparison Between Ultrasound-Guided Supraclavicular and Interscalene Brachial Plexus Blocks in Patients Undergoing Arthroscopic Shoulder Surgery: A Prospective, Randomized, Parallel Study.

PubMed

Ryu, Taeha; Kil, Byung Tae; Kim, Jong Hae

2015-10-01

Although supraclavicular brachial plexus block (SCBPB) was repopularized by the introduction of ultrasound, its usefulness in shoulder surgery has not been widely reported. The objective of this study was to compare motor and sensory blockades, the incidence of side effects, and intraoperative opioid analgesic requirements between SCBPB and interscalene brachial plexus block (ISBPB) in patients undergoing arthroscopic shoulder surgery. Patients were randomly assigned to 1 of 2 groups (ISBPB group: n = 47; SCBPB group: n = 46). The side effects of the brachial plexus block (Horner's syndrome, hoarseness, and subjective dyspnea), the sensory block score (graded from 0 [no cold sensation] to 100 [intact sensation] using an alcohol swab) for each of the 5 dermatomes (C5-C8 and T1), and the motor block score (graded from 0 [complete paralysis] to 6 [normal muscle force]) for muscle forces corresponding to the radial, ulnar, median, and musculocutaneous nerves were evaluated 20 min after the brachial plexus block. Fentanyl was administered in 50 μg increments when the patients complained of pain that was not relieved by the brachial plexus block. There were no conversions to general anesthesia due to a failed brachial plexus block. The sensory block scores for the C5 to C8 dermatomes were significantly lower in the ISBPB group. However, the percentage of patients who received fentanyl was comparable between the 2 groups (27.7% [ISBPB group] and 30.4% [SCBPB group], P = 0.77). SCBPB produced significantly lower motor block scores for the radial, ulnar, and median nerves than did ISBPB. A significantly higher incidence of Horner's syndrome was observed in the ISBPB group (59.6% [ISBPB group] and 19.6% [SCBPB group], P < 0.001). No patient complained of subjective dyspnea. Despite the weaker degree of sensory blockade provided by SCBPB in comparison to ISBPB, opioid analgesic requirements are similar during arthroscopic shoulder surgery under both brachial plexus blocks

A Review of Brachial Plexus Birth Palsy: Injury and Rehabilitation.

PubMed

Raducha, Jeremy E; Cohen, Brian; Blood, Travis; Katarincic, Julia

2017-11-01

Brachial plexus injuries during the birthing process can leave infants with upper extremity deficits corresponding to the location of the lesion within the complex plexus anatomy. Manifestations can range from mild injuries with complete resolution to severe and permanent disability. Overall, patients have a high rate of spontaneous recovery (66-92%).1,2 Initially, all lesions are managed with passive range motion and observation. Prevention and/or correction of contractures with occupational therapy and serial splinting/casting along with encouraging normal development are the main goals of non-operative treatment. Surgical intervention may be war- ranted, depending on functional recovery. [Full article available at http://rimed.org/rimedicaljournal-2017-11.asp].

The phrenic nerve transfer in the treatment of a septuagenarian with brachial plexus avulsion injury: a case report.

PubMed

Jiang, Ye; Lao, Jie

2018-05-01

Phrenic nerve transfer has been a well-established procedure for restoring elbow flexion function in patients with brachial plexus avulsion injury. Concerning about probably detrimental respiratory effects brought by the operation, however, stirred up quite a bit of controversy. We present a case report of the successful application of phrenic nerve as donor to reinnervate the biceps in a septuagenarian with brachial plexus avulsion injury, not accompanied with significant clinical respiratory problem.

A comparative study of nerve stimulator versus ultrasound-guided supraclavicular brachial plexus block.

PubMed

Duncan, Mithun; Shetti, Akshaya N; Tripathy, Debendra Kumar; Roshansingh, D; Krishnaveni, N

2013-01-01

With the advent of ultrasound (US) guidance, this technique saw resurgence in the late 1990s. As US guidance provides real-time view of the block needle, the brachial plexus, and its spatial relationship to the surrounding vital structures; it not only increased the success rates, but also brought down the complication rates. Most of the studies show use of US guidance for performing brachial plexus block, results in near 100% success with or without complications. This study has been designed to examine the technique and usefulness of state-of-the-art US technology-guided supraclavicular brachial plexus block and compare it with routine nerve stimulator (NS)-guided technique. To note block execution time, time of onset of sensory and motor block, quality of block and success rates. Randomized controlled trial. A total of 60 patients were enrolled in this prospective randomized study and were randomly divided into two groups: US (Group US) and NS (Group NS). Both groups received 1:1 mixture of 0.5% bupivacaine and 2% lignocaine with 1:200000 adrenaline. The amount of local anaesthetic injected calculated according to the body weight and not crossing the toxic dosage (Inj. bupivacaine 2 mg/kg, Inj. lignocaine with adrenaline 7 mg/kg). The parameters compared between the two groups are block execution time, time of onset of sensory and motor block, quality of sensory and motor block, success rates are noted. The failed blocks are supplemented with general anesthesia. The data were analyzed using the SPSS (version 19) software. The parametric data were analyzed with student "t" test and the nonparametric data were analyzed with Chi-square test A P < 0.05 was considered significant. There was no significant difference between patient groups with regard to demographic data, the time of onset of sensory and motor block. Comparing the two groups, we found that the difference in the block execution time and success rates is not statistically significant. A failure rate of

Reconstructive operations for the upper limb after brachial plexus palsy.

PubMed

Rühmann, Oliver; Schmolke, Stephan; Bohnsack, Michael; Carls, Jörg; Flamme, Christian; Wirth, Carl Joachim

2004-07-01

Limited function due to paralysis following brachial plexus lesions can be improved by secondary operations of the bony and soft tissue. Between April 1994 and December 2000, 109 patients suffering from arm-plexus lesions underwent a total of 144 reconstructive operations guided by our concept of integrated therapy. The average age at the time of surgery was 32 years (range: 15-59). The following operations were performed: shoulder arthrodesis (23), trapezius transfer (74), rotation osteotomy of humerus (9), triceps to biceps transposition (9), transposition of forearm flexors or extensors (8), latissimus transfer (7), pectoralis transfer (1), teres major transfer (1), transposition of flexor carpi ulnaris to the tendons of extensor digitorum (10), and wrist arthrodesis (2). Prospectively, in all patients, the grade of muscle power of the affected upper extremity was evaluated prior to surgery. The follow-up period for all 144 operations was, on average, 22 months (range: 6-74). By means of operative measures, almost all patients obtained an improvement of shoulder function (100%) and stability (>90%), elbow flexion (85%), and hand, finger, and thumb (100%). When muscles malfunction after brachial plexus lesions, one should take into account the individual neuromuscular defect, passive joint function, and bony deformities; different procedures such as muscle transpositions, arthrodeses, and corrective osteotomies can then be performed to improve function of the upper extremity. Each form of operative treatment presents patients with certain benefits and all are integrated into a total treatment plan for the affected extremity.

The components of shoulder and elbow movements as goals of primary reconstructive operation in obstetric brachial plexus lesions.

PubMed

Luszawski, Jerzy; Marcol, Wiesław; Mandera, Marek

Most of the cases of obstetric brachial plexus lesions (OBPL) show satisfactory improvement with conservative management, but in about 25% some surgical treatment is indicated. The present paper analyzes the effects of primary reconstructive surgeries in aspect of achieving delineated intraoperatively goals. Children operated before the age of 18 months with follow-up period longer than 1 year were selected. Therapeutic goals established during the operation were identified by analysis of initial clinical status and operative protocols. The elementary movement components in shoulder and elbow joints were classified by assessing range of motion, score in Active Movement Scale and modified British Medical Research Council scale of muscle strength. The effect was considered satisfactory when some antigravity movement was possible, and good when strength exceeded M3 or antigravity movement exceeded half of range of passive movement. In 13 of 19 patients most of established goals were achieved at good level, in 2 at satisfactory level. Remaining 4 patients showed improvement only in some aspects of extremity function. In 2 patients improvement in some movements was accompanied by worsening of other movements. The analysis of results separated into individual components of movements showed that goals were achieved in most of the cases, simultaneously clearly indicating which damaged structures failed to provide satisfactory function despite being addressed intraoperatively. The good results were obtained mainly by regeneration through grafts implanted after resection of neuroma in continuity, which proves that this technique is safe in spite of unavoidable temporary regression of function postoperatively. Copyright © 2017 Polish Neurological Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

Effects of shoulder dystocia training on the incidence of brachial plexus injury.

PubMed

Inglis, Steven R; Feier, Nikolaus; Chetiyaar, Jyothi B; Naylor, Margaret H; Sumersille, Melanie; Cervellione, Kelly L; Predanic, Mladen

2011-04-01

We sought to determine whether implementation of shoulder dystocia training reduces the incidence of obstetric brachial plexus injury (OBPI). After implementing training for maternity staff, the incidence of OBPI was compared between pretraining and posttraining periods using both univariate and multivariate analyses in deliveries complicated by shoulder dystocia. The overall incidence of OBPI in vaginal deliveries decreased from 0.40% pretraining to 0.14% posttraining (P < .01). OBPI after shoulder dystocia dropped from 30% to 10.67% posttraining (P < .01). Maternal body mass index (P < .01) and neonatal weight (P = .02) decreased and head-to-body delivery interval increased in the posttraining period (P = .03). Only shoulder dystocia training remained associated with reduced OBPI (P = .02) after logistic regression analysis. OBPI remained less in the posttraining period (P = .01), even after excluding all neonates with birthweights >2 SD above the mean. Shoulder dystocia training was associated with a lower incidence of OBPI and the incidence of OBPI in births complicated by shoulder dystocia. Copyright © 2011 Mosby, Inc. All rights reserved.

Neurogenic Thoracic Outlet Syndrome Caused by Vascular Compression of the Brachial Plexus: A Report of Two Cases

PubMed Central

Hanna, Amgad; Bodden, Larry O'Neil; Siebiger, Gabriel R. L.

2018-01-01

Thoracic outlet syndrome (TOS) is caused by compression of the brachial plexus and/or subclavian vessels as they pass through the cervicothoracobrachial region, exiting the chest. There are three main types of TOS: neurogenic TOS, arterial TOS, and venous TOS. Neurogenic TOS accounts for approximately 95% of all cases, and it is usually caused by physical trauma (posttraumatic etiology), chronic repetitive motion (functional etiology), or bone or muscle anomalies (congenital etiology). We present two cases in which neurogenic TOS was elicited by vascular compression of the inferior portion of the brachial plexus. PMID:29497457

Comparison between isotropic linear-elastic law and isotropic hyperelastic law in the finite element modeling of the brachial plexus.

PubMed

Perruisseau-Carrier, A; Bahlouli, N; Bierry, G; Vernet, P; Facca, S; Liverneaux, P

2017-12-01

Augmented reality could help the identification of nerve structures in brachial plexus surgery. The goal of this study was to determine which law of mechanical behavior was more adapted by comparing the results of Hooke's isotropic linear elastic law to those of Ogden's isotropic hyperelastic law, applied to a biomechanical model of the brachial plexus. A model of finite elements was created using the ABAQUS ® from a 3D model of the brachial plexus acquired by segmentation and meshing of MRI images at 0°, 45° and 135° of shoulder abduction of a healthy subject. The offset between the reconstructed model and the deformed model was evaluated quantitatively by the Hausdorff distance and qualitatively by the identification of 3 anatomical landmarks. In every case the Hausdorff distance was shorter with Ogden's law compared to Hooke's law. On a qualitative aspect, the model deformed by Ogden's law followed the concavity of the reconstructed model whereas the model deformed by Hooke's law remained convex. In conclusion, the results of this study demonstrate that the behavior of Ogden's isotropic hyperelastic mechanical model was more adapted to the modeling of the deformations of the brachial plexus. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Ultrasound-guided approach for axillary brachial plexus, femoral nerve, and sciatic nerve blocks in dogs.

PubMed

Campoy, Luis; Bezuidenhout, Abraham J; Gleed, Robin D; Martin-Flores, Manuel; Raw, Robert M; Santare, Carrie L; Jay, Ariane R; Wang, Annie L

2010-03-01

To describe an ultrasound-guided technique and the anatomical basis for three clinically useful nerve blocks in dogs. Prospective experimental trial. Four hound-cross dogs aged 2 +/- 0 years (mean +/- SD) weighing 30 +/- 5 kg and four Beagles aged 2 +/- 0 years and weighing 8.5 +/- 0.5 kg. Axillary brachial plexus, femoral, and sciatic combined ultrasound/electrolocation-guided nerve blocks were performed sequentially and bilaterally using a lidocaine solution mixed with methylene blue. Sciatic nerve blocks were not performed in the hounds. After the blocks, the dogs were euthanatized and each relevant site dissected. Axillary brachial plexus block Landmark blood vessels and the roots of the brachial plexus were identified by ultrasound in all eight dogs. Anatomical examination confirmed the relationship between the four ventral nerve roots (C6, C7, C8, and T1) and the axillary vessels. Three roots (C7, C8, and T1) were adequately stained bilaterally in all dogs. Femoral nerve block Landmark blood vessels (femoral artery and femoral vein), the femoral and saphenous nerves and the medial portion of the rectus femoris muscle were identified by ultrasound in all dogs. Anatomical examination confirmed the relationship between the femoral vessels, femoral nerve, and the rectus femoris muscle. The femoral nerves were adequately stained bilaterally in all dogs. Sciatic nerve block. Ultrasound landmarks (semimembranosus muscle, the fascia of the biceps femoris muscle and the sciatic nerve) could be identified in all of the dogs. In the four Beagles, anatomical examination confirmed the relationship between the biceps femoris muscle, the semimembranosus muscle, and the sciatic nerve. In the Beagles, all but one of the sciatic nerves were stained adequately. Ultrasound-guided needle insertion is an accurate method for depositing local anesthetic for axillary brachial plexus, femoral, and sciatic nerve blocks.

The diagnostic accuracy of 1.5T magnetic resonance imaging for detecting root avulsions in traumatic adult brachial plexus injuries.

PubMed

Wade, Ryckie G; Itte, Vinay; Rankine, James J; Ridgway, John P; Bourke, Grainne

2018-03-01

Identification of root avulsions is of critical importance in traumatic brachial plexus injuries because it alters the reconstruction and prognosis. Pre-operative magnetic resonance imaging is gaining popularity, but there is limited and conflicting data on its diagnostic accuracy for root avulsion. This cohort study describes consecutive patients requiring brachial plexus exploration following trauma between 2008 and 2016. The index test was magnetic resonance imaging at 1.5 Tesla and the reference test was operative exploration of the supraclavicular plexus. Complete data from 29 males was available. The diagnostic accuracy of magnetic resonance imaging for root avulsion(s) of C5-T1 was 79%. The diagnostic accuracy of a pseudomeningocoele as a surrogate marker of root avulsion(s) of C5-T1 was 68%. We conclude that pseudomeningocoles were not a reliable sign of root avulsion and magnetic resonance imaging has modest diagnostic accuracy for root avulsions in the context of adult traumatic brachial plexus injuries. III.

Investigation of brachial plexus traction lesions by peripheral and spinal somatosensory evoked potentials.

PubMed Central

Jones, S J

1979-01-01

Peripheral, spinal and cortical somatosensory evoked potentials were recorded in 26 patients with unilateral traction injuries of the brachial plexus ganglia. Of 10 cases explored surgically the recordings correctly anticipated the major site of the lesion in eight. PMID:422958

Open Anterior Release of the Superior Transverse Scapular Ligament for Decompression of the Suprascapular Nerve During Brachial Plexus Surgery.

PubMed

Elzinga, Kate E; Curran, Matthew W T; Morhart, Michael J; Chan, K Ming; Olson, Jaret L

2016-07-01

Reconstruction of the suprascapular nerve (SSN) after brachial plexus injury often involves nerve grafting or a nerve transfer. To restore shoulder abduction and external rotation, a branch of the spinal accessory nerve is commonly transferred to the SSN. To allow reinnervation of the SSN, any potential compression points should be released to prevent a possible double crush syndrome. For that reason, the authors perform a release of the superior transverse scapular ligament at the suprascapular notch in all patients undergoing reconstruction of the upper trunk of the brachial plexus. Performing the release through a standard anterior open supraclavicular approach to the brachial plexus avoids the need for an additional posterior incision or arthroscopic procedure. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Successful Outcome of Modified Quad Surgical Procedure in Preteen and Teen Patients with Brachial Plexus Birth Palsy

PubMed Central

Nath, Rahul K.; Somasundaram, Chandra

2012-01-01

Objective: To evaluate the outcome of modified Quad procedure in preteen and teen patients with brachial plexus birth palsy. Background: We have previously demonstrated a significant improvement in shoulder abduction, resulting from the modified Quad procedure in children (mean age 2.5 years; range, 0.5–9 years) with obstetric brachial plexus injury. Methods: We describe in this report the outcome of 16 patients (6 girls and 10 boys; 7 preteen and 9 teen) who have undergone the modified Quad procedure for the correction of the shoulder function, specifically abduction. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and axillary nerve decompression and neurolysis (the modified Quad procedure). Mean age of these patients at surgery was 13.5 years (range, 10.1–17.9 years). Results: The mean preoperative total Mallet score was 14.8 (range, 10–20), and active abduction was 84° (range, 20°–140°). At a mean follow-up of 1.5 years, the mean postoperative total Mallet score increased to 19.7 (range, 13–25, P < .0001), and the mean active abduction improved to 132° (range, 40°–180°, P < .0003). Conclusion: The modified Quad procedure greatly improves not only the active abduction but also other shoulder functions in preteen and teen patients, as this outcome is the combined result of decompression and neurolysis of the axillary nerve and the release of the contracted internal rotators of the shoulder. PMID:23308301

Comparative study of phrenic nerve transfers with and without nerve graft for elbow flexion after global brachial plexus injury.

PubMed

Liu, Yuzhou; Lao, Jie; Gao, Kaiming; Gu, Yudong; Zhao, Xin

2014-01-01

Nerve transfer is a valuable surgical technique in peripheral nerve reconstruction, especially in brachial plexus injuries. Phrenic nerve transfer for elbow flexion was proved to be one of the optimal procedures in the treatment of brachial plexus injuries in the study of Gu et al. The aim of this study was to compare phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury. A retrospective review of 33 patients treated with phrenic nerve transfer for elbow flexion in posttraumatic global root avulsion brachial plexus injury was carried out. All the 33 patients were confirmed to have global root avulsion brachial plexus injury by preoperative and intraoperative electromyography (EMG), physical examination and especially by intraoperative exploration. There were two types of phrenic nerve transfers: type1 - the phrenic nerve to anterolateral bundle of anterior division of upper trunk (14 patients); type 2 - the phrenic nerve via nerve graft to anterolateral bundle of musculocutaneous nerve (19 patients). Motor function and EMG evaluation were performed at least 3 years after surgery. The efficiency of motor function in type 1 was 86%, while it was 84% in type 2. The two groups were not statistically different in terms of Medical Research Council (MRC) grade (p=1.000) and EMG results (p=1.000). There were seven patients with more than 4 month's delay of surgery, among whom only three patients regained biceps power to M3 strength or above (43%). A total of 26 patients had reconstruction done within 4 months, among whom 25 patients recovered to M3 strength or above (96%). There was a statistically significant difference of motor function between the delay of surgery within 4 months and more than 4 months (p=0.008). Phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury had no significant difference for biceps reinnervation according to MRC grading and EMG. A delay of the surgery

Neuro-Myelomatosis of the Brachial Plexus - An Unusual Site of Disease Visualized by FDG-PET/CT: A Case Report.

PubMed

Fukunaga, Hisanori; Mutoh, Tatsushi; Tatewaki, Yasuko; Shimomura, Hideo; Totsune, Tomoko; Terao, Chiaki; Miyazawa, Hidemitsu; Taki, Yasuyuki

2017-05-01

BACKGROUND Peripheral or cranial nerve root dysfunction secondary to invasion of the CNS in multiple myeloma is a rare clinical event that is frequently mistaken for other diagnoses. We describe the clinical utility of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT scanning for diagnosing neuro-myelomatosis. CASE REPORT A 63-year-old woman whose chief complaints were right shoulder and upper extremity pain underwent MRI and 18F-FDG PET/CT scan. MRI revealed a non-specific brachial plexus tumor. 18F-FDG PET/CT demonstrated intense FDG uptake in multiple intramedullary lesions and in the adjacent right brachial plexus, indicating extramedullary neural involvement associated with multiple myeloma, which was confirmed later by a bone marrow biopsy. CONCLUSIONS This is the first reported case of neuro-myelomatosis of the brachial plexus. It highlights the utility of the 18F-FDG PET/CT scan as a valuable diagnostic modality.

Use of brachial plexus blockade and medetomidine-ketamine-isoflurane anaesthesia for repair of radio-ulna fracture in an adult cheetah (Acinonyx jubatus).

PubMed

Kimeli, Peter; Mogoa, Eddy M; Mwangi, Willy E; Kipyegon, Ambrose N; Kirui, Gilbert; Muasya, Daniel W; Mande, John D; Kariuki, Edward; Mijele, Dominic

2014-10-10

Regional anaesthetic techniques have been used in combination with systemic analgesics during small animal surgery to provide multimodal analgesia. Brachial plexus nerves block using local anaesthetics provides analgesia of the thoracic limb through desensitization of the nerves that provide sensory and motor innervation. This has been shown to reduce intra-operative anesthetic requirements and provide postoperative pain relief. Decreasing the doses of general anaesthetics allows more stable cardiopulmonary function during anaesthesia and the development of less side effects. The present case reports a successful use of brachial plexus blockade to supplement medetomidine-ketamine-isoflurane anaesthesia for repair of radio-ulna fracture in an adult cheetah (acinonyx jubatus). An adult male Cheetah weighing about 65 kg was presented with a history of leg carrying lameness of the left forelimb sustained following a car accident a week earlier. Clinical examination under general anaesthesia revealed slight dehydration and a swelling with a wound on the caudo-medial aspect of the left radio-ulna region. Crepitation was present on manipulation and radiography confirmed a complete transverse radio-ulna fracture of the left forelimb, which required open reduction and internal fixation. Brachial plexus blockade using lignocaine hydrochloride was used to supplement medetomidine-ketamine-isoflurane anaesthesia for the surgical procedure. Isoflurane anaesthesia was maintained at 0.5 - 2.0% throughout the surgical procedure, which was uneventful. Temperature and cardio-pulmonary parameters remained stable intra-operatively. Limb paralysis extended for 5 hours post-operatively, suggesting prolonged anaesthesia. To the researchers' knowledge, this is the first reported case of the use of brachial plexus blockade to supplement general anaesthesia to facilitate forelimb surgery in an adult cheetah. The use of brachial plexus block with a light plane of general anaesthesia proved to

Long-term outcome of accessory nerve to suprascapular nerve transfer in obstetric brachial plexus lesion: functional, morphological, and electrophysiological results.

PubMed

Gmeiner, Matthias; Topakian, Raffi; Göschl, Manuel; Wurm, Sarah; Holzinger, Anita; van Ouwerkerk, Willem J R; Holl, Kurt

2015-09-01

An accessory to suprascapular nerve (XIN-SSN) transfer is considered in patients with obstetric brachial plexus lesion who fail to recover active shoulder external rotation. The aim of this study was to evaluate the quality of extraplexal suprascapular nerve neurotization and to perform a detailed analysis of the infraspinatus muscle (IM) and shoulder external rotation. A XIN-SSN transfer was performed in 14 patients between 2000 and 2007. Patients had been operated at the age of 3.7 ± 2.8 years. Follow-up examinations were conducted up to 8.5 ± 2.5 years. Magnetic resonance imaging was performed to investigate muscle trophism. Fatty muscle degeneration of the IM was classified according to the Goutallier classification. We conducted nerve conduction velocity studies of the suprascapular nerve and needle electromyography of the IM to assess pathologic spontaneous activity and interference patterns. Active glenohumeral shoulder external rotation and global shoulder function were evaluated using the Mallet score. Postoperatively, growth of the IM increased equally on the affected and unaffected sides, although significant differences of muscle thickness persisted over time. There was only grade 1 or 2 fatty degeneration pre- and postoperatively. Electromyography of the IM revealed a full interference pattern in all except one patient, and there was no pathological spontaneous activity. Glenohumeral external rotation as well as global shoulder function increased significantly. Our results indicate that the anastomosis after XIN-SSN transfer is functional and that successful reinnervation of the infraspinatus muscle may enable true glenohumeral active external rotation.

Patient satisfaction and self-reported outcomes after complete brachial plexus avulsion injury.

PubMed

Franzblau, Lauren E; Shauver, Melissa J; Chung, Kevin C

2014-05-01

Reconstructive surgery for complete brachial plexus avulsion injuries only partially restores function, and many patients are dissatisfied with results that surgeons consider good. Preoperative expectations have been shown to influence postoperative satisfaction but are poorly understood in patients with complete brachial plexus avulsion injuries. Qualitative methodology can elucidate patient beliefs and attitudes, which are difficult to quantify. The purpose of this study was to examine patient-reported outcomes, including satisfaction, and to understand the patient perspective. We used qualitative interviews and questionnaires to assess patient-reported outcomes. Two members of the research team analyzed interview data using Grounded Theory methodology. Data from participants who had and did not have reconstructive surgery were compared. Twelve patients participated in this study. Of the 7 participants who had reconstructive surgery, 4 felt their expectations had been met and 5 were satisfied with their outcomes. Reconstruction did not produce statistically significant improvements in upper extremity function, pain, or work ability. All patients reported dissatisfaction with upper extremity ability, and 9 expressed hope for innovative treatments (e.g., stem cell therapy, nerve reinsertion) that could potentially provide better outcomes than existing procedures and enable return to work. Satisfaction with surgical outcomes after complete avulsion brachial plexus injury depends heavily on whether preoperative expectations are met, but patients are unfamiliar with nerve avulsion and do not always know what to expect. Low satisfaction with upper extremity ability and the lack of statistically significant differences produced by reconstruction suggest that current treatments may not be meeting patients' needs. Physicians must provide robust preoperative education to encourage realistic expectations and direct patients toward resources for pain management to facilitate

The Impact of Pediatric Brachial Plexus Injury on Families

PubMed Central

Allgier, Allison; Overton, Myra; Welge, Jeffrey; Mehlman, Charles T.

2015-01-01

Purpose To determine the impact on families of children with brachial plexus injuries in order to best meet their clinical and social needs. Methods Our cross-sectional study included families with children between the ages of 1 and 18 with birth or non-neonatal brachial plexus injuries (BPI). The consenting parent or guardian completed a demographic questionnaire and the validated Impact on Family Scale during a single assessment. Total scores can range from 0-100, with the higher the score indicating a higher impact on the family. Factor analysis and item-total correlations were used to examine structure, individual items, and dimensions of family impact. Results One hundred two caregivers participated. Overall, families perceived various dimensions of impact on having a child with a BPI. Total family impact was 43. The 2 individual items correlating most strongly with the overall total score were from the financial dimension of the Impact on Family Scale. The strongest demographic relationship was traveling nationally for care and treatment of the BPI. Severity of injury was marginally correlated with impact on the family. Parent-child agreement about the severity of the illness was relatively high. Conclusion Caretakers of children with a BPI perceived impact on their families in the form of personal strain, family/social factors, financial stress, and mastery. A multidisciplinary clinical care team should address the various realms of impact on family throughout the course of treatment. Level of Evidence II Prognostic PMID:25936738

Measuring surgeons' treatment preferences and satisfaction with nerve reconstruction techniques for children with unique brachial plexus birth palsies.

PubMed

Shah, Amee K; Zurakowski, David; Jessel, Rebecca H; Kuo, Anne; Waters, Peter M

2006-09-15

This study surveyed microsurgeons on treatments chosen for infants with brachial plexus birth palsies who have had failure of antigravity biceps and/or triceps function due to nerve surgery or natural history. Questionnaires were sent to surgeons participating in a prospective multicenter brachial plexus birth palsy study. With a response rate of 82 percent, the sample comprised 22 surgeons with extensive experience in treating brachial plexus birth palsy. The survey gathered collective information on two unique clinical groups: (1) infants with no antigravity biceps function but intact antigravity deltoid and radial nerve function and (2) infants with no antigravity radial nerve function (wrist and digital extension, triceps) but intact antigravity biceps and deltoid function. Analysis of data and age-based trends was performed using the Fisher's exact test. With failure of biceps recovery, surgeons preferred microsurgery for children 6 to 18 months old and tendon transfers for children older than 18 months. Both procedures were preferred over observation alone (p < 0.001). With regard to microsurgery techniques, with increasing age, surgeons used nerve transfers more than resected neuroma and grafting. With tendon transfers, regional transfers were performed more than 90 percent of the time at all ages. For patients with no antigravity radial nerve function, most cases at all ages were managed by observation rather than microsurgery or tendon transfers (p < 0.001). The authors' data indicate a general consensus in treatment choices for the two cases of microsurgical failure in infants with brachial plexus birth palsies as well as in satisfaction among experienced surgeons in using these treatments.

Watson-Jones Lecture, 1976. Some lesions of the brachial plexus.

PubMed Central

Bonney, G.

1977-01-01

Three types of lesion of the brachial plexus are discussed: entrapment syndrome; tumours; and traumatic lesions. In the first the importance of the pathological anatomy is stressed; in the second the rewarding results of accurate diagnosis and careful treatment are noted; and in the third the expanding possibilities of neural reconstruction and of specific treatment for pain are described. Images Fig. 1 Fig. 3 Fig. 4 Fig. 5 Fig. 8 Fig. 9 Fig. 10 PMID:879635

A comparative study of brachial plexus sonography and magnetic resonance imaging in chronic inflammatory demyelinating neuropathy and multifocal motor neuropathy.

PubMed

Goedee, H S; Jongbloed, B A; van Asseldonk, J-T H; Hendrikse, J; Vrancken, A F J E; Franssen, H; Nikolakopoulos, S; Visser, L H; van der Pol, W L; van den Berg, L H

2017-10-01

To compare the performance of neuroimaging techniques, i.e. high-resolution ultrasound (HRUS) and magnetic resonance imaging (MRI), when applied to the brachial plexus, as part of the diagnostic work-up of chronic inflammatory demyelinating neuropathy (CIDP) and multifocal motor neuropathy (MMN). Fifty-one incident, treatment-naive patients with CIDP (n = 23) or MMN (n = 28) underwent imaging of the brachial plexus using (i) a standardized MRI protocol to assess enlargement or T2 hyperintensity and (ii) bilateral HRUS to determine the extent of nerve (root) enlargement. We found enlargement of the brachial plexus in 19/51 (37%) and T2 hyperintensity in 29/51 (57%) patients with MRI and enlargement in 37/51 (73%) patients with HRUS. Abnormal results were only found in 6/51 (12%) patients with MRI and 12/51 (24%) patients with HRUS. A combination of the two imaging techniques identified 42/51 (83%) patients. We found no association between age, disease duration or Medical Research Council sum-score and sonographic nerve size, MRI enlargement or presence of T2 hyperintensity. Brachial plexus sonography could complement MRI in the diagnostic work-up of patients with suspected CIDP and MMN. Our results indicate that combined imaging studies may add value to the current diagnostic consensus criteria for chronic inflammatory neuropathies. © 2017 EAN.

Morphometric Atlas Selection for Automatic Brachial Plexus Segmentation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Van de Velde, Joris, E-mail: joris.vandevelde@ugent.be; Department of Radiotherapy, Ghent University, Ghent; Wouters, Johan

Purpose: The purpose of this study was to determine the effects of atlas selection based on different morphometric parameters, on the accuracy of automatic brachial plexus (BP) segmentation for radiation therapy planning. The segmentation accuracy was measured by comparing all of the generated automatic segmentations with anatomically validated gold standard atlases developed using cadavers. Methods and Materials: Twelve cadaver computed tomography (CT) atlases (3 males, 9 females; mean age: 73 years) were included in the study. One atlas was selected to serve as a patient, and the other 11 atlases were registered separately onto this “patient” using deformable image registration. Thismore » procedure was repeated for every atlas as a patient. Next, the Dice and Jaccard similarity indices and inclusion index were calculated for every registered BP with the original gold standard BP. In parallel, differences in several morphometric parameters that may influence the BP segmentation accuracy were measured for the different atlases. Specific brachial plexus-related CT-visible bony points were used to define the morphometric parameters. Subsequently, correlations between the similarity indices and morphometric parameters were calculated. Results: A clear negative correlation between difference in protraction-retraction distance and the similarity indices was observed (mean Pearson correlation coefficient = −0.546). All of the other investigated Pearson correlation coefficients were weak. Conclusions: Differences in the shoulder protraction-retraction position between the atlas and the patient during planning CT influence the BP autosegmentation accuracy. A greater difference in the protraction-retraction distance between the atlas and the patient reduces the accuracy of the BP automatic segmentation result.« less

Pan-brachial plexus neuropraxia following lightning: A rare case report.

PubMed

Patnaik, Ashis; Mahapatra, Ashok Kumar; Jha, Menka

2015-01-01

Neurological complications following lightning are rare and occur in form of temporary neurological deficits of central origin. Involvement of peripheral nervous system is extremely rare and only a few cases have been described in the literature. Isolated unilateral pan-brachial plexus neuropraxia has never been reported in the literature. Steroids have long been used for treatment of neuropraxia. However, their use in lightning neural injury is unique and requires special mention. We report a rare case of lightning-induced unilateral complete flaccid paralysis along with sensory loss in a young patient. Lightning typically causes central nervous involvement in various types of motor and sensory deficit. Surprisingly, the nerve conduction study showed the involvement of peripheral nervous system involvement. Steroids were administered and there was significant improvement in neurological functions within a short span of days. Patients' functions in the affected limb were normal in one month. Our case was interesting since it is the first such case in the literature where lightning has caused such a rare instance of unilateral pan-brachial plexus lesion. Such cases when seen, raises the possibility of more common central nervous system pathology rather than peripheral involvement. However, such lesions can be purely benign forms of peripheral nerve neuropraxia, which can be managed by steroid treatment without leaving any long-term neurological deficits.

Preventing brachial plexus injury during shoulder surgery: a real-time cadaveric study.

PubMed

Kam, Andrew W; Lam, Patrick H; Haen, Pieter S W A; Tan, Martin; Shamsudin, Aminudin; Murrell, George A C

2018-05-01

Brachial plexopathy is not uncommon after shoulder surgery. Although thought to be due to stretch neuropathy, its etiology is poorly understood. This study aimed to identify arm positions and maneuvers that may risk causing brachial plexopathy during shoulder arthroplasty. Tensions in the cords of the brachial plexuses of 6 human cadaveric upper limbs were measured using load cells while each limb was placed in different arm positions and while they underwent shoulder hemiarthroplasty and revision reverse arthroplasty. Arthroplasty procedures in 4 specimens were performed with standard limb positioning (unsupported), and 2 specimens were supported from under the elbow (supported). Each cord then underwent biomechanical testing to identify tension corresponding to 10% strain (the stretch neuropathy threshold in animal models). Tensions exceeding 15 N, 11 N, and 9 N in the lateral, medial, and posterior cords, respectively, produced 10% strain. Shoulder abduction >70° and combined external rotation >60° with extension >50° increased medial cord tension above the 10% strain threshold. Medial cord tensions (mean ± standard error of the mean) in unsupported specimens increased over baseline during hemiarthroplasty (sounder insertion [4.7 ± 0.6 N, P = .04], prosthesis impaction [6.1 ± 0.8 N, P = .04], and arthroplasty reduction [5.0 ± 0.7 N, P = .04]) and revision reverse arthroplasty (retractor positioning [7.2 ± 0.8 N, P = .02]). Supported specimens experienced lower tensions than unsupported specimens. Shoulder abduction >70°, combined external rotation >60° with extension >50°, and downward forces on the humeral shaft may risk causing brachial plexopathy. Retractor placement, sounder insertion, humeral prosthesis impaction, and arthroplasty reduction increase medial cord tensions during shoulder arthroplasty. Supporting the arm from under the elbow protected the brachial plexus in this cadaveric model

Scapular instability associated with brachial plexus irritation: a proposed causative relationship with treatment implications.

PubMed

Langley, P

1997-01-01

Brachial plexus irritation and other compression neuropathies can be diverse in their presentations and can cause a myriad of signs and symptoms. The purpose of this paper is to review the pertinent anatomy, kinesiology, and neurophysiology and to outline one possible cascade of events that may contribute to more diffuse upper extremity symptoms. Scapular instability and local myofascial trigger points resulting in possible secondary muscle imbalances are described. Their possible relationship to brachial plexus irritation in addition to the implications of the irritation are also discussed. The author postulates that proximal nerve irritation in the region of the thoracic outlet and shoulder may help to account for diffuse or unrelieved symptoms following conventional treatment of distal extremity problems in patients with occupational or cumulative trauma disorders. This paper outlines specific examination procedures for the therapist, which include upper limb tension testing, extensibility testing of the pectoralis minor, and gross manual muscle testing of the lower trapezius.

Brachial Plexus Injuries

MedlinePlus

... inflammation. There is a rare syndrome called Parsonage-Turner Syndrome, or brachial plexitis , which causes inflammation of the ... inflammation. There is a rare syndrome called Parsonage-Turner Syndrome, or brachial plexitis , which causes inflammation of the ...

Use of botulinum toxin type A in the management of neonatal brachial plexus palsy.

PubMed

Michaud, Linda J; Louden, Emily J; Lippert, William C; Allgier, Allison J; Foad, Susan L; Mehlman, Charles T

2014-12-01

To evaluate functional outcomes and the impact on surgical interventions after the use of botulinum neurotoxin type A (BoNT-A) for muscle imbalance, cocontractions, or contractures with neonatal brachial plexus palsy. A retrospective cohort study. A brachial plexus center in a tertiary children's hospital. Fifty-nine patients with neonatal brachial plexus palsy (75 injection procedures, 91 muscles and/or muscle groups) received BoNT-A injections (mean age at injection, 36.2 months; range, 6-123 months; 31 boys; 30 right-sided injuries, 28 left-sided injuries, 1 bilateral injury). Data collected retrospectively from medical records, from procedure notes and clinic visits before BoNT-A use, at ≤6 months follow-up (BoNT-A active [BA]) and at ≥7 months follow-up (BoNT-A not active [BNA]) included demographics, injection indication, side, and site(s), previous surgical history, occupational therapy and/or physical therapy plan, and outcome measurements. Outcomes assessed before and after injections included active and passive range of motion, Mallet and Toronto scores, parent comments about arm function, preinjection surgical considerations, and postinjection surgical history. Injection procedures included 51 to shoulder internal rotators, 15 triceps, 15 pronator teres, 9 biceps, and 1 flexor carpi ulnaris. Active and passive shoulder external rotation (SER) range of motion improved after shoulder internal rotator injections (P = .0003 and P = .002, respectively), as did Mallet scores with BA; the latter were sustained with BNA. Surgical intervention was averted, modified, or deferred after BoNT-A in 45% (n = 20) under surgical consideration before BoNT-A. Active elbow flexion improved in 67% (P = .005), sustained BNA (P = .004) after triceps injections; 2 of 7 patients averted surgery. Active supination improved with BA (P = .002), with gains sustained BNA (P = .016). Passive elbow extension improved after biceps injections by an average 17° (P�

Retropharyngeal Contralateral C7 Nerve Transfer to the Lower Trunk for Brachial Plexus Birth Injury: Technique and Results.

PubMed

Vu, Anthony T; Sparkman, Darlene M; van Belle, Christopher J; Yakuboff, Kevin P; Schwentker, Ann R

2018-05-01

Brachial plexus birth injuries with multiple nerve root avulsions present a particularly difficult reconstructive challenge because of the limited availability of donor nerves. The contralateral C7 has been described for brachial plexus reconstruction in adults but has not been well-studied in the pediatric population. We present our technique and results for retropharyngeal contralateral C7 nerve transfer to the lower trunk for brachial plexus birth injury. We performed a retrospective review. Any child aged less than 2 years was included. Charts were analyzed for patient demographic data, operative variables, functional outcomes, complications, and length of follow-up. We had a total of 5 patients. Average nerve graft length was 3 cm. All patients had return of hand sensation to the ulnar nerve distribution as evidenced by a pinch test, unprompted use of the recipient limb without mirror movement, and an Active Movement Scale (AMS) of at least 2/7 for finger and thumb flexion; one patient had an AMS of 7/7 for finger and thumb flexion. Only one patient had return of ulnar intrinsic hand function with an AMS of 3/7. Two patients had temporary triceps weakness in the donor limb and one had clinically insignificant temporary phrenic nerve paresis. No complications were related to the retropharyngeal nerve dissection in any patient. Average follow-up was 3.3 years. The retropharyngeal contralateral C7 nerve transfer is a safe way to supply extra axons to the severely injured arm in brachial plexus birth injuries with no permanent donor limb deficits. Early functional recovery in these patients, with regard to hand function and sensation, is promising. Therapeutic V. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

OCT/PS-OCT imaging of brachial plexus neurovascular structures

NASA Astrophysics Data System (ADS)

Raphael, David T.; Zhang, Jun; Zhang, Yaoping; Chen, Zhongping; Miller, Carol; Zhou, Li

2004-07-01

Introduction: Optical coherence tomography (OCT) allows high-resolution imaging (less than 10 microns) of tissue structures. A pilot study with OCT and polarization-sensitive OCT (PS-OCT) was undertaken to image ex-vivo neurovascular structures (vessels, nerves) of the canine brachial plexus. Methods: OCT is an interferometry-based optical analog of B-mode ultrasound, which can image through non-transparent biological tissues. With approval of the USC Animal Care and Use Committee, segments of the supra- and infraclavicular brachial plexus were excised from euthanized adult dogs, and the ex-vivo specimens were placed in cold pH-buffered physiologic solution. An OCT beam, in micrometer translational steps, scanned the fixed-position bisected specimens in transverse and longitudinal views. Two-dimensional images were obtained from identified arteries and nerves, with specific sections of interest stained with hematoxylin-eosin for later imaging through a surgical microscope. Results: with the beam scan direction transverse to arteries, the resulting OCT images showed an identifiable arterial lumen and arterial wall tissue layers. By comparison, transverse beam OCT images of nerves revealed a multitude of smaller nerve bundles contained within larger circular-shaped fascicles. PS-OCT imaging was helpful in showing the characteristic birefringence exhibited by arrayed neural structures. Discussion: High-resolution OCT imaging may be useful in the optical identification of neurovascular structures during attempted regional nerve blockade. If incorporated into a needle-shaped catheter endoscope, such a technology could prevent intraneural and intravascular injections immediately prior to local anesthetic injection. The major limitation of OCT is that it can form a coherent image of tissue structures only to a depth of 1.5 - 2 mm.

Refinement of myotome values in the upper limb: Evidence from brachial plexus injuries.

PubMed

Bell, S W; Brown, M J C; Hems, T J

2017-02-01

We reviewed patients with partial supraclavicular brachial plexus injuries in order to refine the myotome values of the upper limb. Forty-two patients with defined partial injuries to the supraclavicular brachial plexus were reviewed from a prospective database. The injuries patterns covered C5, C5-6, C5-7, C5-8, C7-T1 and C8-T1 roots. Upper plexus injuries were classified on the basis of surgical exploration and intraoperative stimulation and lower plexus injuries from MRI. Flexor Carpi Radialis (FCR) was paralyzed in C5-7 injuries, in addition to paralysis of deltoid, supraspinatus, infraspinatus and biceps, when compared to C5-6 injuries. Complete paralysis of Flexor Digitorum Profundus (FDP) and Flexor Digitorum Superficialis (FDS) to all digits was identified in C7-T1 injuries. In C5-8 injuries weakness was noted in FDP of ulnar digits and intrinsics innervated by the ulnar nerve, while in C8-T1 injuries paralysis was noted in the FDP to the radial digits. All patients with C8-T1 injuries had paralysis of FDS and the thenar muscles. In upper plexus injuries paralysis of FCR indicated involvement of C7 root in addition to C5 and C6 roots. The results provide new detail of innervation of muscles acting on the hand. Flexor muscles and intrinsic muscles of the thumb and radial fingers (median nerve) have an important contribution from T1, while for those acting on the ulnar digits (ulnar nerve) the main contribution is from C8 with some input from C7. T1 also gives consistent innervation to extensor pollicis longus. A revised myotome chart for the upper limb is proposed. Copyright © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Bipolar Transfer of Latissimus Dorsi Myocutaneous Flap for Restoration of Elbow Flexion in Late Traumatic Brachial Plexus Injury: Evaluation of 13 Cases.

PubMed

Azab, Ahmed Abo-Hashem; Alsabbahi, Mohammad Salah

2017-02-01

Restoration of elbow flexion following traumatic brachial plexus injury represents a great challenge to the reconstructive surgeons. Functional muscle transfers come next to the sophisticated types of nerve surgery in this area. Many transfers are well known for restoration of elbow flexion; bipolar or unipolar latissimus dorsi, triceps brachii, sternocleidomastoid, pectoralis major, and Steindler flexorplasty. Evaluation of the outcome of bipolar transfer of latissimus dorsi myocutaneous flap when used to restore elbow flexion in late traumatic brachial plexus injury. Thirteen patients were included in this case series with careful evaluation both preoperatively and postoperatively both clinically and using electromyography. Almost 84.6% of patients (11 of 13) developed G3-4 on the Medical Research Council grading with relatively minimal both donor-site and recipient-site morbidity. Bipolar transfer of latissimus dorsi myocutaneous flap is a reliable method for restoration of elbow flexion in patients suffering from late sequelae of traumatic brachial plexus injury.

Use of the DEKA Arm for amputees with brachial plexus injury: A case series

PubMed Central

Fantini, Christopher; Latlief, Gail; Phillips, Samuel; Sasson, Nicole; Sepulveda, Eve

2017-01-01

Objective Patients with upper limb amputation and brachial plexus injuries have high rates of prosthesis rejection. Study purpose is to describe experiences of subjects with transhumeral amputation and brachial plexus injury, who were fit with, and trained to use, a DEKA Arm. Methods This was a mixed-methods study utilizing qualitative (e.g. interview, survey) and quantitative data (e.g. self-report and performance measures). Subject 1, a current prosthesis user, had a shoulder arthrodesis. Subject 2, not a prosthesis user, had a subluxed shoulder. Both were trained in laboratory and participated in a trial of home use. Descriptive analyses of processes and outcomes were conducted. Results Subject 1 was fitted with the transhumeral configuration (HC) DEKA Arm using a compression release stabilized socket. He had 12 hours of prosthetic training and participated in all home study activities. Subject 1 had improved dexterity and prosthetic satisfaction with the DEKA Arm and reported better quality of life (QOL) at the end of participation. Subject 2 was fit with the shoulder configuration (SC) DEKA Arm using a modified X-frame socket. He had 30 hours of training and participated in 3 weeks of home activities. He reported less functional disability at the end of training as compared to baseline, but encountered personal problems and exacerbation of PTSD symptoms and withdrew from home use portion at 3 weeks. Both subjects reported functional benefits from use, and expressed a desire to receive a DEKA Arm in the future. Discussion This paper reported on two different strategies for prosthetic fitting and their outcomes. The advantages and limitations of each approach were discussed. Conclusion Use of both the HC and SC DEKA Arm for patients with TH amputation and brachial plexus injury was reported. Lessons learned may be instructive to clinicians considering prosthetic choices for future cases. PMID:28628623

Use of the DEKA Arm for amputees with brachial plexus injury: A case series.

PubMed

Resnik, Linda; Fantini, Christopher; Latlief, Gail; Phillips, Samuel; Sasson, Nicole; Sepulveda, Eve

2017-01-01

Patients with upper limb amputation and brachial plexus injuries have high rates of prosthesis rejection. Study purpose is to describe experiences of subjects with transhumeral amputation and brachial plexus injury, who were fit with, and trained to use, a DEKA Arm. This was a mixed-methods study utilizing qualitative (e.g. interview, survey) and quantitative data (e.g. self-report and performance measures). Subject 1, a current prosthesis user, had a shoulder arthrodesis. Subject 2, not a prosthesis user, had a subluxed shoulder. Both were trained in laboratory and participated in a trial of home use. Descriptive analyses of processes and outcomes were conducted. Subject 1 was fitted with the transhumeral configuration (HC) DEKA Arm using a compression release stabilized socket. He had 12 hours of prosthetic training and participated in all home study activities. Subject 1 had improved dexterity and prosthetic satisfaction with the DEKA Arm and reported better quality of life (QOL) at the end of participation. Subject 2 was fit with the shoulder configuration (SC) DEKA Arm using a modified X-frame socket. He had 30 hours of training and participated in 3 weeks of home activities. He reported less functional disability at the end of training as compared to baseline, but encountered personal problems and exacerbation of PTSD symptoms and withdrew from home use portion at 3 weeks. Both subjects reported functional benefits from use, and expressed a desire to receive a DEKA Arm in the future. This paper reported on two different strategies for prosthetic fitting and their outcomes. The advantages and limitations of each approach were discussed. Use of both the HC and SC DEKA Arm for patients with TH amputation and brachial plexus injury was reported. Lessons learned may be instructive to clinicians considering prosthetic choices for future cases.

Variations of the origin of collateral branches emerging from the posterior aspect of the brachial plexus

PubMed Central

2007-01-01

Background The frequency of variation found in the arrangement and distribution of the branches in the brachial plexus, make this anatomical region extremely complicated. The medical concerns involved with these variations include anesthetic blocks, surgical approaches, interpreting tumor or traumatic nervous compressions having unexplained clinical symptoms (sensory loss, pain, wakefulness and paresis), and the possibility of these structures becoming compromised. The clinical importance of these variations is discussed in the light of their differential origins. Methods The anatomy of brachial plexus structures from 46 male and 11 female cadaverous specimens were studied. The 40–80 year-old specimens were obtained from the Universidad Industrial de Santander's Medical Faculty's Anatomy Department (dissection laboratory). Parametric measures were used for calculating results. Results Almost half (47.1%) of the evaluated plexuses had collateral variations. Subscapular nerves were the most varied structure, including the presence of a novel accessory nerve. Long thoracic nerve variations were present, as were the absence of C5 or C7 involvement, and late C7 union with C5–C6. Conclusion Further studies are needed to confirm the existence of these variations in a larger sample of cadaver specimens. PMID:17587464

Local infiltration analgesia versus continuous interscalene brachial plexus block for shoulder replacement pain: a randomized clinical trial.

PubMed

Bjørnholdt, Karen T; Jensen, Jan M; Bendtsen, Thomas F; Søballe, Kjeld; Nikolajsen, Lone

2015-12-01

Shoulder replacement involves significant post-operative pain, which is often managed by continuous interscalene brachial plexus block. Catheter displacement and complications limit the beneficial effect of the block. Local infiltration analgesia (LIA) has provided good results in knee replacement. We aimed to assess the effectiveness of LIA for pain after shoulder replacement. Patients scheduled for primary shoulder replacement under general anaesthesia were randomized to receive either local infiltration analgesia (LIA) (150 ml ropivacaine 0.2 % with epinephrine intra-operatively) or interscalene brachial plexus catheter (ISC) (ropivacaine 0.75 %, 7 ml bolus followed by 48-h 5 ml/h infusion). The primary outcome was opioid consumption during the first 24 post-operative hours. Secondary outcomes were pain ratings, supplementary analgesics, and side effects for 3 days, and complications until 3 months after surgery. Data were analysed for 61 patients (LIA 30, ISC 31). Twenty-four-hour opioid consumption was higher in the LIA group compared with the ISC group: median (IQR) 95 mg (70-150 mg) versus 40 mg (8-76 mg) (P = 0.0001). No significant difference in opioid consumption was found between groups during the following 3 days. The LIA group had higher pain scores at 0, 2, 4, and 8 h. Two patients in the ISC group had long-lasting complications. The LIA technique cannot be recommended for shoulder replacement unless substantially modified. Occurrence of inadequate analgesia and complications following interscalene brachial plexus block prompt further studies into pain management after shoulder replacement.

Tendon transfer options about the shoulder in patients with brachial plexus injury.

PubMed

Elhassan, Bassem; Bishop, Allen T; Hartzler, Robert U; Shin, Alexander Y; Spinner, Robert J

2012-08-01

The purpose of this study was to evaluate the early outcome of shoulder tendon transfer in patients with brachial plexus injury and to determine the factors associated with favorable outcomes. Fifty-two patients with traumatic brachial plexus injury and a paralytic shoulder were included in the study. All patients were evaluated at a mean of nineteen months (range, twelve to twenty-eight months) postoperatively. Twelve patients had a C5-6 injury, twenty-two had a C5-7 injury, five had a C5-8 injury, and thirteen had a C5-T1 injury. Transfer of the lower portion of the trapezius muscle was performed either in isolation or as part of multiple tendon transfers to improve shoulder function. Additional muscles transferred included the middle and upper portions of the trapezius, levator scapulae, upper portion of the serratus anterior, teres major, latissimus dorsi, and pectoralis major. All patients had a stable shoulder postoperatively. Shoulder external rotation improved substantially in all patients from no external rotation (hand-on-belly position) to a mean of 20° (p = 0.001). Patients who underwent additional transfers had marginal improvement of shoulder flexion, from a mean of 10° preoperatively to 60° postoperatively, and of shoulder abduction, from a mean of 10° to 50° (p = 0.01 for each). Mean pain on a visual analog scale improved from 6 points preoperatively to 2 points postoperatively. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score improved from 59 to 47 points (p = 0.001). The mean Subjective Shoulder Value improved from 5% to 40% (p = 0.001). Greater age, higher body mass index, and more extensive nerve injury were associated with a poorer DASH score in a multivariate analysis (p = 0.003). Tendon transfers about the shoulder can improve shoulder function in patients with brachial plexus injury resulting in a paralytic shoulder. Significant improvement of shoulder external rotation but only marginal improvements of shoulder

Outcome Following Spinal Accessory to Suprascapular (Spinoscapular) Nerve Transfer in Infants with Brachial Plexus Birth Injuries

PubMed Central

Ruchelsman, David E.; Ramos, Lorna E.; Alfonso, Israel; Price, Andrew E.; Grossman, Agatha

2009-01-01

The purpose of this study is to evaluate the value of distal spinal accessory nerve (SAN) transfer to the suprascapular nerve (SSN) in children with brachial plexus birth injuries in order to better define the application and outcome of this transfer in these infants. Over a 3-year period, 34 infants with brachial plexus injuries underwent transfer of the SAN to the SSN as part of the primary surgical reconstruction. Twenty-five patients (direct repair, n = 20; interposition graft, n = 5) achieved a minimum follow-up of 24 months. Fourteen children underwent plexus reconstruction with SAN-to-SSN transfer at less than 9 months of age, and 11 underwent surgical reconstruction at the age of 9 months or older. Mean age at the time of nerve transfer was 11.6 months (range, 5–30 months). At latest follow-up, active shoulder external rotation was measured in the arm abducted position and confirmed by review of videos. The Gilbert and Miami shoulder classification scores were utilized to report shoulder-specific functional outcomes. The effects of patient age at the time of nerve transfer and the use of interpositional nerve graft were analyzed. Overall mean active external rotation measured 69.6°; mean Gilbert score was 4.1 and the mean Miami score was 7.1, corresponding to overall good shoulder functional outcomes. Similar clinical and shoulder-specific functional outcomes were obtained in patients undergoing early (<9 months of age, n = 14) and late (>9 months of age, n = 11) SAN-to-SSN transfer and primary plexus reconstruction. Nine patients (27%) were lost to follow-up and are not included in the analysis. Optimum results were achieved following direct transfer (n = 20). Results following the use of an interpositional graft (n = 5) were rated satisfactory. No patient required a secondary shoulder procedure during the study period. There were no postoperative complications. Distal SAN-to-SSN (spinoscapular) nerve transfer is a reliable

Experimental study of brachial plexus and vessel compression: evaluation of combined central and peripheral electrodiagnostic approach.

PubMed

Yang, Chaoqun; Xu, Jianguang; Chen, Jie; Li, Shulin; Cao, Yu; Zhu, Yi; Xu, Lei

2017-08-01

We sought to investigate the reliability of a new electrodiagnostic method for identifying Electrodiagnosis of Brachial Plexus & Vessel Compression Syndrome (BPVCS) in rats that involves the application of transcranial electrical stimulation motor evoked potentials (TES-MEPs) combined with peripheral nerve stimulation compound muscle action potentials (PNS-CMAPs). The latencies of the TES-MEP and PNS-CMAP were initially elongated in the 8-week group. The amplitudes of TES-MEP and PNS-CMAP were initially attenuated in the 16-week group. The isolateral amplitude ratio of the TES-MEP to the PNS-CMAP was apparently decreased, and spontaneous activities emerged at 16 weeks postoperatively. Superior and inferior trunk models of BPVCS were created in 72 male Sprague Dawley (SD) rats that were divided into six experimental groups. The latencies, amplitudes and isolateral amplitude ratios of the TES-MEPs and PNS-CMAPs were recorded at different postoperative intervals. Electrophysiological and histological examinations of the rats' compressed brachial plexus nerves were utilized to establish preliminary electrodiagnostic criteria for BPVCS.

Parecoxib added to ropivacaine prolongs duration of axillary brachial plexus blockade and relieves postoperative pain.

PubMed

Liu, Xiaoming; Zhao, Xuan; Lou, Jian; Wang, Yingwei; Shen, Xiaofang

2013-02-01

Cyclooxygenase (COX)-2 antagonist is widely used for intravenous postoperative pain relief. Recent studies reported COX-2 in the spinal dorsal horn could modulate spinal nociceptive processes. Epidural parecoxib in rats showed no neurotoxicity. These findings suggested applying a COX-2 antagonist directly to the central or peripheral nerve might provide better analgesia. We therefore determined: (1) whether the addition of parecoxib to ropivacaine injected locally on the nerve block affected the sensory and motor block times of the brachial plexus nerve block; and (2) whether parecoxib injected locally on the nerve or intravenously had a similar analgesic adjuvant effect. We conducted a randomized controlled trial from January 2009 to November 2010 with 150 patients scheduled for elective forearm surgery, using a multiple-nerve stimulation technique. Patients were randomly allocated into one of three groups: Group A (n = 50) received ropivacaine 0.25% alone on the brachial plexus nerve; Group B (n = 50) received ropivacaine together with 20 mg parecoxib locally on the nerve block; and Group C (n = 50) received 20 mg parecoxib intravenously. We recorded the duration of the sensory and motor blocks, and the most severe pain score during a 24-hour postoperative period. Parecoxib added locally on the nerve block prolonged the motor and sensory block times compared with Group A. However, parecoxib injected intravenously had no such effect. Pain intensity scores in Group B were lower than those in Groups A and C. Parecoxib added to ropivacaine locally on the nerve block prolonged the duration of the axillary brachial plexus blockade and relieved postoperative pain for patients having forearm orthopaedic surgery. Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Pain and brachial plexus lesions: evaluation of initial outcomes after reconstructive microsurgery and validation of a new pain severity scale.

PubMed

Bonilla, Gonzalo; Di Masi, Gilda; Battaglia, Danilo; Otero, José María; Socolovsky, Mariano

2011-01-01

Peripheral nerve lesions usually are associated with neuropathic pain. In the present paper, we describe a simple scale to quantify pain after brachial plexus injuries and apply this scale to a series of patients to determine initial outcomes after reconstructive surgery. Fifty-one patients with traumatic brachial plexus avulsion injuries were treated over the period of one calendar year at one center by the same surgical team. Of these, 28 patients who were available for follow-up reported some degree of neuropathic pain radiating towards the hand or forearm and underwent reconstructive microsurgery and direct pain management, including trunk and nerve neurolysis and repair. A special pain severity rating scale was developed and used to assess patients' pain before and after surgery, over a minimum follow-up of 6 months. An independent researcher, not part of the surgical team, performed all pre- and postoperative evaluations. Of the 28 patients with brachial plexus traction injuries who met eligibility criteria, 93% were male, and most were young (mean age, 27.6 years). The mean preoperative severity of pain using our scale was 30.9 out of a maximum of 37 (± 0.76 SD), which fell to a mean of 6.9 (± 0.68 SD) 6 months post-procedure. On average, pain declined by 78% across the whole series, a decline that was statistically significant (p < .001). Subset analysis revealed similar improvements across all the different parameters of pain. We have designed and tested a simple and reliable method by which to quantify neuropathic pain after traumatic brachial plexus injuries. Initial surgical treatment of the paralysis--including nerve, trunk and root reconstruction, and neurolysis--comprises an effective means by which to initially treat neuropathic pain. Ablative or neuromodulative procedures, like dorsal root entry zone, should be reserved for refractory cases.

Dual Nerve Transfers for Restoration of Shoulder Function After Brachial Plexus Avulsion Injury.

PubMed

Chu, Bin; Wang, Huan; Chen, Liang; Gu, Yudong; Hu, Shaonan

2016-06-01

The purpose of this study was to investigate the effectiveness of shoulder function restoration by dual nerve transfers, spinal accessory nerve to the suprascapular nerve and 2 intercostal nerves to the anterior branch of the axillary nerve, in patients with shoulder paralysis that resulted from brachial plexus avulsion injury. It was a retrospective analysis to assess the impact of a variety of factors on reanimation of shoulder functions with dual nerve transfers. A total of 19 patients were included in this study. Most of these patients sustained avulsions of C5, C6, and C7 nerve roots (16 patients). Three of them had avulsions of C5 and C6 roots only. Through a posterior approach, direct coaptation of the intercostal nerves and the anterior branch of the axillary nerve was performed, along with accessory nerve transfer to the suprascapular nerve. Satisfactory shoulder function recovery (93.83° of shoulder abduction and 54.00° of external rotation on average) was achieved after a 62-month follow-up. This dual nerve transfer procedure provided us with a reliable and effective method for shoulder function reconstruction after brachial plexus root avulsion, especially C5/C6/C7 avulsion. The level of evidence is therapeutic IV.

Bone age in children with obstetrical brachial plexus palsy: effect of peripheral nerve injury on skeletal maturation.

PubMed

Oktay, Fügen; Cömert, Didem; Gökkaya, Nilüfer Kutay Ordu; Ozbudak, Sibel Demir; Uysal, Hilmi

2014-02-01

The purpose of this retrospective study was to analyze the effect of peripheral nerve injury on the skeletal maturation process. The bone ages of the affected and unaffected hand-wrists of 42 children with obstetrical brachial palsy were determined according to the Greulich and Pyle atlas. In 23 patients, the bone ages of the both sides were identical (bone-age-symmetrical group), in 19 patients the bone age of the affected side was delayed (bone-age-delayed group). The mean bone age of the affected side was delayed 0.48 ± 0.25 years that of the unaffected side (P = .000), and the delay of bone age was inversely correlated with chronological age (R (2) = .45, P < .02) in the bone-age-delayed group. Skeletal retardation can be recognized after appearance of ossification centers by plain radiography, dating from the third month of life, in early infancy. Thus, bone age determination method might be helpful for predicting potential future limb shortness.

Collagen nerve guides for surgical repair of brachial plexus birth injury.

PubMed

Ashley, William W; Weatherly, Trisha; Park, Tae Sung

2006-12-01

Standard brachial plexus repair techniques often involve autologous nerve graft placement and neurotization. However, when performed to treat severe injuries, this procedure can sometimes yield poor results. Moreover, harvesting the autologous graft is time-consuming and exposes the patient to additional surgical risks. To improve surgical outcomes and reduce surgical risks associated with autologous nerve graft retrieval and placement, the authors use collagen matrix tubes (Neurogen) instead of autologous nerve graft material. Between 1991 and 2005, the authors surgically treated 65 infants who had suffered brachial plexus injury at birth. During this time, seven patients were treated using collagen matrix tubes (Neurogen). This study is a retrospective analysis of the initial five patients who were treated using the tubes. Two patients underwent tube placement recently and were excluded from the analysis because of the inadequate follow-up period. Four of the five patients experienced a good recovery (motor scale composite [MSC] > 0.6), and three exhibited an excellent recovery (MSC > 0.75) at 2 years postoperatively. The MSC improved by an average of 69 and 78% at 1 and 2 years, respectively. The movement scores improved to greater than or equal to 50% range of motion in most patients, and the contractures were usually mild or moderate. Follow-up physical and occupational therapy evaluations confirm these patients' functional status. When last seen, four of five of these children could feed and dress themselves. Technically, the use of the collagen matrix tubes was straightforward and efficient, and there were no complications. The outcomes in this small series are encouraging.

A cadaveric study to determine the minimum volume of methylene blue to completely color the nerves of brachial plexus in cats. An update in forelimb and shoulder surgeries.

PubMed

Mencalha, Rodrigo; Fernandes, Neide; Sousa, Carlos Augusto dos Santos; Abidu-Figueiredo, Marcelo

2014-06-01

To determine the minimum volume of methylene blue (MB) to completely color the brachial plexus (BP) nerves, simulating an effective anesthetic block in cats. Fifteen adult male cat cadavers were injected through subscapular approach with volumes of 2, 3, 4, 5 and 6 ml in both forelimbs, for a total of 30 brachial plexus blocks (BPB). After infusions, the specimens were carefully dissected preserving each nervous branch. The measurement of the effective area was indicated by the impregnation of MB. Nerves were divided into four segments from the origin at the spinal level until the insertion into the thoracic limb muscles. The blocks were considered effective only when all the nerves were strongly or totally colored. Volumes of 2, 3 and 4 ml were considered insufficient suggesting a failed block, however, volumes of 5 and 6 ml were associated with a successful block. The injection of methylene blue, in a volume of 6 ml, completely colored the brachial plexus. At volumes of 5 and 6 ml the brachial plexus blocks were considered a successful regional block, however, volumes of 2, 3 and 4 ml were considered a failed regional block.

A Retrospective Study Evaluating the Effect of Low Doses of Perineural Dexamethasone on Ropivacaine Brachial Plexus Peripheral Nerve Block Analgesic Duration.

PubMed

Schnepper, Gregory D; Kightlinger, Benjamin I; Jiang, Yunyun; Wolf, Bethany J; Bolin, Eric D; Wilson, Sylvia H

2017-09-23

Examination of the effectiveness of perineural dexamethasone administered in very low and low doses on ropivacaine brachial plexus block duration. Retrospective evaluation of brachial plexus block duration in a large cohort of patients receiving peripheral nerve blocks with and without perineural dexamethasone in a prospectively collected quality assurance database. A single academic medical center. A total of 1,942 brachial plexus blocks placed over a 16-month period were reviewed. Demographics, nerve block location, and perineural dexamethasone utilization and dose were examined in relation to block duration. Perineural dexamethasone was examined as none (0 mg), very low dose (2 mg or less), and low dose (greater than 2 mg to 4 mg). Continuous catheter techniques, local anesthetics other than ropivacaine, and block locations with fewer than 15 subjects were excluded. Associations between block duration and predictors of interest were examined using multivariable regression models. A subgroup analysis of the impact of receiving dexamethasone on block duration within each block type was also conducted using a univariate linear regression approach. A total of 1,027 subjects were evaluated. More than 90% of brachial plexus blocks contained perineural dexamethasone (≤4 mg), with a median dose of 2 mg. Increased block duration was associated with receiving any dose of perineural dexamethasone (P < 0.0001), female gender (P = 0.022), increased age (P = 0.048), and increased local anesthetic dose (P = 0.01). In a multivariable model, block duration did not differ with very low- or low-dose perineural dexamethasone after controlling for other factors (P = 0.420). Perineural dexamethasone prolonged block duration compared with ropivacaine alone; however, duration was not greater with low-dose compared with very low-dose perineural dexamethasone. © 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e

Dexmedetomidine prolongs the effect of bupivacaine in supraclavicular brachial plexus block

PubMed Central

Agarwal, Sandhya; Aggarwal, Ritu; Gupta, Praveen

2014-01-01

Background: We compared the effects of adding dexmedetomidine to a 30 ml solution of 0.325% bupivacaine in supraclavicular brachial plexus block. Onset and duration of sensory and motor block along with the duration of analgesia were the primary endpoints. Materials and Methods: Fifty patients posted for upper limb surgeries were enrolled for a prospective, randomized, double-blind, placebo-controlled trial. Patients were divided into two groups, the control group S and the study group SD. In group S (n = 25), 30 ml of 0.325% bupivacaine + 1 ml normal saline; and in group SD (n = 25), 30 ml of 0.325% bupivacaine + 1 ml (100 μg) dexmedetomidine were given for supraclavicular brachial plexus block using the peripheral nerve stimulator. Onset and duration of sensory and motor blocks were assessed along with the duration of analgesia, sedation, and adverse effects, if any. Hemodynamic parameters, like heart rate (HR), systolic arterial blood pressure (SBP), and diastolic arterial blood pressure (DBP) were also monitored. Results: Demographic data and surgical characteristics were comparable in both the groups. The onset times for sensory and motor blocks were significantly shorter in SD than S group (P < 0.001), while the duration of blocks was significantly longer (P < 0.001) in SD group. Except for the initial recordings (at 0, 5, 10, and 15 min), heart rate levels in group SD were significantly lower (P < 0.001). SBP and DBP levels in SD group at 15, 30, 45, 60, 90 and 120 min were significantly lower than in S group (P < 0.001). In fact, when the percentage changes in HR/SBP/DBP were compared from 0-5/0-10/0-15/0-30/0-45/0-60/0-90/0-120 min in SD with S group, they came out to be highly significant (P < 0.001) in group SD. The duration of analgesia (DOA) was significantly longer in SD group than S group (P < 0.001). Except that, bradycardia was observed in one patient in the group SD, no other adverse effects were observed in either of the groups. Conclusion

SEPT9 Mutations and a Conserved 17q25 Sequence in Sporadic and Hereditary Brachial Plexus Neuropathy

PubMed Central

Klein, Christopher J.; Wu, Yanhong; Cunningham, Julie M.; Windebank, Anthony J.; Dyck, P. James B.; Friedenberg, Scott M.; Klein, Diane M.; Dyck, Peter J.

2009-01-01

Background The clinical characteristics of sporadic brachial plexus neuropathy (S-BPN) and hereditary brachial plexus neuropathy (H-BPN) are similar. At times of attack inflammation in brachial plexus nerves has been identified in both conditions. SEPT-9 mutations (Arg88Trp, Ser93Phe, 5UTR-131G to C) occur in some families with H-BPN. These mutations were not found in American H-BPN kindreds with a conserved 500 Kb sequence of DNA at 17q25 (the location of SEPT-9) where a founder mutation has been suggested. Objective To study 17q25 and SEPT-9 in S-BPN (56 patients) and H-BPN (13 kindreds). Methods Allele analysis at 17q25, SEPT-9 DNA sequencing and mRNA analysis from lymphoblast cultures. Results A conserved 17q25 sequence was found in 5 of 13 H-BPN kindreds and one S-BPN patient. This conserved sequence was not found in the family with a SEPT-9 mutation (Arg88Trp) or controls (182). SEPT-9 mRNA expression did not differ between forms of H-BPN and controls. No known mutations of SEPT-9 were found in S-BPN. Conclusions/Relevance Rare S-BPN patients have the same conserved 17q25 sequence found in many American H-BPN kindreds. BPN patients with this conserved sequence do not appear to have SEPT-9 mutations or alterations of its mRNA expression levels in lymphoblast cultures. BPN patients with this conserved sequence may have the most common genetic cause in the Americas by a founder effect mutation. PMID:19204161

Outcomes associated with a structured prenatal counseling program for shoulder dystocia with brachial plexus injury.

PubMed

Daly, Mary Veronica; Bender, Christina; Townsend, Kathryn E; Hamilton, Emily F

2012-08-01

We examined outcomes that were associated with a novel program to identify patients who are at high risk for shoulder dystocia with brachial plexus injury. The program included a checklist of key risk factors and a multifactorial algorithm to estimate risk of shoulder dystocia with brachial plexus injury. We examined rates of cesarean delivery and shoulder dystocia in 8767 deliveries by clinicians who were enrolled in the program and in 11,958 patients of clinicians with no access to the program. Key risk factors were identified in 1071 of 8767 mothers (12.2%), of whom 40 of 8767 women (0.46%) had results in the high-risk category. The rate of primary cesarean delivery rate was stable (21.2-20.8%; P = .57). Shoulder dystocia rates fell by 56.8% (1.74-0.75%; P = .002). The rates of shoulder dystocia and cesarean birth showed no changes in the group with no access to the program. With the introduction of this program, overall shoulder dystocia rates fell by more than one-half with no increase in the primary cesarean delivery rate. Copyright © 2012 Mosby, Inc. All rights reserved.

Clinical aspects of patients with traumatic lesions of the brachial plexus following surgical treatment☆

PubMed Central

de Moraes, Frederico Barra; Kwae, Mário Yoshihide; da Silva, Ricardo Pereira; Porto, Celmo Celeno; Magalhães, Daniel de Paiva; Paulino, Matheus Veloso

2015-01-01

Objective To evaluate sociodemographic and clinical aspects of patients undergoing operations due to traumatic lesions of the brachial plexus. Method This was a retrospective study in which the medical files of a convenience sample of 48 patients operated between 2000 and 2010 were reviewed. The following were evaluated: (1) range of motion (ROM) of the shoulder, elbow and wrist/hand, in degrees; (2) grade of strength of the shoulder, elbow and wrist/hand; (3) sensitivity; and (4) visual analogue scale (VAS) (from 0 to 10). The Student's t, chi-square, Friedman, Wilcoxon and Kruskal–Wallis tests were used (p < 0.05). Results The patients’ mean age was 30.6 years; 60.4% of them had suffered motorcycle accidents and 52.1%, multiple trauma. The mean length of time until surgery was 8.7 months (range: 2–48). Thirty-one patients (64.6%) presented complete rupture of the plexus. The frequent operation was neurosurgery in 39 cases (81.3%). The ROM achieved was ≥30° in 20 patients (41.6%), with a range from 30° to 90° and mean of 73° (p = 0.001). Thirteen (27.1%) already had shoulder strength ≥M3 (p = 0.001). Twenty-seven patients (56.2%) had elbow flexion ≥80°, with a range from 30° to 160° and mean of 80.6° (p < 0.001). Twenty-two had strength ≥M3 (p < 0.001). Twenty-two patients (45.8%) had wrist extension ≥30° starting from flexion of 45°, with a range from 30° to 90° and mean of 70° (p = 0.003). Twenty-seven (56.3%) presented wrist/hand extension strength ≥M3 (p = 0.002). Forty-five (93.8%) had hypoesthesia and three (6.2%) had anesthesia (p = 0.006). The initial VAS was 4.5 (range: 1.0–9.0) and the final VAS was 3.0 (range: 1.0–7.0) (p < 0.001). Conclusion Traumatic lesions of the brachial plexus were more prevalent among young adults (21–40 years), men, people living in urban areas, manual workers and motorcycle accidents, with multiple trauma and total rupture of the plexus. Neurosurgery, with a second

A Thematic Analysis of Online Discussion Boards for Brachial Plexus Injury.

PubMed

Morris, Marie T; Daluiski, Aaron; Dy, Christopher J

2016-08-01

Patients with brachial plexus injury (BPI) and their family members contribute to Internet discussion groups dedicated to BPI. We hypothesized that a thematic analysis of posts from BPI Internet discussion groups would reveal common themes related to the BPI patient experience, providing topics for patient education and counseling. Internet discussion boards were identified using the search term "brachial plexus injury support group" in Google, Bing, and Yahoo! search engines. Two discussion boards had substantially more posts than other Web sites and were chosen for analyses. Posts from January 1, 2015, through January 1, 2016, were examined. Using an iterative and established process, 2 investigators (M.T.M. and C.J.D) independently analyzed each post using thematic analysis in 3 steps (open coding, axial coding, and selective coding) to determine common themes. In this process, each post was reviewed 3 times. A total of 328 posts from the 2 leading discussion boards were analyzed. Investigators reached a consensus on themes for all posts. One central theme focused on emotional aspects of BPI. Four other central themes regarding information support were identified: BPI disease, BPI treatment, recovery after BPI treatment, and process of seeking care for BPI. Examination of posts on Internet support groups for BPI revealed recurring concerns, questions, and opinions of patients and their family members. The most common themes related to disease information, treatment, recovery, and the emotional element of BPI. These findings provide a helpful starting point in refining topics for patient education and support that are targeted on patients' interests and concerns. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Risk Factors for Brachial Plexus Birth Injury

PubMed Central

Louden, Emily; Marcotte, Michael; Mehlman, Charles; Lippert, William; Huang, Bin; Paulson, Andrea

2018-01-01

Over the course of decades, the incidence of brachial plexus birth injury (BPBI) has increased despite advances in healthcare which would seem to assist in decreasing the rate. The aim of this study is to identify previously unknown risk factors for BPBI and the risk factors with potential to guide preventative measures. A case control study of 52 mothers who had delivered a child with a BPBI injury and 132 mothers who had delivered without BPBI injury was conducted. Univariate, multivariable and logistic regressions identified risk factors and their combinations. The odds of BPBI were 2.5 times higher when oxytocin was used and 3.7 times higher when tachysystole occurred. The odds of BPBI injury are increased when tachysystole and oxytocin occur during the mother’s labor. Logistic regression identified a higher risk for BPBI when more than three of the following variables (>30 lbs gained during the pregnancy, stage 2 labor >61.5 min, mother’s age >26.4 years, tachysystole, or fetal malpresentation) were present in any combination. PMID:29596309

Depression and Anxiety in Traumatic Brachial Plexus Injury Patients Are Associated With Reduced Motor Outcome After Surgical Intervention for Restoration of Elbow Flexion.

PubMed

Wilson, Thomas J; Chang, Kate W C; Yang, Lynda J-S

2016-06-01

Depression has been associated with poor outcomes in neurosurgical patients, including increased pain, poorer functional recovery, delayed return to work, and decreased patient satisfaction. No reports exist regarding an association of psychiatric diagnoses with outcomes after brachial plexus reconstruction. As outcomes and patient satisfaction become increasingly important to payers and physician reimbursement, assessing modifiable preoperative risk factors for their association with poor outcome and patient satisfaction is imperative. To analyze patients undergoing brachial plexus reconstruction to assess the relationship of depression/anxiety with functional outcome. Data were collected retrospectively on all patients who underwent brachial plexus reconstruction to restore elbow flexion between 2005 and 2013. Elbow flexion, graded via the Medical Research Council scale, was assessed at latest follow-up. Multiple variables, including the presence of Axis I psychiatric diagnoses, were assessed for their association with the dichotomous outcome of Medical Research Council scale score ≥3 (antigravity) vs <3 elbow flexion. Standard statistical methods were used. Thirty-seven patients met inclusion criteria. The median postsurgical follow-up time was 21 months. Operations included neurolysis (n = 3), nerve graft repair (n = 6), and nerve transfer (n = 28). Depression was present in 10 of 37 patients (27%). Of variables tested, only depression was associated with poor elbow flexion outcome (odds ratio: 6.038; P = .04). Preoperative depression is common after brachial plexus injury. The presence of depression is associated with reduced elbow flexion recovery after reconstruction. Our data suggest assessment and treatment of preoperative mental health is important in designing a comprehensive postoperative management plan to optimize outcomes and patient satisfaction. MRC, Medical Research CouncilTBI, traumatic brain injury.

Effects of Botulinum Toxin on Reducing the Co-contraction of Antagonists in Birth Brachial Plexus Palsy

PubMed Central

Shin, Yong Beom; Chang, Jae Hyeok; Cha, Young Sun; Ko, Hyun-Yoon

2014-01-01

Birth brachial plexus palsy (BBPP) is usually caused by plexus traction during difficult delivery. Although the possibility of complete recovery is relatively high, 5% to 25% of BBPP cases result in prolonged and persistent disability. In particular, muscle imbalance and co-contraction around the shoulder and elbow cause abnormal motor performance, osseous deformities, and joint contracture. Physical and occupational therapies have most commonly been used, but these conventional therapeutic strategies have often been inadequate, in managing the residual muscle imbalance and muscle co-contraction. Therefore, we attempted to improve the functional movements, by using botulinum toxin type A, to reduce the abnormal co-contraction of the antagonist muscles. PMID:24639937

A novel rat model of brachial plexus injury with nerve root stumps.

PubMed

Fang, Jintao; Yang, Jiantao; Yang, Yi; Li, Liang; Qin, Bengang; He, Wenting; Yan, Liwei; Chen, Gang; Tu, Zhehui; Liu, Xiaolin; Gu, Liqiang

2018-02-01

The C5-C6 nerve roots are usually spared from avulsion after brachial plexus injury (BPI) and thus can be used as donors for nerve grafting. To date, there are no appropriate animal models to evaluate spared nerve root stumps. Hence, the aim of this study was to establish and evaluate a rat model with spared nerve root stumps in BPI. In rupture group, the proximal parts of C5-T1 nerve roots were held with the surrounding muscles and the distal parts were pulled by a sudden force after the brachial plexus was fully exposed, and the results were compared with those of sham group. To validate the model, the lengths of C5-T1 spared nerve root stumps were measured and the histologies of the shortest one and the corresponding spinal cord were evaluated. C5 nerve root stump was found to be the shortest. Histology findings demonstrated that the nerve fibers became more irregular and the continuity decreased; numbers and diameters of myelinated axons and thickness of myelin sheaths significantly decreased over time. The survival of motoneurons was reduced, and the death of motoneurons may be related to the apoptotic process. Our model could successfully create BPI model with nerve root stumps by traction, which could simulate injury mechanisms. While other models involve root avulsion or rupturing by distal nerve transection. This model would be suitable for evaluating nerve root stumps and testing new therapeutic strategies for neuroprotection through nerve root stumps in the future. Copyright © 2017. Published by Elsevier B.V.

A comparative study of clonidine and dexmedetomidine as an adjunct to bupivacaine in supraclavicular brachial plexus block.

PubMed

Tripathi, Archana; Sharma, Khushboo; Somvanshi, Mukesh; Samal, Rajib Lochan

2016-01-01

Various additives are mixed with local anesthetic agents to increase the quality of block in regional anesthesia. We compared clonidine and dexmedetomidine as an adjunct to bupivacaine in supraclavicular brachial plexus block with respect to the onset and duration of sensory and motor block and duration of analgesia. Sixty American Society of Anesthesiologists Grades I and II patients scheduled for various orthopedic surgeries of the upper limb under supraclavicular brachial plexus block were divided into two equal groups in a randomized, double-blind manner. Patients were assigned randomly to one of the two groups. In Group C (n = 30), 39 ml of 0.25% bupivacaine plus 1 ml (1 μg/kg) clonidine and in Group D (n = 30), 39 ml of 0.25% bupivacaine plus 1 ml (1 μg/kg) dexmedetomidine were given. The onset and duration of sensory and motor block, duration of analgesia, and quality of anesthesia were studied in both the groups. There was no statistically significant difference in the onset of sensory and motor block in both the groups. The durations of sensory and motor block were 316.67 ± 45.21 and 372.67 ± 44.48 min, respectively, in Group C, whereas they were 502.67 ± 43.78 and 557.67 ± 38.83 min, respectively, in Group D. The duration of analgesia was 349.33 ± 42.91 min, significantly less in Group C compared to 525.33 ± 42.89 min in Group D (P < 0.001). The quality of anesthesia was significantly better in dexmedetomidine group compared to clonidine group (P < 0.001). The addition of dexmedetomidine prolongs the durations of sensory and motor block and duration of analgesia and improves the quality of anesthesia as compared with clonidine when injected with bupivacaine in supraclavicular brachial plexus block.

Rhabdomyolysis resulting in concurrent Horner's syndrome and brachial plexopathy: a case report.

PubMed

Lee, Susan C; Geannette, Christian; Wolfe, Scott W; Feinberg, Joseph H; Sneag, Darryl B

2017-08-01

This case report describes a 29-year-old male who presented with immediate onset of Horner's syndrome and ipsilateral brachial plexopathy after sleeping with his arm dangling outside a car window for 8 h. Outside workup and imaging revealed rhabdomyolysis of the left neck musculature. Subsequent electrodiagnostic testing and high-resolution brachial plexus magnetic resonance imaging at the authors' institution attributed the Horner's syndrome and concurrent brachial plexopathy to rhabdomyolysis of the longus colli and scalene musculature, which had compressed-and consequently scar tethered-the cervical sympathetic trunk and brachial plexus. This case of co-existent Horner's syndrome and brachial plexopathy demonstrates the role of high-resolution brachial plexus MRI in diagnosing plexopathy and the importance of being familiar with plexus and paravertebral muscle anatomy.

Evaluation of nerve transfer options for treating total brachial plexus avulsion injury: a retrospective study of 73 participants

PubMed Central

Gao, Kai-ming; Hu, Jing-jing; Lao, Jie; Zhao, Xin

2018-01-01

Despite recent great progress in diagnosis and microsurgical repair, the prognosis in total brachial plexus-avulsion injury remains unfavorable. Insufficient number of donors and unreasonable use of donor nerves might be key factors. To identify an optimal treatment strategy for this condition, we conducted a retrospective review. Seventy-three patients with total brachial plexus avulsion injury were followed up for an average of 7.3 years. Our analysis demonstrated no significant difference in elbow-flexion recovery between phrenic nerve-transfer (25 cases), phrenic nerve-graft (19 cases), intercostal nerve (17 cases), or contralateral C7-transfer (12 cases) groups. Restoration of shoulder function was attempted through anterior accessory nerve (27 cases), posterior accessory nerve (10 cases), intercostal nerve (5 cases), or accessory + intercostal nerve transfer (31 cases). Accessory nerve + intercostal nerve transfer was the most effective method. A significantly greater amount of elbow extension was observed in patients with intercostal nerve transfer (25 cases) than in those with contralateral C7 transfer (10 cases). Recovery of median nerve function was noticeably better for those who received entire contralateral C7 transfer (33 cases) than for those who received partial contralateral C7 transfer (40 cases). Wrist and finger extension were reconstructed by intercostal nerve transfer (31 cases). Overall, the recommended surgical treatment for total brachial plexus-avulsion injury is phrenic nerve transfer for elbow flexion, accessory nerve + intercostal nerve transfer for shoulder function, intercostal nerves transfer for elbow extension, entire contralateral C7 transfer for median nerve function, and intercostal nerve transfer for finger extension. The trial was registered at ClinicalTrials.gov (identifier: NCT03166033). PMID:29623932

Evaluation of nerve transfer options for treating total brachial plexus avulsion injury: A retrospective study of 73 participants.

PubMed

Gao, Kai-Ming; Hu, Jing-Jing; Lao, Jie; Zhao, Xin

2018-03-01

Despite recent great progress in diagnosis and microsurgical repair, the prognosis in total brachial plexus-avulsion injury remains unfavorable. Insufficient number of donors and unreasonable use of donor nerves might be key factors. To identify an optimal treatment strategy for this condition, we conducted a retrospective review. Seventy-three patients with total brachial plexus avulsion injury were followed up for an average of 7.3 years. Our analysis demonstrated no significant difference in elbow-flexion recovery between phrenic nerve-transfer (25 cases), phrenic nerve-graft (19 cases), intercostal nerve (17 cases), or contralateral C 7 -transfer (12 cases) groups. Restoration of shoulder function was attempted through anterior accessory nerve (27 cases), posterior accessory nerve (10 cases), intercostal nerve (5 cases), or accessory + intercostal nerve transfer (31 cases). Accessory nerve + intercostal nerve transfer was the most effective method. A significantly greater amount of elbow extension was observed in patients with intercostal nerve transfer (25 cases) than in those with contralateral C 7 transfer (10 cases). Recovery of median nerve function was noticeably better for those who received entire contralateral C 7 transfer (33 cases) than for those who received partial contralateral C 7 transfer (40 cases). Wrist and finger extension were reconstructed by intercostal nerve transfer (31 cases). Overall, the recommended surgical treatment for total brachial plexus-avulsion injury is phrenic nerve transfer for elbow flexion, accessory nerve + intercostal nerve transfer for shoulder function, intercostal nerves transfer for elbow extension, entire contralateral C 7 transfer for median nerve function, and intercostal nerve transfer for finger extension. The trial was registered at ClinicalTrials.gov (identifier: NCT03166033).

[The plexal hand (involvement of the hand in traumatic lesions of the brachial plexus in adults)].

PubMed

Alnot, J Y; Salon, A

1993-01-01

After spontaneous recovery following brachial plexus injuries, or after nerve regeneration following nervous surgery on traumatic brachial plexus, there usually is a variable residual distal deficit involving the hand and wrist. This deficit is defined by both a functional approach, and its anatomical nervous correspondence, in order to predict which motor muscles will be available for palliative surgery, and to establish the most reasonable therapeutic plan. Total palsy of the hand will only be mentioned, whereas three main presentations of the "plexic hand" are of a greater surgical interest and will be detailed: the "wrist drop", due to C5 C6 +/- C7 supra-clavicular lesions, the hand presenting with a deficit of digit flexion, pinch and intrinsic functions, due to C8 T1 +/- C7 supra-clavicular lesions, non-standardized deficits due to infra- and retro-clavicular lesions, whose therapeutic indications and prognosis are closer to more classical trunk palsies. The review of 44 "plexic hands" after distal palliative surgery indicates the need to modify the fundamental rules of tendinous transfer surgery, and suggests new principles properly adapted to the surgery of plexic hand palsies.

Usefulness of IDEAL T2 imaging for homogeneous fat suppression and reducing susceptibility artefacts in brachial plexus MRI at 3.0 T.

PubMed

Tagliafico, Alberto; Bignotti, Bianca; Tagliafico, Giulio; Martinoli, Carlo

2016-01-01

To quantitatively and qualitatively compare fat-suppressed MR imaging quality using iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) with that using frequency-selective fat-suppressed (FSFS) T2 images of the brachial plexus at 3.0 T. Prospective MR image analysis was performed in 40 volunteers and 40 patients at a single centre. Oblique-sagittal and coronal IDEAL fat-suppressed T2 images and FSFS T2 images were compared. Visual assessment was performed by two independent musculoskeletal radiologists with respect to: (1) susceptibility artefacts around the neck, (2) homogeneity of fat suppression, (3) image sharpness and (4) tissue resolution contrast of pathologies. The signal-to-noise ratios (SNR) for each image sequence were assessed. Compared to FSFS sequences, IDEAL fat-suppressed T2 images significantly reduced artefacts around the brachial plexus and significantly improved homogeneous fat suppression (p < 0.05). IDEAL significantly improved sharpness and lesion-to-tissue contrast (p < 0.05). The mean SNRs were significantly improved on T2-weighted IDEAL images (p < 0.05). IDEAL technique improved image quality by reducing artefacts around the brachial plexus while maintaining a high SNR and provided superior homogeneous fat suppression than FSFS sequences.

Phrenic nerve block caused by interscalene brachial plexus block: breathing effects of different sites of injection.

PubMed

Bergmann, Lars; Martini, Stefan; Kesselmeier, Miriam; Armbruster, Wolf; Notheisen, Thomas; Adamzik, Michael; Eichholz, Rϋdiger

2016-07-29

Interscalene brachial plexus (ISB) block is often associated with phrenic nerve block and diaphragmatic paresis. The goal of our study was to test if the anterior or the posterior ultrasound guided approach of the ISB is associated with a lower incidence of phrenic nerve blocks and impaired lung function. This was a prospective, randomized and single-blinded study of 84 patients scheduled for elective shoulder surgery who fullfilled the inclusion and exclusion critereria. Patients were randomized in two groups to receive either the anterior (n = 42) or the posterior (n = 42) approach for ISB. Clinical data were recorded. In both groups patients received ISB with a total injection volume of 15 ml of ropivacaine 1 %. Spirometry was conducted at baseline (T0) and 30 min (T30) after accomplishing the block. Changes in spirometrical variables between T0 and T30 were investigated by Wilcoxon signed-rank test for each puncture approach. The temporal difference between the posterior and the anterior puncture approach groups were again analyzed by the Wilcoxon-Mann-Whitney test. The spirometric results showed a significant decrease in vital capacity, forced expiratory volume per second, and maximum nasal inspiratory breathing after the Interscalene brachial plexus block; indicating a phrenic nerve block (p <0.001, Wilcoxon signed-rank). A significant difference in the development of the spirometric parameters between the anterior and the posterior group could not be identified (Wilcoxon-Mann-Whitney test). Despite the changes in spirometry, no cases of dyspnea were reported. A different site of injection (anterior or posterior) did not show an effect in reducing the cervical block spread of the local anesthetic and the incidence of phrenic nerve blocks during during ultrasound guided Interscalene brachial plexus block. Clinical breathing effects of phrenic nerve blocks are, however, usually well compensated, and subjective dyspnea did not occur in our patients

Local injection of autologous bone marrow cells to regenerate muscle in patients with traumatic brachial plexus injury: a pilot study.

PubMed

Hogendoorn, S; Duijnisveld, B J; van Duinen, S G; Stoel, B C; van Dijk, J G; Fibbe, W E; Nelissen, R G H H

2014-01-01

Traumatic brachial plexus injury causes severe functional impairment of the arm. Elbow flexion is often affected. Nerve surgery or tendon transfers provide the only means to obtain improved elbow flexion. Unfortunately, the functionality of the arm often remains insufficient. Stem cell therapy could potentially improve muscle strength and avoid muscle-tendon transfer. This pilot study assesses the safety and regenerative potential of autologous bone marrow-derived mononuclear cell injection in partially denervated biceps. Nine brachial plexus patients with insufficient elbow flexion (i.e., partial denervation) received intramuscular escalating doses of autologous bone marrow-derived mononuclear cells, combined with tendon transfers. Effect parameters included biceps biopsies, motor unit analysis on needle electromyography and computerised muscle tomography, before and after cell therapy. No adverse effects in vital signs, bone marrow aspiration sites, injection sites, or surgical wound were seen. After cell therapy there was a 52% decrease in muscle fibrosis (p = 0.01), an 80% increase in myofibre diameter (p = 0.007), a 50% increase in satellite cells (p = 0.045) and an 83% increase in capillary-to-myofibre ratio (p < 0.001) was shown. CT analysis demonstrated a 48% decrease in mean muscle density (p = 0.009). Motor unit analysis showed a mean increase of 36% in motor unit amplitude (p = 0.045), 22% increase in duration (p = 0.005) and 29% increase in number of phases (p = 0.002). Mononuclear cell injection in partly denervated muscle of brachial plexus patients is safe. The results suggest enhanced muscle reinnervation and regeneration. Cite this article: Bone Joint Res 2014;3:38-47.

Decreased rates of shoulder dystocia and brachial plexus injury via an evidence-based practice bundle.

PubMed

Sienas, Laura E; Hedriana, Herman L; Wiesner, Suzanne; Pelletreau, Barbara; Wilson, Machelle D; Shields, Laurence E

2017-02-01

To evaluate whether a standardized approach to identify pregnant women at risk for shoulder dystocia (SD) is associated with reduced incidence of SD and brachial plexus injury (BPI). Between 2011 and 2015, prospective data were collected from 29 community-based hospitals in the USA during implementation of an evidence-based practice bundle, including an admission risk assessment, required "timeout" before operative vaginal delivery (OVD), and low-fidelity SD drills. All women with singleton vertex pregnancies admitted for vaginal delivery were included. Rates of SD, BPI, OVD, and cesarean delivery were compared between a baseline period (January 2011-September 2013) and an intervention period (October 2013-June 2015), during which there was a system-wide average bundle compliance of 90%. There was a significant reduction in the incidence of SD (17.6%; P=0.028), BPI (28.6%; P=0.018), and OVD (18.0%; P<0.001) after implementation of the evidence-based practice bundle. There was a nonsignificant reduction in primary (P=0.823) and total (P=0.396) cesarean rates, but no association between SD drills and incidence of BPI. Implementation of a standard evidence-based practice bundle was found to be associated with a significant reduction in the incidence of SD and BPI. Utilization of low-fidelity drills was not associated with a reduction in BPI. © 2016 International Federation of Gynecology and Obstetrics.

Patient satisfaction and disability after brachial plexus surgery.

PubMed

Kretschmer, Thomas; Ihle, Sarah; Antoniadis, Gregor; Seidel, Julia A; Heinen, Christian; Börm, Wolfgang; Richter, Hans-Peter; König, Ralph

2009-10-01

Little is known about patient satisfaction and disability after brachial plexus surgery. Would patients undergo the procedure again, if they knew the current result beforehand? How do they rate their result and their disability? Of 319 plexus patients who had undergone surgery between 1995 and 2005, 199 received a 65-item questionnaire. Measurement instruments included a new plexus-specific outcome questionnaire (Ulm Questionnaire) with categories of satisfaction, functionality, pain, comorbidities, and work; and the disability of the arm, shoulder, and hand questionnaire (DASH; scale, 0-100). Of 99 returned questionnaires, 70 were returned in a useful form for evaluation. The results of patients with C5-C6 lesions (21 of 70) are as follows: 90% (19 of 21) would undergo surgery again, 95% (20 of 21) were satisfied with the result, and 86% (18 of 21) subjectively improved. The mean DASH score was 41 (standard deviation [SD], 24). The results of patients with C5-C7 lesions (6 of 70) are as follows: 50% (3 of 6) were satisfied and would undergo surgery again, and 67% (4 of 6) improved. The mean DASH score was 46 (SD, 13). The results of patients with C5-T1 lesions (43 of 70) are as follows: 67% (29 of 43) would undergo surgery again, 81% (35 of 42) were satisfied, and 74% (32 of 43) reported improvement. The mean DASH score was 58 (SD, 26). The overall mean DASH score was 52 (SD, 26). Pain since the injury was prevalent in 86% of patients (60 of 70), back pain in 53%, and depression/anxiety in 21%. Fifty-two percent of those who worked before their injury (27 of 53 patients) remained unemployed or incapacitated for work. Forty-five percent of previous workers (24 of 53) returned to their former occupation. Occupational retraining was successful for 70% of patients (16 of 23). The mean duration until return to work was 9 months overall and 5 months for those who returned to their previous occupation. Eighty-seven percent of patients were satisfied with the results and

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement.

PubMed

Heise, Carlos O; Siqueira, Mario G; Martins, Roberto S; Foroni, Luciano H; Sterman-Neto, Hugo

2017-09-01

Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach. We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results. The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers. Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.

Dexmedetomidine as an adjuvant to 0.5% ropivacaine in ultrasound-guided axillary brachial plexus block.

PubMed

Koraki, E; Stachtari, C; Kapsokalyvas, I; Stergiouda, Z; Katsanevaki, A; Trikoupi, A

2018-06-01

The aim of this study was to elucidate the effect of dexmedetomidine added to ropivacaine on the onset and duration of sensory and motor block and duration of analgesia of ultrasound-guided axillary brachial plexus block. Thirty-seven ASA physical status I-II patients with elective forearm and hand surgery under ultrasound-guided axillary brachial plexus block were randomly divided into 2 groups. Patients in ropivacaine-dexmedetomidine group (group RD, n = 19) received 15 mL of 0.5% ropivacaine with 100 μg (1 mL) dexmedetomidine, and patients in ropivacaine group (group R, n = 18) received 15 mL of 0.5% ropivacaine with 1 mL of normal saline. Onset time and duration of sensory and motor block and duration of analgesia were assessed. Duration of sensory block (U-value = 35, P < .001), duration of motor block (P = .001) and duration of analgesia (P < .001) were extended in group RD compared to group R. Onset time of sensory block in group RD was significantly faster than in group R (U-value = 65.5, P = .001). Onset time of motor block showed no significant difference between the 2 groups (U-value = 116.5, P = .096). Adverse reactions were reported only in group RD (bradycardia in 2 and hypotension in 3 patients). Our study indicated that dexmedetomidine 100 μg as adjuvant on ultrasound-guided axillary plexus block significantly prolonged the duration of sensory block and analgesia, as well as accelerated the time to onset of sensory block. These results should be weighed against the increased risks of motor block prolongation, transient bradycardia and hypotension and allow for attentive optimism, only if prolonged clinical trials provide a definitive answer. © 2017 John Wiley & Sons Ltd.

[Physiokinesitherapeutic management of traumatic lesions of the brachial plexus. Indications and results].

PubMed

Gusso, M I; Innocenti, M; Mauceri, M C

1985-03-31

An account is given of the indications and results of physical and rehabilitative management of brachial plexus lesions when used electively or as a complement to surgery. Material from the Florence Traumatological and Orthopaedics Centre and the V. Putti Mutilated Patients Centre, Bologna (formerly directed by Prof. O. Scaglietti) dating from 1940 to 1980 is used to explain the indications for conservative and surgical management, in the conviction that sound results depend on exact indication. A selected sample of 51 patients treated conservatively and 194 surgically is presented. The results were satisfactory in about 50% of each group, with a slight advantage in favour of physiotherapy, this being obviously employed when lesions were less severe.

Brachial plexus palsy with the use of haloperidol and a geriatric chair.

PubMed

King, T; Mallet, L

1991-10-01

An 81-year-old white man was admitted to an intermediate care facility because of increased wandering and confusion secondary to dementia. On the first day after admission, the patient tried to leave the facility and was hitting and kicking the employees. Haloperidol 0.5 mg tid was prescribed to help control his behavior. He became more agitated and confused; haloperidol was then increased to 1 mg qid and the patient was confined to a geriatric chair to prevent injuries. Cogwheel movements, rigidity, and marked sedation were documented. A right brachial plexus palsy was diagnosed. This case demonstrated the hazards of two commonly used interventions in a nursing home: antipsychotic agents and the geriatric chair.

Recovery of brachial plexus lesions resulting from heavy backpack use: A follow-up case series

PubMed Central

2011-01-01

Background Brachial plexus lesions as a consequence of carrying a heavy backpack have been reported, but the typical clinical course and long-term consequences are not clear. Here we evaluated the clinical course and pattern of recovery of backpack palsy (BPP) in a large series of patients. Methods Thirty-eight consecutive patients with idiopathic BPP were identified from our population of 193,450 Finnish conscripts by means of computerised register. A physiotherapist provided instructions for proper hand use and rehabilitative exercises at disease onset. The patients were followed up for 2 to 8 years from the diagnosis. We also searched for genetic markers of hereditary neuropathy with pressure palsies. Mann-Whitney U-test was used to analyze continuous data. The Fischer's exact test was used to assess two-way tables. Results Eighty percent of the patients recovered totally within 9 months after the onset of weakness. Prolonged symptoms occurred in 15% of the patients, but daily activities were not affected. The weight of the carried load at the symptom onset significantly affected the severity of the muscle strength loss in the physiotherapeutic testing at the follow-up. The initial electromyography did not predict recovery. Genetic testing did not reveal de novo hereditary neuropathy with pressure palsies. Conclusions The prognosis of BPP is favorable in the vast majority of cases. Electromyography is useful for diagnosis. To prevent brachial plexus lesions, backpack loads greater than 40 kg should be avoided. PMID:21429232

[Efficacy and safety of ultrasound-guided or neurostimulator-guided bilateral axillary brachial plexus block].

PubMed

Xu, C S; Zhao, X L; Zhou, H B; Qu, Z J; Yang, Q G; Wang, H J; Wang, G

2017-10-17

Objective: To explore the efficacy and safety of bilateral axillary brachial plexus block under the guidance of ultrasound or neurostimulator. Methods: From February 2012 to April 2014, 120 patients undergoing bilateral hand/forearm surgery in Beijing Jishuitan Hospital were enrolled and anaesthetized with bilateral axillary brachial plexus block. All patients were divided into two groups randomly using random number table: the ultrasound-guided group (group U, n =60) and the neurostimulator-guidedgroup (group N, n =60). The block was performed with 0.5% ropivacaine. Patients' age, sex and operation duration were recorded. Moreover, success rate, performance time, onset of sensor and motor block, performance pain, patient satisfaction degree and the incidence of related complications were also documented. Venous samples were collected at selected time points and the total and the plasma concentrations of ropivacaine were analyzed with HPLC. Results: The performance time, the onset of sensor block and the onset of motor block of group U were (8.2±1.5), (14.2± 2.2)and (24.0±3.5)min respectively, which were markedly shorter than those in group N( (14.6±3.9), (19.9±3.8), (28.8±4.2)min, respectively), and the differences were statistically significant( t =11.74, 10.09, 6.73, respectively, all P <0.01). The performance pain score of group N was (25.5± 13.2), which was obviously more serious than group U (31.7± 11.2) and a significant statistical difference was detected ( t =2.856, P <0.05). The patient satisfaction degree of group U was 95.0%, which was significantly higher than group N (83.3%) and a markedly statistical difference was detected (χ(2)=4.227, P <0.05). Fifty min after performance, the total plasma concentration of ropivacaine of group U was(1.76±0.48)mg/L, which was significantly lower than group N (1.88±0.53)mg/L and a significant statistical difference was detected ( t =2.43, P <0.05), while no significant differences were detected at the

Characteristic features of hereditary neuropathy with liability to pressure palsy (HNPP) presenting with brachial plexopathy in soldiers.

PubMed

Kim, Kyoung-Eun

2014-11-15

A brachial plexus lesion is not common in hereditary neuropathy with liability to pressure palsy (HNPP). We report the clinical and electrodiagnostic features of young soldiers with HNPP presenting with brachial plexopathy. By reviewing 2year medical records from Korean military hospitals, we identified soldiers with brachial plexus lesions. Among them, patients diagnosed with HNPP were determined and clinical and electrophysiological findings were compared between HNPP and non-HNPP patients with a brachial plexus lesion. Thirteen patients (6.8%) were diagnosed with HNPP among 189 patients with a brachial plexus lesion. Push-ups, as either a punishment or an exercise, was the most frequent preceding event in HNPP patients (76.9%), whereas it was rare in non-HNPP patients. The distal motor latency of the median nerve showed the highest sensitivity (90.9%) and specificity (100%) for HNPP in patients with a brachial plexus lesion. In conclusion, HNPP should be suspected in patients with brachial plexopathy if brachial plexopathy develops after push-ups or if the distal motor latency of median nerves is prolonged. Copyright © 2014 Elsevier B.V. All rights reserved.

Clinical Assessment of the Infant and Child Following Perinatal Brachial Plexus Injury

PubMed Central

Duff, Susan V.; DeMatteo, Carol

2015-01-01

STUDY DESIGN Literature review INTRODUCTION After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome. PURPOSE To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians. METHODS We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians. DISCUSSION With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest. PMID:25840493

Brachial plexopathy

MedlinePlus

... problems are more common in certain groups. For example, young men more often have inflammatory or post-viral brachial plexus disease called Parsonage-Turner syndrome. Tests that may be done to diagnose this condition ...

Postoperative physical therapy program for latissimus dorsi and teres major tendons transfer to rotator cuff in children with obstetrical brachial plexus injury.

PubMed

Safoury, Yasser A; Eldesoky, Mohamed T; Abutaleb, Enas E; Atteya, Mohamed R; Gabr, Ahmed M

2017-04-01

The transfer of latissimus dorsi and teres major tendons to rotator cuff have been developed to rebalance the muscular dysfunction and improve shoulder range of motion in children with obstetrical brachial plexus palsy (OBPP). No previous study reported the ideal postoperative physical therapy program for these cases. The aim of the present study was to design appropriate postoperative physical therapy (PT) program after latissimus dorsi and teres major tendons transfer to rotator cuff in OBPP to improve upper limb function. Time series design. The patients were recruited from outpatient clinic of Kasr EL Aini Hospital, Cairo, Egypt. Forty seven OBPP infants (4.64±1.21 years with a range of 2.5 to 7 years, 21male and26 female) were allocated to one group. All patients had functional limitation in the involved arm due to muscle paralysis and contracture. Twenty-five patients had C5-C6 nerve root lesions while 22 had C5-C6-C7 nerve root lesions. The children underwent the surgical procedures of the transfer of latissimus dorsi and teres major tendons to rotator cuff. After the surgery the children participated in a designed physical therapy program for 6 months. Active shoulder abduction, flexion and external rotation range of motion (ROM) were assessed by electrogoniometer, and functional assessments were measured using the modified Mallet scale. All measurements were taken preoperative, 6 weeks, 3 months, and 6 months postoperatively after the application of the designed PT program. Repeated measure analysis of variance (ANOVA) followed by Bonferroni post-hoc test were used to show the improvement in all measured variables. Analysis revealed that shoulder abduction, flexion and external rotation ROM and shoulder function measured by modified Mallet scale were significantly improved (P<0.0001) after the designed postoperative PT program. It can be concluded that the combination treatment of surgical procedure and the postoperative physical therapy program seem to

HDAC inhibition inhibits brachial plexus avulsion induced neuropathic pain.

PubMed

Zhao, Yingbo; Wu, Tianjian

2018-05-09

Introduction Neuropathic pain induced by brachial plexus avulsion (BPA) is a pathological condition. We hypothesized that inhibition of histone deacetylase (HDAC) could suppress BPA-induced neuropathic pain through inhibition of transient reception potential (TRP) overexpression and protein kinase B (Akt) mediated mammalian target of rapamycin (mTOR) activation. Methods We generated a rat BPA model, administered HDAC inhibitor Tricostatin A (TSA) for 7 days post-surgery and assessed the effects on HDAC expression, Akt phosphorylation, neuroinflammation and mTOR activation. Results TSA treatment alleviated BPA induced mechanical hyperalgesia, suppressed Akt phosphorylation and increased HDAC. We found suppressed pro-inflammatory cytokine levels, TRP cation channel subfamily V member 1 (TRPV1) and TRP melastatin 8 (TRPM8) expression and mTOR activity in TSA treated BPA rats. Discussion Our results suggest that altered HDAC and Akt signaling are involved in BPA-induced neuropathic pain and that inhibition of HDAC could be an effective therapeutic approach in reducing neuropathic pain. This article is protected by copyright. All rights reserved. © 2018 Wiley Periodicals, Inc.

[F-waves in brachial plexus palsy correlated to the prognosis of intrinsic paralysis].

PubMed

Nobuta, S

1995-04-01

F-waves were examined in 80 nerves of 40 brachial plexus palsies in 37 cases. The electrical responses were evoked by 30 consecutive supramaximal electric stimuli to the median and ulnar nerves at the wrist and elbow, and recorded from the abductor pollicis brevis and abductor digiti minimi muscles. Three parameters in the F-waves were analyzed--conduction velocity, the difference between the maximal and minimal latencies, and the amplitude. In all cases, examinations were done repeatedly to detect changes in these parameters, and the results were compared with the clinical course of the intrinsic muscle function. Twenty-seven cases were investigated before and after explorative surgery. The findings were divided into four groups. The 1st group consisted of 12 nerves in which F-waves were not recorded. The intrinsic muscle power in this group was zero, and did not show any restoration. The 2nd group consisted of 10 nerves in which the conduction velocity was delayed. The muscle power in this group was fair, poor or trace, and there was no change in conduction velocity and muscle function. The 3rd group consisted of 18 nerves in which parameters other than the conduction velocity were abnormal, and the intrinsic muscle power in this group was fair, good or normal. In 7 of these nerves, the large latency difference decreased to normal at the 2nd, 3rd or 4th test with functional recovery in the intrinsic muscle. The high amplitude also changed to normal at the 2nd test with functional recovery. The 4th group consisted of 40 nerves in which all the parameters were normal and had full intrinsic muscle power. In conclusion, an examination of the F-waves was valuable to indicate the prognosis of the intrinsic muscle in the hand in brachial plexus palsy.

MR Neurography of Brachial Plexus at 3.0 T with Robust Fat and Blood Suppression.

PubMed

Wang, Xinzeng; Harrison, Crystal; Mariappan, Yogesh K; Gopalakrishnan, Karthik; Chhabra, Avneesh; Lenkinski, Robert E; Madhuranthakam, Ananth J

2017-05-01

Purpose To develop and evaluate magnetic resonance (MR) neurography of the brachial plexus with robust fat and blood suppression for increased conspicuity of nerves at 3.0 T in clinically feasible acquisition times. Materials and Methods This prospective study was HIPAA compliant, with institutional review board approval and written informed consent. A low-refocusing-flip-angle three-dimensional (3D) turbo spin-echo (TSE) sequence was modified to acquire both in-phase and out-of-phase echoes, required for chemical shift (Dixon) reconstruction, in the same repetition by using partial echoes combined with modified homodyne reconstruction with phase preservation. This multiecho TSE modified Dixon (mDixon) sequence was optimized by using simulations and phantom studies and in three healthy volunteers. The sequence was tested in five healthy volunteers and was evaluated in 10 patients who had been referred for brachial plexopathy at 3.0 T. The images were evaluated against the current standard of care, images acquired with a 3D TSE short inversion time inversion recovery (STIR) sequence, qualitatively by using the Wilcoxon signed-rank test and quantitatively by using the Friedman two-way analysis of variance, with P < .05 considered to indicate a statistically significant difference. Results Multiecho TSE-mDixon involving partial-echo and homodyne reconstruction with phase preservation achieved uniform fat suppression in half the imaging time compared with multiacquisition TSE-mDixon. Compared with 3D TSE STIR, fat suppression, venous suppression, and nerve visualization were significantly improved (P < .05), while arterial suppression was better but not significantly so (P = .06), with increased apparent signal-to-noise ratio in the dorsal nerve root ganglion and C6 nerve (P < .001) with the multiecho TSE-mDixon sequence. Conclusion The multiecho 3D TSE-mDixon sequence provides robust fat and blood suppression, resulting in increased conspicuity of the nerves, in

Utility of ultrasound-guided injection of botulinum toxin type A for muscle imbalance in children with obstetric brachial plexus palsy: Description of the procedure and action protocol.

PubMed

García Ron, A; Gallardo, R; Huete Hernani, B

2017-03-24

Obstetric brachial plexus palsy (OBPP) usually has a favourable prognosis. However, nearly one third of all severe cases have permanent sequelae causing a high level of disability. In this study, we explore the effectiveness of ultrasound-guided injection of botulinum toxin A (BoNT-A) and describe the procedure. We designed a prospective, descriptive study including patients with moderate to severe OBPP who were treated between January 2010 and December 2014. We gathered demographic data, type of OBPP, and progression. Treatment effectiveness was assessed with the Active Movement Scale (AMS), the Mallet classification, and video recordings. We gathered a total of 14 133 newborns, 15 of whom had OBPP (1.6 per 1000 live births). Forty percent of the cases had severe OBPP (0.4/1000), a dystocic delivery, and APGAR scores < 5; mean weight was 4038g. Mean age at treatment onset was 11.5 months. The muscles most frequently receiving BoNT-A injections were the pronator teres, subscapularis, teres major, latissimus dorsi, and pectoralis major. All the patients who completed the follow-up period (83%) experienced progressive improvements: up to 3 points on the AMS and a mean score of 19.5 points out of 25 on the Mallet classification at 2 years. Treatment improved muscle function and abnormal posture in all cases. Surgery was avoided in 3 patients and delayed in one. Adverse events were mild and self-limited. Due to its safety and effectiveness, BoNT-A may be used off-label as an adjuvant to physical therapy and/or surgery in moderate to severe OBPP. Ultrasound may increase effectiveness and reduce adverse effects. Copyright © 2017 The Authors. Publicado por Elsevier España, S.L.U. All rights reserved.

Cellular Therapy for Chronic Traumatic Brachial Plexus Injury

PubMed Central

Sharma, Alok; Sane, Hemangi; Gokulchandran, Nandini; Badhe, Prerna; Pai, Suhasini; Kulkarni, Pooja; Yadav, Jayanti; Inamdar, Sanket

2018-01-01

Cellular therapy is being actively pursued as a therapeutic modality in many of the neurological diseases. A variety of stem cells from diverse sources have been studied in detail and have been shown to exhibit angiogenetic and immunomodulatory properties in addition to other neuroprotective effects. Published clinical data have shown bone marrow mononuclear cell (BMMNC) injection in neurological disorders is safe and possesses regenerative potential. We illustrate a case of 27-year-old male with traumatic brachial plexus injury, administered with autologous BMMNCs intrathecally and intramuscularly, followed by multidisciplinary rehabilitation. At the follow-up assessment of 3 and 7 months after first cell transplantation, improvements were recorded in muscle strength and movements. Electromyography (EMG) performed after the intervention showed a response in biceps and deltoid muscles suggesting the process of reinnervation at the site of injury. In view of the improvements observed after the treatment, the patient underwent second cell transplantation 8 months after the first transplantation. Muscle wasting had completely stopped with an increase in the muscle girth. No adverse effects were noted. Improvements were maintained for 4 years. A comprehensive randomized study for this type of injury is needed to establish the therapeutic benefits of cellular therapy. PMID:29657936

Augmentation of partially regenerated nerves by end-to-side side-to-side grafting neurotization: experience based on eight late obstetric brachial plexus cases

PubMed Central

2006-01-01

Objective The effect of end-to-side neurotization of partially regenerated recipient nerves on improving motor power in late obstetric brachial plexus lesions, so-called nerve augmentation, was investigated. Methods Eight cases aged 3 – 7 years were operated upon and followed up for 4 years (C5,6 rupture C7,8T1 avulsion: 5; C5,6,7,8 rupture T1 avulsion:1; C5,6,8T1 rupture C7 avulsion:1; C5,6,7 ruptureC8 T1 compression: one 3 year presentation after former neurotization at 3 months). Grade 1–3 muscles were neurotized. Grade0 muscles were neurotized, if the electromyogram showed scattered motor unit action potentials on voluntary contraction without interference pattern. Donor nerves included: the phrenic, accessory, descending and ascending loops of the ansa cervicalis, 3rd and 4th intercostals and contralateral C7. Results Superior proximal to distal regeneration was observed firstly. Differential regeneration of muscles supplied by the same nerve was observed secondly (superior supraspinatus to infraspinatus regeneration). Differential regeneration of antagonistic muscles was observed thirdly (superior biceps to triceps and pronator teres to supinator recovery). Differential regeneration of fibres within the same muscle was observed fourthly (superior anterior and middle to posterior deltoid regeneration). Differential regeneration of muscles having different preoperative motor powers was noted fifthly; improvement to Grade 3 or more occurred more in Grade2 than in Grade0 or Grade1 muscles. Improvements of cocontractions and of shoulder, forearm and wrist deformities were noted sixthly. The shoulder, elbow and hand scores improved in 4 cases. Limitations The sample size is small. Controls are necessary to rule out any natural improvement of the lesion. There is intra- and interobserver variability in testing muscle power and cocontractions. Conclusion Nerve augmentation improves cocontractions and muscle power in the biceps, pectoral muscles, supraspinatus

Brachial Plexus Injury in a 6-Year-Old Boy with 100% Displaced Proximal Humeral Metaphyseal Fracture: A Case Presentation.

PubMed

Jovanovich, Elizabeth Nora; Howard, James F

2017-12-01

Posttraumatic brachial plexopathies can occur following displaced proximal humeral fractures, causing profound functional deficits. Described here is an unusual case of a displaced proximal humeral metaphyseal fracture in a young child. The patient underwent closed reduction and serial casting, but hand weakness and forearm sensory loss persisted. Needle electromyography localized the injury to the mid/proximal arm near the fracture site, resulting in damage to the posterior and medial cords of the brachial plexus with profound involvement of the radial, ulnar, and median nerves and sparing of the axillary nerve. After months of occupational therapy, hand strength improved, with a nearly full return of function. V. Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

Can we use lower volume of local anesthetic for infraclavicular brachial plexus nerve block under ultrasound guidance in children?

PubMed

Ince, Ilker; Aksoy, Mehmet; Dostbil, Aysenur; Tuncer, Kutsi

2017-09-01

To determine if the infraclavicular brachial plexus block can be applied with lower volume of local anesthetic. Randomised, double-blinded clinical trial. 60 patients aged 5-15years with ASA I-II who underwent emergent or elective arm, forearm or hand operations were included in the study. Patients were divided into two groups randomly; standard volume local anesthetic administered group (Group S, n=30) and low volume anesthetic administered group (Group L, n=30). Postoperative pain scores, sensory and motor block durations were noted. Pain scores (Wong-Baker Face Scale) were evaluated and the results were detected to be similar at all times (30min, 1, 2, 4, 8, 12, 24h). Durations of motor block were 168(±16) minutes and 268(±15) minutes in Group L and Group S respectively and the difference was statistically significant (p<0.001). Durations of sensory block were 385(±26) and 402(±39) in Group L and Group S respectively and no statistically significant difference was detected (p=0.064). Similar block success, postoperative sensory block durations and pain scores could be obtained during infraclavicular brachial plexus in pediatric patients with lower local anesthetic volumes. Copyright © 2016 Elsevier Inc. All rights reserved.

C8 cross transfer for the treatment of caudal brachial plexus avulsion in three dogs.

PubMed

Moissonnier, Pierre; Carozzo, Claude; Thibaut, Jean-Laurent; Escriou, Catherine; Hidalgo, Antoine; Blot, Stéphane

2017-01-01

To evaluate the cervical nerve 8 cross-transfer technique (C8CT) as a part of surgical treatment of caudal brachial plexus avulsion (BPA) in the dog. Case series. Client-owned dogs suspected to have caudal BPA based on neurological examination and electrophysiological testing (n = 3). The distal stump of the surgically transected contralateral C8 ventral branch (donor) was bridged to the proximal stump of the avulsed C8 ventral branch (recipient) and secured with 9-0 polypropylene suture under an operating microscope. A carpal panarthrodesis was performed on the injured limb after C8CT. Surgical exploration confirmed avulsion of nerve roots C7, C8, and T1 in all cases. There was no evidence of an iatrogenic effect on the donor forelimb. Gradual improvement in function of the affected forelimb occurred in all dogs, with eventual recovery of voluntary elbow extension. Reinnervation was evident in EMG recordings 6 months postoperatively in all three dogs. Stimulation of the donor C8 ventral branch led to motor evoked potentials in the avulsed side triceps brachialis and radial carpus extensor muscles. Variable functional outcome was observed in the 3 dogs during clinical evaluation 3-4 years after surgery. Digital abrasion wounds, distal interphalangeal infectious arthritis, and self-mutilation necessitated distal phalanx amputation of digits 3 and 4 in 2 dogs. C8CT provided partial reconnection of the donor C8 ventral branch to the avulsed brachial plexus in the 3 dogs of this series. Reinnervation resulted in active elbow extension and promoted functional recovery in the affected limb. © 2017 The American College of Veterinary Surgeons.

Consideration of Dose Limits for Organs at Risk of Thoracic Radiotherapy: Atlas for Lung, Proximal Bronchial Tree, Esophagus, Spinal Cord, Ribs, and Brachial Plexus

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kong, Feng-Ming, E-mail: fengkong@med.umich.edu; Ritter, Timothy; Quint, Douglas J.

2011-12-01

Purpose: To review the dose limits and standardize the three-dimenional (3D) radiographic definition for the organs at risk (OARs) for thoracic radiotherapy (RT), including the lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus. Methods and Materials: The present study was performed by representatives from the Radiation Therapy Oncology Group, European Organization for Research and Treatment of Cancer, and Soutwestern Oncology Group lung cancer committees. The dosimetric constraints of major multicenter trials of 3D-conformal RT and stereotactic body RT were reviewed and the challenges of 3D delineation of these OARs described. Using knowledge of the human anatomy andmore » 3D radiographic correlation, draft atlases were generated by a radiation oncologist, medical physicist, dosimetrist, and radiologist from the United States and reviewed by a radiation oncologist and medical physicist from Europe. The atlases were then critically reviewed, discussed, and edited by another 10 radiation oncologists. Results: Three-dimensional descriptions of the lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus are presented. Two computed tomography atlases were developed: one for the middle and lower thoracic OARs (except for the heart) and one focusing on the brachial plexus for a patient positioned supine with their arms up for thoracic RT. The dosimetric limits of the key OARs are discussed. Conclusions: We believe these atlases will allow us to define OARs with less variation and generate dosimetric data in a more consistent manner. This could help us study the effect of radiation on these OARs and guide high-quality clinical trials and individualized practice in 3D-conformal RT and stereotactic body RT.« less

An Update on the Management of Neonatal Brachial Plexus Palsy-Replacing Old Paradigms: A Review.

PubMed

Smith, Brandon W; Daunter, Alecia K; Yang, Lynda J-S; Wilson, Thomas J

2018-06-01

Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, "all neonatal brachial plexus palsy recovers," "wait a year to see if recovery occurs," and "don't move the arm." Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms. Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function. Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved

Dexamethasone as a ropivacaine adjuvant for ultrasound-guided interscalene brachial plexus block: A randomized, double-blinded clinical trial.

PubMed

Sakae, Thiago Mamôru; Marchioro, Patricia; Schuelter-Trevisol, Fabiana; Trevisol, Daisson José

2017-05-01

The purpose of this study was to evaluate the effect of intravenous or perineural dexamethasone added to ropivacaine on the duration of ultrasound-guided interscalene brachial plexus blocks (BPB). Randomized clinical trial. Sixty ASA physical status I-II patients with elective shoulder arthroscopic surgeries under interscalene brachial plexus blocks were randomly allocated to receive 20ml of 0.75% ropivacaine with 1ml of isotonic saline (C group, n=20), 20ml of 0.75% ropivacaine with 1ml (4mg) of perineural dexamethasone (Dpn group, n=20), or 20ml of 0.75% ropivacaine with 1ml of isotonic saline and intravenous 4mg dexamethasone (IV) (Div group, n=20). A nerve stimulation technique with ultrasound was used in all patients. The onset time and duration of sensory blocks were assessed. Secondary outcomes were pain scores (VAS) and postoperative vomiting and nausea (PONV). The duration of the motor and sensory block was extended in group Dpn compared with group Div and group C (P<0.05). In addition, within 24h, group Dpn presented lower levels of VAS and lower incidence of PONV as compared with the other groups. Moreover, there was a significant reduction on onset time between group Dpn and the other groups. Perineural 4mg dexamethasone was more effective than intravenous in extending the duration of ropivacaine in ultrasound-guided interscalene BPB. Moreover, Dpn has significant effects on onset time, PONV, and VAS. Copyright © 2017 Elsevier Inc. All rights reserved.

A case study from a nursing and occupational therapy perspective - Providing care for a patient with a traumatic brachial plexus injury.

PubMed

Wellington, Beverley; McGeehan, Claire

2015-02-01

This paper presents a case study that demonstrates how collaborative working between professionals enhanced the holistic care for a patient following a traumatic brachial plexus injury. The paper will describe the patient's journey of care from initial presentation, diagnosis and assessment, acute care provision, discharge & rehabilitation to ongoing supportive counselling. The care encompasses input from both a nursing and occupational therapy perspective. Copyright © 2014 Elsevier Ltd. All rights reserved.

Shoulder arthrodesis in adult brachial plexus injury: what is the optimal position?

PubMed

Sousa, R; Pereira, A; Massada, M; Trigueiros, M; Lemos, R; Silva, C

2011-09-01

Brachial plexus injuries are a major indication for shoulder arthrodesis. However, there is no consensus concerning the optimal position of the glenohumeral joint for fusion. Between 1997 and 2008, 19 shoulder arthrodeses were performed using pelvic reconstruction plates. The radiographic and functional characteristics of 13 patients of mean age 46 years were examined at a mean of 101 months after arthrodesis. Arthrodeses showed 30° mean angle of abduction, 32° forward flexion and 44° internal rotation of the humerus with respect to the scapula. Abduction >35° and forward flexion ≥30° seem to offer slightly better functional results. Internal rotation ≤45° significantly relates to better ability of the hand to reach the face (p = 0.012). Neither abduction >35° nor forward flexion ≥30° showed a higher prevalence of periscapular pain. Abduction around 35° and forward flexion around 30° are needed for good functional results. Internal rotation should not exceed 45°.

Biceps Tendon Lengthening Surgery for Failed Serial Casting Patients With Elbow Flexion Contractures Following Brachial Plexus Birth Injury.

PubMed

Nath, Rahul K; Somasundaram, Chandra

2016-01-01

Assessment of surgical outcomes of biceps tendon lengthening (BTL) surgery in obstetric brachial plexus injury (OBPI) patients with elbow flexion contractures, who had unsuccessful serial casting. Serial casting and splinting have been shown to be effective in correcting elbow flexion contractures in OBPI. However, the possibilities of radial head dislocations and other complications have been reported in serial casting and splinting. Literature indicates surgical intervention when such nonoperative techniques and range-of-motion exercises fail. Here, we demonstrated a significant reduction of the contractures of the affected elbow and improvement in arm length to more normal after BTL in these patients, who had unsuccessful serial casting. Ten OBPI patients (6 girls and 4 boys) with an average age of 11.2 years (4-17.7 years) had BTL surgery after unsuccessful serial casting. Mean elbow flexion contracture was 40° before and 37° (average) after serial casting. Mean elbow flexion contracture was reduced to 8° (0°-20°) post-BTL surgical procedure with an average follow-up of 11 months. This was 75% improvement and statistically significant (P < .001) when compared to 7% insignificant (P = .08) improvement after serial casting. These OBPI patients in our study had 75% significant reduction in elbow flexion contractures and achieved an improved and more normal length of the affected arm after the BTL surgery when compared to only 7% insignificant reduction and no improvement in arm length after serial casting.

Contributions of muscle imbalance and impaired growth to postural and osseous shoulder deformity following brachial plexus birth palsy: a computational simulation analysis.

PubMed

Cheng, Wei; Cornwall, Roger; Crouch, Dustin L; Li, Zhongyu; Saul, Katherine R

2015-06-01

Two potential mechanisms leading to postural and osseous shoulder deformity after brachial plexus birth palsy are muscle imbalance between functioning internal rotators and paralyzed external rotators and impaired longitudinal growth of paralyzed muscles. Our goal was to evaluate the combined and isolated effects of these 2 mechanisms on transverse plane shoulder forces using a computational model of C5-6 brachial plexus injury. We modeled a C5-6 injury using a computational musculoskeletal upper limb model. Muscles expected to be denervated by C5-6 injury were classified as affected, with the remaining shoulder muscles classified as unaffected. To model muscle imbalance, affected muscles were given no resting tone whereas unaffected muscles were given resting tone at 30% of maximal activation. To model impaired growth, affected muscles were reduced in length by 30% compared with normal whereas unaffected muscles remained normal in length. Four scenarios were simulated: normal, muscle imbalance only, impaired growth only, and both muscle imbalance and impaired growth. Passive shoulder rotation range of motion and glenohumeral joint reaction forces were evaluated to assess postural and osseous deformity. All impaired scenarios exhibited restricted range of motion and increased and posteriorly directed compressive glenohumeral joint forces. Individually, impaired muscle growth caused worse restriction in range of motion and higher and more posteriorly directed glenohumeral forces than did muscle imbalance. Combined muscle imbalance and impaired growth caused the most restricted joint range of motion and the highest joint reaction force of all scenarios. Both muscle imbalance and impaired longitudinal growth contributed to range of motion and force changes consistent with clinically observed deformity, although the most substantial effects resulted from impaired muscle growth. Simulations suggest that treatment strategies emphasizing treatment of impaired longitudinal

Spinal accessory nerve to triceps muscle transfer using long autologous nerve grafts for recovery of elbow extension in traumatic brachial plexus injuries.

PubMed

Bulstra, Liselotte F; Rbia, Nadia; Kircher, Michelle F; Spinner, Robert J; Bishop, Allen T; Shin, Alexander Y

2017-12-08

OBJECTIVE Reconstructive options for brachial plexus lesions continue to expand and improve. The purpose of this study was to evaluate the prevalence and quality of restored elbow extension in patients with brachial plexus injuries who underwent transfer of the spinal accessory nerve to the motor branch of the radial nerve to the long head of the triceps muscle with an intervening autologous nerve graft and to identify patient and injury factors that influence functional triceps outcome. METHODS A total of 42 patients were included in this retrospective review. All patients underwent transfer of the spinal accessory nerve to the motor branch of the radial nerve to the long head of the triceps muscle as part of their reconstruction plan after brachial plexus injury. The primary outcome was elbow extension strength according to the modified Medical Research Council muscle grading scale, and signs of triceps muscle recovery were recorded using electromyography. RESULTS When evaluating the entire study population (follow-up range 12-45 months, mean 24.3 months), 52.4% of patients achieved meaningful recovery. More specifically, 45.2% reached Grade 0 or 1 recovery, 19.1% obtained Grade 2, and 35.7% improved to Grade 3 or better. The presence of a vascular injury impaired functional outcome. In the subgroup with a minimum follow-up of 20 months (n = 26), meaningful recovery was obtained by 69.5%. In this subgroup, 7.7% had no recovery (Grade 0), 19.2% had recovery to Grade 1, and 23.1% had recovery to Grade 2. Grade 3 or better was reached by 50% of patients, of whom 34.5% obtained Grade 4 elbow extension. CONCLUSIONS Transfer of the spinal accessory nerve to the radial nerve branch to the long head of the triceps muscle with an interposition nerve graft is an adequate option for restoration of elbow extension, despite the relatively long time required for reinnervation. The presence of vascular injury impairs functional recovery of the triceps muscle, and the use of

Lack of effectiveness of primary conservative management for infants with brachial plexus birth palsy.

PubMed

Bialocerkowski, Andrea Emmi; Vladusic, Sharon; Moore, Rosemary Patricia

Brachial plexus birth palsy (BPBP) is the most common peripheral nerve injury in children (prevalence <5.1 per 1000 live births) and conservative management is routinely used to manage them. We have previously systematically reviewed studies investigating primary conservative management, published between 1992 and 2002, and found these to be inconclusive. The aim of this review was to update our previous systematic review to include studies published between 2002 and 2008, synthesise the data thus obtained with that of our previous review and create an up-to-date body of evidence for conservative management of infants with BPBP. Fifteen databases were searched systematically for quantitative studies (randomised controlled trials, comparative studies, case series), published in English between January 2002 and June 2008 inclusive. Studies were excluded if they investigated infants who, in their first two years of life, underwent microsurgical repair of the brachial plexus, surgical management of secondary deformities or received other treatments traditionally delivered by surgeons, such as Botulinum toxin injections. The eligibility of each study identified from the database searches was evaluated against the inclusion criteria by two independent reviewers. These studies were then critically appraised for level of evidence using the National Health and Medical Research Council of Australia Hierarchy of Evidence and methodological quality using the Critical Review Form - Quantitative Studies. Data pertaining to the demographic characteristics of study participants, treatments received, main results and outcome measures used were also extracted. Where any disagreement between reviewers occurred, consensus was reached by discussion. Data from the recently published studies were narratively synthesised and then combined with the data gained from our previous systematic review to create a body of evidence on primary conservative management for BPBP infants. Four

[Pulley for strengthening a muscle replacement operation across two joints in brachial plexus lesion: description of the surgical technique].

PubMed

Berger, A; Schaller, E; Becker, M H

1994-01-01

The reconstruction of lost muscle functions in cases of brachial plexus lesion is possible even in those cases where primary nerve reconstruction was not performed or unsuccessful. If there are only few motor nerves available, we prefer free latissimus dorsi transplantation or pedicled latissimus dorsi transposition for replacement of biceps and finger flexors. The combination of elbow flexion and finger flexion becomes possible when the transposed motor is passed around a suitable pulley in the elbow region like the flexor carpi ulnaris or carpi radialis.

Risk factors for brachial plexus injury in a large cohort with shoulder dystocia.

PubMed

Volpe, Katherine A; Snowden, Jonathan M; Cheng, Yvonne W; Caughey, Aaron B

2016-11-01

To examine birthweight and other predictors of brachial plexus injury (BPI) among births complicated by shoulder dystocia. A retrospective cohort study of term births complicated by shoulder dystocia in California between 1997 and 2006. Birthweight at time of delivery was stratified into 500-g intervals. Women were further stratified by diabetes status, parity, and race/ethnicity. The perinatal outcome of BPI was assessed. This study included 62,762 deliveries complicated by shoulder dystocia, of which 3168 (5 %) resulted in BPI. The association between birthweight and BPI remained significant regardless of confounders. Each increasing birthweight interval was associated with an increasing risk of BPI compared with 3000-3499-g birthweight. Race/ethnicity, diabetes, and parity were also independently associated with BPI. Increasing birthweight increases the risk of BPI among births with shoulder dystocia, independent of advanced maternal age, race, parity, gestational diabetes, or operative vaginal delivery.

Biceps Tendon Lengthening Surgery for Failed Serial Casting Patients With Elbow Flexion Contractures Following Brachial Plexus Birth Injury

PubMed Central

Somasundaram, Chandra

2016-01-01

Objective: Assessment of surgical outcomes of biceps tendon lengthening (BTL) surgery in obstetric brachial plexus injury (OBPI) patients with elbow flexion contractures, who had unsuccessful serial casting. Background: Serial casting and splinting have been shown to be effective in correcting elbow flexion contractures in OBPI. However, the possibilities of radial head dislocations and other complications have been reported in serial casting and splinting. Literature indicates surgical intervention when such nonoperative techniques and range-of-motion exercises fail. Here, we demonstrated a significant reduction of the contractures of the affected elbow and improvement in arm length to more normal after BTL in these patients, who had unsuccessful serial casting. Methods and Patients: Ten OBPI patients (6 girls and 4 boys) with an average age of 11.2 years (4-17.7 years) had BTL surgery after unsuccessful serial casting. Results: Mean elbow flexion contracture was 40° before and 37° (average) after serial casting. Mean elbow flexion contracture was reduced to 8° (0°-20°) post-BTL surgical procedure with an average follow-up of 11 months. This was 75% improvement and statistically significant (P < .001) when compared to 7% insignificant (P = .08) improvement after serial casting. Conclusion: These OBPI patients in our study had 75% significant reduction in elbow flexion contractures and achieved an improved and more normal length of the affected arm after the BTL surgery when compared to only 7% insignificant reduction and no improvement in arm length after serial casting. PMID:27648115

The efficacy of adding dexamethasone, midazolam, or epinephrine to 0.5% bupivacaine in supraclavicular brachial plexus block.

PubMed

El-Baradey, Ghada F; Elshmaa, Nagat S

2014-11-01

The aim was to assess the effectiveness of adding either dexamethasone or midazolam in comparison with epinephrine addition to 0.5% bupivacaine in supraclavicular brachial plexus block. This is a prospective randomized controlled observer-blinded study. This study was carried out in Tanta University Hospital on 60 patients of both sexes; American Society of Anesthesiologists physical Status I and II, age range from 18 to 45 years undergo elective surgery to upper limb. All patients were anesthetized with ultrasound guided supraclavicular brachial plexus block and randomly divided into three groups (each group 20 patients) Group E (epinephrine): 30 mL bupivacaine 0.5%with 1:200,000 epinephrine (5 μg/mL). Group D (dexamethasone): 30 mL bupivacaine 0.5% and dexamethasone 8 mg. Group M (midazolam): 30 ml bupivacaine 0.5% and midazolam 50 μg/kg. The primary outcome measures were onset and duration of sensory and motor block and time to first analgesic request. The windows version of SPSS 11.0.1 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Data were presented in form of mean ± standard deviation multiple analysis of variance (ANOVA) was used to compare the three groups and Scheffe test was used after ANOVA. Power of significance P < 0.05 was considered to be statistically significant. Onset of sensory and motor block was significantly rapid (P < 0.05) in Groups D and M in comparison with Group E. Time of administration of rescue analgesic, duration of sensory and motor block showed significant increase (P < 0.05) in Group D in comparison with Group M which showed significant increase (P < 0.05) in comparison with Group E. In comparison with epinephrine and midazolam addition of dexamethasone to bupivacaine had rapid onset of block and longer time to first analgesic request with fewer side-effects.

Inflammation and neuropathic attacks in hereditary brachial plexus neuropathy

PubMed Central

Klein, C; Dyck, P; Friedenberg, S; Burns, T; Windebank, A; Dyck, P

2002-01-01

Objective: To study the role of mechanical, infectious, and inflammatory factors inducing neuropathic attacks in hereditary brachial plexus neuropathy (HBPN), an autosomal dominant disorder characterised by attacks of pain and weakness, atrophy, and sensory alterations of the shoulder girdle and upper limb muscles. Methods: Four patients from separate kindreds with HBPN were evaluated. Upper extremity nerve biopsies were obtained during attacks from a person of each kindred. In situ hybridisation for common viruses in nerve tissue and genetic testing for a hereditary tendency to pressure palsies (HNPP; tomaculous neuropathy) were undertaken. Two patients treated with intravenous methyl prednisolone had serial clinical and electrophysiological examinations. One patient was followed prospectively through pregnancy and during the development of a stereotypic attack after elective caesarean delivery. Results: Upper extremity nerve biopsies in two patients showed prominent perivascular inflammatory infiltrates with vessel wall disruption. Nerve in situ hybridisation for viruses was negative. There were no tomaculous nerve changes. In two patients intravenous methyl prednisolone ameliorated symptoms (largely pain), but with tapering of steroid dose, signs and symptoms worsened. Elective caesarean delivery did not prevent a typical postpartum attack. Conclusions: Inflammation, probably immune, appears pathogenic for some if not all attacks of HBPN. Immune modulation may be useful in preventing or reducing the neuropathic attacks, although controlled trials are needed to establish efficacy, as correction of the mutant gene is still not possible. The genes involved in immune regulation may be candidates for causing HBPN disorders. PMID:12082044

Short-term Clinical Results of Manipulation Under Ultrasound-Guided Brachial Plexus Block in Patients with Idiopathic Frozen Shoulder and Diabetic Secondary Frozen Shoulder.

PubMed

Ando, Akira; Hamada, Junichiro; Hagiwara, Yoshihiro; Sekiguchi, Takuya; Koide, Masashi; Itoi, Eiji

2018-01-01

This study examined the effectiveness of manipulation under ultrasound-guided brachial plexus block in patients with recalcitrant idiopathic frozen shoulder and diabetic secondary frozen shoulder (diabetic frozen shoulder). Forty-four idiopathic frozen shoulders and 10 diabetic frozen shoulders with failed conservative treatment for at least 3 months were included in this study. The manipulation was performed under ultrasound-guided brachial plexus block and visual analogue scale, range of motion, and Constant scores were measured before manipulation and at the last follow-up examination. No major complications were observed during the procedure. Sufficient improvement was not obtained in two patients during the procedure and to avoid complications, the procedure was discontinued and subsequently arthroscopic capsular release was performed. Visual analogue scale, range of motion towards all directions, and Constant scores were significantly improved after the manipulation in both the idiopathic frozen shoulder and diabetic frozen shoulder groups, however the diabetic group showed inferior results compared with those of the idiopathic group. This manipulation was effective and shortened the duration of symptoms in most of the idiopathic and diabetic frozen shoulders without major complications during the procedure. Diabetic frozen shoulder showed inferior clinical results and difficulty in recovery in range of motion, which indicated that diabetic frozen shoulder should be discussed as a different entity.

The application of paramagnetic contrast-based T2 effect to 3D heavily T2W high-resolution MR imaging of the brachial plexus and its branches.

PubMed

Wang, Lixia; Niu, Yanfeng; Kong, Xiangquan; Yu, Qun; Kong, Xiangchuang; Lv, Yinzhang; Shi, Heshui; Li, Chungao; Wu, Wenjun; Wang, Bing; Liu, Dingxi

2016-03-01

To introduce a new 3D magnetic resonance neurography (MRN) method involving a paramagnetic contrast-based T2 effect coupled with an advanced 3D heavily T2W SPACE-STIR high resolution imaging sequence that would enhance the contrast between nervous tissue and surrounding tissues. Thirty subjects (average age, 39.6±17.0 years; 18 male and 12 female) were enrolled, including three patients with brachial plexopathy and 27 healthy volunteers. Subjective scores from two neuroradiologists, evaluating noncontrast MRN (cMRN) and 3D SPACE-STIR contrast enhanced MRN (ceMRN) 3D data using a 3-point scoring system, were compared using Wilcoxon signed-rank test. Contrast-to-noise ratios (CNRs), SNRs, and contrast ratios within the brachial plexus on cMRN vs. ceMRN MIP and source images were also compared using the paired t-test. The average score for cMRN (0.77±0.43) was significantly lower than ceMRN (1.73±0.45) (p<0.001). Lower nerve vs. vein CNRs were found on cMRN vs. ceMRN, respectively (p<0.001 for both source and MIP images). All nerve-to-surrounding tissue contrast ratios (i.e., fat, muscle, veins, and bone) were higher for ceMRN compared with cMRN for both source and MIP images (all p<0.05). The improved 3D visualization of the brachial plexus and its branches, using this new contrast-enhanced MRN method, can provide high resolution imaging which may be of significant value in the assessment of brachial plexopathy. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Serial casting for elbow flexion contractures in neonatal brachial plexus palsy.

PubMed

Duijnisveld, B J; Steenbeek, D; Nelissen, R G H H

2016-09-02

The objective of this study was to evaluate the effectiveness of serial casting of elbow flexion contractures in neonatal brachial plexus palsy. A prospective consecutive cohort study was performed with a median follow-up of 5 years. Forty-one patients with elbow flexion contractures ≥ 30° were treated with serial casting until the contracture was ≤ 10°, for a maximum of 8 weeks. Range of motion, number of recurrences and patient satisfaction were recorded and analyzed using Wilcoxon signed-rank and Cox regression tests. Passive extension increased from a median of -40° (IQR -50 to -30) to -15° (IQR -10 to -20, p < 0.001). Twenty patients showed 37 recurrences. The baseline severity of passive elbow extension had a hazard ratio of 0.93 (95% CI 0.89 to 0.96, p < 0.001) for first recurrence. Median patient satisfaction was moderate. Four patients showed loss of flexion mobility and in two patients serial casting had to be prematurely replaced by night splinting due to complaints. Serial casting improved elbow flexion contractures, although recurrences were frequent. The severity of elbow flexion contracture is a predictor of recurrence. We recommend more research on muscle degeneration and determinants involved in elbow flexion contractures to improve treatment strategies and prevent side-effects.

An early shoulder repositioning program in birth-related brachial plexus injury: a pilot study of the Sup-ER protocol.

PubMed

Verchere, Cynthia; Durlacher, Kim; Bellows, Doria; Pike, Jeffrey; Bucevska, Marija

2014-06-01

Birth-related brachial plexus injury (BRBPI) occurs in 1.2/1,000 births in British Columbia. Even in children with "good" recovery, external rotation (ER) and supination (Sup) are often weaker, and permanent skeletal imbalance ensues. A preventive early infant shoulder passive repositioning program was created using primarily a novel custom splint holding the affected arm in full ER and Sup: the Sup-ER splint. The details of the splint and the shoulder repositioning program evolved with experience over several years. This study reviews the first 4 years. A retrospective review of BCCH patients managed with the Sup-ER protocol from 2008 to 2011 compared their recovery scores to matched historical controls selected from our database by two independent reviewers. The protocol was initiated in 18 children during the study period. Six were excluded due to the following: insufficient data points, non-compliance, late splint initiation, and loss to follow-up. Of the 12 matches, the Sup-ER group final score at 2 years was better than controls by 1.18 active movement scale (AMS) points (p = 0.036) in Sup and 0.96 AMS points in ER (but not statistically significant (p = 0.13)). Unexpectedly, but importantly, during the study period, zero subjects were assessed to have the active functional criteria to indicate brachial plexus reconstruction, where previously we operated on 13 %. Early application of passive shoulder repositioning into Sup and ER may improve outcomes in function of the arm in infants with BRBPI. A North American multi-site randomized control trial has been approved and has started recruitment.

Nerve transfer to relieve pain in upper brachial plexus injuries: Does it work?

PubMed

Emamhadi, Mohammadreza; Andalib, Sasan

2017-12-01

Patients with C5 and C6 nerve root avulsion may complain from pain. For these patients, end-to-side nerve transfer of the superficial radial nerve into the median nerve is suggested to relieve pain. Eleven patients (with a primary brachial plexus reconstruction) undergoing end-to-side nerve transfer of the superficial radial nerve into the ulnovolar part of the median nerve were assessed. Pain before surgery was compared to that at 6-month follow-up using visual analog scale (VAS) scores. A significant difference was seen between the mean VAS before (8.5) and after surgery (0.7) (P=0.0). After the six-month follow-up, 6 patients felt no pain according to VAS, notwithstanding 5 patients with a mild pain. The evidence from the present study suggests that end-to-side nerve transfer of the superficial radial nerve into the ulnovolar part of the median nerve is an effective technique in reducing pain in patients with C5 and C6 nerve root avulsion. Copyright © 2017 Elsevier B.V. All rights reserved.

Outcome in adolescence of brachial plexus birth palsy

PubMed Central

Hulleberg, Gunn; Elvrum, Ann-Kristin G; Brandal, Merethe; Vik, Torstein

2014-01-01

Background and purpose — The frequency and severity of a permanent lesion after brachial plexus birth palsy (BPBP) and its impact on activities of daily living are not well documented. We therefore investigated the outcome of BPBP in adolescents, regarding arm function and consequences for activity and participation. Participants and methods — Of 30,574 babies born at St. Olavs University Hospital in 1991–2000, 91 had BPBP (prevalence 3 per 1,000), and 69 of these individuals were examined at a median age of 14 (10–20) years. The examination included the modified Mallet classification, range of motion, shoulder rotation and grip strength, Assisting Hand Assessment, and Canadian Occupational Performance Measure. Of the 22 subjects who were not examined, 3 could not be traced and 19 reported having no problems in the affected arm. Results — At follow-up, 17 adolescents had a permanent lesion (i.e. individual Mallet subscore below 4) with a median Mallet total score of 15 (9–19), while 52 had good or normal shoulder function (median Mallet total score 25 (23–25)). All participants with a permanent lesion had reduced active shoulder rotation (≤ 15°), 16 had elbow extension deficit, and 10 had subnormal grip strength. External rotation was considerably weaker in the affected shoulder. In addition, they had ineffective use of the affected arm in bimanual activities. Even so, all except 1 were independent in activities of daily living, although 15 experienced minor difficulties. Interpretation — Every fourth to fifth child with BPBP had a permanent lesion as an adolescent. External rotation was the most impaired movement. Despite ineffective use of the affected arm in bimanual activities, all of the participants except one were independent in activities of daily living. PMID:25238434

Effect of perineural dexmedetomidine on the quality of supraclavicular brachial plexus block with 0.5% ropivacaine and its interaction with general anaesthesia.

PubMed

Gurajala, Indira; Thipparampall, Anil Kumar; Durga, Padmaja; Gopinath, R

2015-02-01

The effect of perineural dexmedetomidine on the time to onset, quality and duration of motor block with ropivacaine has been equivocal and its interaction with general anaesthesia (GA) has not been reported. We assessed the influence of dexmedetomidine added to 0.5% ropivacaine on the characteristics of supraclavicular brachial plexus block and its interaction with GA. In a randomised, double blind study, 36 patients scheduled for orthopaedic surgery on the upper limb under supraclavicular block and GA were divided into either R group (35 ml of 0.5% ropivacaine with 0.5 ml of normal saline [n - 18]) or RD group (35 mL of 0.5% ropivacaine with 50 μg dexmedetomidine [n - 18]). The onset time and duration of motor and sensory blockade were noted. The requirement of general anaesthetics was recorded. Both the groups were comparable in demographic characteristics. The time of onset of sensory block was not significantly different. The proportion of patients who achieved complete motor blockade was more in the RD group. The onset of motor block was earlier in group RD than group R (P < 0.05). The durations of analgesia, sensory and motor blockade were significantly prolonged in group RD (P < 0.00). The requirement of entropy guided anaesthetic agents was not different in both groups. The addition of dexmedetomidine to 0.5% ropivacaine improved the time of onset, quality and duration of supraclavicular brachial plexus block but did not decrease the requirement of anaesthetic agents during GA.

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

PubMed

Wade, Ryckie G; Takwoingi, Yemisi; Wormald, Justin C R; Ridgway, John P; Tanner, Steven; Rankine, James J; Bourke, Grainne

2018-05-19

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

Results of Operative Treatment of Brachial Plexus Injury Resulting from Shoulder Dislocation: A Study with A Long-Term Follow-Up.

PubMed

Gutkowska, Olga; Martynkiewicz, Jacek; Mizia, Sylwia; Bąk, Michał; Gosk, Jerzy

2017-09-01

Injury to the infraclavicular brachial plexus is an uncommon but serious complication of shoulder dislocation. This work aims to determine the effectiveness of operative treatment in patients with this type of injury. Thirty-three patients (26 men and 7 women; mean age, 45 years and 3 months) treated operatively for brachial plexus injury resulting from shoulder dislocation between the years 2000 and 2013 were included in this retrospective case series. Motor function of affected limbs was assessed pre- and postoperatively with the use of the British Medical Research Council (BMRC) scale. Sensory function in the areas innervated by ulnar and median nerves was evaluated with the BMRC scale modified by Omer and Dellon and in the remaining areas with the Highet classification. Follow-up lasted 2-10 years (mean, 5.1 years). Good postoperative recovery of nerve function was observed in 100% of musculocutaneous, 93.3% of radial, 66.7% of median, 64% of axillary, and 50% of ulnar nerve injuries. No recovery was observed in 5.6% of median, 6.7% of radial, 10% of ulnar, and 20% of axillary nerve injuries. Injury to a single nerve was associated with worse treatment outcome than multiple nerve injury. Obtaining improvement in peripheral nerve function after injury resulting from shoulder dislocation may require operative intervention. The type of surgical procedure depends on intraoperative findings: sural nerve grafting in cases of neural elements' disruption, internal neurolysis when intraneural fibrosis is observed, and external neurolysis in the remaining cases. The outcomes of surgical treatment are good, and the risk of intra- and postoperative complications is low. Copyright © 2017 Elsevier Inc. All rights reserved.

Brachial plexus endoscopic dissection and correlation with open dissection.

PubMed

Lafosse, T; Masmejean, E; Bihel, T; Lafosse, L

2015-12-01

Shoulder endoscopy is evolving and becoming extra-articular. More and more procedures are taking place in the area of the brachial plexus (BP). We carried out an anatomical study to describe the endoscopic anatomy of the BP and the technique used to dissect and expose the BP endoscopically. Thirteen fresh cadavers were dissected. We first performed an endoscopic dissection of the BP, using classical extra-articular shoulder arthroscopy portals. Through each portal, we dissected as many structures as possible and identified them. We then did an open dissection to corroborate the endoscopic findings and to look for damage to the neighboring structures. In the supraclavicular area, we were able to expose the C5, C6 and C7 roots, and the superior and middle trunks in 11 of 13 specimens through two transtrapezial portals by following the suprascapular nerve. The entire infraclavicular portion of the BP (except the medial cord and its branches) was exposed in 11 of 13 specimens. The approach to the infraclavicular portion of the BP led directly to the lateral and posterior cords, but the axillary artery hid the medial cord. The musculocutaneous nerve was the first nerve encountered when dissecting medially from the anterior aspect of the coracoid process. The axillary nerve was the first nerve encountered when following the anterior border of the subscapularis medially from the posterior aspect of the coracoid process. Knowledge of the endoscopic anatomy of the BP is mandatory to expose and protect this structure while performing advanced arthroscopic shoulder procedures. Copyright © 2015 SFCM. Published by Elsevier Masson SAS. All rights reserved.

The obstetric nightmare of shoulder dystocia: a tale from two perspectives.

PubMed

Beck, Cheryl Tatano

2013-01-01

Shoulder dystocia is one of the most terrifying of obstetric emergencies. In this secondary analysis of two qualitative studies, the experiences of shoulder dystocia are compared and contrasted from two perspectives: the mothers and the labor and delivery nurses. In the first study mothers' experiences of shoulder dystocia and caring for their children with obstetric brachial plexus injuries were explored. The second study explored secondary traumatic stress in labor and delivery nurses due to exposure to traumatic births. Krippendorff's content analysis technique of clustering was used to identify data that could be grouped together into themes. It was striking how similar the perspectives of mothers and their nurses were regarding a shoulder dystocia birth. Four themes emerged from the content analysis of these two data sets: (1) in the midst of the obstetric nightmare; (2) reeling from the trauma that just transpired; (3) enduring heartbreak: the heavy toll on mothers; and (4) haunted by memories: the heavy toll on nurses. Providing emotional support to the mother during shoulder dystocia births and afterward in the postpartum period has been acknowledged. What now needs to be added to best practices for shoulder dystocia are interventions for the nurses themselves. Support for labor and delivery nurses who are involved in this obstetric nightmare is critical.

Neonatal Magnetic Resonance Imaging Without Sedation Correlates With Injury Severity in Brachial Plexus Birth Palsy.

PubMed

Bauer, Andrea S; Shen, Peter Y; Nidecker, Anna E; Lee, Paul S; James, Michelle A

2017-05-01

Which infants with brachial plexus birth palsy (BPBP) should undergo microsurgical plexus reconstruction remains controversial. The current gold standard for the decision for plexus reconstruction is serial clinical examinations, but this approach obviates the possibility of early surgical treatment. We hypothesize that a new technique using 3-dimensional volumetric proton density magnetic resonance imaging (MRI) without sedation can evaluate the severity of BPBP injury earlier than serial clinical examinations. Infants were prospectively enrolled prior to 12 weeks of age and imaged using 3 Tesla MRI without sedation. Clinical scores were collected at all visits. The imaging findings were graded based on the number of injured levels and the severity of each injury, and a radiological score was calculated. All infants were followed at least until the decision for surgery was made based on clinical examination. Nine infants completed the MRI scan and clinical follow-up. The average Toronto score at presentation was 4.4 out of 10 (range, 0-8.2); the average Active Movement Scale score was 50 out of 105 (range, 0-86). Four infants required surgery: 2 because of a flail limb and Horner syndrome and 2 owing to failure to recover antigravity elbow flexion by age 6 months. Radiological scores ranged from 0 to 18 out of a maximum score of 25. The average radiological score for those infants who required surgery was 12 (range, 6.5-18), whereas the average score for infants who did not require surgery was 3.5 (range, 0-8). Three-dimensional proton density MRI can evaluate spinal nerve roots in infants without the need for radiation, contrast agents, or sedation. These data suggest that MRI can help determine the severity of injury earlier than clinical examination in infants with BPBP, although further study of a larger sample of infants with varying severity of disease is necessary. Diagnostic II. Copyright © 2017 American Society for Surgery of the Hand. Published by

Pre-operative brachial plexus block compared with an identical block performed at the end of surgery: a prospective, double-blind, randomised clinical trial.

PubMed

Holmberg, A; Sauter, A R; Klaastad, Ø; Draegni, T; Raeder, J C

2017-08-01

We evaluated whether pre-emptive analgesia with a pre-operative ultrasound-guided infraclavicular brachial plexus block resulted in better postoperative analgesia than an identical block performed postoperatively. Fifty-two patients undergoing fixation of a fractured radius were included. All patients received general anaesthesia with remifentanil and propofol. Patients were randomly allocated into two groups: a pre-operative block or a postoperative block with 0.5 ml.kg -1 ropivacaine 0.75%. After surgery, all patients received regular paracetamol plus opioids for breakthrough pain. Mean (SD) time to first rescue analgesic after emergence from general anaesthesia was 544 (217) min in the pre-operative block group compared with 343 (316) min in the postoperative block group (p = 0.015). Postoperative pain scores were higher and more patients required rescue analgesia during the first 4 h after surgery in the postoperative block group. There were no significant differences in plasma stress mediators between the groups. Analgesic consumption was lower at day seven in the pre-operative block group. Pain was described as very strong at block resolution in 27 (63%) patients and 26 (76%) had episodes of mild pain after 6 months. We conclude that a pre-operative ultrasound-guided infraclavicular brachial plexus block provides longer and better analgesia in the acute postoperative period compared with an identical postoperative block in patients undergoing surgery for fractured radius. © 2017 The Association of Anaesthetists of Great Britain and Ireland.

Rehabilitation of patient with brachial plexus lesion and break in axillary artery. Case study.

PubMed

Bajuk, S; Jelnikar, T; Ortar, M

1996-01-01

This paper describes the physiotherapy and occupational therapy used in treating a 74-year-old woman with a left brachial plexus lesion, a break in the axillary artery, dislocation of the acromioclavicular joint, a broken scapula and clavicula, serial left rib fractures, and lacerations on the upper and lower arm. After testing the patient, the following goals were set: reduce pain, soften scar tissue, and improve joint motion, muscle strength, and functionality of the hand. A 12-month outpatient program was used. Various analgesics were used to reduce pain, and a special aid was made to unweight the shoulder and elbow joints. Physiotherapy included kinesiotherapy, audiovisual biofeedback, electrical stimulation, friction massage, and lymph drainage. Occupational therapy included active functional exercises and re-education. As a result of this program, the patient no longer had pain, passive range of motion was close to normal, active motion where present was improved, swelling was reduced, and the hand became functional again. Complex physiotherapy, occupational therapy, and the patient's motivation resulted in the rehabilitation of severe trauma of the hand.

Evaluation of Internal Construct Validity and Unidimensionality of the Brachial Assessment Tool, A Patient-Reported Outcome Measure for Brachial Plexus Injury.

PubMed

Hill, Bridget; Pallant, Julie; Williams, Gavin; Olver, John; Ferris, Scott; Bialocerkowski, Andrea

2016-12-01

To evaluate the internal construct validity and dimensionality of a new patient-reported outcome measure for people with traumatic brachial plexus injury (BPI) based on the International Classification of Functioning, Disability and Health definition of activity. Cross-sectional study. Outpatient clinics. Adults (age range, 18-82y) with a traumatic BPI (N=106). There were 106 people with BPI who completed a 51-item 5-response questionnaire. Responses were analyzed in 4 phases (missing responses, item correlations, exploratory factor analysis, and Rasch analysis) to evaluate the properties of fit to the Rasch model, threshold response, local dependency, dimensionality, differential item functioning, and targeting. Not applicable, as this study addresses the development of an outcome measure. Six items were deleted for missing responses, and 10 were deleted for high interitem correlations >.81. The remaining 35 items, while demonstrating fit to the Rasch model, showed evidence of local dependency and multidimensionality. Items were divided into 3 subscales: dressing and grooming (8 items), arm and hand (17 items), and no hand (6 items). All 3 subscales demonstrated fit to the model with no local dependency, minimal disordered thresholds, no unidimensionality or differential item functioning for age, time postinjury, or self-selected dominance. Subscales were combined into 3 subtests and demonstrated fit to the model, no misfit, and unidimensionality, allowing calculation of a summary score. This preliminary analysis supports the internal construct validity of the Brachial Assessment Tool, a unidimensional targeted 4-response patient-reported outcome measure designed to solely assess activity after traumatic BPI regardless of level of injury, age at recruitment, premorbid limb dominance, and time postinjury. Further examination is required to determine test-retest reliability and responsiveness. Copyright © 2016 American Congress of Rehabilitation Medicine

Congenital symmetrical weakness of the upper limbs resembling brachial plexus palsy: a possible sequel of drug toxicity in first trimester of pregnancy?

PubMed

Philpot, J; Muntoni, F; Skellett, S; Dubowitz, V

1995-01-01

We report a 14-month-old girl with a symmetrical paralysis from birth, limited to the upper limbs and resembling a severe, complete bilateral brachial plexus palsy. The presence of dimples over the wrists, shoulders and scapulae and abnormal palmar dermatoglyphics suggested an early prenatal onset. Previous reports and the course of the disease in our case suggest this sporadic condition is not progressive. Although no definitive causative factor has been identified in previously reported cases, the affection in our case is possibly related to Debendox (Bendectin) and nitrofurantoin taken in early pregnancy for nausea and renal tract infection, respectively.

Computer adaptive test approach to the assessment of children and youth with brachial plexus birth palsy.

PubMed

Mulcahey, M J; Merenda, Lisa; Tian, Feng; Kozin, Scott; James, Michelle; Gogola, Gloria; Ni, Pengsheng

2013-01-01

This study examined the psychometric properties of item pools relevant to upper-extremity function and activity performance and evaluated simulated 5-, 10-, and 15-item computer adaptive tests (CATs). In a multicenter, cross-sectional study of 200 children and youth with brachial plexus birth palsy (BPBP), parents responded to upper-extremity (n = 52) and activity (n = 34) items using a 5-point response scale. We used confirmatory and exploratory factor analysis, ordinal logistic regression, item maps, and standard errors to evaluate the psychometric properties of the item banks. Validity was evaluated using analysis of variance and Pearson correlation coefficients. Results show that the two item pools have acceptable model fit, scaled well for children and youth with BPBP, and had good validity, content range, and precision. Simulated CATs performed comparably to the full item banks, suggesting that a reduced number of items provide similar information to the entire set of items. Copyright © 2013 by the American Occupational Therapy Association, Inc.

Transposition of branches of radial nerve innervating supinator to posterior interosseous nerve for functional reconstruction of finger and thumb extension in 4 patients with middle and lower trunk root avulsion injuries of brachial plexus.

PubMed

Wu, Xia; Cong, Xiao-Bing; Huang, Qi-Shun; Ai, Fang-Xin; Liu, Yu-Tian; Lu, Xiao-Cheng; Li, Jin; Weng, Yu-Xiong; Chen, Zhen-Bing

2017-12-01

This study aimed to investigate the reconstruction of the thumb and finger extension function in patients with middle and lower trunk root avulsion injuries of the brachial plexus. From April 2010 to January 2015, we enrolled in this study 4 patients diagnosed with middle and lower trunk root avulsion injuries of the brachial plexus via imaging tests, electrophysiological examinations, and clinical confirmation. Muscular branches of the radial nerve, which innervate the supinator in the forearm, were transposed to the posterior interosseous nerve to reconstruct the thumb and finger extension function. Electrophysiological findings and muscle strength of the extensor pollicis longus and extensor digitorum communis, as well as the distance between the thumb tip and index finger tip, were monitored. All patients were followed up for 24 to 30 months, with an average of 27.5 months. Motor unit potentials (MUP) of the extensor digitorum communis appeared at an average of 3.8 months, while MUP of the extensor pollicis longus appeared at an average of 7 months. Compound muscle action potential (CMAP) appeared at an average of 9 months in the extensor digitorum communis, and 12 months in the extensor pollicis longus. Furthermore, the muscle strength of the extensor pollicis longus and extensor digitorum communis both reached grade III at 21 months. Lastly, the average distance between the thumb tip and index finger tip was 8.8 cm at 21 months. In conclusion, for patients with middle and lower trunk injuries of the brachial plexus, transposition of the muscular branches of the radial nerve innervating the supinator to the posterior interosseous nerve for the reconstruction of thumb and finger extension function is practicable and feasible.

SU-F-R-06: Traumatic Brachial Plexus Injury Imaging, Developing a Coherent Clinical Protocol From Literature Review Through Practice

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wu, D; France, E; Lambert, J

Purpose: Medical Physics teams can now play a critical role to help plan and provide studied approaches for traumatic brachial plexus MR imaging (tbpMRI). This is especially important for coordination with uncommon applications, since it is challenging to select the right modality, parameters, and train technologists on the essential components. For this work, we started with a review of the medical literature, performed crossover/volunteer studies to bring tbpMRI to practice with greater image QC and protocol management. Methods: To the best of our knowledge, we reviewed the known searchable domain for tbpMRI. We found 69 total articles since 2000. Articlesmore » were evaluated with our published protocol for literature management (LIMES3). Two physicists and two radiologists condensed the information from all articles into a knowledgebase. Results: The initial literature demonstrated great heterogeneity, which was a sign that this area needed greater consistency. Despite inconsistency and imprecision, we extracted the most relevant targets using our long-term experience with protocol development in MSK. We ran volunteers on six different magnets of various field strengths with multiple receiver coils, and rebuilt a coherent protocol for tbpMRI. Our radiologists rated LIMES3 work as superior. We have received referrals from the ER and have conducted four patient evaluations. Conclusion: Traumatic brachial plexus MRI has great possible benefits for patients. This work supports the complexity of tbpMRI scanning. As this is rarely performed, it requires a more diligent protocol workflow, coordination of caregivers, and education within multiple clinical departments. Choosing the correct imaging exam can be critical, as patients can have significant neuropathy and/or paralysis. The LIMES3 protocol is well liked at our institution, and forms the cornerstone of understanding for our work. Our literature management led to a better clinical protocol creation despite the

High prevalence of cranial asymmetry exists in infants with neonatal brachial plexus palsy.

PubMed

Tang, Megan; Gorbutt, Kimberly A; Peethambaran, Ammanath; Yang, Lynda; Nelson, Virginia S; Chang, Kate Wan-Chu

2016-11-30

This study aimed to: 1) evaluate the prevalence of cranial asymmetry (positional plagiocephaly) in infants with neonatal brachial plexus palsy (NBPP); 2) examine the association of patient demographics, arm function, and NBPP-related factors to positional plagiocephaly; and 3) determine percentage of spontaneous recovery from positional plagiocephaly and its association with arm function. Infants < 1 year of age with NBPP and no previous exposure to plagiocephaly cranial remolding therapy or surgical intervention were recruited for this prospective cross-sectional study. Positional plagiocephaly (diagonal difference) measurements were captured using a fiberglass circumferential mold of the cranium. Included infants were divided into 2 groups: 1) those with positional plagiocephaly at most recent evaluation (plagio group), including infants with resolved positional plagiocephaly (plagio-resolved subgroup); and 2) those who never had positional plagiocephaly (non-plagio group). Standard statistics were applied. Eighteen of 28 infants (64%) had positional plagiocephaly. Delivery type might be predictive for plagiocephaly. Infants in the non-plagio group exhibited more active range of motion than infants in the plagio group. All other factors had no significant correlations. A high prevalence of positional plagiocephaly exists among the NBPP population examined. Parents and physicians should encourage infants to use their upper extremities to change position and reduce chance of cranial asymmetry.

Expectations and limitations due to brachial plexus injury: a qualitative study.

PubMed

Mancuso, Carol A; Lee, Steve K; Dy, Christopher J; Landers, Zoe A; Model, Zina; Wolfe, Scott W

2015-12-01

This study described physical and psychosocial limitations associated with adult brachial plexus injuries (BPI) and patients' expectations of BPI surgery. During in-person interviews, preoperative patients were asked about expectations of surgery and preoperative and postoperative patients were asked about limitations due to BPI. Postoperative patients also rated improvement in condition after surgery. Data were analyzed with qualitative and quantitative techniques. Ten preoperative and 13 postoperative patients were interviewed; mean age was 37 years, 19 were men, all were employed/students, and most injuries were due to trauma. Preoperative patients cited several main expectations, including pain-related issues, and improvement in arm movement, self-care, family interactions, and global life function. Work-related expectations were tailored to employment type. Preoperative and postoperative patients reported that pain, altered sensation, difficulty managing self-care, becoming physically and financially dependent, and disability in work/school were major issues. All patients reported making major compensations, particularly using the uninjured arm. Most reported multiple mental health effects, were distressed with long recovery times, were self-conscious about appearance, and avoided public situations. Additional stresses were finding and paying for BPI surgery. Some reported BPI impacted overall physical health, life priorities, and decision-making processes. Four postoperative patients reported hardly any improvement, four reported some/a good deal, and five reported a great deal of improvement. BPI is a life-altering event affecting physical function, mental well-being, financial situation, relationships, self-image, and plans for the future. This study contributes to clinical practice by highlighting topics to address to provide comprehensive BPI patient-centered care.

High resolution neurography of the lumbosacral plexus on 3T magneteic resonance imaging.

PubMed

Cejas, C; Escobar, I; Serra, M; Barroso, F

2015-01-01

Magnetic resonance neurography is a technique that complements clinical and electrophysiological study of the peripheral nerves and brachial and lumbosacral plexuses. Numerous focal processes (inflammatory, traumatic, primary tumors, secondary tumors) and diffuse processes (diabetic polyneuropathy, chronic idiopathic demyelinating polyneuropathy due to amyloidosis or Charcot-Marie-Tooth disease) can involve the lumbosacral plexus. This article reviews the anatomy of the lumbosacral plexus, describes the technique for neurography of the plexus at our institution, and shows the diverse diseases that affect it. Copyright © 2014 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

Comparison Between the Two-Injection Technique and the Four-Injection Technique in Axillary Brachial Plexus Block with Articaine.

PubMed

Ertikin, Aysun; Argun, Güldeniz; Mısırlıoğlu, Mesut; Aydın, Murat; Arıkan, Murat; Kadıoğulları, Nihal

2017-10-01

In this study, we aimed to compare axillary brachial plexus block using the two-injection and four-injection techniques assisted with ultrasonography (USG) and nerve stimulator in patients operated for carpal tunnel syndrome with articaine. To evaluate which technique is more effective, we compared the onset time, effectiveness, and duration of block procedures, patient satisfaction, adverse effect of the drug, and complication rates of the motor and sensory blocks. Sixty patients were randomly divided into two groups. A mixture of physiologic serum added to articain with NaHCO 3 (30 mL) was injected into the patients' axilla in both the groups. After the blockage of the musculocutaneous nerve in both the groups, the median nerve in the two-injection group and the median nerve, ulnar nerve, and radial nerve in the four-injection group were blocked. In brachial plexus nerves, sensorial blockage was evaluated with pinprick test, and motor block was evaluated by contraction of the muscles innervated by each nerve. The adverse effects and complications, visual analog scale (VAS) values during the operation, and post-operative patient satisfaction were recorded. Sufficient analgesia and anaesthesia were achieved with no need for an additional local anaesthetics in both the groups. Furthermore, additional sedation requirements were found to be similar in both the groups. A faster rate and a more effective complete block were achieved in more patients from the four-injection group. In the two-injection group, the block could not be achieved for N. radialis in one patient. All other nerves were successfully blocked. Whereas the blockage procedure lasted longer in the four-injection group, the VAS values recorded during the blockage procedure were higher in the four-injection group. No statistical difference was found with regard to patient satisfaction, and no adverse effects and complications were observed in any group. Although the multi-injection method takes more time

Transfer of supinator motor branches to the posterior interosseous nerve in C7-T1 brachial plexus palsy.

PubMed

Bertelli, Jayme Augusto; Ghizoni, Marcos Flavio

2010-07-01

In C7-T1 palsies of the brachial plexus, shoulder and elbow function are preserved, but finger motion is absent. Finger flexion has been reconstructed by tendon or nerve transfers. Finger extension has been restored ineffectively by attaching the extensor tendons to the distal aspect of the dorsal radius (termed tenodesis) or by tendon transfers. In these palsies, supinator muscle function is preserved, because innervation stems from the C-6 root. The feasibility of transferring supinator branches to the posterior interosseous nerve has been documented in a previous anatomical study. In this paper, the authors report the clinical results of supinator motor nerve transfer to the posterior interosseous nerve in 4 patients with a C7-T1 root lesion. Four adult patients with C7-T1 root lesions underwent surgery between 5 and 7 months postinjury. The patients had preserved motion of the shoulder, elbow, and wrist, but they had complete palsy of finger motion. They underwent finger flexion reconstruction via transfer of the brachialis muscle, and finger and thumb extension were restored by transferring the supinator motor branches to the posterior interosseous nerve. This nerve transfer was performed through an incision over the proximal third of the radius. Dissection was carried out between the extensor carpi radialis brevis and the extensor digitorum communis. The patients were followed up as per regular protocol and underwent a final evaluation 12 months after surgery. To document the extent of recovery, the authors assessed the degree of active metacarpophalangeal joint extension of the long fingers. The thumb span was evaluated by measuring the distance between the thumb pulp and the lateral aspect of the index finger. Surgery to transfer the supinator motor branches to the posterior interosseous nerve was straightforward. Twelve months after surgery, all patients were capable of opening their hand and could fully extend their metacarpophalangeal joints. The

Outcome after brachial plexus injury surgery and impact on quality of life.

PubMed

Rasulić, Lukas; Savić, Andrija; Živković, Bojana; Vitošević, Filip; Mićović, Mirko; Baščarević, Vladimir; Puzović, Vladimir; Novaković, Nenad; Lepić, Milan; Samardžić, Miroslav; Mandić-Rajčević, Stefan

2017-07-01

The aim of this study was to investigate outcomes after surgery for brachial plexus injury (BPI), not only motor outcomes but also the quality of life of the patients. We operated on 128 consecutive patients with BPI from 1992 to 2012. We documented the information on the injured nerve, level of injury, type of treatment used, timing of surgery, patient age, and preoperative and postoperative motor deficits. In 69 patients who agreed to participate in a quality of life study, additional assessments included functionality, pain, quality of life, patient satisfaction, and psychosocial health. Of patients who underwent only exploration and neurolysis, 35.3% showed a good quality of recovery. Patients who underwent nerve reconstruction using nerve grafting showed a better rate of good quality recovery (56.7%), and the results following nerve transfer depended on the type of transfer used. After surgery, 82.6% of patients showed significant improvement, 82.6% were satisfied, and 81.2% responded positively when asked if they would undergo surgery again if they knew the current result beforehand. Overall, 69.6% patients continued working after surgery. The mean DASH disability score was high (58.7) in the study group. Patients who had early surgery showed a consistently higher DASH score. About 76% of patients reported having pain regularly, and 18.8% reported depression or anxiety. We consider that it is important to report not only muscle recovery, but also other aspects of recovery.

Early onset of bilateral brachial plexopathy during mantle radiotherapy for Hodgkin's disease.

PubMed

Churn, M; Clough, V; Slater, A

2000-01-01

We report a case of brachial plexus neuropathy occurring in a 50-year-old man treated with standard mantle radiotherapy for early-stage Hodgkin's disease. A dose of 35 Gy in 20 fractions was given to the mantle field, following by a boost to the right side of the neck (8 Gy in four fractions). The onset of symptoms was early in the course of treatment and a gradual and almost full recovery was observed over 3 years after completion ofradiotherapy. The diagnosis was supported by electromyography. The temporal relationship of the radiotherapy and the onset of the brachial plexus neuropathy suggests a cause and effect, but this association is rarely reported after mantle radiotherapy. We review the aetiology of this condition and postulate possible mechanisms in this patient.

Shoulder and Elbow Recovery at 2 and 11 Years Following Brachial Plexus Reconstruction.

PubMed

Wang, Jung-Pan; Rancy, Schneider K; Lee, Steve K; Feinberg, Joseph H; Wolfe, Scott W

2016-02-01

To report short-term and long-term outcomes on a single patient cohort observed longitudinally after nerve reconstruction for adult brachial plexus injury. Eleven male patients who underwent plexus reconstruction by the same surgeon at 2 institutions presented for clinical examination 7.5 or more years after surgery (average, 11.4 years; range, 7.5-22 years). Average age at the time of operation was 35 years (range, 17-73 years). Mean delay until surgery was 5 months (range, 2-11 months). Two patients had C5 paralysis, 2 had C5-C6 paralysis, 2 had C5-C7 paralysis, and 5 had complete 5-level injuries. Outcome parameters included active range of motion (ROM) in degrees, a modified British Medical Research Council (mBMRC) scale for muscle strength, and electromyographic motor unit configuration and recruitment pattern. Differences in ROM and mBMRC between 2-year and long-term follow-up were assessed with paired-sample t tests using an alpha value of .05. Average shoulder abduction and mBMRC at final follow-up were both significantly improved compared with the 2-year follow-up results (P < .05). Average elbow flexion and mBMRC increased significantly between 2 years and final follow-up (P < .05). Electromyographic results for 6 patients at final follow-up showed improved motor unit configuration in 10 of 15 muscles and improved recruitment in 3 of 15 muscles compared with 2-year electromyographic results. Patients continued to gain ROM and strength in the shoulder and elbow well after 2 to 3 years after surgery, contrary to previous reports. Although the precise mechanism is unknown, we speculate that a number of factors may be involved, including terminal collateral sprouting, maturation of motor units, improvements in motor unit recruitment, additional muscle fiber hypertrophy, or an as-yet undescribed mechanism. We recommend that patients be encouraged to continue strengthening exercises well after the initial recovery period and that more comparative long-term data

Radiation Therapy to the Plexus Brachialis in Breast Cancer Patients: Analysis of Paresthesia in Relation to Dose and Volume.

PubMed

Lundstedt, Dan; Gustafsson, Magnus; Steineck, Gunnar; Sundberg, Agnetha; Wilderäng, Ulrica; Holmberg, Erik; Johansson, Karl-Axel; Karlsson, Per

2015-06-01

To identify volume and dose predictors of paresthesia after irradiation of the brachial plexus among women treated for breast cancer. The women had breast surgery with axillary dissection, followed by radiation therapy with (n=192) or without irradiation (n=509) of the supraclavicular lymph nodes (SCLNs). The breast area was treated to 50 Gy in 2.0-Gy fractions, and 192 of the women also had 46 to 50 Gy to the SCLNs. We delineated the brachial plexus on 3-dimensional dose-planning computerized tomography. Three to eight years after radiation therapy the women answered a questionnaire. Irradiated volumes and doses were calculated and related to the occurrence of paresthesia in the hand. After treatment with axillary dissection with radiation therapy to the SCLNs 20% of the women reported paresthesia, compared with 13% after axillary dissection without radiation therapy, resulting in a relative risk (RR) of 1.47 (95% confidence interval [CI] 1.02-2.11). Paresthesia was reported by 25% after radiation therapy to the SCLNs with a V40 Gy ≥ 13.5 cm(3), compared with 13% without radiation therapy, RR 1.83 (95% CI 1.13-2.95). Women having a maximum dose to the brachial plexus of ≥55.0 Gy had a 25% occurrence of paresthesia, with RR 1.86 (95% CI 0.68-5.07, not significant). Our results indicate that there is a correlation between larger irradiated volumes of the brachial plexus and an increased risk of reported paresthesia among women treated for breast cancer. Copyright © 2015 Elsevier Inc. All rights reserved.

Different functional reorganization of motor cortex after transfer of the contralateral C7 to different recipient nerves in young rats with total brachial plexus root avulsion.

PubMed

Pan, Feng; Wei, Hai-feng; Chen, Liang; Gu, Yu-dong

2012-12-07

Clinically, contralateral C7 transfer is used for nerve reconstruction in brachial plexus injuries. Postoperatively, synchronous motions at the donor limb are noteworthy. This study studied if different recipient nerves influenced transhemispheric functional reorganization of motor cortex after this procedure. 90 young rats with total root avulsion of the brachial plexus were divided into groups 1-3 of contralateral C7 transfer to anterior division of the upper trunk, to both the musculocutaneous and median nerves, and to the median nerve, respectively. After reinnervation of target muscles, number of sites for forelimb representations in bilateral motor cortices was determined by intracortical microstimulation at 1.5, 3, 6, 9, and 12 months postoperatively. At nine months, transhemispheric reorganization of nerves neurotized by contralateral C7 was fulfilled in four of six rats in group 1, one of six in group 2 and none in group 3, respectively; at 12 months, that was fulfilled in five of six in group 1, four of six in groups 2 and 3, respectively. Logistic regression analysis showed that rate of fulfilled transhemispheric reorganization in group 1 was 12.19 times that in group 3 (95% CI 0.006-0.651, p=0.032). At 12 months, number of sites for hindlimb representations which had encroached upon original forelimb representations on the uninjured side was statistically more in group 3 than in group 2 (t=9.5, p<0.0001). It is concluded that contralateral C7 transfer to upper trunk or to both the musculocutaneous and median nerves induces faster transhemispheric functional reorganization of motor cortex than that to median nerve alone in rats. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Mobile technology: Creation and use of an iBook to teach the anatomy of the brachial plexus.

PubMed

Stewart, Stuart; Choudhury, Bipasha

2015-01-01

In an era of digitally connected students, there is a demand for academic material to be delivered through electronic mobile devices and not just through traditional methods such as lectures and tutorials. A digital interactive book-iBook (for use on the Apple iPad)-was created to teach undergraduate anatomical science students (n = 26) four key areas of the brachial plexus: definitions, gross anatomy, relative anatomy, and functions of terminal branches. Students were asked to complete preresource and postresource questionnaires, which were used to calculate the mean improvement score and ultimately the efficacy of the resource. Free text comments were gathered to evaluate student opinions on this mode of learning. The mean score on the preresource and postresource questionnaires was 4.07 of 8 and 5.69 of 8, respectively. The overall mean improvement score was 1.62, determined statistically significant by a dependent t-test (P = 0.0004). Findings demonstrate that digital books on the iPad provide a uniquely interactive way of delivering information and engaging students. Furthermore, digital books can be used alongside traditional methods of teaching anatomy to enhance and promote deep learning in students. © 2014 American Association of Anatomists.

Using Contingent Reinforcement to Augment Muscle Activation After Perinatal Brachial Plexus Injury: A Pilot Study.

PubMed

Duff, S V; Sargent, B; Kutch, J J; Berggren, J; Leiby, B E; Fetters, L

2017-10-20

Examine the feasibility of increasing muscle activation with electromyographically (EMG)-triggered musical-video as reinforcement for children with perinatal brachial plexus injury (PBPI). Six children with PBPI (9.3 ± 6.3 months; 5 female, 1 male) and 13 typically developing (TD) controls (7.8 ± 3.5 months; 4 female, 9 males) participated. The left arm was affected in 5/6 children with PBPI. We recorded the integral (Vs) of biceps activation with surface EMG during two conditions per arm in one session: (1) 100 second (s) baseline without reinforcement and (2) 300 s reinforcement (musical-video triggered to play with biceps activation above threshold [V]). We examined the relation between the mean integral with reinforcement and hand preference. Mean biceps activation significantly increased from baseline in the affected arm of the group with PBPI by the 2nd (p < .008) and 3rd (p < .0004) 100 s intervals of reinforcement. Six of 6 children with PBPI and 12/13 TD controls increased activation in at least one arm. A lower integral was linked with hand preference for the unaffected right side in the PBPI group. This study supports contingent reinforcement as a feasible method to increase muscle activation. Future work will examine training dose and intensity to increase arm function.

N-Acetylcysteine Prevents Retrograde Motor Neuron Death after Neonatal Peripheral Nerve Injury.

PubMed

Catapano, Joseph; Zhang, Jennifer; Scholl, David; Chiang, Cameron; Gordon, Tessa; Borschel, Gregory H

2017-05-01

Neuronal death may be an overlooked and unaddressed component of disability following neonatal nerve injuries, such as obstetric brachial plexus injury. N-acetylcysteine and acetyl-L-carnitine improve survival of neurons after adult nerve injury, but it is unknown whether they improve survival after neonatal injury, when neurons are most susceptible to retrograde neuronal death. The authors' objective was to examine whether N-acetylcysteine or acetyl-L-carnitine treatment improves survival of neonatal motor or sensory neurons in a rat model of neonatal nerve injury. Rat pups received either a sciatic nerve crush or transection injury at postnatal day 3 and were then randomized to receive either intraperitoneal vehicle (5% dextrose), N-acetylcysteine (750 mg/kg), or acetyl-L-carnitine (300 mg/kg) once or twice daily. Four weeks after injury, surviving neurons were retrograde-labeled with 4% Fluoro-Gold. The lumbar spinal cord and L4/L5 dorsal root ganglia were then harvested and sectioned to count surviving motor and sensory neurons. Transection and crush injuries resulted in significant motor and sensory neuron loss, with transection injury resulting in significantly less neuron survival. High-dose N-acetylcysteine (750 mg/kg twice daily) significantly increased motor neuron survival after neonatal sciatic nerve crush and transection injury. Neither N-acetylcysteine nor acetyl-L-carnitine treatment improved sensory neuron survival. Proximal neonatal nerve injuries, such as obstetric brachial plexus injury, produce significant retrograde neuronal death after injury. High-dose N-acetylcysteine significantly increases motor neuron survival, which may improve functional outcomes after obstetrical brachial plexus injury.

Dexmedetomidine as an adjuvant to local anesthetics in brachial plexus blocks

PubMed Central

Ping, Yongmei; Ye, Qigang; Wang, Wenwei; Ye, Pingke; You, Zhibin

2017-01-01

Abstract Background: Brachial plexus block (BPB) for upper extremity surgery provides superior analgesia, but this advantage is limited by the pharmacological duration of local anesthetics. Dexmedetomidine (DEX) as a local anesthetics adjuvant for BPB has been utilized to prolong the duration of the nerve block in some randomized controlled trials (RCTs) but is far from unanimous in the efficacy and safety of the perineural route. Hence, an updated meta-analysis was conducted to assess the efficacy and safety of DEX as local anesthetic adjuvants on BPB. Methods: A search in electronic databases was conducted to collect the RCTs that investigated the impact of adding DEX to local anesthetics for BPB. Sensory block duration, motor block duration, onset time of sensory and motor block, time to first analgesic request, the common adverse effects were analyzed. Results: Eighteen trails (1014 patients) were included with 515 patients receiving perineural DEX. The addition of DEX prolonged the duration of sensory block (WMD 257 minutes, 95%CI 191.79–322.24, P < 0.001), motor block (WMD 242 minutes, 95%CI 174.94–309.34, P < 0.001), and analgesia (WMD 26 6 minutes, 95%CI 190.75–342.81, P < 0.001). Perineural DEX also increased the risk of bradycardia (OR=8.25, 95%CI 3.95–17.24, P < 0.001), hypotension (OR = 5.62, 95%CI 1.52–20.79, P < 0.01), and somnolence (OR = 19.67, 95%CI 3.94–98.09, P < 0.001). There was a lack of evidence that perineural DEX increased the risk of other adverse events. Conclusions: DEX is a potential anesthetic adjuvant that can facilitate better anesthesia and analgesia when administered in BPB. However, it also increased the risk of bradycardia, hypotension, and somnolence. Further research should focus on the efficacy and safety of the preneural administration of DEX. PMID:28121930

Patient perceptions and recall of consent for regional anaesthesia compared with consent for surgery.

PubMed

Zarnegar, Roxaneh; Brown, Matthew R D; Henley, Matthew; Tidman, Victoria; Pathmanathan, Ahilan

2015-11-01

In Britain, consent for surgery is documented using a Department of Health form signed by the surgeon and the patient. In contrast, anaesthetic procedures have no formalised consent process. Evidence on the process of consent for regional anaesthesia, and patient perceptions of this, is scarce outside obstetric practice. We aimed to determine patient recall and perceptions of consent for interscalene brachial plexus block and compared this to surgical consent for shoulder arthroplasty. Prospective observational survey. A specialist musculoskeletal centre, UK. Forty-six patients (female:male 30:16, mean age 61 years) undergoing shoulder arthroplasty with interscalene brachial plexus block. Recall and understanding of consent for regional anaesthesia and surgery was examined using a semi-structured questionnaire 1-2 days after arthroplasty. Surgical consent forms and discussions recorded by the anaesthetist were examined in participants' medical notes to compare against the level of recall. Analysis to determine statistical significance was conducted using McNemar's test. Recall of surgical risks was overall significantly better than recall of brachial plexus block risks. Compared to their recollections of surgical risk, patients remembered fewer specific risks for brachial plexus block (p < 0.001). There were more patients unable to recall any risks when questioned about brachial plexus block than about their surgery (p < 0.05). One-third of patients did not regard the consent discussion about regional anaesthesia as important as consent for surgery and over one-quarter had not recognised the preoperative discussion about the brachial plexus block as a consent process similar to that conducted for surgery. Fundamental misunderstandings about the consent process are prevalent. Future work in this area should seek to investigate how documentation of the consent process and patients' understanding of consent for regional anaesthesia can be improved. © The Royal

Real-time three-dimensional ultrasound-assisted axillary plexus block defines soft tissue planes.

PubMed

Clendenen, Steven R; Riutort, Kevin; Ladlie, Beth L; Robards, Christopher; Franco, Carlo D; Greengrass, Roy A

2009-04-01

Two-dimensional (2D) ultrasound is commonly used for regional block of the axillary brachial plexus. In this technical case report, we described a real-time three-dimensional (3D) ultrasound-guided axillary block. The difference between 2D and 3D ultrasound is similar to the difference between plain radiograph and computer tomography. Unlike 2D ultrasound that captures a planar image, 3D ultrasound technology acquires a 3D volume of information that enables multiple planes of view by manipulating the image without movement of the ultrasound probe. Observation of the brachial plexus in cross-section demonstrated distinct linear hyperechoic tissue structures (loose connective tissue) that initially inhibited the flow of the local anesthesia. After completion of the injection, we were able to visualize the influence of arterial pulsation on the spread of the local anesthesia. Possible advantages of this novel technology over current 2D methods are wider image volume and the capability to manipulate the planes of the image without moving the probe.

Brain functional network abnormality extends beyond the sensorimotor network in brachial plexus injury patients.

PubMed

Feng, Jun-Tao; Liu, Han-Qiu; Hua, Xu-Yun; Gu, Yu-Dong; Xu, Jian-Guang; Xu, Wen-Dong

2016-12-01

Brachial plexus injury (BPI) is a type of severe peripheral nerve trauma that leads to central remodeling in the brain, as revealed by functional MRI analysis. However, previously reported remodeling is mostly restricted to sensorimotor areas of the brain. Whether this disturbance in the sensorimotor network leads to larger-scale functional remodeling remains unknown. We sought to explore the higher-level brain functional abnormality pattern of BPI patients from a large-scale network function connectivity dimension in 15 right-handed BPI patients. Resting-state functional MRI data were collected and analyzed using independent component analysis methods. Five components of interest were recognized and compared between patients and healthy subjects. Patients showed significantly altered brain local functional activities in the bilateral fronto-parietal network (FPN), sensorimotor network (SMN), and executive-control network (ECN) compared with healthy subjects. Moreover, functional connectivity between SMN and ECN were significantly less in patients compared with healthy subjects, and connectivity strength between ECN and SMN was negatively correlated with patients' residual function of the affected limb. Functional connectivity between SMN and right FPN were also significantly less than in controls, although connectivity between ECN and default mode network (DMN) was greater than in controls. These data suggested that brain functional disturbance in BPI patients extends beyond the sensorimotor network and cascades serial remodeling in the brain, which significantly correlates with residual hand function of the paralyzed limb. Furthermore, functional remodeling in these higher-level functional networks may lead to cognitive alterations in complex tasks.

Pharmacokinetics of Lidocaine Hydrochloride Administered with or without Adrenaline for the Paravertebral Brachial Plexus Block in Dogs.

PubMed

Choquette, Amélie; Troncy, Eric; Guillot, Martin; Varin, France; Del Castillo, Jérôme R E

2017-01-01

Adrenaline is known to prolong the duration of local anesthesia but its effects on the pharmacokinetic processes of local anesthetic drugs are not fully understood. Our objective was to develop a compartmental model for quantification of adrenaline's impact on the pharmacokinetics of perineurally-injected lidocaine in the dog. Dogs were subjected to paravertebral brachial plexus block using lidocaine alone or adrenalinated lidocaine. Data was collected through a prospective, randomised, blinded crossover protocol performed over three periods. Blood samples were collected during 180 minutes following block execution. Compartmental pharmacokinetic models were developed and their goodness-of-fit were compared. The lowering effects of adrenaline on the absorption of lidocaine were statistically determined with one-sided tests. A one-compartment disposition model with two successive zero-order absorption processes best fitted our experimental data. Adrenaline decreased the peak plasma lidocaine concentration by approximately 60% (P < 0.001), decreased this local anesthetic's fast and slow zero-order absorption rates respectively by 50% and 90% (P = 0.046, and P < 0.001), which respective durations were prolonged by 90% and 1300% (P < 0.020 and P < 0.001). Lidocaine demonstrated a previously unreported atypical absorption profile following its paravertebral injection in dogs. Adrenaline decreased the absorption rate of lidocaine and prolonged the duration of its absorption.

[Macrosomia, shoulder dystocia and elongation of the brachial plexus: what is the role of caesarean section?

PubMed

Kehila, Mehdi; Derouich, Sadok; Touhami, Omar; Belghith, Sirine; Abouda, Hassine Saber; Cheour, Mariem; Chanoufi, Mohamed Badis

2016-01-01

The delivery of a macrosomic infant is associated with a higher risk for maternofoetal complications. Shoulder dystocia is the most feared fetal complication, leading sometimes to a disproportionate use of caesarean section. This study aims to evaluate the interest of preventive caesarean section. We conducted a retrospective study of 400 macrosomic births between February 2010 and December 2012. We also identified cases of infants with shoulder dystocia occurred in 2012 as well as their respective birthweight. Macrosomic infants weighed between 4000g and 4500g in 86.25% of cases and between 4500 and 5000 in 12.25% of cases. Vaginal delivery was performed in 68% of cases. Out of 400 macrosomic births, 9 cases with shoulder dystocia were recorded (2.25%). All of these cases occurred during vaginal delivery. The risk for shoulder dystocia invaginal delivery has increased significantly with the increase in birth weight (p <10-4). The risk for elongation of the brachial plexus was 11 per thousand vaginal deliveries of macrosomic infants. This risk was not correlated with birthweight (p = 0.38). The risk for post-traumatic sequelae was 0.71%. Shoulder dystocia affectd macrosoic infants in 58% of cases. Shoulder dystocia is not a complication exclusively associated with macrosomia. Screening for risky deliveries and increasing training of obstetricians on maneuvers in shoulder dystocia seem to be the best way to avoid complications.

Obstetric and gynecologic malpractice claims in Saudi Arabia: Incidence and cause.

PubMed

AlDakhil, Lateefa O

2016-05-01

The occurrence of a bad outcome, injury or death of a patient during treatment increases the chance of malpractice litigation, increases legal responsibility and leads to increased fees for malpractice insurance. Physicians practicing obstetrics and gynecology face among the highest risks of malpractice litigation, and such litigation has led to an increase in the practice of defensive medicine and has made this specialty less appealing. Previous clinical data from Saudi Arabia have shown that more malpractice litigation concerns claims in obstetrics and gynecology than claims in any other field of medicine. To identify the main causes of obstetrics and gynecology (OBGYN) professional liability claims in Saudi Arabia to have a better understanding and management of risks. All OBGYN claims opened in Saudi Arabia between 2008 and 2013 were analyzed to identify the most common causes of claims. The results of these claims and the times until a final judgment made were also analyzed. Out of a total of 463 malpractice claims that were closed during the study period, 114 (24.6%) claims were in obstetrics and gynecology, and 92 (80.7%) of these claims concerned complications related to delivery room events. The most common causes of obstetric malpractice litigation were shoulder dystocia (brachial plexus injury) and fetal distress (hypoxic ischemic encephalopathy). Urinary system injury was the most common cause of gynecology cases. Most cases were decided in favor of the defendants with the exception of cases for which maternal and/or fetal death was the cause of litigation; nearly all of those cases were decided against the defendants. Obstetricians face a high risk of malpractice claims in Saudi Arabia, although most claims do not end in payments to plaintiffs. However, the effects of such claims on obstetric care should not be underestimated. Adherence to standards of care and careful documentation may decrease litigation and the number of indefensible malpractice

Optimal Dose of Perineural Dexamethasone to Prolong Analgesia After Brachial Plexus Blockade: A Systematic Review and Meta-analysis.

PubMed

Kirkham, Kyle Robert; Jacot-Guillarmod, Alain; Albrecht, Eric

2018-01-01

Perineural dexamethasone has gained popularity in regional anesthesia to prolong analgesia duration. However, uncertainty remains regarding the optimal perineural dose. Clarification of this characteristic is of significant importance as the administration of dexamethasone may lead to dose-dependent complications. The objective of this meta-analysis was to define the optimal perineural dexamethasone dose to prolong analgesia after brachial plexus blockade for adult patients undergoing upper limb surgery. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines and searched databases including MEDLINE, PubMed, and EMBASE until January 2017, without language restriction. Only trials comparing perineural dexamethasone and local anesthetics with local anesthetics alone for brachial plexus blocks were included in the present meta-analysis. The Cochrane Collaboration's Risk of Bias Tool was used to assess the methodological quality of each trial and meta-analyses were performed following a random effects model. The primary outcome was duration of analgesia for each type of local anesthetic (short-/intermediate-acting and long-acting local anesthetics). A meta-regression followed by a subgroup analysis were performed to assess the impact of different perineural dexamethasone doses on duration of analgesia; for the latter analysis, trials were grouped in low (1-4 mg) and moderate (5-10 mg) dexamethasone doses. Secondary outcomes included the rate of neurologic complication and resting pain scores and morphine consumption within the first 24 hours. Thirty-three controlled trials, including 2138 patients, were identified. The meta-regression revealed a ceiling effect with a perineural dexamethasone dose of 4 mg when combined with short-/intermediate-acting (8 trials; 366 participants) or long-acting local anesthetics (23 trials; 1869 participants). This finding was confirmed by subgroup analyses comparing low and moderate

Clinical evaluation of the anaesthetic sparing effect of brachial plexus block in cats.

PubMed

Mosing, Martina; Reich, Heidi; Moens, Yves

2010-03-01

To evaluate the isoflurane sparing effect and the post-surgical analgesia provided by a brachial plexus block (BPB) in cats undergoing distal thoracic limb surgery. Prospective randomized blinded clinical study. Twenty client-owned cats. Cats were assigned to receive either no BPB (group NB) or a nerve stimulator guided BPB (group BPB) using lidocaine (3.6 mg kg(-1)) and bupivacaine (1.2 mg kg(-1)). Pre-medication consisted of midazolam and ketamine intravenously (IV). Anaesthesia was induced with propofol IV to effect and maintained with isoflurane delivered in oxygen and a continuous rate infusion of fentanyl (2 microg kg(-1) hour(-1)). End-tidal isoflurane concentration (Fe'ISO) was adjusted every 3 minutes guided by changes in cardiorespiratory parameters and reflexes present, to maintain a stable depth of anaesthesia. Five time points were chosen to record all parameters and compare values between groups. Recovery and post-operative pain assessment were performed using a visual analogue scale (VAS) at 15 and 45 minutes after extubation and thereafter at hourly intervals until 5 hours after placement of the BPB. No clinically significant differences were seen for heart rate, respiratory rate and non-invasive blood pressure between groups. Mean Fe'ISO was significantly lower in group BPB compared with group NB at all time points. In group NB, all intraoperative measurements of Fe'ISO were significantly higher compared with baseline (3 minutes before start of surgery) measurements. During recovery, VAS scores for group BPB were significantly lower than for group NB. Additional analgesics were needed in all cats within the study period. In cats undergoing orthopaedic surgery of the thoracic limb, BPB reduced intra-operative isoflurane requirement and pain during the early post-operative period when compared with procedures without a BPB. BPB is a useful adjunct to anaesthesia in such cases.

Preoperative interscalene brachial plexus block aids in perioperative temperature management during arthroscopic shoulder surgery.

PubMed

Lim, Se Hun; Lee, Wonjin; Park, JaeGwan; Kim, Myoung-Hun; Cho, Kwangrae; Lee, Jeong Han; Cheong, Soon Ho; Lee, Kun Moo

2016-08-01

Hypothermia is common during arthroscopic shoulder surgery under general anesthesia, and anesthetic-impaired thermoregulation is thought to be the major cause of hypothermia. This prospective, randomized, double-blind study was designed to compare perioperative temperature during arthroscopic shoulder surgery with interscalene brachial plexus block (IBPB) followed by general anesthesia vs. general anesthesia alone. Patients scheduled for arthroscopic shoulder surgery were randomly allocated to receive IBPB followed by general anesthesia (group GB, n = 20) or general anesthesia alone (group GO, n = 20), and intraoperative and postoperative body temperatures were measured. The initial body temperatures were 36.5 ± 0.3℃ vs. 36.4 ± 0.4℃ in group GB vs. GO, respectively (P = 0.215). The body temperature at 120 minutes after induction of anesthesia was significantly higher in group GB than in group GO (35.8 ± 0.3℃ vs. 34.9 ± 0.3℃; P < 0.001). The body temperatures at 60 minutes after admission to the post-anesthesia care unit were 35.8 ± 0.3℃ vs. 35.2 ± 0.2℃ in group GB vs. GO, respectively (P < 0.001). The concentrations of desflurane at 0, 15, and 120 minutes after induction of anesthesia were 6.0 vs. 6.0% (P = 0.330), 5.0 ± 0.8% vs. 5.8 ± 0.4% (P = 0.001), and 3.4 ± 0.4% vs. 7.1 ± 0.9% (P < 0.001) in group GB vs. GO, respectively. The present study demonstrated that preoperative IBPB could reduce both the intraoperative concentration of desflurane and the reduction in body temperature during and after arthroscopic shoulder surgery.

Single, double or multiple-injection techniques for non-ultrasound guided axillary brachial plexus block in adults undergoing surgery of the lower arm.

PubMed

Chin, Ki Jinn; Alakkad, Husni; Cubillos, Javier E

2013-08-08

Regional anaesthesia comprising axillary block of the brachial plexus is a common anaesthetic technique for distal upper limb surgery. This is an update of a review first published in 2006 and updated in 2011. To compare the relative effects (benefits and harms) of three injection techniques (single, double and multiple) of axillary block of the brachial plexus for distal upper extremity surgery. We considered these effects primarily in terms of anaesthetic effectiveness; the complication rate (neurological and vascular); and pain and discomfort caused by performance of the block. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and reference lists of trials. We contacted trial authors. The date of the last search was March 2013 (updated from March 2011). We included randomized controlled trials that compared double with single-injection techniques, multiple with single-injection techniques, or multiple with double-injection techniques for axillary block in adults undergoing surgery of the distal upper limb. We excluded trials using ultrasound-guided techniques. Independent study selection, risk of bias assessment and data extraction were performed by at least two investigators. We undertook meta-analysis. The 21 included trials involved a total of 2148 participants who received regional anaesthesia for hand, wrist, forearm or elbow surgery. Risk of bias assessment indicated that trial design and conduct were generally adequate; the most common areas of weakness were in blinding and allocation concealment.Eight trials comparing double versus single injections showed a statistically significant decrease in primary anaesthesia failure (risk ratio (RR 0.51), 95% confidence interval (CI) 0.30 to 0.85). Subgroup analysis by method of nerve location showed that the effect size was greater when neurostimulation was used rather than the transarterial technique.Eight trials comparing multiple with single

Plexus structure imaging with thin slab MR neurography: rotating frames, fly-throughs, and composite projections

NASA Astrophysics Data System (ADS)

Raphael, David T.; McIntee, Diane; Tsuruda, Jay S.; Colletti, Patrick; Tatevossian, Raymond; Frazier, James

2006-03-01

We explored multiple image processing approaches by which to display the segmented adult brachial plexus in a three-dimensional manner. Magnetic resonance neurography (MRN) 1.5-Tesla scans with STIR sequences, which preferentially highlight nerves, were performed in adult volunteers to generate high-resolution raw images. Using multiple software programs, the raw MRN images were then manipulated so as to achieve segmentation of plexus neurovascular structures, which were incorporated into three different visualization schemes: rotating upper thoracic girdle skeletal frames, dynamic fly-throughs parallel to the clavicle, and thin slab volume-rendered composite projections.

Evaluation of Self-Concept and Emotional-Behavioral Functioning of Children with Brachial Plexus Birth Injury

PubMed Central

Belfiore, Lori A.; Rosen, Carol; Sarshalom, Rachel; Grossman, Leslie; Sala, Debra A.; Grossman, John A. I.

2016-01-01

Background The reported incidence of brachial plexus birth injury (BPBI) is 0.87 to 2.2 per 1,000 live births. The psychological functioning, including self-concept and emotional-behavioral functioning, of children with BPBI has only been examined to a limited extent. Objective The purpose of this study was to describe the self-concept and emotional-behavioral functioning in children with BPBI from both the child's and parent's perspective. Methods Thirty-one children with BPBI, mean age 11 years 1 month, completed the Draw A Person: Screening Procedure for Emotional Disturbance (DAP:SPED) and Piers Harris Children's Self-Concept Scale (PHCSCS). The parents answered questions from the Behavior Assessment System for Children, Parent Rating Scales (BASC-2 PRS). Results The scores from the DAP:SPED drawings showed further evaluation was not strongly indicated in the majority of the children. The PHCSCS Total score demonstrated that the children had a strongly positive self-concept. The parental responses to the BASC-2 PRS indicated that few children were at risk or in the clinically significant range for the four composite scores and all of the component clinical or adaptive scales. Gender comparison revealed females exhibited greater anxiety than males. Conclusion Both children and parents reported a positive psychological well-being for the majority of the children. Parents had greater concerns about their child's social-emotional functioning, particularly anxiety. An interdisciplinary approach (occupational therapy evaluation, clinical observation, and parental interview) is necessary to determine the need for mental health referral. PMID:28077960

Evaluation of Self-Concept and Emotional-Behavioral Functioning of Children with Brachial Plexus Birth Injury.

PubMed

Belfiore, Lori A; Rosen, Carol; Sarshalom, Rachel; Grossman, Leslie; Sala, Debra A; Grossman, John A I

2016-01-01

Background  The reported incidence of brachial plexus birth injury (BPBI) is 0.87 to 2.2 per 1,000 live births. The psychological functioning, including self-concept and emotional-behavioral functioning, of children with BPBI has only been examined to a limited extent. Objective  The purpose of this study was to describe the self-concept and emotional-behavioral functioning in children with BPBI from both the child's and parent's perspective. Methods  Thirty-one children with BPBI, mean age 11 years 1 month, completed the Draw A Person: Screening Procedure for Emotional Disturbance (DAP:SPED) and Piers Harris Children's Self-Concept Scale (PHCSCS). The parents answered questions from the Behavior Assessment System for Children, Parent Rating Scales (BASC-2 PRS). Results  The scores from the DAP:SPED drawings showed further evaluation was not strongly indicated in the majority of the children. The PHCSCS Total score demonstrated that the children had a strongly positive self-concept. The parental responses to the BASC-2 PRS indicated that few children were at risk or in the clinically significant range for the four composite scores and all of the component clinical or adaptive scales. Gender comparison revealed females exhibited greater anxiety than males. Conclusion  Both children and parents reported a positive psychological well-being for the majority of the children. Parents had greater concerns about their child's social-emotional functioning, particularly anxiety. An interdisciplinary approach (occupational therapy evaluation, clinical observation, and parental interview) is necessary to determine the need for mental health referral.

Early nerve repair in traumatic brachial plexus injuries in adults: treatment algorithm and first experiences.

PubMed

Pondaag, Willem; van Driest, Finn Y; Groen, Justus L; Malessy, Martijn J A

2018-01-26

OBJECTIVE The object of this study was to assess the advantages and disadvantages of early nerve repair within 2 weeks following adult traumatic brachial plexus injury (ATBPI). METHODS From 2009 onwards, the authors have strived to repair as early as possible extended C-5 to C-8 or T-1 lesions or complete loss of C-5 to C-6 or C-7 function in patients in whom there was clinical and radiological suspicion of root avulsion. Among a group of 36 patients surgically treated in the period between 2009 and 2011, surgical findings in those who had undergone treatment within 2 weeks after trauma were retrospectively compared with results in those who had undergone delayed treatment. The result of biceps muscle reanimation was the primary outcome measure. RESULTS Five of the 36 patients were referred within 2 weeks after trauma and were eligible for early surgery. Nerve ruptures and/or avulsions were found in all early cases of surgery. The advantages of early surgery are as follows: no scar formation, easy anatomical identification, and gap length reduction. Disadvantages include less-clear demarcation of vital nerve tissue and unfamiliarity with the interpretation of frozen-section examination findings. All 5 early-treatment patients recovered a biceps force rated Medical Research Council grade 4. CONCLUSIONS Preliminary results of nerve repair within 2 weeks of ATBPI are encouraging, and the benefits outweigh the drawbacks. The authors propose a decision algorithm to select patients eligible for early surgery. Referral standards for patients with ATBPI must be adapted to enable early surgery.

Differences in Brain Adaptive Functional Reorganization in Right and Left Total Brachial Plexus Injury Patients.

PubMed

Feng, Jun-Tao; Liu, Han-Qiu; Xu, Jian-Guang; Gu, Yu-Dong; Shen, Yun-Dong

2015-09-01

Total brachial plexus avulsion injury (BPAI) results in the total functional loss of the affected limb and induces extensive brain functional reorganization. However, because the dominant hand is responsible for more cognitive-related tasks, injuries on this side induce more adaptive changes in brain function. In this article, we explored the differences in brain functional reorganization after injuries in unilateral BPAI patients. We applied resting-state functional magnetic resonance imaging scanning to 10 left and 10 right BPAI patients and 20 healthy control subjects. The amplitude of low-frequency fluctuation (ALFF), which is a resting-state index, was calculated for all patients as an indication of the functional activity level of the brain. Two-sample t-tests were performed between left BPAI patients and controls, right BPAI patients and controls, and between left and right BPAI patients. Two-sample t-tests of the ALFF values revealed that right BPAIs induced larger scale brain reorganization than did left BPAIs. Both left and right BPAIs elicited a decreased ALFF value in the right precuneus (P < 0.05, Alphasim corrected). In addition, right BPAI patients exhibited increased ALFF values in a greater number of brain regions than left BPAI patients, including the inferior temporal gyrus, lingual gyrus, calcarine sulcus, and fusiform gyrus. Our results revealed that right BPAIs induced greater extents of brain functional reorganization than left BPAIs, which reflected the relatively more extensive adaptive process that followed injuries of the dominant hand. Copyright © 2015 Elsevier Inc. All rights reserved.

The role of botulinum toxin in the neuro-rehabilitation of young patients with brachial plexus birth palsy.

PubMed

Desiato, M T; Risina, B

2001-01-01

To favour the active movements of the shoulder abductor/external rotator, elbow extensor and supinator muscles, through the partial inhibition of the uninvolved antagonistic muscles, in the Brachial Plexus birth Palsy (BPP). The type A Botulinum Neuro Toxin (BNT-Dysport, Ipsen) was injected in 50 outpatients (mean age: 4.7 +/- 3.4 years) with BPP according to the criteria: early and current neuro-rehabilitation (Reflex Locomotion-RL), age <14 years, no cognitive impairment. Repeat injections (1.9 +/- 0.8) were performed in 30 patients. The range of active movements increased at the maximal benefit phase, compared to the baseline values (p < 0.05-0.01). The gain of shoulder's abduction was directly related to the youngest age (r = 0.6). An expanded compliance of the injected muscles and a faster response to the RL, in respect to that experienced in the pre-BNT sessions, was detected. The Global Clinical Rating Scale disclosed the temporal profile of the clinical outcome, with step-like increases of the function in 70% of the patients, and a 'plateau' trait in the remaining ones (+29.8 +/- 10.5%). The video-taped recordings showed an improvement in the global movements. The employment of BNT in the management of young patients with BPP has beneficial effects in the integration of the bodily scheme.

Efficacy of Ultrasound-Guided Axillary Brachial Plexus Block for Analgesia During Percutaneous Transluminal Angioplasty for Dialysis Access

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chiba, Emiko, E-mail: chibaemi23@comet.ocn.ne.jp; Hamamoto, Kohei, E-mail: hkouhei917@gmail.com; Nagashima, Michio, E-mail: nagamic00@gmail.com

PurposeTo evaluate the efficacy and safety of ultrasound (US)-guided axillary brachial plexus block (ABPB) for analgesia during percutaneous transluminal angioplasty (PTA) for dialysis access.Subjects and MethodsTwenty-one patients who underwent PTA for stenotic dialysis access shunts and who had previous experience of PTA without sedation, analgesia, and anesthesia were included. The access type in all patients was native arteriovenous fistulae in the forearm. Two radiologists performed US-guided ABPB for the radial and musculocutaneous nerves before PTA. The patients’ pain scores were evaluated using a visual analog scale (VAS) after PTA, and these were compared with previous sessions without US-guided ABPB. Themore » patient’s motor/sensory paralysis after PTA was also examined.ResultsThe mean time required to achieve US-guided ABPB was 8 min. The success rate of this procedure was 100 %, and there were no significant complications. All 21 patients reported lower VAS with US-guided ABPB as compared to without the block (p < 0.01). All patients expressed the desire for an ABPB for future PTA sessions, if required. Transient motor paralysis occurred in 8 patients, but resolved in all after 60 min.ConclusionUS-guided ABPB is feasible and effective for analgesia in patients undergoing PTA for stenotic dialysis access sites.Level of EvidenceLevel 4 (case series).« less

Prevention of shoulder dystocia: A randomized controlled trial to evaluate an obstetric maneuver.

PubMed

Poujade, Olivier; Azria, Elie; Ceccaldi, Pierre-François; Davitian, Carine; Khater, Carine; Chatel, Paul; Pernin, Emilie; Aflak, Nizar; Koskas, Martin; Bourgeois-Moine, Agnès; Hamou-Plotkine, Laurence; Valentin, Morgane; Renner, Jean-Paul; Roy, Carine; Estellat, Candice; Luton, Dominique

2018-08-01

Shoulder dystocia is a major obstetric emergency defined as a failure of delivery of the fetal shoulder(s). This study evaluated whether an obstetric maneuver, the push back maneuver performed gently on the fetal head during delivery, could reduce the risk of shoulder dystocia. We performed a multicenter, randomized, single-blind trial to compare the push back maneuver with usual care in parturient women at term. The primary outcome, shoulder dystocia, was considered to have occurred if, after delivery of the fetal head, any additional obstetric maneuver, beginning with the McRoberts maneuver, other than gentle downward traction and episiotomy was required. We randomly assigned 522 women to the push back maneuver group (group P) and 523 women to the standard vaginal delivery group (group S). Finally, 473 women assigned to group P and 472 women assigned to group S delivered vaginally. The rate of shoulder dystocia was significantly lower in group P (1·5%) than in group S (3·8%) (odds ratio [OR] 0·38 [0·16-0·92]; P = 0·03). After adjustment for predefined main risk factors, dystocia remained significantly lower in group P than in group S. There were no significant between-group differences in neonatal complications, including brachial plexus injury, clavicle fracture, hematoma and generalized asphyxia. In this trial in 945 women who delivered vaginally, the push back maneuver significantly decreased the risk of shoulder dystocia, as compared with standard vaginal delivery. Copyright © 2018 Elsevier B.V. All rights reserved.

Ultrasound-guided axillary brachial plexus block versus local infiltration anesthesia for arteriovenous fistula creation at the forearm for hemodialysis in patients with chronic renal failure.

PubMed

Nofal, W H; El Fawal, S M; Shoukry, A A; Sabek, Eas; Malak, Wfa

2017-01-01

The primary failure rate for arteriovenous fistula (AVF) creation under local anesthesia for hemodialysis is about 30%. Axillary brachial plexus block (BPB) may improve blood flow through blood vessels used in fistula creation; it may improve the AVF blood flow and thus may reduce the primary failure rate after 3 months. Hundred and forty patients with chronic renal failure scheduled for AVF creation for hemodialysis were divided into two equal groups; Group 1 (AxBP-G) received ultrasound (US) guided axillary BPB, and Group 2 (LI-G) received local infiltration. We recorded the measurements of the brachial and radial arteries before and after anesthesia and the AVF blood flow in both groups at three different time points. Furthermore, the primary failure rate was recorded in each group and compared. After anesthesia, the mean radial artery blood flow in the AxBP-group was 3.52 ml/min more than the LI-group, and the brachial artery diameter was also 0.68 mm more than in the LI-group, both differences were statistically significant ( P < 0.05). There were significant increases ( P < 0.05) in the AVF blood flow in the AxBP-group more than the LI-group with mean differences of 29.6, 69.8, and 27.2 ml/min at 4 h, 1 week, and 3 months, respectively. The overall mean of AVF blood flow was 42.21 ml/min more in the AxBP group than the LI-group a difference which is statistically significant ( P < 0.001). The primary failure rate was 17% in the AxBP group versus 30% in the LI-group; however, this difference is not significant statistically ( P = 0.110). The US-guided axillary block increases AVF blood flow significantly more than local infiltration and nonsignificantly decreases the primary failure rate of the AVF after 3 months.

A comparison of the dose of anesthetic agents and the effective interval from the block procedure to skin incision for ultrasound-guided supraclavicular brachial plexus block in upper extremity surgery.

PubMed

Nakayama, Masanori; Sakuma, Yu; Imamura, Hitoshi; Yano, Koichiro; Kodama, Takao; Ikari, Katsunori

2017-12-01

The aim of this study was to review and evaluate the selection and dose of anesthetic agents and the interval from the block procedure to skin incision for supraclavicular brachial plexus block in upper extremity surgery. We reviewed our cases that underwent upper extremity surgery using only ultrasound-guided supraclavicular brachial plexus block in our hospital between 2011 and 2016. Adverse events during surgery were evaluated. Receiver operating characteristic (ROC) curves were constructed to investigate the relationship between the time from the end of the block procedure to skin incision and the use of local anesthesia on the surgical site. There were 255 patients who were divided into three groups according to the anesthetic agents used: group 1, 1% lidocaine (L) 10 ml + 0.75% ropivacaine (R) 20 ml (n = 62); group 2, L 20 ml + R 10 ml (n = 93); and group 3, L 10 ml + R 15 ml (n = 100). The rate of use of local anesthesia on the surgical site was significantly higher in group 3 than in the other two groups. There were no significant differences in the other evaluated items among the three groups. ROC curve analysis indicated that ≥24 min from the end of the block procedure to skin incision might reduce the use of local anesthesia. The total volume of anesthetic agents had an important influence on the rate of the addition of local anesthesia for surgical pain; however, the combined dose of agents did not influence the evaluation items. For effective analgesia, ≥24 min should elapse from the end of the block procedure to skin incision. Copyright © 2017. Published by Elsevier B.V.

A population-based analysis of time to surgery and travel distances for brachial plexus surgery

PubMed Central

Dy, Christopher J.; Baty, Jack; Saeed, Mohammed J; Olsen, Margaret A.; Osei, Daniel A.

2016-01-01

Purpose Despite the importance of timely evaluation for patients with brachial plexus injuries (BPI), in clinical practice we have noted delays in referral. Because the published BPI experience is largely from individual centers, we used a population-based approach to evaluate the delivery of care for patients with BPI. Methods We used statewide administrative databases from Florida (2007–2013), New York (2008–2012) and North Carolina (2009–2010) to create a cohort of patients who underwent surgery for BPI (exploration, repair, neurolysis, grafting, or nerve transfer). Emergency department and inpatient records were used to determine the time interval between the injury and surgical treatment. The distances between the treating hospitals and between the patient’s home ZIP code and the surgical hospital were recorded. A multivariable logistic regression model was used to determine predictors for time from injury to surgery exceeding 365 days. Results Within the 222 patients in our cohort, the median time from injury to surgery was 7.6 months and exceeded 365 days in 29% of cases. Treatment at a smaller hospital for the initial injury was significantly associated with surgery beyond 365 days after injury. Patient insurance type, travel distance for surgery, the distance between the two treating hospitals, or changing hospitals between injury and surgery did not significantly influence time to surgery. Conclusions Nearly one-third of patients in FL, NY, and NC underwent BPI surgery more than one year after their injury. Patients initially treated at smaller hospitals are at risk for undergoing delayed BPI surgery. Clinical Relevance These findings can inform administrative and policy efforts to expedite timely referral of patients with BPI to experienced centers. PMID:27570225

Three-Dimensional Magnetic Resonance Imaging of Glenohumeral Dysplasia in Neonatal Brachial Plexus Palsy.

PubMed

Eismann, Emily A; Laor, Tal; Cornwall, Roger

2016-01-20

Existing quantitative measurements of glenohumeral dysplasia in children with unresolved neonatal brachial plexus palsy (NBPP) have been mostly limited to the axial plane. The purpose of this study was to describe the three-dimensional (3D) pathoanatomy of glenohumeral dysplasia using 3D magnetic resonance imaging (MRI) reformations. 3D MRI reformations of the scapula, glenoid labrum, and proximal part of the humerus were created from a volume-acquisition proton-density-weighted MRI sequence of both the affected and the unaffected shoulder of seventeen children less than six years of age with unresolved NBPP who had not undergone shoulder surgery. Glenoid retroversion and posterior humeral head displacement were measured on axial 2D images. Humeral head displacement in all planes, labral circumference, glenoid retroversion, glenoid declination, and scapular morphometric values were measured on 3D reformations. Contiguity of the humeral head with the labrum and the shape of the glenoid were classified. Measurements were compared between the affected and unaffected sides. On 3D evaluation, the humeral head was completely posteriorly translated in ten patients but was never outside the glenoid labrum. Instead, in these patients, the humeral head was eccentrically articulating with the dysplastic glenoid and was contained by a posteriorly elongated labrum. Glenoid dysplasia was not limited to the axial plane. Less declination of the glenoid in the coronal plane correlated with greater 3D glenoid retroversion. Glenoid retroversion resulted from underdevelopment of the posterior aspect of the glenoid rather than overdevelopment of the anterior aspect of the glenoid. 3D measurements of greater glenoid retroversion and less declination correlated with 2D measurements of glenoid retroversion and posterior humeral head displacement. Posterior humeral head displacement in NBPP should not be considered a simple "dislocation." Glenohumeral dysplasia is not limited to the axial

Rehabilitation, Using Guided Cerebral Plasticity, of a Brachial Plexus Injury Treated with Intercostal and Phrenic Nerve Transfers.

PubMed

Dahlin, Lars B; Andersson, Gert; Backman, Clas; Svensson, Hampus; Björkman, Anders

2017-01-01

Recovery after surgical reconstruction of a brachial plexus injury using nerve grafting and nerve transfer procedures is a function of peripheral nerve regeneration and cerebral reorganization. A 15-year-old boy, with traumatic avulsion of nerve roots C5-C7 and a non-rupture of C8-T1, was operated 3 weeks after the injury with nerve transfers: (a) terminal part of the accessory nerve to the suprascapular nerve, (b) the second and third intercostal nerves to the axillary nerve, and (c) the fourth to sixth intercostal nerves to the musculocutaneous nerve. A second operation-free contralateral gracilis muscle transfer directly innervated by the phrenic nerve-was done after 2 years due to insufficient recovery of the biceps muscle function. One year later, electromyography showed activation of the biceps muscle essentially with coughing through the intercostal nerves, and of the transferred gracilis muscle by deep breathing through the phrenic nerve. Voluntary flexion of the elbow elicited clear activity in the biceps/gracilis muscles with decreasing activity in intercostal muscles distal to the transferred intercostal nerves (i.e., corresponding to eighth intercostal), indicating cerebral plasticity, where neural control of elbow flexion is gradually separated from control of breathing. To restore voluntary elbow function after nerve transfers, the rehabilitation of patients operated with intercostal nerve transfers should concentrate on transferring coughing function, while patients with phrenic nerve transfers should focus on transferring deep breathing function.

Functional outcome after the Hoffer procedure.

PubMed

Murabit, Amera; Gnarra, Maria; O'Grady, Kathleen; Morhart, Michael; Olson, Jaret L

2013-06-01

Children with obstetrical brachial plexus injury often develop an internal rotation and adduction contracture about the shoulder as a secondary deformity, resulting in an inability to externally rotate and abduct the shoulder. The Hoffer procedure is evaluated for its potential benefit in improving shoulder abduction and external rotation and its impact on activities of daily living. This is a retrospective review of patients treated in brachial plexus injury clinic who underwent tendon transfer procedures about the shoulder. Preoperative and postoperative active movement and active range of motion were measured and recorded using the Mallet scale and the Active Movement Scale. Twenty patients were included in the study. Average age at time of surgery was 6.35 years. Thirteen patients had primary brachial plexus reconstructive surgery and four patients had concomitant wrist extension tendon transfer procedures. All patients had full passive range of motion preoperatively. The average follow-up period was 25.45 months. Average differences in pre-Hoffer and post-Hoffer Mallet scale scores are as follows: active abduction, 1.20; external rotation, 1.35; hand-to-neck, 1.25; hand-to-back, 0.75; hand-to-mouth, 0.65; and aggregate score, 5.20 (p<0.001 for all). Average differences in relevant pre-Hoffer and post-Hoffer Active Movement Scale scores are as follows: shoulder abduction, 2.10; shoulder external rotation, 4.25; and shoulder internal rotation, -0.80. All patients maintained full range of motion passively; thus, no functional loss was experienced. These results showed very high statistical significance (p<0.001 for all) and clinical significance. Younger patients (≤6 years) and those with better preoperative shoulder flexion and shoulder internal rotation yielded better postoperative results. The Hoffer procedure provides clinically and statistically significant improvement in external rotation and abduction while preserving functional internal rotation range

Blood pressure response to combined general anaesthesia/interscalene brachial plexus block for outpatient shoulder arthroscopy.

PubMed

Janssen, Hauke; Stosch, Roland von; Pöschl, Rupert; Büttner, Benedikt; Bauer, Martin; Hinz, José Maria; Bergmann, Ingo

2014-01-01

Shoulder surgery is often performed in the beach-chair position, a position associated with arterial hypotension and subsequent risk of cerebral ischaemia. It can be performed under general anaesthesia or with an interscalene brachial plexus block, each of which has specific advantages but also specific negative effects on blood pressure control. It would be worthwhile to combine the advantages of the two, but the effects of the combination on the circulation are not well investigated. We studied blood pressure, heart rate, and incidence of adverse circulatory events in patients undergoing shoulder surgery in general anaesthesia with or without an interscalene block. Prospective, randomised, blinded study in outpatients (age 18 to 80 years) undergoing shoulder arthroscopy. General anaesthesia was with propofol/opioid, interscalene block with 40 ml 1% mepivacaine. Hypotension requiring treatment was defined as a mean arterial pressure <60 mmHg or a systolic pressure <80% of baseline; relevant bradycardia was a heart rate <50 bpm with a decrease in blood pressure. Forty-two patients had general anaesthesia alone, 41 had general anaesthesia plus interscalene block. The average systolic blood pressure under anaesthesia in the beach-chair position was 114 ± 7.3 vs. 116 ± 8.3 mmHg (p = 0.09; all comparisons General vs. General-Regional). The incidence of a mean arterial pressure under 60 mmHg or a decrease in systolic pressure of more than 20% from baseline was 64% vs. 76% (p = 0.45). The number of patients with a heart rate lower than 50 and a concomitant blood pressure decrease was 8 vs. 5 (p = 0.30). One can safely combine interscalene block with general anaesthesia for surgery in the beach-chair position in ASA I and II patients. DRKS00005295.

A Population-Based Analysis of Time to Surgery and Travel Distances for Brachial Plexus Surgery.

PubMed

Dy, Christopher J; Baty, Jack; Saeed, Mohammed J; Olsen, Margaret A; Osei, Daniel A

2016-09-01

Despite the importance of timely evaluation for patients with brachial plexus injuries (BPIs), in clinical practice we have noted delays in referral. Because the published BPI experience is largely from individual centers, we used a population-based approach to evaluate the delivery of care for patients with BPI. We used statewide administrative databases from Florida (2007-2013), New York (2008-2012), and North Carolina (2009-2010) to create a cohort of patients who underwent surgery for BPI (exploration, repair, neurolysis, grafting, or nerve transfer). Emergency department and inpatient records were used to determine the time interval between the injury and surgical treatment. Distances between treating hospitals and between the patient's home ZIP code and the surgical hospital were recorded. A multivariable logistic regression model was used to determine predictors for time from injury to surgery exceeding 365 days. Within the 222 patients in our cohort, median time from injury to surgery was 7.6 months and exceeded 365 days in 29% (64 of 222 patients) of cases. Treatment at a smaller hospital for the initial injury was significantly associated with surgery beyond 365 days after injury. Patient insurance type, travel distance for surgery, distance between the 2 treating hospitals, and changing hospitals between injury and surgery did not significantly influence time to surgery. Nearly one third of patients in Florida, New York, and North Carolina underwent BPI surgery more than 1 year after the injury. Patients initially treated at smaller hospitals are at risk for undergoing delayed BPI surgery. These findings can inform administrative and policy efforts to expedite timely referral of patients with BPI to experienced centers. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Delayed bilateral vocal cord paresis after a continuous interscalene brachial plexus block and endotracheal intubation

PubMed Central

Park, Hee-Sun; Kim, Ha-Jung; Ro, Young-Jin; Yang, Hong-Seuk; Koh, Won-Uk

2017-01-01

Abstract Rationale: Recurrent laryngeal nerve block is an uncommon complication that can occur after an interscalene brachial plexus block (ISB), which may lead to vocal cord palsy or paresis. However, if the recurrent laryngeal nerve is blocked in patients with a preexisting contralateral vocal cord palsy following neck surgery, this may lead to devastating acute respiratory failure. Thus, ISB is contraindicated in patients with contralateral vocal cord lesion. To the best of our knowledge, there are no reports of bilateral vocal cord paresis, which occurred after a continuous ISB and endotracheal intubation in a patient with no history of vocal cord injury or surgery of the neck. Patient concerns: A 59 year old woman was planned for open acromioplasty and rotator cuff repair under general anesthesia. General anesthesia was induced following an ISB using 0.2% ropivacaine and catheter insertion for postoperative pain control. Diagnoses: While recovering in the postanesthesia care unit (PACU), however, the patient complained of a sore throat and hoarseness without respiratory insufficiency. On the morning of the first postoperative day, she still complained of mild dyspnea, dysphonia, and slight aspiration. She was subsequently diagnosed with bilateral vocal cord paresis following an endoscopic laryngoscopy examination. Interventions: The continuous ISB catheter was immediately removed and the dyspnea and hoarseness symptoms improved, although mild aspiration during drinking water was still present. Outcomes: On the 4th postoperative day, a laryngoscopy examination revealed that the right vocal cord movement had returned to normal but that the left vocal cord paresis still remained. Lessons: When ISB is planned, a detailed history-taking and examination of the airway are essential for patient safety and we recommend that any local anesthetics be carefully injected under ultrasound guidance. We also recommend the use of low concentration of local anesthetics to avoid

Continuous interscalene brachial plexus blockade provides good analgesia at home after major shoulder surgery-report of four cases.

PubMed

Nielsen, Karen C; Greengrass, Roy A; Pietrobon, Ricardo; Klein, Stephen M; Steele, Susan M

2003-01-01

Continuous interscalene brachial plexus blockade (CIBPB) in a hospital setting can provide excellent surgical conditions and postoperative analgesia for major shoulder surgery. This is a case report of four patients on the efficacy and advantages of CIBPB for postoperative analgesia at home. Four patients scheduled for rotator cuff repair under CIBPB were discharged home the day of surgery with an interscalene catheter connected to an automated infusion pump administering 0.2% ropivacaine at 10 mL x hr(-1) for 72 hr. Prior to discharge, patients and their attendant were given verbal and written instructions concerning local anesthetic toxicity and explicit contact information for an anesthesiologist or nurse. Outcomes were measured pre- and postoperatively, including verbal analogue pain scores (pain VAS), verbal analogue nausea scores (nausea VAS), side effects, cognitive function (mini-mental state questionnaire), sleep (hours/night), and patient satisfaction (Likert scale). Postoperative VAS scores over three days were very low. Two patients reported only one episode of nausea. There were no complications associated with local anesthetic toxicity or catheter use. Cognitive function improved over three days. Sleep increased from a mean of five hours before surgery to seven hours over the next three nights. Patient satisfaction with care was high. Significant cost savings were documented. The use of CIBPB for 72 hr in patients undergoing major ambulatory shoulder surgery can result in good analgesia with minimal opioid requirement, cost savings and possibly improvement in outcome measures.

Effect of Locally Administered Dexmedetomidine as Adjuvant to Levobupivacaine in Supraclavicular Brachial Plexus Block: Double-blind Controlled Study.

PubMed

Bisui, Bikash; Samanta, Swastika; Ghoshmaulik, Sumanta; Banerjee, Amit; Ghosh, Tirtha R; Sarkar, Suman

2017-01-01

Brachial plexus block is effective with good postoperative analgesia in upper limb surgery has gained importance as it safe, low cost, and maintains stable hemodynamics intraoperatively. To decrease the onset time and prolong the duration of nerve block bicarbonate, opioids (morphine, fentanyl, etc.), sympathomimetic agents (epinephrine, phenylephrine, etc.), α-2 agonists (clonidine and dexmedetomidine), calcium channel blocker (verapamil), magnesium sulfate, etc., were studied with local anesthetics and their isomers. For their sedative, analgesic, perioperative sympatholytic, and cardiovascular stabilizing effects with reduced anesthetic requirements, α-2 adrenergic receptor agonists, such as more potent and highly selective dexmedetomidine, have been the focus of interest for regional anesthesia. Intravenous dexmedetomidine infusion resulted in significant opioid-sparing effects as well as a decrease in inhalational anesthetic requirements. Animal studies proved that dexmedetomidine enhances sensory and motor blockade along with increased duration of analgesia. In humans, dexmedetomidine has also shown to prolong the duration of block and postoperative analgesia when added to local anesthetic in various regional blocks. Bupivacaine, the widely used local anesthetic in regional anesthesia, is available in a commercial preparation as a racemic mixture (50:50) of its two enantiomers: levobupivacaine, S (-) isomer and dextrobupivacaine, R (+) isomer. Severe central nervous system and cardiovascular adverse reactions reported in the literature after inadvertent intravascular injection or intravenous regional anesthesia have been linked to the R (+) isomer of bupivacaine. The levorotatory isomers were shown to have a safer pharmacological profile with less cardiac and neurotoxic adverse effects. The decreased toxicity of levobupivacaine is attributed to its faster protein binding rate. The pure S (-) enantiomers of bupivacaine, i.e., ropivacaine and levobupivacaine

Medical Decision-Making Among Adolescents with Neonatal Brachial Plexus Palsy and their Families: A Qualitative Study

PubMed Central

Squitieri, Lee; Larson, Bradley P.; Chang, Kate W-C; Yang, Lynda J-S.; Chung, Kevin C.

2016-01-01

Background Elective surgical management of neonatal brachial plexus palsy is complex, variable, and often individualized. Little is known about the medical decision-making process among adolescents with NBPP and their families faced with making complex treatment decisions. The experiences of these patients and their parents were analyzed to identify key factors in the decision-making process. Patients and Methods Eighteen adolescents with residual NBPP deficits between the ages of 10 to 17 years along with their parents were included in the present study. A qualitative research design was employed involving the use of separate one hour, in person, semi-structured interviews, which were audio recorded and transcribed. Grounded theory was applied by two independent members of the research team to identify recurrent themes and ultimately create a codebook that was then applied to the data. Results Medical decision-making among adolescents with NBPP and their families is multifaceted and individualized, comprised of both patient and system dependent factors. Four codes pertaining to the medical decision-making process were identified: 1) knowledge acquisition, 2) multidisciplinary care, 3) adolescent autonomy, and 4) patient expectations and treatment desires. Overall, parental decision-making was heavily influenced by system dependent factors, while adolescents largely based their medical decision-making on individual treatment desires to improve function and/or aesthetics. Conclusions There are many areas for improving the delivery of information and health care organization among adolescents with NBPP and their families. We recommend the development of educational interdisciplinary programs and decision aids containing evidence-based management guidelines targeted toward primary care providers and patients. We believe that a computer-based learning module may provide the best avenue to achieve maximum penetrance and convenience of information sharing. PMID:23714810

Comparative study of phrenic and intercostal nerve transfers for elbow flexion after global brachial plexus injury.

PubMed

Liu, Yuzhou; Lao, Jie; Zhao, Xin

2015-04-01

Global brachial plexus injuries (BPIs) are devastating events frequently resulting in severe functional impairment. The widely used nerve transfer sources for elbow flexion in patients with global BPIs include intercostal and phrenic nerves. The aim of this study was to compare phrenic and intercostal nerve transfers for elbow flexion after global BPI. A retrospective review of 33 patients treated with phrenic and intercostal nerve transfer for elbow flexion in posttraumatic global root avulsion BPI was carried out. In the phrenic nerve transfer group, the phrenic nerve was transferred to the anterolateral bundle of the anterior division of the upper trunk (23 patients); in the intercostal nerve transfer group, three intercostal nerves were coapted to the anterolateral bundles of the musculocutaneous nerve. The British Medical Research Council (MRC) grading system, angle of elbow flexion, and electromyography (EMG) were used to evaluate the recovery of elbow flexion at least 3 years postoperatively. The efficiency of motor function in the phrenic nerve transfer group was 83%, while it was 70% in the intercostal nerve transfer group. The two groups were not statistically different in terms of the MRC grade (p=0.646) and EMG results (p=0.646). The outstanding rates of angle of elbow flexion were 48% and 40% in the phrenic and intercostal nerve transfer groups, respectively. There was no significant difference of outstanding rates in the angle of elbow flexion between the two groups. Phrenic nerve transfer had a higher proportion of good prognosis for elbow flexion than intercostal nerve transfer, but the effective and outstanding rate had no significant difference for biceps reinnervation between the two groups according to MRC grading, angle of elbow flexion, and EMG. Copyright © 2014 Elsevier Ltd. All rights reserved.

Ontology-based image navigation: exploring 3.0-T MR neurography of the brachial plexus using AIM and RadLex.

PubMed

Wang, Kenneth C; Salunkhe, Aditya R; Morrison, James J; Lee, Pearlene P; Mejino, José L V; Detwiler, Landon T; Brinkley, James F; Siegel, Eliot L; Rubin, Daniel L; Carrino, John A

2015-01-01

Disorders of the peripheral nervous system have traditionally been evaluated using clinical history, physical examination, and electrodiagnostic testing. In selected cases, imaging modalities such as magnetic resonance (MR) neurography may help further localize or characterize abnormalities associated with peripheral neuropathies, and the clinical importance of such techniques is increasing. However, MR image interpretation with respect to peripheral nerve anatomy and disease often presents a diagnostic challenge because the relevant knowledge base remains relatively specialized. Using the radiology knowledge resource RadLex®, a series of RadLex queries, the Annotation and Image Markup standard for image annotation, and a Web services-based software architecture, the authors developed an application that allows ontology-assisted image navigation. The application provides an image browsing interface, allowing users to visually inspect the imaging appearance of anatomic structures. By interacting directly with the images, users can access additional structure-related information that is derived from RadLex (eg, muscle innervation, muscle attachment sites). These data also serve as conceptual links to navigate from one portion of the imaging atlas to another. With 3.0-T MR neurography of the brachial plexus as the initial area of interest, the resulting application provides support to radiologists in the image interpretation process by allowing efficient exploration of the MR imaging appearance of relevant nerve segments, muscles, bone structures, vascular landmarks, anatomic spaces, and entrapment sites, and the investigation of neuromuscular relationships. RSNA, 2015

Ontology-based Image Navigation: Exploring 3.0-T MR Neurography of the Brachial Plexus Using AIM and RadLex

PubMed Central

Salunkhe, Aditya R.; Morrison, James J.; Lee, Pearlene P.; Mejino, José L. V.; Detwiler, Landon T.; Brinkley, James F.; Siegel, Eliot L.; Rubin, Daniel L.; Carrino, John A.

2015-01-01

Disorders of the peripheral nervous system have traditionally been evaluated using clinical history, physical examination, and electrodiagnostic testing. In selected cases, imaging modalities such as magnetic resonance (MR) neurography may help further localize or characterize abnormalities associated with peripheral neuropathies, and the clinical importance of such techniques is increasing. However, MR image interpretation with respect to peripheral nerve anatomy and disease often presents a diagnostic challenge because the relevant knowledge base remains relatively specialized. Using the radiology knowledge resource RadLex®, a series of RadLex queries, the Annotation and Image Markup standard for image annotation, and a Web services–based software architecture, the authors developed an application that allows ontology-assisted image navigation. The application provides an image browsing interface, allowing users to visually inspect the imaging appearance of anatomic structures. By interacting directly with the images, users can access additional structure-related information that is derived from RadLex (eg, muscle innervation, muscle attachment sites). These data also serve as conceptual links to navigate from one portion of the imaging atlas to another. With 3.0-T MR neurography of the brachial plexus as the initial area of interest, the resulting application provides support to radiologists in the image interpretation process by allowing efficient exploration of the MR imaging appearance of relevant nerve segments, muscles, bone structures, vascular landmarks, anatomic spaces, and entrapment sites, and the investigation of neuromuscular relationships. ©RSNA, 2015 PMID:25590394

Outcome in adolescence of brachial plexus birth palsy. 69 individuals re-examined after 10–20 years.

PubMed

Hulleberg, Gunn; Elvrum, Ann-Kristin G; Brandal, Merethe; Vik, Torstein

2014-12-01

The frequency and severity of a permanent lesion after brachial plexus birth palsy (BPBP) and its impact on activities of daily living are not well documented. We therefore investigated the outcome of BPBP in adolescents, regarding arm function and consequences for activity and participation. Of 30,574 babies born at St. Olavs University Hospital in 1991-2000, 91 had BPBP (prevalence 3 per 1,000), and 69 of these individuals were examined at a median age of 14 (10-20) years. The examination included the modified Mallet classification, range of motion, shoulder rotation and grip strength, Assisting Hand Assessment, and Canadian Occupational Performance Measure. Of the 22 subjects who were not examined, 3 could not be traced and 19 reported having no problems in the affected arm. At follow-up, 17 adolescents had a permanent lesion (i.e. individual Mallet subscore below 4) with a median Mallet total score of 15 (9-19), while 52 had good or normal shoulder function (median Mallet total score 25 (23-25)). All participants with a permanent lesion had reduced active shoulder rotation (≤15°), 16 had elbow extension deficit, and 10 had subnormal grip strength. External rotation was considerably weaker in the affected shoulder. In addition, they had ineffective use of the affected arm in bimanual activities. Even so, all except 1 were independent in activities of daily living, although 15 experienced minor difficulties. Every fourth to fifth child with BPBP had a permanent lesion as an adolescent. External rotation was the most impaired movement. Despite ineffective use of the affected arm in bimanual activities, all of the participants except one were independent in activities of daily living.

Comparison of the coracoid and retroclavicular approaches for ultrasound-guided infraclavicular brachial plexus block.

PubMed

Kavrut Ozturk, Nilgun; Kavakli, Ali Sait

2017-08-01

This prospective randomized study compared the coracoid and retroclavicular approaches to ultrasound-guided infraclavicular brachial plexus block (IBPB) in terms of needle tip and shaft visibility and quality of block. We hypothesized that the retroclavicular approach would increase needle tip and shaft visibility and decrease the number of needle passes compared to the coracoid approach. A total of 100 adult patients who received IBPB block for upper limb surgery were randomized into two groups: a coracoid approach group (group C) and a retroclavicular approach group (group R). In group C, the needle was inserted 2 cm medial and 2 cm inferior to the coracoid process and directed from ventral to dorsal. In group R, the needle insertion point was posterior to the clavicle and the needle was advanced from cephalad to caudal. All ultrasound images were digitally stored for analysis. The primary aim of the present study was to compare needle tip and shaft visibility between the coracoid approach and retroclavicular approach in patients undergoing upper limb surgery. The secondary aim was to investigate differences between the two groups in the number of needle passes, sensory and motor block success rates, surgical success rate, block performance time, block performance-related pain, patient satisfaction, use of supplemental local anesthetic and analgesic, and complications. Needle tip visibility and needle shaft visibility were significantly better in group R (p = 0.040, p = 0.032, respectively). Block performance time and anesthesia-related time were significantly shorter in group R (p = 0.022, p = 0.038, respectively). Number of needle passes was significantly lower in group R (p = 0.044). Paresthesia during block performance was significantly higher in group C (p = 0.045). There were no statistically significant differences between the two groups in terms of sensory or motor block success, surgical success, block-related pain, and patient satisfaction

Volumetric tumor burden and its effect on brachial plexus dosimetry in head and neck intensity-modulated radiotherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Romesser, Paul B.; Qureshi, Muhammad M.; Kovalchuk, Nataliya

2014-07-01

To determine the effect of gross tumor volume of the primary (GTV-P) and nodal (GTV-N) disease on planned radiation dose to the brachial plexus (BP) in head and neck intensity-modulated radiotherapy (IMRT). Overall, 75 patients underwent definitive IMRT to a median total dose of 69.96 Gy in 33 fractions. The right BP and left BP were prospectively contoured as separate organs at risk. The GTV was related to BP dose using the unpaired t-test. Receiver operating characteristics curves were constructed to determine optimized volumetric thresholds of GTV-P and GTV-N corresponding to a maximum BP dose cutoff of > 66 Gy.more » Multivariate analyses were performed to account for factors associated with a higher maximal BP dose. A higher maximum BP dose (> 66 vs ≤ 66 Gy) correlated with a greater mean GTV-P (79.5 vs 30.8 cc; p = 0.001) and ipsilateral GTV-N (60.6 vs 19.8 cc; p = 0.014). When dichotomized by the optimized nodal volume, patients with an ipsilateral GTV-N ≥ 4.9 vs < 4.9 cc had a significant difference in maximum BP dose (64.2 vs 59.4 Gy; p = 0.001). Multivariate analysis confirmed that an ipsilateral GTV-N ≥ 4.9 cc was an independent predictor for the BP to receive a maximal dose of > 66 Gy when adjusted individually for BP volume, GTV-P, the use of a low anterior neck field technique, total planned radiation dose, and tumor category. Although both the primary and the nodal tumor volumes affected the BP maximal dose, the ipsilateral nodal tumor volume (GTV-N ≥ 4.9 cc) was an independent predictor for high maximal BP dose constraints in head and neck IMRT.« less

The Vienna psychosocial assessment procedure for bionic reconstruction in patients with global brachial plexus injuries.

PubMed

Hruby, Laura Antonia; Pittermann, Anna; Sturma, Agnes; Aszmann, Oskar Christian

2018-01-01

Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand. Many patients report of psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation and prosthetic replacement of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. In this paper we describe a psychosocial assessment procedure for bionic reconstruction in patients with complete brachial plexopathies and present psychosocial outcome variables associated with bionic reconstruction. Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted semi-structured interviews exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. During the interview patients were asked to respond freely. Their answers were transcribed verbatim by the interviewer and analyzed afterwards on the basis of a pre-defined item scoring system. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning (SF-36 Health Survey), body image (FKB-20) and deafferentation pain (VAS). Additionally, psychosocial outcome variables were presented for seven patients before and after bionic reconstruction. Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. 88% of patients felt functionally limited to a great extent due to their disability, and all of them reported constant, debilitating pain in the deafferented hand. After bionic reconstruction the physical component summary

Human Evolution: The Real Cause for Birth Palsy

PubMed Central

Sreekanth, R; Thomas, BP

2015-01-01

ABSTRACT Objective: Birth palsy, otherwise known as obstetric brachial plexus paralysis (OBPP), is a closed stretch injury to the brachial plexus of nerves during the birth process resulting in varying degree of paralysis and contractures of the upper limb. The study aimed to find out the susceptibility of humans and small-bodied primates to birth palsy. Method: A comparative study on parturition in modern humans, hominoids, hominids, small-bodied primates and great apes was done to determine if changes in the female pelvis and neonatal head and shoulder during human evolution is the real cause for OBPP. Results: During evolution, the morphology of the female pelvis and birth canal changed into a narrow and twisted one and also the size of the fetal head increased. Thus, the narrow and twisted pelvis of the mother, and the relatively large head and broad shoulders of the newborn has made the birthing process of modern human and small bodied primates a precarious fine-tuned act with a very narrow margin for error. This has necessitated proper obstetric care to reduce or even at times obviate the incidence of birth injuries like OBPP. Conclusion: Human evolution has made human babies susceptible to birth palsy and thus is the real cause of birth palsy. PMID:26624599

Axillary brachial plexus block duration with mepivacaine in patients with chronic renal failure. Case-control study.

PubMed

Mojica, V; Nieuwveld, D; Herrera, A E; Mestres, G; López, A M; Sala-Blanch, X

2017-04-01

Regional anaesthesia is commonly preferred for arteriovenous fistula (AVF) creation. Previous studies suggest a shorter block duration in patients with chronic renal failure, maybe because of the changes in regional blood flow. The aim of our study was to evaluate the duration of the axillary block with 1.5% mepivacaine in patients with chronic renal failure scheduled for AVF compared with healthy controls. Patients scheduled for AVF creation for the first time (GIRC) were included. They were compared with patients without renal failure (GC), with similar anthropometric characteristics. Ultrasound-guided axillary blocks with 20mL of 1.5% mepivacaine were performed on all patients. We evaluated onset time, humeral artery diameter and blood flow before and after the block, as well as the block duration. Twenty-three patients (GIRC: 12 and GC: 11) were included. No differences between groups were observed in block duration (GIRC: 227±43min vs GC: 229±27min; P=.781), or in onset time (GIRC: 13±5min vs GC: 12.2±3min; P=.477). The humeral blood flow before and after block was significantly lower in the GIRC (pre-block: GIRC: 52±21ml/min GC: 100±62ml/min; P=.034 and p ost block: GIRC: 130±57ml/min and GC: 274±182ml/min; P=.010). There was no significant correlation between the duration of the block and the preblock humeral blood flow (Spearman Rho: 0.106; P=.657) or the postblock humeral blood flow (Spearman Rho: 0.267; P=.254). The duration of the axillary block with 1.5% mepivacaine in patients with chronic renal failure was similar to that of the control patients. The duration of axillary brachial plexus block seems not to be related to changes in regional blood flow. Copyright © 2016 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

The Vienna psychosocial assessment procedure for bionic reconstruction in patients with global brachial plexus injuries

PubMed Central

Sturma, Agnes

2018-01-01

Background Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand. Many patients report of psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation and prosthetic replacement of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. In this paper we describe a psychosocial assessment procedure for bionic reconstruction in patients with complete brachial plexopathies and present psychosocial outcome variables associated with bionic reconstruction. Methods Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted semi-structured interviews exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. During the interview patients were asked to respond freely. Their answers were transcribed verbatim by the interviewer and analyzed afterwards on the basis of a pre-defined item scoring system. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning (SF-36 Health Survey), body image (FKB-20) and deafferentation pain (VAS). Additionally, psychosocial outcome variables were presented for seven patients before and after bionic reconstruction. Results Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. 88% of patients felt functionally limited to a great extent due to their disability, and all of them reported constant, debilitating pain in the deafferented hand. After bionic reconstruction the

Understanding quality of life and patient expectations among adolescents with neonatal brachial plexus palsy: a qualitative and quantitative pilot study.

PubMed

Squitieri, Lee; Larson, Bradley P; Chang, Kate W C; Yang, Lynda J S; Chung, Kevin C

2013-12-01

To explore the quality of life (QOL) and patient expectations among adolescents with neonatal brachial plexus palsy (NBPP)and their parents using qualitative and quantitative approaches. A total of 18 adolescents (10-17 y) with residual NBPP impairment and their parents under went separate 1-hour tape-recorded semistructured interviews. We also collected quantitative physical examination measures and patient-rated outcome scores, specifically the Pediatric Outcomes Data Collection Instrument and the Child Health Questionnaire, to quantify the severity of each adolescent’s functional deficit and increase our understanding of QOL and patient expectations. Through qualitative analysis, we identified several patient- and system-dependent factors contributing to QOL, such as social impact and peer acceptance, emotional adjustment,aesthetic concerns and body image, functional limitations, physical and occupational therapy, finances, pain, and family dynamics. Despite residual impairment, most adolescents and their parents reported a good overall QOL according to quantitative outcome measures. Our study results showed that functional and aesthetic factors were responsible for most observed differences in QOL among NBPP adolescents. We also found that the Pediatric Outcomes Data Collection Instrument might be more sensitive than the Child Health Questionnaire in assessing patient expectations and QOL among this patient population. Understanding patient expectations and QOL in NBPP adolescents is essential for medical decision making and advancing care. Physical examination measurements alone may not be sufficient for measuring outcome, and knowledge regarding environmental factors and family dynamics is important for clinicians to consider when counseling families of children with NBPP and improving overall outcome. Prognostic IV.

Double Versus Single Tendon Transfers to Improve Shoulder Function in Brachial Plexus Birth Palsy.

PubMed

Greenhill, Dustin A; Smith, William R; Ramsey, F V; Kozin, Scott H; Zlotolow, Dan A

2017-03-27

In children with brachial plexus birth palsy (BPBP) undergoing tendon transfers to augment shoulder external rotation, it is unclear whether transfer of the latissimus dorsi with its combined latissimus dorsi and teres major (cLT) versus isolated teres major (iTM) tendon transfer yield different outcomes. Records of patients with BPBP who underwent shoulder tendon transfers to augment external rotation were retrospectively reviewed. Transfer type (cLT or iTM) was considered indiscriminate by virtue of surgeon preference. Modified Mallet Scale (mMS) and Active Movement Scale scores were recorded. Patients with <12 months' follow-up, C7 or lower palsy, humeral osteotomy, shoulder procedure(s) within 8 months, microsurgery within 1 year, or recurrent glenohumeral subluxation confirmed by postoperative imaging were excluded. Matched cohorts were identified within each tendon transfer group to yield similar preoperative shoulder function and glenohumeral alignment status. Outcomes for all tendon transfers as well as differences between cLT and iTM cohorts were analyzed. Among 121 cLT and 34 iTM transfers, 49 cLT and 14 iTM met the inclusion criteria. Subsequent matching of cohorts yielded 28 patients (14 cLT and 14 iTM). Average age at time of transfer was 3.0±1.4 years. Follow-up averaged 4.1±3.1 years. There were no statistically significant preoperative differences between cohorts, thus matching criteria were validated. Regardless of tendon(s) transferred, mMS external rotation improved (2.2 to 3.5, P<0.001), whereas mMS internal rotation decreased (3.8 to 3.2, P<0.001). When comparing matched cohorts, cLT transfer produced a greater mMS external rotation improvement than iTM (2.1 vs. 1.5, respectively; P=0.025). Loss of midline function (defined as mMS external rotation <3) occurred in 5 (35.7%) cLT and 2 (14.3%) iTM patients. Both cLT or iTM transfer are effective at augmenting shoulder external rotation in children with C5-C6 BPBP. Furthermore, cLT transfers may

Observations on the Use of Seprafilm® on the Brachial Plexus in 249 Operations for Neurogenic Thoracic Outlet Syndrome

PubMed Central

Hammond, Sharon L.; Rao, Neal M.

2007-01-01

Purpose Seprafilm® was initially used successfully as a membrane to reduce abdominal adhesions. Subsequently it was tried in a number of other areas to reduce postoperative scarring. Seprafilm® was employed in this study to see if it would reduce postoperative scarring after supraclavicular thoracic outlet decompression for neurogenic thoracic outlet syndrome (NTOS). Material and methods There were 249 operations for primary NTOS (185) and recurrent NTOS (64). Seprafilm® was applied to the nerve roots at the end of each procedure. Diagnosis was established by careful history and extensive physical exam consisting of several provocative maneuvers. Scalene muscle block confirmed the diagnosis. Results Success rates for primary operations, 1–2 years postoperation were 74% for scalenectomy without first rib resection and 70% for scalenectomy with first rib resection. For reoperations, success rate for scalenectomy and neurolysis after transaxillary rib resection was 78% whereas success rate for neurolysis after supraclavicular scalenectomy was 68%. Seprafilm® did not significantly improve overall results compared to our results 15 years ago, although in reoperations there was a trend toward improvement with Seprafilm®. Observations in 10 reoperations after use of Seprafilm® revealed that there were fewer adhesions between fat pad and nerve roots, making it much easier to find the nerve roots. Recurrence was because of scar formation around individual nerve roots. Conclusion Seprafilm® made reoperations easier by reducing scarring between scalene fat pad and brachial plexus. However, it did not prevent scar tissue forming around the individual nerve roots nor did it significantly lower the failure rate for primary operations. The trend supported the use of Seprafilm® in reoperations. PMID:18780049

Surgical correction of shoulder rotation deformity in brachial plexus birth palsy: long-term results in 118 patients.

PubMed

Hultgren, T; Jönsson, K; Roos, F; Järnbert-Pettersson, H; Hammarberg, H

2014-10-01

We present the long-term results of open surgery for internal shoulder rotational deformity in brachial plexus birth palsy (BPBP). From 1997 to 2005, 207 patients (107 females, 100 males, mean age 6.2 (0.6 to 34)) were operated on with subscapularis elongation and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder joints were relocated. The early results of these patients has been reported previously. We analysed 118 (64 females, 54 males, mean age 15.1 (7.6 to 34)) of the original patient cohort at a mean of 10.4 years (7.0 to 15.1) post-operatively. A third of patients with relocated joints had undergone secondary internal rotational osteotomy of the humerus. A mixed effects models approach was used to evaluate the effects of surgery on shoulder rotation, abduction, and the Mallet score. Independent factors were time (pre-and post-surgery), gender, age, joint category (congruent, relocated, relocated plus osteotomy) and whether or not a transfer had been performed. Data from a previously published short-term evaluation were reworked in order to obtain pre-operative values. The mean improvement in external rotation from pre-surgery to the long-term follow-up was 66.5° (95% confidence interval (CI) 61.5 to 71.6). The internal rotation had decreased by a mean of 22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95% CI 8.4 to 9.0) to 11.8 (11.5 to 12.1). Our results show that open subscapularis elongation achieves good long-term results for patients with BPBP and an internal rotation contracture, providing lasting joint congruency and resolution of the trumpet sign, but with a moderate mean loss of internal rotation. ©2014 The British Editorial Society of Bone & Joint Surgery.

Understanding Long-Term Outcomes and Patient Expectations Among Adolescents with Neonatal Brachial Plexus Palsy: A Qualitative and Quantitative Study

PubMed Central

Squitieri, Lee; Larson, Bradley P.; Chang, Kate W-C.; Yang, Lynda J-S.; Chung, Kevin C.

2014-01-01

Purpose Quality of life (QOL) among adolescents with neonatal brachial plexus palsy (NBPP) is an important but unexplored topic. To date, few NBPP studies use comprehensive patient-reported outcome measures, and none specifically address the adolescent population. This study explores the long-term QOL and patient expectations among adolescents with NBPP using qualitative and quantitative approaches. Methods Eighteen adolescents with residual NBPP impairment between the ages of 10 to 17 years along with their parents were included in our study. Adolescents and their parents underwent separate one hour tape-recorded semi-structured interviews, which were audio recorded and transcribed. We also collected quantitative patient outcome measures to quantify the degree of each adolescent’s functional impairment and to increase our understanding of long-term quality of life and patient expectations. Results Thirteen females and five males with a mean age of 11.6 years participated in our study. Through qualitative analysis we identified the following factors contributing to overall QOL from the patient and parent perspective: social impact and peer acceptance, emotional adjustment, aesthetic concerns and body image, functional limitations, physical and occupational therapy, finances, pain, and family dynamics. Despite residual impairment, most adolescents and their parents reported a good overall QOL according to quantitative outcome measures, with adolescents reporting slightly higher QOL than their parents. However, both adolescents and their parents report relatively modest satisfaction with their current condition and express expectations for improvement in multiple areas. Discussion Understanding patient expectations and QOL in NBPP adolescents are essential for medical decision-making and advancing care. Our study results showed that functional and aesthetic factors were responsible for the majority of observed differences in QOL among NBPP adolescents. We also

Quantitative magnetic resonance (MR) neurography for evaluation of peripheral nerves and plexus injuries

PubMed Central

Barousse, Rafael; Socolovsky, Mariano; Luna, Antonio

2017-01-01

Traumatic conditions of peripheral nerves and plexus have been classically evaluated by morphological imaging techniques and electrophysiological tests. New magnetic resonance imaging (MRI) studies based on 3D fat-suppressed techniques are providing high accuracy for peripheral nerve injury evaluation from a qualitative point of view. However, these techniques do not provide quantitative information. Diffusion weighted imaging (DWI) and diffusion tensor imaging (DTI) are functional MRI techniques that are able to evaluate and quantify the movement of water molecules within different biological structures. These techniques have been successfully applied in other anatomical areas, especially in the assessment of central nervous system, and now are being imported, with promising results for peripheral nerve and plexus evaluation. DWI and DTI allow performing a qualitative and quantitative peripheral nerve analysis, providing valuable pathophysiological information about functional integrity of these structures. In the field of trauma and peripheral nerve or plexus injury, several derived parameters from DWI and DTI studies such as apparent diffusion coefficient (ADC) or fractional anisotropy (FA) among others, can be used as potential biomarkers of neural damage providing information about fiber organization, axonal flow or myelin integrity. A proper knowledge of physical basis of these techniques and their limitations is important for an optimal interpretation of the imaging findings and derived data. In this paper, a comprehensive review of the potential applications of DWI and DTI neurographic studies is performed with a focus on traumatic conditions, including main nerve entrapment syndromes in both peripheral nerves and brachial or lumbar plexus. PMID:28932698

[Acute osteomyelitis of the clavicle in the newborn infant: a case report].

PubMed

Allagui, M; Bellaaj, Z; Zrig, M; Abid, A; Koubaa, M

2014-02-01

Acute osteomyelitis of the clavicle accounts for less than 3% of osteomyelitis cases, with its usual location in the middle third. It may be hematogenous, due to contiguity, or secondary to catheterization of the subclavian vein or neck surgery. The diagnosis is often delayed, and clinical symptoms may simulate obstetric brachial plexus palsy in young children. We report a new case of osteomyelitis of the clavicle in a 30-day-old newborn. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Phrenic and intercostal nerves with rhythmic discharge can promote early nerve regeneration after brachial plexus repair in rats.

PubMed

Rui, Jing; Xu, Ya-Li; Zhao, Xin; Li, Ji-Feng; Gu, Yu-Dong; Lao, Jie

2018-05-01

distal to the coaptation site of the musculocutaneous nerve at 1 month after surgery was significantly higher in phrenic and intercostal nerve groups than in thoracodorsal nerve and negative control groups. These results indicate that endogenous autonomic discharge from phrenic and intercostal nerves can promote nerve regeneration in early stages after brachial plexus injury.

Motor and Sensory Cortical Changes after Contralateral Cervical Seventh Nerve Root (CC7) Transfer in Patients with Brachial Plexus Injuries.

PubMed

Kakinoki, Ryosuke; Duncan, Scott F M; Ikeguchi, Ryosuke; Ohta, Souichi; Nankaku, Manabu; Sakai, Hiroshi; Noguchi, Takashi; Kaizawa, Yukitoshi; Akagi, Masao

2017-06-01

Previous animal studies demonstrated that the sensory and motor functions in ipsilesional upper limbs that had been reconstructed by CC7 transfer eventually associated with the contralesional brain cortices that had originally mediated the functions of the ipsilesional upper limbs before brachial plexus injury (BPI). Our hypothesis was that the same findings would be seen in humans. Four patients with total BPI treated with CC7 transfer were included. Changes in the locations of the activated areas in the primary motor (M1) and somatosensory (S1) cortices corresponding to the motor outputs to and sensory inputs from the ipsilesional limbs were investigated using functional near-infrared spectroscopy (fNIRS) 2-3 years and 6-7 years after surgery. One patient was excluded from the evaluation of motor function after CC7 transfer. The motor and sensory functions of the ipsilesional upper limb in all patients were still controlled by the ipsilesional brain hemisphere 2-3 years after CC7 transfer. The reconstructed motions of the ipsilesional upper limbs correlated with the contralesional M1 in one patient and the bilateral M1s in another patient (both of whom demonstrated good motor recovery in the ipsilesional upper limbs) and with the ipsilesional M1 in a third patient with poor motor recovery in the ipsilesional upper limb. Sensory stimulation of the ipsilesional hands 6-7 years after CC7 transfer activated the contralesional S1 in two patients who achieved good sensory recovery in the ipsilesional hands but activated the ipsilesional S1 in the other two patients with poor sensory recovery of the ipsilesional hands. Transhemispheric transposition of the activated brain cortices associated with the recovery of motor and sensory functions of the ipsilesional upper limbs was seen in patients with CC7 transfer as has been reported for animal models of CC7 transfer.

The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis.

PubMed

Socolovsky, Mariano; di Masi, Gilda; Bonilla, Gonzalo; Domínguez Paez, Miguel; Robla, Javier; Calvache Cabrera, Camilo

2015-06-01

Controversy exists surrounding the use of the phrenic nerve for transfer in severe brachial plexus injuries. The objectives of this study are: (1) to present the experience of the authors using the phrenic nerve in a single institution; and (2) to thoroughly review the existing literature to date. Adult patients with C5-D1 and C5-C8 lesions and a phrenic nerve transfer were retrospectively included. Patients with follow-up shorter than 18 months were excluded. The MRC muscle strength grading system was used to rate the outcome. Clinical repercussions relating to sectioning of the phrenic nerve were studied. An intense rehabilitation program was started after surgery, and compliance to this program was monitored using a previously described scale. Statistical analysis was performed with the obtained data. Fifty-one patients were included. The mean time between trauma and surgery was 5.7 months. Three-quarters of the patients had C5-D1, with the remainder C5-C8. Mean post-operative follow-up was 32.5 months A MRC of M4 was achieved in 62.7% patients, M3 21.6%, M2 in 3.9%, and M1 in 11.8%. The only significant differences between the two groups were in graft length (9.8 vs. 15.1 cm, p = 0.01); and in the rehabilitation compliance score (2.86 vs. 2.00, p = 0.01). Results of phrenic nerve transfer are predictable and good, especially if the grafts are short and the rehabilitation is adequate. It may adversely affect respiratory function tests, but this rarely correlates clinically. Contraindications to the use of the phrenic nerve exist and should be respected.

Brachial Plexopathy in Apical Non-Small Cell Lung Cancer Treated With Definitive Radiation: Dosimetric Analysis and Clinical Implications

DOE Office of Scientific and Technical Information (OSTI.GOV)

Eblan, Michael J.; Corradetti, Michael N.; Lukens, J. Nicholas

2013-01-01

Purpose: Data are limited on the clinical significance of brachial plexopathy in patients with apical non-small cell lung cancers (NSCLC) treated with definitive radiation therapy. We report the rates of radiation-induced brachial plexopathy (RIBP) and tumor-related brachial plexopathy (TRBP) and associated dosimetric parameters in apical NSCLC patients. Methods and Materials: Charts of NSCLC patients with primary upper lobe or superiorly located nodal disease who received {>=}50 Gy of definitive conventionally fractionated radiation or chemoradiation were retrospectively reviewed for evidence of brachial plexopathy and categorized as RIBP, TRBP, or trauma-related. Dosimetric data were gathered on ipsilateral brachial plexuses (IBP) contoured accordingmore » to Radiation Therapy Oncology Group atlas guidelines. Results: Eighty patients were identified with a median follow-up and survival time of 17.2 and 17.7 months, respectively. The median prescribed dose was 66.6 Gy (range, 50.4-84.0), and 71% of patients received concurrent chemotherapy. RIBP occurred in 5 patients with an estimated 3-year rate of 12% when accounting for competing risk of death. Seven patients developed TRBP (estimated 3-year rate of 13%), comprising 24% of patients who developed locoregional failures. Grade 3 brachial plexopathy was more common in patients who experienced TRBP than RIBP (57% vs 20%). No patient who received {<=}78 Gy to the IBP developed RIBP. On multivariable competing risk analysis, IBP V76 receiving {>=}1 cc, and primary tumor failure had the highest hazard ratios for developing RIBP and TRBP, respectively. Conclusions: RIBP is a relatively uncommon complication in patients with apical NSCLC tumors receiving definitive doses of radiation, while patients who develop primary tumor failures are at high risk for developing morbid TRBP. These findings suggest that the importance of primary tumor control with adequate doses of radiation outweigh the risk of RIBP in this

Progression of choroid plexus papilloma.

PubMed

Dhillon, Rana S; Wang, Yi Yuen; McKelvie, Penny A; O'Brien, Brendan

2013-12-01

Choroid plexus papillomas are rare neoplasms that arise from choroid plexus epithelium. The World Health Organization classification describes three histological grades. Grade I is choroid plexus papilloma, grade II is atypical choroid plexus papilloma and grade III is choroid plexus carcinoma. Progression between grades is rare but documented. We present two adult cases, a 53-year-old female and a 70-year-old male, who demonstrated clear interval histological progression from grade I choroid plexus papilloma to higher grades. Copyright © 2013 Elsevier Ltd. All rights reserved.

A Comparison of Obstetric Maneuvers for the Acute Management of Shoulder Dystocia

PubMed Central

Hoffman, Matthew K; Bailit, Jennifer L; Branch, D. Ware; Burkman, Ronald T; Van Veldhusien, Paul; Lu, Li; Kominiarek, Michelle A.; Hibbard, Judith U; Landy, Helain J; Haberman, Shoshana; Wilkins, Isabelle; Gonzalez Quintero, Victor H; Gregory, Kimberly D; Hatjis, Christos G; Ramirez, Mildred M; Reddy, Uma M.; Troendle, James; Zhang, Jun

2011-01-01

Objective To assess the efficacy of obstetric maneuvers for resolving shoulder dystocia, and the effect that these maneuvers have on neonatal injury when shoulder dystocia occurs. Methods Using an electronic database encompassing 206,969 deliveries, we identified all women with a vertex fetus beyond 34 0/7 weeks of gestation who incurred a shoulder dystocia during the process of delivery. Women whose fetuses had a congenital anomaly and women with an antepartum stillbirth were excluded. Medical records of all cases were reviewed by trained abstractors. Cases involving neonatal injury (defined as brachial plexus injury, clavicular or humerus fracture, or hypoxic ischemic encephalopathy or intrapartum neonatal death attributed to the shoulder dystocia) were compared to those without injury. RESULTS Among 132,098 women who delivered a term cephalic liveborn fetus vaginally, 2,018 incurred a shoulder dystocia (1.5%), and 101 (5.2%) of these incurred a neonatal injury. Delivery of the posterior shoulder was associated with the highest rate of delivery when compared to other maneuvers (84.4% compared with 24.3% to 72.0% for other maneuvers; P<.005 to P<.001) and similar rates of neonatal injury (8.4% compared with 6.1% to 14.0%; P=.23 to P=.7). The total number of maneuvers performed significantly correlated with the rate of neonatal injury (P<.001). CONCLUSIONS Delivery of the posterior shoulder should be considered following McRoberts maneuver and suprapubic pressure in the management of shoulder dystocia. The need for additional maneuvers was associated with higher rates of neonatal injury. PMID:21555962

Effect of fascicle composition on ulnar to musculocutaneous nerve transfer (Oberlin transfer) in neonatal brachial plexus palsy.

PubMed

Smith, Brandon W; Chulski, Nicholas J; Little, Ann A; Chang, Kate W C; Yang, Lynda J S

2018-06-01

OBJECTIVE Neonatal brachial plexus palsy (NBPP) continues to be a problematic occurrence impacting approximately 1.5 per 1000 live births in the United States, with 10%-40% of these infants experiencing permanent disability. These children lose elbow flexion, and one surgical option for recovering it is the Oberlin transfer. Published data support the use of the ulnar nerve fascicle that innervates the flexor carpi ulnaris as the donor nerve in adults, but no analogous published data exist for infants. This study investigated the association of ulnar nerve fascicle choice with functional elbow flexion outcome in NBPP. METHODS The authors conducted a retrospective study of 13 cases in which infants underwent ulnar to musculocutaneous nerve transfer for NBPP at a single institution. They collected data on patient demographics, clinical characteristics, active range of motion (AROM), and intraoperative neuromonitoring (IONM) (using 4 ulnar nerve index muscles). Standard statistical analysis compared pre- and postoperative motor function improvement between specific fascicle transfer (1-2 muscles for either wrist flexion or hand intrinsics) and nonspecific fascicle transfer (> 2 muscles for wrist flexion and hand intrinsics) groups. RESULTS The patients' average age at initial clinic visit was 2.9 months, and their average age at surgical intervention was 7.4 months. All NBPPs were unilateral; the majority of patients were female (61%), were Caucasian (69%), had right-sided NBPP (61%), and had Narakas grade I or II injuries (54%). IONM recordings for the fascicular dissection revealed a donor fascicle with nonspecific innervation in 6 (46%) infants and specific innervation in the remaining 7 (54%) patients. At 6-month follow-up, the AROM improvement in elbow flexion in adduction was 38° in the specific fascicle transfer group versus 36° in the nonspecific fascicle transfer group, with no statistically significant difference (p = 0.93). CONCLUSIONS Both specific and

[Axillary blockade of the brachial plexus. A prospective evaluation of 1133 cases of plexus catheter anesthesia].

PubMed

Büttner, J; Kemmer, A; Argo, A; Klose, R; Forst, R

1988-01-01

The results of 1133 axillary catheter brachial blocks are reported. Effectiveness and side-effects were monitored in a prospective manner over a period of 1 year. The puncture was performed with an 18-gauge plastic cannula fitted with a solid steel stylet. The stylet has a 45 degrees, short bevel with rounded edges. When puncturing the axillary neurovascular sheath, no attempt was made to elicit paresthesias with the needle. A distinct "click" and very easy advancement of the plastic cannula were signs of being well inside the neurovascular sheath. To confirm the correct positioning, 0.5-3 ml refrigerated saline solution were injected. If no paresthesias could be produced, a new puncture was performed using a nerve stimulator. The plastic cannula was fixed to the skin. For long-lasting operations or if postoperative analgesia or sympatholysis was required, a more flexible catheter was introduced through the plastic cannula. As an initial dose 40 ml 1% mepivacaine was injected via the cannula. If there was an insufficient block after 20 min, another 20 ml 1% mepivacaine was given. For long-lasting operations, 40 ml 1% mepivacaine was injected every 2 h. Surgery was completed in 72% of patients; 24% required some form of supplementation including 17.2% of patients who received a "top-up" after 20 min (Table 1). In 3.8% of cases the technique was considered to be a complete failure, meaning that patients needed some type of general anesthesia including the use of i.v. ketamine.(ABSTRACT TRUNCATED AT 250 WORDS)

A literature review of intercostal-to-musculocutaneous-nerve transfers in brachial plexus injury patients: Does body mass index influence results in Eastern versus Western countries?

PubMed

Socolovsky, Mariano; Paez, Miguel Domínguez

2013-11-27

A wide range of results have appeared in the literature for intercostal nerve transfers in brachial plexus patients. Oriental countries generally have a lower body mass index (BMI) than their occidental counterparts. We analyzed published series of intercostal nerve transfers for elbow reinnervation to determine if a difference in outcomes exists between Eastern and Western series that could be inversely related to BMI. A PubMed search was conducted. Inclusion criteria were: (1) time from trauma to surgery <12 months, (2) minimum follow-up one year, (3) intercostal to musculocutaneous nerve transfer the only surgical procedure performed to reestablish elbow flexion, and (4) males comprising more than 75% of cases. Two groups were created: Series from western countries, including America, Europe, and Africa; and series from Asia. Pearson correlation analysis was performed to assess for the degree of correlation between percent responders and mean national BMI. A total of 26 series were included, 14 from western countries and 12 from Eastern countries, encompassing a total of 274 and 432 surgical cases, respectively. The two groups were almost identical in mean age, but quite different in mean national BMI (26.3 vs. 22.5) and in the percentage of patients who achieved at least a Medical Research Council (MRC) level 3 (59.5% vs. 79.3%). Time from trauma to surgery was slightly shorter in Eastern (3.4 months) versus Western countries (5.0 months). The percentage of responders to intercostal to musculocutaneous nerve transfer was inversely correlated with the mean national BMI among male residents of the country where the series was performed.

Effect of tramadol as an adjuvant to local anesthetics for brachial plexus block: A systematic review and meta-analysis

PubMed Central

Ju, Bum Jun; Jang, Yoo Kyung; You, Hae Seun; Kang, Hyun; Park, Ji Yong

2017-01-01

Background Tramadol, a 4-phenyl-piperidine analog of codeine, has a unique action in that it has a central opioidergic, noradrenergic, serotonergic analgesic, and peripheral local anesthetic (LA) effect. Many studies have reported contradictory findings regarding the peripheral analgesic effect of tramadol as an adjuvant to LA in brachial plexus block (BPB). This meta-analysis aimed to evaluate the effects of tramadol as an adjunct to LA in BPB during shoulder or upper extremity surgery. Methods We searched the PubMed, EMBASE, Cochrane, KoreaMed databases, and Google Scholar for eligible randomized controlled trials (RCTs) that compared BPB with LA alone and BPB with LA and tramadol. Primary outcomes were the effects of tramadol as an adjuvant on duration of sensory block, motor block, and analgesia. Secondary outcomes were the effects of tramadol as an adjuvant on time to onset of sensory block and motor block and on adverse effects. We performed the meta-analysis using Review Manager 5.3 software. Results We identified 16 RCTs with 751 patients. BPB with tramadol prolonged the duration of sensory block (mean difference [MD], -61.5 min; 95% CI, -95.5 to -27.6; P = 0.0004), motor block (MD, -65.6 min; 95% CI, -101.5 to -29.7; P = 0.0003), and analgesia (MD, -125.5 min; 95% CI, -175.8 to -75.3; P < 0.0001) compared with BPB without tramadol. Tramadol also shortened the time to onset of sensory block (MD, 2.1 min; 95% CI, 1.1 to 3.1; P < 0.0001) and motor block (MD, 1.2 min; 95% CI, 0.2 to 2.1; P = 0.010). In subgroup analysis, the duration of sensory block, motor block, and analgesia was prolonged for BPB with tramadol 100 mg (P < 0.05) but not for BPB with tramadol 50 mg. The quality of evidence was high for duration of analgesia according to the GRADE system. Adverse effects were comparable between the studies. Conclusions In upper extremity surgery performed under BPB, use of tramadol 100 mg as an adjuvant to LA appears to prolong the duration of sensory block

Effect of tramadol as an adjuvant to local anesthetics for brachial plexus block: A systematic review and meta-analysis.

PubMed

Shin, Hye Won; Ju, Bum Jun; Jang, Yoo Kyung; You, Hae Seun; Kang, Hyun; Park, Ji Yong

2017-01-01

Tramadol, a 4-phenyl-piperidine analog of codeine, has a unique action in that it has a central opioidergic, noradrenergic, serotonergic analgesic, and peripheral local anesthetic (LA) effect. Many studies have reported contradictory findings regarding the peripheral analgesic effect of tramadol as an adjuvant to LA in brachial plexus block (BPB). This meta-analysis aimed to evaluate the effects of tramadol as an adjunct to LA in BPB during shoulder or upper extremity surgery. We searched the PubMed, EMBASE, Cochrane, KoreaMed databases, and Google Scholar for eligible randomized controlled trials (RCTs) that compared BPB with LA alone and BPB with LA and tramadol. Primary outcomes were the effects of tramadol as an adjuvant on duration of sensory block, motor block, and analgesia. Secondary outcomes were the effects of tramadol as an adjuvant on time to onset of sensory block and motor block and on adverse effects. We performed the meta-analysis using Review Manager 5.3 software. We identified 16 RCTs with 751 patients. BPB with tramadol prolonged the duration of sensory block (mean difference [MD], -61.5 min; 95% CI, -95.5 to -27.6; P = 0.0004), motor block (MD, -65.6 min; 95% CI, -101.5 to -29.7; P = 0.0003), and analgesia (MD, -125.5 min; 95% CI, -175.8 to -75.3; P < 0.0001) compared with BPB without tramadol. Tramadol also shortened the time to onset of sensory block (MD, 2.1 min; 95% CI, 1.1 to 3.1; P < 0.0001) and motor block (MD, 1.2 min; 95% CI, 0.2 to 2.1; P = 0.010). In subgroup analysis, the duration of sensory block, motor block, and analgesia was prolonged for BPB with tramadol 100 mg (P < 0.05) but not for BPB with tramadol 50 mg. The quality of evidence was high for duration of analgesia according to the GRADE system. Adverse effects were comparable between the studies. In upper extremity surgery performed under BPB, use of tramadol 100 mg as an adjuvant to LA appears to prolong the duration of sensory block, motor block, and analgesia, and shorten

Management of complex regional pain syndrome type I in upper extremity-evaluation of continuous stellate ganglion block and continuous infraclavicular brachial plexus block: a pilot study.

PubMed

Toshniwal, Gokul; Sunder, Rani; Thomas, Ronald; Dureja, G P

2012-01-01

Interventional pain management techniques play an important role in the multidisciplinary approach to management of complex regional pain syndrome (CRPS). In this preliminary study we compared the efficacy of continuous stellate ganglion (CSG) block with that of continuous infraclavicular brachial plexus (CIBP) block in management of CRPS type I of upper extremity. Thirty-three patients with CRPS type I of upper extremity were randomly assigned to either CSG or CIBP group. Patients were treated for 1 week with continuous infusion of 0.125% bupivacaine at 2and 5mL/h, respectively. Catheter was removed at 1 week and patients were followed up for 4 weeks. The outcome was evaluated in terms of neuropathic pain scale score (NPSS), edema scores (Grades 0-2), and range of motion (ROM) of all upper extremity joints (Grades 0-2). CIBP group showed statistically significant improvement in NPSS compared with CSG group during the first 12 hours after the procedures (P value <0.05). After 12 hours, the NPSS was comparable between the groups. At 4 weeks, both groups showed clinically significant improvement in edema score and ROM of all upper extremity joints when compared with the baseline. This preliminary study suggests that CIBP block and CSG block may be feasible and effective interventional techniques for the management of CRPS type I of upper extremities. Hence, we recommend a larger well-randomized, well-controlled, clinical trial to confirm our findings and determine if any significant difference exists between the groups in terms of long-term pain relief and functional restoration. Wiley Periodicals, Inc.

Direct Coaptation of the Phrenic Nerve With the Posterior Division of the Lower Trunk to Restore Finger and Elbow Extension Function in Patients With Total Brachial Plexus Injuries.

PubMed

Wang, Shu-feng; Li, Peng-cheng; Xue, Yun-hao; Zou, Ji-yao; Li, Wen-jun; Li, Yucheng

2016-02-01

To overcome the mismatch in nerve sizes in phrenic nerve transfer to the radial nerve for elbow and finger extension reanimation for patients with total brachial plexus injuries (TBPI), a selective neurotization procedure was designed. To investigate the long-term results of phrenic nerve transfer to the posterior division of the lower trunk with direct coaptation in restoring elbow and finger extension after TBPI. Phrenic nerve was transferred to and directly coapted with the posterior division of the lower trunk in 27 patients with TBPI. Seven patients were <18 years old (adolescent group), and the remaining 20 patients ≥18 years (adult group). Postoperative mean follow-up period was 54 ± 9 months (range, 48-85 months). The motor function attained M3 or greater in 81.5% of patients for elbow extension and in 48% of patients for finger extension. The percentage of patients who regained M3 or greater muscle power of finger extension in the adolescent group and the adult group was 71.4%, and 40%, respectively. Meanwhile, 85.7% in the adolescent group and 80% in the adult group achieved M3 or greater muscle power of elbow extension. There were no significant differences between the 2 groups. The elbow extension and finger extension were synchronous contractions and did not become independent of respiratory effort. This procedure simultaneously and effectively restores the function of elbow and finger extension in patients after TBPI. However, the patients could not do elbow and finger extension separately.

Interscalene brachial plexus blocks under general anesthesia in children: is this safe practice?: A report from the Pediatric Regional Anesthesia Network (PRAN).

PubMed

Taenzer, Andreas; Walker, Benjamin J; Bosenberg, Adrian T; Krane, Elliot J; Martin, Lynn D; Polaner, David M; Wolf, Christie; Suresh, Santhanam

2014-01-01

A practice advisory on regional anesthesia in children in 2008, published in this journal, supported the placement of regional blocks in children under general anesthesia (GA). Interscalene brachial plexus (IS) blocks were specifically excluded, based on case reports (level 3 evidence) of injury, which occurred predominantly in heavily sedated or anesthetized adult patients. Apart from case reports, there is a paucity of data that explore the safety of IS blocks placed in patients under GA, and the level of evidence available on which to base recommendations is limited. Querying the database of the Pediatric Regional Anesthesia Network (PRAN), we report on the incidence of postoperative neurological symptoms, local anesthetic systemic toxicity, and other reported adverse events in children receiving IS blocks under GA or sedated. A total of 518 interscalene blocks were performed, 390 under GA and 123 with the patient sedated or awake (5 cases had missing status); 472 of these were single injection, and 46 involved the placement of infusion catheters. Eighty-eight percent of blocks were placed with ultrasound guidance, 7.7% with no location device, and 2.5% with a nerve stimulator. No local anesthetic systemic toxicity, postoperative neurological symptoms, cardiovascular complications, or dural puncture was reported in this cohort. There were 1 vascular puncture and 1 postoperative infection. These negative results are compatible with 0 to 7.7/1000 events for each of these complications for IS blocks placed under GA. There was no paralysis, motor block, or sensory deficit beyond the expected block duration time. Analyzing interscalene blocks in children placed under GA, we identified no serious adverse events. The upper limit of the confidence interval for these events is similar to that in awake or sedated adults receiving IS blocks. Based on these prospectively collected data, placement of IS blocks under GA in children is no less safe than placement in awake

Psychometric Evaluation of the Brachial Assessment Tool Part 1: Reproducibility.

PubMed

Hill, Bridget; Williams, Gavin; Olver, John; Ferris, Scott; Bialocerkowski, Andrea

2018-04-01

To evaluate reproducibility (reliability and agreement) of the Brachial Assessment Tool (BrAT), a new patient-reported outcome measure for adults with traumatic brachial plexus injury (BPI). Prospective repeated-measure design. Outpatient clinics. Adults with confirmed traumatic BPI (N=43; age range, 19-82y). People with BPI completed the 31-item 4-response BrAT twice, 2 weeks apart. Results for the 3 subscales and summed score were compared at time 1 and time 2 to determine reliability, including systematic differences using paired t tests, test retest using intraclass correlation coefficient model 1,1 (ICC 1,1 ), and internal consistency using Cronbach α. Agreement parameters included standard error of measurement, minimal detectable change, and limits of agreement. BrAT. Test-retest reliability was excellent (ICC 1,1 =.90-.97). Internal consistency was high (Cronbach α=.90-.98). Measurement error was relatively low (standard error of measurement range, 3.1-8.8). A change of >4 for subscale 1, >6 for subscale 2, >4 for subscale 3, and >10 for the summed score is indicative of change over and above measurement error. Limits of agreement ranged from ±4.4 (subscale 3) to 11.61 (summed score). These findings support the use of the BrAT as a reproducible patient-reported outcome measure for adults with traumatic BPI with evidence of appropriate reliability and agreement for both individual and group comparisons. Further psychometric testing is required to establish the construct validity and responsiveness of the BrAT. Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Outcome following phrenic nerve transfer to musculocutaneous nerve in patients with traumatic brachial palsy: a qualitative systematic review.

PubMed

de Mendonça Cardoso, Marcio; Gepp, Ricardo; Correa, José Fernando Guedes

2016-09-01

The phrenic nerve can be transferred to the musculocutaneous nerve in patients with traumatic brachial plexus palsy in order to recover biceps strength, but the results are controversial. There is also a concern about pulmonary function after phrenic nerve transection. In this paper, we performed a qualitative systematic review, evaluating outcomes after this procedure. A systematic review of published studies was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Data were extracted from the selected papers and related to: publication, study design, outcome (biceps strength in accordance with BMRC and pulmonary function) and population. Study quality was assessed using the "strengthening the reporting of observational studies in epidemiology" (STROBE) standard or the CONSORT checklist, depending on the study design. Seven studies were selected for this systematic review after applying inclusion and exclusion criteria. One hundred twenty-four patients completed follow-up, and most of them were graded M3 or M4 (70.1 %) for biceps strength at the final evaluation. Pulmonary function was analyzed in five studies. It was not possible to perform a statistical comparison between studies because the authors used different parameters for evaluation. Most of the patients exhibited a decrease in pulmonary function tests immediately after surgery, with recovery in the following months. Study quality was determined using STROBE in six articles, and the global score varied from 8 to 21. Phrenic nerve transfer to the musculocutaneous nerve can recover biceps strength ≥M3 (BMRC) in most patients with traumatic brachial plexus injury. Early postoperative findings revealed that the development of pulmonary symptoms is rare, but it cannot be concluded that the procedure is safe because there is no study evaluating pulmonary function in old age.

Transport across the choroid plexus epithelium.

PubMed

Praetorius, Jeppe; Damkier, Helle Hasager

2017-06-01

The choroid plexus epithelium is a secretory epithelium par excellence. However, this is perhaps not the most prominent reason for the massive interest in this modest-sized tissue residing inside the brain ventricles. Most likely, the dominant reason for extensive studies of the choroid plexus is the identification of this epithelium as the source of the majority of intraventricular cerebrospinal fluid. This finding has direct relevance for studies of diseases and conditions with deranged central fluid volume or ionic balance. While the concept is supported by the vast majority of the literature, the implication of the choroid plexus in secretion of the cerebrospinal fluid was recently challenged once again. Three newer and promising areas of current choroid plexus-related investigations are as follows: 1 ) the choroid plexus epithelium as the source of mediators necessary for central nervous system development, 2 ) the choroid plexus as a route for microorganisms and immune cells into the central nervous system, and 3 ) the choroid plexus as a potential route for drug delivery into the central nervous system, bypassing the blood-brain barrier. Thus, the purpose of this review is to highlight current active areas of research in the choroid plexus physiology and a few matters of continuous controversy. Copyright © 2017 the American Physiological Society.

Unique Phrenic Nerve-Sparing Regional Anesthetic Technique for Pain Management after Shoulder Surgery

PubMed Central

Olsen, David A.; Amundson, Adam W.

2017-01-01

Background Ipsilateral phrenic nerve blockade is a common adverse event after an interscalene brachial plexus block, which can result in respiratory deterioration in patients with preexisting pulmonary conditions. Diaphragm-sparing nerve block techniques are continuing to evolve, with the intention of providing satisfactory postoperative analgesia while minimizing hemidiaphragmatic paralysis after shoulder surgery. Case Report We report the successful application of a combined ultrasound-guided infraclavicular brachial plexus block and suprascapular nerve block in a patient with a complicated pulmonary history undergoing a total shoulder replacement. Conclusion This case report briefly reviews the important innervations to the shoulder joint and examines the utility of the infraclavicular brachial plexus block for postoperative pain management. PMID:29410922

Karolinska institutet 200-year anniversary. Symposium on traumatic injuries in the nervous system: injuries to the spinal cord and peripheral nervous system - injuries and repair, pain problems, lesions to brachial plexus.

PubMed

Sköld, Mattias K; Svensson, Mikael; Tsao, Jack; Hultgren, Thomas; Landegren, Thomas; Carlstedt, Thomas; Cullheim, Staffan

2011-01-01

The Karolinska Institutet 200-year anniversary symposium on injuries to the spinal cord and peripheral nervous system gathered expertise in the spinal cord, spinal nerve, and peripheral nerve injury field spanning from molecular prerequisites for nerve regeneration to clinical methods in nerve repair and rehabilitation. The topics presented at the meeting covered findings on adult neural stem cells that when transplanted to the hypoglossal nucleus in the rat could integrate with its host and promote neuron survival. Studies on vascularization after intraspinal replantation of ventral nerve roots and microarray studies in ventral root replantation as a tool for mapping of biological patterns typical for neuronal regeneration were discussed. Different immune molecules in neurons and glia and their very specific roles in synapse plasticity after injury were presented. Novel strategies in repair of injured peripheral nerves with ethyl-cyanoacrylate adhesive showed functional recovery comparable to that of conventional epineural sutures. Various aspects on surgical techniques which are available to improve function of the limb, once the nerve regeneration after brachial plexus lesions and repair has reached its limit were presented. Moreover, neurogenic pain after amputation and its treatment with mirror therapy were shown to be followed by dramatic decrease in phantom limb pain. Finally clinical experiences on surgical techniques to repair avulsed spinal nerve root and the motoric as well as sensoric regain of function were presented.

True congenital dislocation of shoulder: A case report and review of the literature.

PubMed

Sudesh, Pebam; Rangdal, Sushil; Bali, Kamal; Kumar, Vishal; Gahlot, Nitesh; Patel, Sandeep

2010-10-01

The dislocation of a shoulder joint in infancy is extremely rare and is usually the result of traumatic birth injuries, a sequel to brachial plexus injury, or a true congenital dislocation of shoulder. With more advanced obstetric care, the incidence of first two types has drastically decreased. We report a case of true congenital dislocation of shoulder, second of its kind, in a child who was delivered by cesarean section thereby negating any influence of trauma. We report the case because of its rarity, and review the available literature on this topic. We also discuss the management options when encountered with such a rare case scenario.

Karolinska Institutet 200-Year Anniversary. Symposium on Traumatic Injuries in the Nervous System: Injuries to the Spinal Cord and Peripheral Nervous System – Injuries and Repair, Pain Problems, Lesions to Brachial Plexus

PubMed Central

Sköld, Mattias K.; Svensson, Mikael; Tsao, Jack; Hultgren, Thomas; Landegren, Thomas; Carlstedt, Thomas; Cullheim, Staffan

2011-01-01

The Karolinska Institutet 200-year anniversary symposium on injuries to the spinal cord and peripheral nervous system gathered expertise in the spinal cord, spinal nerve, and peripheral nerve injury field spanning from molecular prerequisites for nerve regeneration to clinical methods in nerve repair and rehabilitation. The topics presented at the meeting covered findings on adult neural stem cells that when transplanted to the hypoglossal nucleus in the rat could integrate with its host and promote neuron survival. Studies on vascularization after intraspinal replantation of ventral nerve roots and microarray studies in ventral root replantation as a tool for mapping of biological patterns typical for neuronal regeneration were discussed. Different immune molecules in neurons and glia and their very specific roles in synapse plasticity after injury were presented. Novel strategies in repair of injured peripheral nerves with ethyl-cyanoacrylate adhesive showed functional recovery comparable to that of conventional epineural sutures. Various aspects on surgical techniques which are available to improve function of the limb, once the nerve regeneration after brachial plexus lesions and repair has reached its limit were presented. Moreover, neurogenic pain after amputation and its treatment with mirror therapy were shown to be followed by dramatic decrease in phantom limb pain. Finally clinical experiences on surgical techniques to repair avulsed spinal nerve root and the motoric as well as sensoric regain of function were presented. PMID:21629875

Management options for echogenic intracardiac focus and choroid plexus cysts: a review including Australian Association of Obstetrical and Gynaecological Ultrasonologists consensus statement.

PubMed

Bethune, M

2007-08-01

Echogenic intracardiac focus and choroid plexus cysts are common findings at the midtrimester ultrasound. These findings have been linked with an increased risk of Down syndrome and trisomy 18. Most fetuses with these findings will, however, not have chromosomal abnormalities, especially when these findings are isolated. Patients experience considerable anxiety when informed of these findings and require extensive counselling in order to minimize anxiety not only about aneuploidy but also about the structure and development of the heart and brain. Although early studies showed an association with aneuploidies, several recent studies have cast doubt on this association. Many of the early studies were carried out in high-risk populations or in populations that had not had the benefit of other screening tests. Many Australian and New Zealand patients will access screening tests designed to detect these aneuploidies before presenting for a midtrimester ultrasound. Patients who have been screened by nuchal translucency, maternal serum screening or some combination of the two will already have had most cases of Down syndrome and trisomy 18 detected, and any soft marker found will almost certainly be a false positive. It is time to rethink the management of these markers. Recent evidence indicates that if these markers are found in isolation in an otherwise low-risk pregnancy, then there is minimal or no increase in the risk of Down syndrome or trisomy 18: these markers should be considered normal variants. The Australian Association of Obstetrical and Gynaecological Ultrasonologists consensus statement on these markers is included.

Shoulder dystocia.

PubMed

Grobman, William

2013-03-01

The frequency of shoulder dystocia in different reports has varied, ranging 0.2-3% of all vaginal deliveries. Once a shoulder dystocia occurs, even if all actions are appropriately taken, there is an increased frequency of complications, including third- or fourth-degree perineal lacerations, postpartum hemorrhage, and neonatal brachial plexus palsies. Health care providers have a poor ability to predict shoulder dystocia for most patients and there remains no commonly accepted model to accurately predict this obstetric emergency. Consequently, optimal management of shoulder dystocia requires appropriate management at the time it occurs. Multiple investigators have attempted to enhance care of shoulder dystocia by utilizing protocols and simulation training. Copyright © 2013 Elsevier Inc. All rights reserved.

Rehabilitation of the Burned Hand

DTIC Science & Technology

2009-01-01

injury in the upper extremity are the shoulder for brachial plexus injuries , the elbow for ulnar nerve lesions, and the wrist for injuries to the ulnar or...median nerves. A brachial plexus injury may result from improper positioning of the shoulder for prolonged periods of time. Shoulder abduction greater...in the early postinjury period as a result of edema, tendon injury , or scar contracture. An immediate consequence of a Rehabilitation Therapies and

Arthroscopic shoulder surgery under general anesthesia with brachial plexus block: postoperative respiratory dysfunction of combined obstructive and restrictive pathology.

PubMed

Gwak, M S; Kim, W H; Choi, S J; Lee, J J; Ko, J S; Kim, G S; Kim, Y I; Kim, M H

2013-02-01

Changes in respiratory parameters and pulmonary function tests were evaluated after shoulder arthroscopic surgery with brachial plexus block (BPB). The purpose of this study was to identify the mechanism of respiratory dysfunction after this type of surgery. Patients undergoing arthroscopic rotator cuff repair under general anesthesia (GA) with BPB were enrolled in the arthroscopy group (n = 30) while those undergoing open reduction of a clavicle or humerus fracture under GA were enrolled in the control group (n = 30). Forced vital capacity (FVC) and forced expiratory volume 1 s (FEV(1)) were measured at the outpatient clinic stage (#1) before (#2) and 20 min after BPB (#3) and 1 h after extubation (#4). Respiratory variable measurements along with the cuff leak test were performed 5 min after surgical positioning (T1) and at the start of skin closure (T2). Respiratory discomfort was evaluated after extubation. The upper airway diameters and soft tissue depth of chest wall were also measured by ultrasonography at stages #3 and #4. Static compliance decreased significantly at T2 in the arthroscopy group (50 ± 11 at T1 vs. 44 ± 9 ml/cm H(2)O at T2, p =0.035) but not in the control group. The incidence of positive cuff leak tests at T2 was significantly higher in the arthroscopy group than in the control group (47% in the arthroscopy group vs. 17% in controls, p =0.010). While FEV(1) and FVC remained stable at stages #1 and #2, FVC and FEV(1) decreased at stages #3 and #4 only in the arthroscopy group (FVC in arthroscopy group, #2: 3.26 ± 0.77 l; #3: 2.55 ± 0.63 l, p =0.015 vs. #2; #4: 2.66 ± 0.41 l, p =0.040 vs. #2). The subglottic diameter decreased at #4 in the arthroscopy group, while no changes occurred in the control group (0.70 ± 0.21 cm vs. 0.85 ± 0.23 cm in the arthroscopy and control groups, respectively, p =0.011). Depth of skin to pleura increased at both intercostal spaces 1-2 and 3-4 in the

United States v. Kubrick: Scope and Application

DTIC Science & Technology

1987-04-01

clavicles were broken, the injury to the brachial plexus was a separate injury . The Burgesses did not discover this injury until they were told about...of injury , was not applied. 106 Just as the Stoleson court noted defendants’ occupations should not control when a claim accrues, the presence of...canal. The fracture caused Erb’s Palsy, a paralysis of the muscles of the upper arm, because the fracture injured his right brachial plexus , a nerve

Planning, execution and monitoring of physical rehabilitation therapies with a robotic architecture.

PubMed

González, José Carlos; Pulido, José Carlos; Fernández, Fernando; Suárez-Mejías, Cristina

2015-01-01

Traditional methods of rehabilitation require continuous attention of therapists during the therapy sessions. This is a hard and expensive task in terms of time and effort. In many cases, the therapeutic objectives cannot be achieved due to the overwork or the difficulty for therapists to plan accurate sessions according to the medical criteria. For this purpose, a wide range of studies is opened in order to research new ways of rehabilitation, as in the field of social robotics. This work presents the current state of the THERAPIST project. Our main goal is to develop a cognitive architecture which provides a robot with enough autonomy to carry out an upper-limb rehabilitation therapy for patients with physical impairments, such as Cerebral Palsy and Obstetric Brachial Plexus Palsy.

Nerve compression injuries due to traumatic false aneurysm.

PubMed Central

Robbs, J V; Naidoo, K S

1984-01-01

Experience with 17 patients with delayed onset of compression neuropraxia due to hemorrhage following nonoperative treatment of penetrating arterial injuries is presented. Fifteen cases involved the arteries of the neck shoulder girdle and upper extremity and two the gluteal vessels. This resulted in dysfunction of components of the brachial plexus, median ulnar, and sciatic nerves. Follow-up extended from 3 to 18 months. Of 10 brachial plexus lesions two recovered fully, five partially, and three not at all. Of seven peripheral nerve injuries, full recovery occurred in two patients and none in five. Adverse prognostic factors for neurological recovery are sepsis, involvement of intrinsic hand innervation and the sciatic nerve. An improved prognosis may be expected for upper trunk lesions of the brachial plexus and radial nerve lesions. The complication is essentially avoidable and a careful appraisal of the circulatory status must be made in all patients with penetrating trauma in the neck and shoulder girdle and buttock. PMID:6732331

Ankle-Brachial Index

MedlinePlus

... in which the arteries in your legs or arms are narrowed or blocked. People with peripheral artery ... ankle with your blood pressure measured at your arm. A low ankle-brachial index number can indicate ...

Effects of arthroscopy-guided suprascapular nerve block combined with ultrasound-guided interscalene brachial plexus block for arthroscopic rotator cuff repair: a randomized controlled trial.

PubMed

Lee, Jae Jun; Hwang, Jung-Taek; Kim, Do-Young; Lee, Sang-Soo; Hwang, Sung Mi; Lee, Na Rea; Kwak, Byung-Chan

2017-07-01

The aim of this study was to compare the pain relieving effect of ultrasound-guided interscalene brachial plexus block (ISB) combined with arthroscopy-guided suprascapular nerve block (SSNB) with that of ultrasound-guided ISB alone within the first 48 h after arthroscopic rotator cuff repair. Forty-eight patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled. The 24 patients in group 1 received ultrasound-guided ISB and arthroscopy-guided SSNB; the remaining 24 patients in group 2 underwent ultrasound-guided ISB alone. Visual analogue scale pain score and patient satisfaction score were checked at 1, 3, 6, 12, 18, 24, and 48 h post-operatively. Group 1 had a lower visual analogue scale pain score at 3, 6, 12, 18, 24, and 48 h post-operatively (1.7 < 2.6, 1.6 < 4.0, 3.5 < 5.8, 3.6 < 5.2, 3.2 < 4.2, 1.3 < 2.0), and a higher patient satisfaction score at 6, 12, 18, 24, and 36 h post-operatively than group 2 (7.8 > 6.0, 6.2 > 4.3, 6.4 > 5.1, 6.9 > 5.9, 7.9 > 7.1). Six patients in group 1 developed rebound pain twice, and the others in group 1 developed it once. All of the patients in group 2 had one rebound phenomenon each (p = 0.010). The mean timing of rebound pain in group 1 was later than that in group 2 (15.5 > 9.3 h, p < 0.001), and the mean size of rebound pain was smaller in group 1 than that in group 2 (2.5 > 4.0, p = 0.001). Arthroscopy-guided SSNB combined with ultrasound-guided ISB resulted in lower visual analogue scale pain scores at 3-24 and 48 h post-operatively, and higher patient satisfaction scores at 6-36 h post-operatively with the attenuated rebound pain compared to scores in patients who received ultrasound-guided ISB alone after arthroscopic rotator cuff repair. The combined blocks may relieve post-operative pain more effectively than the single block within 48 h after arthroscopic cuff repair. Randomized controlled trial, Level I. ClinicalTrials.gov Identifier

Psammoma bodies - friends or foes of the aging choroid plexus.

PubMed

Jovanović, Ivan; Ugrenović, Sladjana; Vasović, Ljiljana; Petrović, Dragan; Cekić, Sonja

2010-06-01

Psammoma bodies are structures classified in the group of dystrophic calcifications, which occur in some kind of tumors and in choroid plexus during the aging process. Despite early discovery of their presence in choroid plexus stroma, mechanisms responsible for their formation remained unclear. Their presence in some kind of tumors was even more extensively studied, but significant breakthrough in the field of their etiology was not attained, too. However, till today correlation between their presence in tumors and aging is not established. Also, there are not any data about structural differences between ones found in tumors and ones found in choroid plexus. This might points to the assumption that besides the aging, some other causes might be involved in their formation in choroid plexus. Furthermore, it is contradictory that forms, like psammoma bodies, present in such malignant formations as tumors, represent quite benign phenomenon in choroid plexus. Literature data and the results of our previous researches revealed that there might be connections between, these, on the first sight quite different processes. Firstly, psammoma bodies are present in stroma of tumors with predominantly papillomatous morphology, which is present in choroid plexus, too. Initial forms of psammoma bodies might be formed in fibrovascular core of choroid plexus villi, similarly like in tumors papillae of papillary thyroid cancer. Their further growth leads to the progressive destruction of both tumors papillae and choroidal villi. Choroid plexus stroma is characterized by the fenestrated blood vessels presence, which are similar to newly formed vessels in tumors. This makes it vulnerable to the noxious agents from circulation. It can contain lymphocytes, macrophages, dendritic cells and myofibroblasts in cases with psammoma bodies, similarly to tumors stroma which is in activated, proinflammatory state. So, all these facts can suggest that similar processes can lead to psammoma

[Shoulder dystocia: Quality of retranscription in medical files].

PubMed

Martin, E; Bouet, P-E; Sentilhes, L; Legendre, G

2016-03-01

Shoulder dystocia is a rare obstetrical event and potentially serious. Apart from possible psychological implications, it may be responsible for maternal (haemorrhage and perineal tear) and neonatal complications (brachial plexus) leading to complaints and even lawsuits. The transcription of this event in medical files is essential as it is a reflection of the work in an emergency. It allows the obstetrician to defend him in case of trial. Our objective was to assess the quality of the transcription of shoulder dystocia situations in medical files. Retrospective chart study conducted in a university hospital with maternity type III. The primary objective was the rate of comprehensive records (name maneuvers and order of maneuvers of the anterior shoulder hand, time between the expulsion of the head and body, Apgar score). Between 2007 and 2015, 54 cases of shoulder dystocia requiring a second line maneuver after vaginal delivery (Wood and/or Jacquemier) were included. In all, 98.2% of the files were incomplete. The maneuvers and their order were noted in 100% of cases. However, the operation was not correctly described in 16.7% of cases. The anterior shoulder was noted in 16.7% of cases. The time between the expulsion of the head and the body was noted in one single files. Neither broken collarbone nor brachial plexus were observed. To improve the management of dystocia shoulder and transcription of data in files, simulation sessions and the creation of a standardized form would be needed. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Interscalene plexus block versus general anaesthesia for shoulder surgery: a randomized controlled study.

PubMed

Lehmann, Lars J; Loosen, Gregor; Weiss, Christel; Schmittner, Marc D

2015-02-01

This randomized clinical trial evaluates interscalene brachial plexus block (ISB), general anaesthesia (GA) and the combination of both anaesthetic methods (GA + ISB) in patients undergoing shoulder arthroscopy. From July 2011 until May 2012, 120 patients (male/female), aged 20-80 years, were allocated randomly to receive ISB (10 ml mepivacaine 1 % and 20 ml ropivacaine 0.375%), GA (propofol, sunfentanil, desflurane) or ISB + GA. The primary outcome variable was opioid consumption at the day of surgery. Anaesthesia times were analysed as secondary endpoints. After surgery, 27 of 40 patients with a single ISB bypassed the recovery room (p < 0.0001). Postoperative monitoring time was significantly shorter with single ISB compared with both other groups [GA: 93 (5-182) min vs. GA + ISB: 57.5 (11-220) min vs. ISB: 35 (5-106) min, p < 0.0001]. Opioid consumption was reduced using a single ISB at the day of surgery [GA: n = 25 vs. GA + ISB: n = 10 vs. ISB: n = 10, p = 0.0037]. ISB is superior to GA and GA + ISB in patients undergoing shoulder arthroscopy in terms of faster recovery and analgesics consumption.

Diaphragm-Sparing Nerve Blocks for Shoulder Surgery.

PubMed

Tran, De Q H; Elgueta, Maria Francisca; Aliste, Julian; Finlayson, Roderick J

Shoulder surgery can result in significant postoperative pain. Interscalene brachial plexus blocks (ISBs) constitute the current criterion standard for analgesia but may be contraindicated in patients with pulmonary pathology due to the inherent risk of phrenic nerve block and symptomatic hemidiaphragmatic paralysis. Although ultrasound-guided ISB with small volumes (5 mL), dilute local anesthetic (LA) concentrations, and LA injection 4 mm lateral to the brachial plexus have been shown to reduce the risk of phrenic nerve block, no single intervention can decrease its incidence below 20%. Ultrasound-guided supraclavicular blocks with LA injection posterolateral to the brachial plexus may anesthetize the shoulder without incidental diaphragmatic dysfunction, but further confirmatory trials are required. Ultrasound-guided C7 root blocks also seem to offer an attractive, diaphragm-sparing alternative to ISB. However, additional large-scale studies are needed to confirm their efficacy and to quantify the risk of periforaminal vascular breach. Combined axillary-suprascapular nerve blocks may provide adequate postoperative analgesia for minor shoulder surgery but do not compare favorably to ISB for major surgical procedures. One intriguing solution lies in the combined use of infraclavicular brachial plexus blocks and suprascapular nerve blocks. Theoretically, the infraclavicular approach targets the posterior and lateral cords, thus anesthetizing the axillary nerve (which supplies the anterior and posterior shoulder joint), as well as the subscapular and lateral pectoral nerves (both of which supply the anterior shoulder joint), whereas the suprascapular nerve block anesthetizes the posterior shoulder. Future randomized trials are required to validate the efficacy of combined infraclavicular-suprascapular blocks for shoulder surgery.

Brachial plexus injury in newborns

MedlinePlus

... A loss of movement or weakness of the arm may occur if these nerves are damaged. This ... head-first delivery Pressure on the baby's raised arms during a breech (feet-first) delivery There are ...

Methylation profiling of choroid plexus tumors reveals 3 clinically distinct subgroups.

PubMed

Thomas, Christian; Sill, Martin; Ruland, Vincent; Witten, Anika; Hartung, Stefan; Kordes, Uwe; Jeibmann, Astrid; Beschorner, Rudi; Keyvani, Kathy; Bergmann, Markus; Mittelbronn, Michel; Pietsch, Torsten; Felsberg, Jörg; Monoranu, Camelia M; Varlet, Pascale; Hauser, Peter; Olar, Adriana; Grundy, Richard G; Wolff, Johannes E; Korshunov, Andrey; Jones, David T; Bewerunge-Hudler, Melanie; Hovestadt, Volker; von Deimling, Andreas; Pfister, Stefan M; Paulus, Werner; Capper, David; Hasselblatt, Martin

2016-06-01

Choroid plexus tumors are intraventricular neoplasms derived from the choroid plexus epithelium. A better knowledge of molecular factors involved in choroid plexus tumor biology may aid in identifying patients at risk for recurrence. Methylation profiles were examined in 29 choroid plexus papillomas (CPPs, WHO grade I), 32 atypical choroid plexus papillomas (aCPPs, WHO grade II), and 31 choroid plexus carcinomas (CPCs, WHO grade III) by Illumina Infinium HumanMethylation450 Bead Chip Array. Unsupervised hierarchical clustering identified 3 subgroups: methylation cluster 1 (pediatric CPP and aCPP of mainly supratentorial location), methylation cluster 2 (adult CPP and aCPP of mainly infratentorial location), and methylation cluster 3 (pediatric CPP, aCPP, and CPC of supratentorial location). In methylation cluster 3, progression-free survival (PFS) accounted for a mean of 72 months (CI, 55-89 mo), whereas only 1 of 42 tumors of methylation clusters 1 and 2 progressed (P< .001). On stratification of outcome data according to WHO grade, all CPCs clustered within cluster 3 and were associated with shorter overall survival (mean, 105 mo [CI, 81-128 mo]) and PFS (mean, 55 mo [CI, 36-73 mo]). The aCPP of methylation cluster 3 also progressed frequently (mean, 69 mo [CI, 44-93 mo]), whereas no tumor progression was observed in aCPP of methylation clusters 1 and 2 (P< .05). Only 1 of 29 CPPs recurred. Methylation profiling of choroid plexus tumors reveals 3 distinct subgroups (ie, pediatric low-risk choroid plexus tumors [cluster 1], adult low-risk choroid plexus tumors [cluster 2], and pediatric high-risk choroid plexus tumors [cluster 3]) and may provide useful prognostic information in addition to histopathology. Published by Oxford University Press on behalf of the Society for Neuro-Oncology 2016. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Upper Extremity Regional Anesthesia

PubMed Central

Neal, Joseph M.; Gerancher, J.C.; Hebl, James R.; Ilfeld, Brian M.; McCartney, Colin J.L.; Franco, Carlo D.; Hogan, Quinn H.

2009-01-01

Brachial plexus blockade is the cornerstone of the peripheral nerve regional anesthesia practice of most anesthesiologists. As part of the American Society of Regional Anesthesia and Pain Medicine’s commitment to providing intensive evidence-based education related to regional anesthesia and analgesia, this article is a complete update of our 2002 comprehensive review of upper extremity anesthesia. The text of the review focuses on (1) pertinent anatomy, (2) approaches to the brachial plexus and techniques that optimize block quality, (4) local anesthetic and adjuvant pharmacology, (5) complications, (6) perioperative issues, and (6) challenges for future research. PMID:19282714

Choroid plexus adenoma in a child: expanding the clinical and pathological spectrum.

PubMed

Prendergast, Nicole; Goldstein, Jeffrey D; Beier, Alexandra D

2018-04-01

Primary choroid plexus tumors encompass a variety of tumors, with choroid plexus papilloma and carcinoma being the most common. Also in the differential diagnosis is the rare benign choroid plexus adenoma. As these tumors are infrequently described, the histological profile continues to evolve. The authors present a case with unusual characteristics that will broaden the pathological spectrum for choroid plexus adenomas.

Syringomyelia with intramedullary ectopic choroid plexus: Case report.

PubMed

Duan, Hongzhou; Zhang, Jiayong; Xu, Feifan; Zhang, Zongqiang; Zhao, Xiaowen

2018-06-01

Intramedullary ectopic choroid plexus is rarely reported, here, we reported a rare case of symptomatic syringomyelia resulted of intramedullary ectopic choroid plexus. The patient was a 30-year-old female who presented with a 2-month history of progressive pain of upper back and bilateral ankle joint and progressive loss of upper-extremity function. MRI examination showed an intramedullary cystic lesion at T2-T4 without enhancement. Operative exploration was indicated. A reddish vascular villus-like lesion was found being located in the left dorsal part of the cyst, which was enblock removed and was confirmed as an ectopic choroid plexus tissue by pathological examination. The patient recovered uneventful and the symptom resolved during follow-up. Although ectopic choroid plexus is extremely rare, it should be taken into acount in the differential diagnosis of pathogenesis in syringomyelia or intramedullary cyst, aggressive surgical exploration should be considered when necessary. Copyright © 2018 Elsevier B.V. All rights reserved.

[Choroid plexus tumors].

PubMed

Pianetti, G; Fonseca, L F

1998-06-01

This analysis comprises 15 children under 16 years of age, with choroid plexus tumors, seen in the Service of Paediatric Neurosurgery, Hospital das Clínicas and Hospital São Francisco de Assis in Belo Horizonte, Brazil, between 1981 and 1996. The patients were aged between 4 months and 16 years (average of 3 years and a half); 10 were less than 2 years, 9 were female; 14 children had clinical evidence of intracranial hypertension. All the children underwent CT scan and the choroid plexus tumors were clearly demonstrated in 14 of then. In 8 children the tumors were located in one lateral ventricle, 5 in the fourth ventricle and 2 had the tumors in more than one ventricle, 11 children required ventriculo-peritoneal shunt; 14 cases were operated on, 13 with total excision; 2 children died, respectively 7 days and one year after the surgery. Pathological examination revealed papillomas in 12 cases and carcinoma in two cases.

Development of the lateral ventricular choroid plexus in a marsupial, Monodelphis domestica

PubMed Central

2010-01-01

Background Choroid plexus epithelial cells are the site of blood/cerebrospinal fluid (CSF) barrier and regulate molecular transfer between the two compartments. Their mitotic activity in the adult is low. During development, the pattern of growth and timing of acquisition of functional properties of plexus epithelium are not known. Methods Numbers and size of choroid plexus epithelial cells and their nuclei were counted and measured in the lateral ventricular plexus from the first day of its appearance until adulthood. Newborn Monodelphis pups were injected with 5-bromo-2-deoxyuridine (BrdU) at postnatal day 3 (P3), P4 and P5. Additional animals were injected at P63, P64 and P65. BrdU-immunopositive nuclei were counted and their position mapped in the plexus structure at different ages after injections. Double-labelling immunocytochemistry with antibodies to plasma protein identified post-mitotic cells involved in protein transfer. Results Numbers of choroid plexus epithelial cells increased 10-fold between the time of birth and adulthood. In newborn pups each consecutive injection of BrdU labelled 20-40 of epithelial cells counted. After 3 injections, numbers of BrdU positive cells remained constant for at least 2 months. BrdU injections at an older age (P63, P64, P65) resulted in a smaller number of labelled plexus cells. Numbers of plexus cells immunopositive for both BrdU and plasma protein increased with age indicating that protein transferring properties are acquired post mitotically. Labelled nuclei were only detected on the dorsal arm of the plexus as it grows from the neuroependyma, moving along the structure in a 'conveyor belt' like fashion. Conclusions The present study established that lateral ventricular choroid plexus epithelial cells are born on the dorsal side of the structure only. Cells born in the first few days after choroid plexus differentiation from the neuroependyma remain present even two months later. Protein-transferring properties are

Development of the lateral ventricular choroid plexus in a marsupial, Monodelphis domestica.

PubMed

Liddelow, Shane A; Dziegielewska, Katarzyna M; Vandeberg, John L; Saunders, Norman R

2010-10-05

Choroid plexus epithelial cells are the site of blood/cerebrospinal fluid (CSF) barrier and regulate molecular transfer between the two compartments. Their mitotic activity in the adult is low. During development, the pattern of growth and timing of acquisition of functional properties of plexus epithelium are not known. Numbers and size of choroid plexus epithelial cells and their nuclei were counted and measured in the lateral ventricular plexus from the first day of its appearance until adulthood. Newborn Monodelphis pups were injected with 5-bromo-2-deoxyuridine (BrdU) at postnatal day 3 (P3), P4 and P5. Additional animals were injected at P63, P64 and P65. BrdU-immunopositive nuclei were counted and their position mapped in the plexus structure at different ages after injections. Double-labelling immunocytochemistry with antibodies to plasma protein identified post-mitotic cells involved in protein transfer. Numbers of choroid plexus epithelial cells increased 10-fold between the time of birth and adulthood. In newborn pups each consecutive injection of BrdU labelled 20-40 of epithelial cells counted. After 3 injections, numbers of BrdU positive cells remained constant for at least 2 months. BrdU injections at an older age (P63, P64, P65) resulted in a smaller number of labelled plexus cells. Numbers of plexus cells immunopositive for both BrdU and plasma protein increased with age indicating that protein transferring properties are acquired post mitotically. Labelled nuclei were only detected on the dorsal arm of the plexus as it grows from the neuroependyma, moving along the structure in a 'conveyor belt' like fashion. The present study established that lateral ventricular choroid plexus epithelial cells are born on the dorsal side of the structure only. Cells born in the first few days after choroid plexus differentiation from the neuroependyma remain present even two months later. Protein-transferring properties are acquired post-mitotically and relatively

Surgical anesthesia with a combination of T12 paravertebral block and lumbar plexus, sacral plexus block for hip replacement in ankylosing spondylitis: CARE-compliant 4 case reports.

PubMed

Ke, Xijian; Li, Ji; Liu, Yong; Wu, Xi; Mei, Wei

2017-06-26

Anesthesia management for patients with severe ankylosing spondylitis scheduled for total hip arthroplasty is challenging due to a potential difficult airway and difficult neuraxial block. We report 4 cases with ankylosing spondylitis successfully managed with a combination of lumbar plexus, sacral plexus and T12 paravertebral block. Four patients were scheduled for total hip arthroplasty. All of them were diagnosed as severe ankylosing spondylitis with rigidity and immobilization of cervical and lumbar spine and hip joints. A combination of T12 paravertebral block, lumbar plexus and sacral plexus block was successfully used for the surgery without any additional intravenous anesthetic or local anesthetics infiltration to the incision, and none of the patients complained of discomfort during the operations. The combination of T12 paravertebral block, lumbar plexus and sacral plexus block, which may block all nerves innervating the articular capsule, surrounding muscles and the skin involved in total hip arthroplasty, might be a promising alternative for total hip arthroplasty in ankylosing spondylitis.

Optimal dose of perineural dexmedetomidine for interscalene brachial plexus block to control postoperative pain in patients undergoing arthroscopic shoulder surgery: A prospective, double-blind, randomized controlled study.

PubMed

Jung, Hong Soo; Seo, Kwon Hui; Kang, Jae Hyuk; Jeong, Jin-Young; Kim, Yong-Shin; Han, Na-Re

2018-04-01

Adjuvant perineural dexmedetomidine can be used to prolong the analgesic effect of interscalene brachial plexus block (ISB). We investigated the optimal dose of dexmedetomidine in ISB for postoperative analgesia in patients undergoing arthroscopic shoulder surgery. One hundred patients scheduled for elective shoulder arthroscopic surgery were enrolled in this randomized, double-blind study. Ultrasound-guided ISB was performed before general anesthesia using 22 mL of ropivacaine 0.5% combined with 1, 1.5, or 2 μg/kg of dexmedetomidine (group D1, D2, and D3, respectively) or with normal saline as a control (group R, n = 25 per group). The primary outcome was the duration of analgesia (DOA), numeric pain rating scale (NRS), and consumption of additional analgesics during 36 h after ISB. Secondary outcome included durations of motor and sensory block (DOM and DOS), hemodynamic variables and sedation and dyspnea scores. Ninety-seven patients completed the study. The DOS, DOM, and DOA were significantly longer in the dexmedetomidine groups than in group R. The DOA was significantly longer in group D3 than in groups D1 (P = .026) and D2 (P = .039). The DOA was 808.13 ± 179.97, 1032.60 ± 288.14, 1042.04 ± 188.13, and 1223.96 ± 238.06 min in groups R, D1, D2, and D3, respectively. The NRS score was significantly higher in group R than in the dexmedetomidine groups 12 h after ISB (P < .001) and significantly lower in group D3 than in the other groups 18 h after ISB (P = .02). The incidence of hypotension was higher in groups D2 and D3 than in group R during surgery (P = .008 and P = .011, respectively). There were no significant differences in consumption of rescue analgesics, sedation, and dyspnea scores between the study groups. Perineural dexmedetomidine 2 μg/kg could be the optimal dose in ISB for arthroscopic shoulder surgery in that it provides an adequate DOA. However, this dose was associated with

Choroid plexus papilloma in a beluga whale (Delphinapterus leucas).

PubMed

Thomas, Christian; Mergl, June; Gehring, Erica; Paulus, Werner; Martineau, Daniel; Hasselblatt, Martin

2016-07-01

We report herein a choroid plexus papilloma in a beluga whale (Delphinapterus leucas). This case was positive for choroid plexus tumor marker Kir7.1 on immunohistochemistry. These results and the high conservation of Kir7.1 across species at the amino acid sequence level strongly suggest that antibodies directed against Kir7.1 not only can be employed for the diagnosis of choroid plexus tumors in cetaceans, but are also likely to be diagnostically useful in other animal species. © 2016 The Author(s).

True Brachial Artery Aneurysm Presenting as a Non-Pulsatile Mass.

PubMed

Pradhananga, A; Chao, X

2017-01-01

Brachial artery aneurysms are rare disease that can be encountered. It is divided into true and false. The frequency of true aneurysm of the brachial artery is so much unusual. So, we present a case of a 59 year old male who presented to us with complaint of mass in left upper limb since many years ago. Now, there was sudden onset of progressive pain with coldness, numbness, tingling sensation and blackish discolouration of skin from 8 hours. The left upper limb was pulseless and color Doppler ultrasound showed a non-pulsatile aneurysm at the mid level of left brachial artery associated with arterial occlusion in its distal branch by thrombus. The patient was successfully revascularised by interposing a saphenous vein graft. Thus,this case suggest that the prompt diagnosis of true brachial artery aneurysm by ultrasound or color Doppler ultrasound and the proper treatment by surgical repair can save limb from dangerous sequel Keywords: brachial artery aneurysm; color doppler ultrasound; true aneurysm; ultrasound.

Choroid plexus papillomas: advances in molecular biology and understanding of tumorigenesis.

PubMed

Safaee, Michael; Oh, Michael C; Bloch, Orin; Sun, Matthew Z; Kaur, Gurvinder; Auguste, Kurtis I; Tihan, Tarik; Parsa, Andrew T

2013-03-01

Choroid plexus papillomas are rare, benign tumors originating from the choroid plexus. Although generally found within the ventricular system, they can arise ectopically in the brain parenchyma or disseminate throughout the neuraxis. We sought to review recent advances in our understanding of the molecular biology and oncogenic pathways associated with this disease. A comprehensive PubMed literature review was conducted to identify manuscripts discussing the clinical, molecular, and genetic features of choroid plexus papillomas. Articles concerning diagnosis, treatment, and long-term patient outcomes were also reviewed. The introduction of atypical choroid plexus papilloma as a distinct entity has increased the need for accurate histopathologic diagnosis. Advances in immunohistochemical staining have improved our ability to differentiate choroid plexus papillomas from other intracranial tumors or metastatic lesions using combinations of key markers and mitotic indices. Recent findings have implicated Notch3 signaling, the transcription factor TWIST1, platelet-derived growth factor receptor, and the tumor necrosis factor-related apoptosis-inducing ligand pathway in choroid plexus papilloma tumorigenesis. A combination of commonly occurring chromosomal duplications and deletions has also been identified. Surgical resection remains the standard of care, although chemotherapy and radiotherapy may be considered for recurrent or metastatic lesions. While generally considered benign, these tumors possess a complex biology that sheds insight into other choroid plexus tumors, particularly malignant choroid plexus carcinomas. Improving our understanding of the molecular biology, genetics, and oncogenic pathways associated with this tumor will allow for the development of targeted therapies and improved outcomes for patients with this disease.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lundstedt, Dan, E-mail: dan.lundstedt@gu.se; Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg; Gustafsson, Magnus

Purpose: To identify volume and dose predictors of paresthesia after irradiation of the brachial plexus among women treated for breast cancer. Methods and Materials: The women had breast surgery with axillary dissection, followed by radiation therapy with (n=192) or without irradiation (n=509) of the supraclavicular lymph nodes (SCLNs). The breast area was treated to 50 Gy in 2.0-Gy fractions, and 192 of the women also had 46 to 50 Gy to the SCLNs. We delineated the brachial plexus on 3-dimensional dose-planning computerized tomography. Three to eight years after radiation therapy the women answered a questionnaire. Irradiated volumes and doses were calculated andmore » related to the occurrence of paresthesia in the hand. Results: After treatment with axillary dissection with radiation therapy to the SCLNs 20% of the women reported paresthesia, compared with 13% after axillary dissection without radiation therapy, resulting in a relative risk (RR) of 1.47 (95% confidence interval [CI] 1.02-2.11). Paresthesia was reported by 25% after radiation therapy to the SCLNs with a V{sub 40} {sub Gy} ≥ 13.5 cm{sup 3}, compared with 13% without radiation therapy, RR 1.83 (95% CI 1.13-2.95). Women having a maximum dose to the brachial plexus of ≥55.0 Gy had a 25% occurrence of paresthesia, with RR 1.86 (95% CI 0.68-5.07, not significant). Conclusion: Our results indicate that there is a correlation between larger irradiated volumes of the brachial plexus and an increased risk of reported paresthesia among women treated for breast cancer.« less

A new scenario of the evolutionary derivation of the mammalian diaphragm from shoulder muscles

PubMed Central

Hirasawa, Tatsuya; Kuratani, Shigeru

2013-01-01

The evolutionary origin of the diaphragm remains unclear, due to the lack of a comparable structure in other extant taxa. However, recent researches into the developmental mechanism of this structure have yielded new insights into its origin. Here we summarize current understanding regarding the development of the diaphragm, and present a possible scenario for the evolutionary acquisition of this uniquely mammalian structure. Recent developmental analyses indicate that the diaphragm and forelimb muscles are derived from a shared cell population during embryonic development. Therefore, the embryonic positions of forelimb muscle progenitors, which correspond to the position of the brachial plexus, likely played an important role in the evolution of the diaphragm. We surveyed the literature to reexamine the position of the brachial plexus among living amniotes and confirmed that the cervico-thoracic transition in ribs reflects the brachial plexus position. Using this osteological correlate, we concluded that the anterior borders of the brachial plexuses in the stem synapsids were positioned at the level of the fourth spinal nerve, suggesting that the forelimb buds were laid in close proximity of the infrahyoid muscles. The topology of the phrenic and suprascapular nerves of mammals is similar to that of subscapular and supracoracoid nerves, respectively, of the other amniotes, suggesting that the diaphragm evolved from a muscle positioned medial to the pectoral girdle (cf. subscapular muscle). We hypothesize that the diaphragm was acquired in two steps: first, forelimb muscle cells were incorporated into tissues to form a primitive diaphragm in the stem synapsid grade, and second, the diaphragm in cynodonts became entrapped in the region controlled by pulmonary development. PMID:23448284

Gelsolin Restores Aβ-Induced Alterations in Choroid Plexus Epithelium

PubMed Central

Vargas, Teo; Antequera, Desiree; Ugalde, Cristina; Spuch, Carlos; Carro, Eva

2010-01-01

Histologically, Alzheimer's disease (AD) is characterized by senile plaques and cerebrovascular amyloid deposits. In previous studies we demonstrated that in AD patients, amyloid-β (Aβ) peptide also accumulates in choroid plexus, and that this process is associated with mitochondrial dysfunction and epithelial cell death. However, the molecular mechanisms underlying Aβ accumulation at the choroid plexus epithelium remain unclear. Aβ clearance, from the brain to the blood, involves Aβ carrier proteins that bind to megalin, including gelsolin, a protein produced specifically by the choroid plexus epithelial cells. In this study, we show that treatment with gelsolin reduces Aβ-induced cytoskeletal disruption of blood-cerebrospinal fluid (CSF) barrier at the choroid plexus. Additionally, our results demonstrate that gelsolin plays an important role in decreasing Aβ-induced cytotoxicity by inhibiting nitric oxide production and apoptotic mitochondrial changes. Taken together, these findings make gelsolin an appealing tool for the prophylactic treatment of AD. PMID:20369065

Debates to personal conclusion in peripheral nerve injury and reconstruction: A 30-year experience at Chang Gung Memorial Hospital

PubMed Central

Chuang, David Chwei-Chin

2016-01-01

Significant progress has been achieved in the science and management of peripheral nerve injuries over the past 40 years. Yet there are many questions and few answers. The author, with 30 years of experience in treating them at the Chang Gung Memorial Hospital, addresses debates on various issues with personal conclusions. These include: (1) Degree of peripheral nerve injury, (2) Timing of nerve repair, (3)Technique of nerve repair, (4) Level of brachial plexus injury,(5) Level of radial nerve injury,(6) Traction avulsion amputation of major limb, (7) Proximal Vs distal nerve transfers in brachial plexus injuries and (8) Post paralysis facial synkinesis. PMID:27833273

Thermoablation of Liver Metastases: Efficacy of Temporary Celiac Plexus Block

DOE Office of Scientific and Technical Information (OSTI.GOV)

Beck, A.N., E-mail: alexander.beck@charite.de; Schaefer, M.; Werk, M.

Purpose. To determine the efficacy of celiac plexus block during thermoablation of liver metastases. Methods. Fifty-five consecutive patients underwent thermoablation therapy of liver tumors by laser-induced thermotherapy. Twenty-nine patients received a temporary celiac plexus block, 26 patients acted as control group. In both groups fentanyl and midazolam were administered intravenously upon request of the patient. The duration of the intervention, consumption of opiates, and individual pain sensations were documented. Results. No complications resulting from the celiac plexus block were recorded. Celiac plexus block significantly reduced the amount of pain medication used during thermoablation therapy of liver tumors (with block, 2.45more » {mu}g fentanyl per kg body weight; without block, 3.58 {mu}g fentanyl per kg body weight, p < 0.05; midazolam consumption was not reduced) in patients with metastases {<=}5 mm from the liver capsule. For metastases farther away from the capsule no significant differences in opiate consumption were seen. Celiac plexus block reduced the time for thermoablation significantly (178 min versus 147 min, p < 0.05) no matter how far the metastases were from the liver capsule. Average time needed to set the block was 12 min (range 9-15 min); additional costs for the block were marginal. As expected (as pain medications were given according to individual patients' needs) pain indices did not differ significantly between the two groups. Conclusion. In patients with liver metastases {<=}5 mm from the liver capsule, celiac plexus block reduces the amount of opiates necessary, simplifying patient monitoring. In addition celiac plexus block reduces intervention time, with positive effects on overall workflow for all patients.« less

Is fetal manipulation during shoulder dystocia management associated with severe maternal and neonatal morbidities?

PubMed

Gachon, Bertrand; Desseauve, David; Fritel, Xavier; Pierre, Fabrice

2016-09-01

There is a lack of data regarding maternal morbidity and neonatal hypoxia associated with shoulder dystocia (SD), particularly with respect to whether SD is managed with our without fetal manipulation (FM). Our main objective was to compare severe maternal and neonatal morbidities associated with SD according to FM execution. We conducted a retrospective study based on a medical record analysis that included all SD cases from 2007 to 2012. SD was considered when additional maneuvers were required to complete a delivery. Severe maternal morbidity was defined as the occurrence of an obstetric anal sphincter injury. Severe neonatal morbidity was defined as the occurrence of one of these complications: permanent brachial plexus palsy, arterial cord pH < 7.1, Apgar score < 7 at 5 min. We compared severe maternal and neonatal morbidities in the FM and the no-FM group. We report an SD incidence of 2.4 % (n = 227) with 93.8 % of patients treated without FM. We identified two cases of permanent brachial plexus palsy, fifteen cases of arterial cord pH < 7.1 and six cases with an Apgar score < 7 at 5 min; all of them were from the no-FM group. There were more cases of OASI in the FM group (odd ratio = 9.2 [1.32-50.71]). No statistical differences between these groups were observed with respect to severe neonatal morbidity. Severe neonatal morbidity does not appear to be associated with FM during SD management, but severe maternal morbidity is associated with FM execution.

Ankle-Brachial Index, Toe-Brachial Index, and Pulse Volume Recording in Healthy Young Adults

PubMed Central

Masaki, Hisao; Yunoki, Yasuhiro; Tabuchi, Atushi; Morita, Ichiro; Mohri, Satoshi; Tanemoto, Kazuo

2015-01-01

Objective: To clarify the characteristics of ankle-brachial index (ABI), toe-brachial index (TBI), and pulse volume recording (PVR) of the ankle with brachial-ankle pulse wave velocity (baPWV) in healthy young adults. Material and Methods: We analyzed ABI, TBI, baPWV, and PVR in the ankle of healthy adults aged 20 to 25 years (median, 20 years) using an automatic oscillometric device between 2002 and 2013. The ABI, baPWV, and PVR in 1282 legs of 641 subjects (301 men and 340 women) and the TBI in 474 toes of 237 subjects (117 men and 120 women) were evaluated. Results: The measured values showed no bilateral differences. ABI and baPWV were higher in men than in women, but TBI was similar in both sexes. ABI <1.0 was observed in 18.1% of the legs in men and in 25.6% in women. TBI <0.7 was observed in 16.2% of the toes in men and 19.1% in women. For ankle PVR, the % mean arterial pressure was higher in women than in men. The upstroke time was <180 ms in most subjects. Conclusions: For young people, ABI <1.0 or TBI <0.7 may not always indicate vascular abnormalities. When evaluating circulatory indexes, age and sex should be considered. PMID:26421072

Does regional compared to local anaesthesia influence outcome after arteriovenous fistula creation?

PubMed

Macfarlane, Alan James Robert; Kearns, Rachel Joyce; Aitken, Emma; Kinsella, John; Clancy, Marc James

2013-08-19

An arteriovenous fistula is the optimal form of vascular access in patients with end-stage renal failure requiring haemodialysis. Unfortunately, approximately one-third of fistulae fail at an early stage. Different anaesthetic techniques can influence factors associated with fistula success, such as intraoperative blood flow and venous diameter. A regional anaesthetic brachial plexus block results in vasodilatation and improved short- and long-term fistula flow compared to the infiltration of local anaesthetic alone. This, however, has not yet been shown in a large trial to influence long-term fistula patency, the ultimate clinical measure of success.The aim of this study is to compare whether a regional anaesthetic block, compared to local anaesthetic infiltration, can improve long-term fistula patency. This study is an observer-blinded, randomised controlled trial. Patients scheduled to undergo creation of either brachial or radial arteriovenous fistulae will receive a study information sheet, and consent will be obtained in keeping with the Declaration of Helsinki. Patients will be randomised to receive either: (i) an ultrasound guided brachial plexus block using lignocaine with adrenaline and levobupivicaine, or (ii) local anaesthetic infiltration with lignocaine and levobupivicaine.A total of 126 patients will be recruited. The primary outcome is fistula primary patency at three months. Secondary outcomes include primary patency at 1 and 12 months, secondary patency and fistula flow at 1, 3 and 12 months, flow on first haemodialysis, procedural pain, patient satisfaction, change in cephalic vein diameter pre- and post-anaesthetic, change in radial or brachial artery flow pre- and post-anaesthetic, alteration of the surgical plan after anaesthesia as guided by vascular mapping with ultrasound, and fistula infection requiring antibiotics. No large randomised controlled trial has examined the influence of brachial plexus block compared with local anaesthetic

Contemporary Obstetric Triage.

PubMed

Sandy, Edward Allen; Kaminski, Robert; Simhan, Hygriv; Beigi, Richard

2016-03-01

The role of obstetric triage in the care of pregnant women has expanded significantly. Factors driving this change include the Emergency Medical Treatment and Active Labor Act, improved methods of testing for fetal well-being, increasing litigation risk, and changes in resident duty hour guidelines. The contemporary obstetric triage facility must have processes in place to provide a medical screening examination that complies with regulatory statues while considering both the facility's maternal level of care and available resources. This review examines the history of the development of obstetric triage, current considerations in a contemporary obstetric triage paradigm, and future areas for consideration. An example of a contemporary obstetric triage program at an academic medical center is presented. A successful contemporary obstetric triage paradigm is one that addresses the questions of "sick or not sick" and "labor or no labor," for every obstetric patient that presents for care. Failure to do so risks poor patient outcome, poor patient satisfaction, adverse litigation outcome, regulatory scrutiny, and exclusion from federal payment programs. Understanding the role of contemporary obstetric triage in the current health care environment is important for both providers and health care leadership. This study is for obstetricians and gynecologists as well as family physicians. After completing this activity, the learner should be better able to understand the scope of a medical screening examination within the context of contemporary obstetric triage; understand how a facility's level of maternal care influences clinical decision making in a contemporary obstetric triage setting; and understand the considerations necessary for the systematic evaluation of the 2 basic contemporary obstetric questions, "sick or not sick?" and "labor or no labor?"

[Prediction, prevention and management of shoulder dystocia].

PubMed

Csorba, Roland

2012-05-20

Shoulder dystocia is one of the most tragic, fatal and unexpected obstetrical events, which is mostly unpredictable and unpreventable. This clinical picture is defined as a delivery that requires additional obstetric maneuvers to release the shoulders after gentle downward traction has failed. Shoulder dystocia occurs when the fetal shoulder impacts on the maternal symphysis or sacral promontory. The incidence of shoulder dystocia is 0.2-0.6%. High perinatal mortality and morbidity is associated with the condition, even when it is managed appropriately. Obstetricians should be aware of the existing risk factors, but should always be alert to the possibility of shoulder dystocia in all labors. Maternal morbidity is also increased, particularly postpartum hemorrhage, rupture of the uterus, injury of the bladder, urethra and the bowels and fourth-degree perineal tears. Complications of the newborn include asphyxia, perinatal mortality, fracture of the clavicula and the humerus. Brachial plexus injuries are one of the most important fetal complications of shoulder dystocia, complicating 4-16% of such deliveries. The purpose of this article is to review the current evidence regarding the possible prediction, prevention and management of shoulder dystocia.

Clearance of amyloid-β peptide across the choroid plexus in Alzheimer's disease.

PubMed

Alvira-Botero, Ximena; Carro, Eva M

2010-12-01

Aging and several neurodegenerative diseases bring about changes in the anatomy and physiology of the choroid plexus. The identification of specific membrane receptors that bind and internalize extracellular ligands has revolutionized the traditional roles of this tissue. Amyloid beta peptide (Aβ), the major constituent of the amyloid core of senile plaques in patients with Alzheimer's disease (AD) is known to contribute to disease neuropathology and progression. Recent emphasis on comorbidity of AD and a deficient clearance of Aβ across the blood-brain barrier and blood-cerebrospinal fluid barrier have highlighted the importance of brain Aβ clearance in AD. The megalin receptor has also been implicated in the pathogenesis of AD. Faulty Aβ clearance from the brain across the choroid plexus epithelium by megalin appears to mediate focal Aβ accumulation in AD. Patients with AD have reduced levels of megalin at the choroid plexus, which in turn seem to increase brain levels of Aβ through a decreased efflux of brain Aβ. Therapies that increase megalin expression at the choroid plexus could potentially control accumulation of brain Aβ. This review covers in depth the anatomy and function of the choroid plexus, focusing on the brain barrier at the choroid plexus, as it actively participates in Aβ clearance. In addition, we describe the role of the choroid plexus in brain functions, aging and AD, as well as the role of megalin in the process of Aβ clearance. Finally, we present current data on the use of choroid plexus cells to repair the damaged brain.

The Macroanatomy of the Sacral Plexus and Its Nerves in Eurasian Eagle Owls (Bubo bubo).

PubMed

Akbulut, Y; Demiraslan, Y; Aslan, K; Coban, A

2016-10-01

This study was carried out to reveal the formation of the sacral plexus in the Eurasian Eagle Owls (Bubo bubo) and the nerves originating from this plexus. Five EEOs, three of them were male and two were female, were provided from Wildlife Rescue and Rehabilitation Center of Kafkas University and used as materials. Following the euthanizing of the animals, abdominal cavity was opened. The nerves of plexus sacrales were dissected and photographed. It was detected that the sacral plexus was formed by the ventral ramus of five synsacral nerves. Moreover, it was determined that the roots of the sacral plexus formed three trunks: the truncus cranialis, the truncus medius and the truncus caudalis in fossa renalis. The availability of the n. ischiofemoralis and the availability of n. parafibularis were detected in the EEOs. Five branches were specified as having segregated from the sacral plexus: the n. cutaneus femoralis caudalis, the mutual root of n. fibularis with n. tibialis (n. ischiadicus), the rami musculares, the n. coxalis caudalis and the ramus muscularis. It was observed that the sacral plexus was linked to the lumbar plexus by the n. furcalis, to the pudendus plexus via the n. bigeminus. Consequently, the anatomic structure of the EEO's sacral plexus, the participating synsacral nerves to plexus and the innervation areas of these nerves were revealed. © 2015 Blackwell Verlag GmbH.

Comparison of Ultrasound with Peripheral Nerve Stimulator-guided Technique for Supraclavicular Block in Upper Limb Surgeries: A Randomized Controlled Trial.

PubMed

Alfred, Vinu Mervick; Srinivasan, Gnanasekaran; Zachariah, Mamie

2018-01-01

The supraclavicular approach is considered to be the easiest and most effective approach to block the brachial plexus for upper limb surgeries. The classical approach using the anatomical landmark technique was associated with higher failure rates and complications. Ultrasonography (USG) guidance and peripheral nerve stimulator (PNS) have improved the success rates and safety margin. The aim of the present study is to compare USG with PNS in supraclavicular brachial plexus block for upper limb surgeries with respect to the onset of motor and sensory blockade, total duration of blockade, procedure time, and complications. Prospective, randomized controlled study. Sixty patients aged above 18 years scheduled for elective upper limb surgery were randomly allocated into two groups. Group A patients received supraclavicular brachial plexus block under ultrasound guidance and in Group B patients, PNS was used. In both groups, local anesthetic mixture consisting of 15 ml of 0.5% bupivacaine and 10 ml of 2% lignocaine with 1:200,000 adrenaline were used. Independent t -test used to compare mean between groups; Chi-square test for categorical variables. The procedure time was shorter with USG (11.57 ± 2.75 min) compared to PNS (21.73 ± 4.84). The onset time of sensory block (12.83 ± 3.64 min vs. 16 ± 3.57 min) and onset of motor block (23 ± 4.27 min vs. 27 ± 3.85 min) were significantly shorter in Group A compared to Group B ( P < 0.05). The duration of sensory block was significantly prolonged in Group A (8.00 ± 0.891 h) compared to Group B (7.25 ± 1.418 h). None of the patients in either groups developed any complications. The ultrasound-guided supraclavicular brachial plexus block can be done quicker, with a faster onset of sensory and motor block compared to nerve stimulator technique.

Iatrogenic nerve injuries during shoulder surgery.

PubMed

Carofino, Bradley C; Brogan, David M; Kircher, Michelle F; Elhassan, Bassem T; Spinner, Robert J; Bishop, Allen T; Shin, Alexander Y

2013-09-18

The current literature indicates that neurologic injuries during shoulder surgery occur infrequently and result in little if any morbidity. The purpose of this study was to review one institution's experience treating patients with iatrogenic nerve injuries after shoulder surgery. A retrospective review of the records of patients evaluated in a brachial plexus specialty clinic from 2000 to 2010 identified twenty-six patients with iatrogenic nerve injury secondary to shoulder surgery. The records were reviewed to determine the operative procedure, time to presentation, findings on physical examination, treatment, and outcome. The average age was forty-three years (range, seventeen to seventy-two years), and the average delay prior to referral was 5.4 months (range, one to fifteen months). Seven nerve injuries resulted from open procedures done to treat instability; nine, from arthroscopic surgery; four, from total shoulder arthroplasty; and six, from a combined open and arthroscopic operation. The injury occurred at the level of the brachial plexus in thirteen patients and at a terminal nerve branch in thirteen. Fifteen patients (58%) did not recover nerve function after observation and required surgical management. A structural nerve injury (laceration or suture entrapment) occurred in nine patients (35%), including eight of the thirteen who presented with a terminal nerve branch injury and one of the thirteen who presented with an injury at the level of the brachial plexus. Nerve injuries occurring during shoulder surgery can produce severe morbidity and may require surgical management. Injuries at the level of a peripheral nerve are more likely to be surgically treatable than injuries of the brachial plexus. A high index of suspicion and early referral and evaluation should be considered when evaluating patients with iatrogenic neurologic deficits after shoulder surgery.

Obstetric Ultrasound

PubMed Central

Nicholson, Stuart F.; Nimrod, Carl A.

1988-01-01

This article addresses the current indications for an obstetric ultrasound and describes the findings that it is reasonable to expect when reading an ultrasound report. The authors discuss several common obstetrical problems focussing the attention on the usefulness of the imaging information. Finally, they provide a glimpse into the future direction of obstetric ultrasound by discussing vaginal scanning, Doppler assessment of fetal blood flow, and routine ultrasound in pregnancy. PMID:21253229

Deep dopamine extravasation injury: a case report.

PubMed

Phillips, Reid A; Andrades, Patricio; Grant, John H; Ray, Peter D

2009-07-01

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.

Neurogenic effects of β-amyloid in the choroid plexus epithelial cells in Alzheimer's disease.

PubMed

Bolos, Marta; Spuch, Carlos; Ordoñez-Gutierrez, Lara; Wandosell, Francisco; Ferrer, Isidro; Carro, Eva

2013-08-01

β-amyloid (Aβ) can promote neurogenesis, both in vitro and in vivo, by inducing neural progenitor cells to differentiate into neurons. The choroid plexus in Alzheimer's disease (AD) is burdened with amyloid deposits and hosts neuronal progenitor cells. However, neurogenesis in this brain tissue is not firmly established. To investigate this issue further, we examined the effect of Aβ on the neuronal differentiation of choroid plexus epithelial cells in several experimental models of AD. Here we show that Aβ regulates neurogenesis in vitro in cultured choroid plexus epithelial cells as well as in vivo in the choroid plexus of APP/Ps1 mice. Treatment with oligomeric Aβ increased proliferation and differentiation of neuronal progenitor cells in cultured choroid plexus epithelial cells, but decreased survival of newly born neurons. These Aβ-induced neurogenic effects were also observed in choroid plexus of APP/PS1 mice, and detected also in autopsy tissue from AD patients. Analysis of signaling pathways revealed that pre-treating the choroid plexus epithelial cells with specific inhibitors of TyrK or MAPK diminished Aβ-induced neuronal proliferation. Taken together, our results support a role of Aβ in proliferation and differentiation in the choroid plexus epithelial cells in Alzheimer's disease.

Anatomy of the nerves and ganglia of the aortic plexus in males

PubMed Central

Beveridge, Tyler S; Johnson, Marjorie; Power, Adam; Power, Nicholas E; Allman, Brian L

2015-01-01

It is well accepted that the aortic plexus is a network of pre- and post-ganglionic nerves overlying the abdominal aorta, which is primarily involved with the sympathetic innervation to the mesenteric, pelvic and urogenital organs. Because a comprehensive anatomical description of the aortic plexus and its connections with adjacent plexuses are lacking, these delicate structures are prone to unintended damage during abdominal surgeries. Through dissection of fresh, frozen human cadavers (n = 7), the present study aimed to provide the first complete mapping of the nerves and ganglia of the aortic plexus in males. Using standard histochemical procedures, ganglia of the aortic plexus were verified through microscopic analysis using haematoxylin & eosin (H&E) and anti-tyrosine hydroxylase stains. All specimens exhibited four distinct sympathetic ganglia within the aortic plexus: the right and left spermatic ganglia, the inferior mesenteric ganglion and one previously unidentified ganglion, which has been named the prehypogastric ganglion by the authors. The spermatic ganglia were consistently supplied by the L1 lumbar splanchnic nerves and the inferior mesenteric ganglion and the newly characterized prehypogastric ganglion were supplied by the left and right L2 lumbar splanchnic nerves, respectively. Additionally, our examination revealed the aortic plexus does have potential for variation, primarily in the possibility of exhibiting accessory splanchnic nerves. Clinically, our results could have significant implications for preserving fertility in men as well as sympathetic function to the hindgut and pelvis during retroperitoneal surgeries. PMID:25382240

First bite syndrome: our experience of laser tympanic plexus ablation.

PubMed

Amin, N; Pelser, A; Weighill, J

2014-02-01

First bite syndrome is a condition characterised by severe facial pain brought on by the first bite of each meal. This can severely affect the patient's ability to eat. We present a 70-year-old woman for whom we performed a laser ablation of the left ear tympanic plexus, as treatment of first bite syndrome. A permeatal approach was used to raise a tympanomeatal flap. The tympanic plexus was identified on the promontory and a 4 mm2 area of the plexus was ablated using CO2 laser. The flap was repositioned and a dressing was placed with topical antibiotics. At two-month follow up, there was full resolution of the patient's symptoms. First bite syndrome carries a high morbidity; treatment options are variable, and often unsuccessful. We describe the first documented case of laser tympanic plexus ablation, with a very effective initial response. This procedure represents a useful therapeutic option for first bite syndrome.

Ultrasound-Guided Regional Anesthesia in a Glucose-6-Phosphate Dehydrogenase (G6PD)-Deficient Geriatric Trauma Patient

PubMed Central

Födinger, Agnes M.; Kammerlander, Christian; Luger, Thomas J.

2012-01-01

Objective: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a genetic enzymatic disorder causing hemolytic anemia. Exposure to drugs is considered to be the most common cause of acute hemolysis in patients with G6PD deficiency. Experience with regional anesthesia, in particular peripheral nerve blocks, is rarely described in patients with G6PD deficiency, but is of great clinical interest. For this reason, we now report on the successful management of ultrasound-guided axillary brachial plexus block in a patient with geriatric G6PD deficiency. Case report: A female, 75-year-old geriatric trauma patient with G6PD deficiency and a fracture of the left forearm, was scheduled for osteosynthesis of the left forearm. For surgery regional anesthesia with ultrasound-guided axillary brachial plexus block with 30 mL bupivacaine 0.5% was established. Surgical operation und postoperative course were uneventful and with no signs of hemolysis. Conclusion: Ultrasound-guided axillary brachial plexus block with bupivacaine was a safe and effective technique in this patient with G6PD deficiency. Peripheral nerve block is a major analgesic approach and of great value for anesthesiologists and surgeons, especially in our aging and multimorbid society. PMID:23569708

Effect of warming bupivacaine 0.5% on ultrasound-guided axillary plexus block. Randomized prospective double-blind study.

PubMed

Trabelsi, W; Ben Gabsia, A; Lebbi, A; Sammoud, W; Labbène, I; Kchelfi, S; Ferjani, M

2017-02-01

To evaluate the effect of warming bupivacaine 0.5% on ultrasound-guided axillary brachial plexus block. Prospective, randomized, double-blind. Eighty patients undergoing elective or emergency surgery beyond the distal third of the upper limb were divided into two groups of 40 patients: the warm group received 15mL bupivacaine 0.5% heated to 37°C; the cold group received 15mL 0.5% bupivacaine stored for at least 24hours in the lower compartment of a refrigerator at 13-15°C. Onset and duration of sensory and motor blocks were evaluated every 5minutes for 40minutes. Postoperative pain was evaluated at 1, 3, 6, 12 and 24hours. Effective analgesia time was recorded as the interval between anesthetic injection and the first analgesia requirement (VAS>30mm). Time to onset of sensory and motor block was significantly shorter in the warm group, and mean duration of sensory and motor block and of postoperative analgesia significantly longer. Warming bupivacaine 0.5% to 37°C accelerated onset of sensory and motor block and extended action duration. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Effects of posture on shear rates in human brachial and superficial femoral arteries

PubMed Central

Newcomer, S. C.; Sauder, C. L.; Kuipers, N. T.; Laughlin, M. H.; Ray, C. A.

2012-01-01

Shear rate is significantly lower in the superficial femoral compared with the brachial artery in the supine posture. The relative shear rates in these arteries of subjects in the upright posture (seated and/or standing) are unknown. The purpose of this investigation was to test the hypothesis that upright posture (seated and/or standing) would produce greater shear rates in the superficial femoral compared with the brachial artery. To test this hypothesis, Doppler ultrasound was used to measure mean blood velocity (MBV) and diameter in the brachial and superficial femoral arteries of 21 healthy subjects after being in the supine, seated, and standing postures for 10 min. MBV was significantly higher in the brachial compared with the superficial femoral artery during upright postures. Superficial femoral artery diameter was significantly larger than brachial artery diameter. However, posture had no significant effect on either brachial or superficial femoral artery diameter. The calculated shear rate was significantly greater in the brachial (73 ± 5, 91 ± 11, and 97 ± 13 s−1) compared with the superficial femoral (53 ± 4, 39 ± 77, and 44 ± 5 s−1) artery in the supine, seated, and standing postures, respectively. Contrary to our hypothesis, our current findings indicate that mean shear rate is lower in the superficial femoral compared with the brachial artery in the supine, seated, and standing postures. These findings of lower shear rates in the superficial femoral artery may be one mechanism for the higher propensity for atherosclerosis in the arteries of the leg than of the arm. PMID:18245564

Obstetric antiphospholipid syndrome.

PubMed

Esteve-Valverde, E; Ferrer-Oliveras, R; Alijotas-Reig, J

2016-04-01

Obstetric antiphospholipid syndrome is an acquired autoimmune disorder that is associated with various obstetric complications and, in the absence of prior history of thrombosis, with the presence of antiphospholipid antibodies directed against other phospholipids, proteins called cofactors or PL-cofactor complexes. Although the obstetric complications have been related to the procoagulant properties of antiphospholipid antibodies, pathological studies of human placenta have shown the proinflammatory capacity of antiphospholipid antibodies via the complement system and proinflammatory cytokines. There is no general agreement on which antiphospholipid antibodies profile (laboratory) confers the greatest obstetric risk, but the best candidates are categories I and IIa. Combined treatment with low doses of aspirin and heparin achieves good obstetric and maternal outcomes. In this study, we also review the therapeutic possibilities in refractory cases, although the likelihood of progressing to other autoimmune diseases is low. We briefly comment on incomplete obstetric antiphospholipid syndrome, also known as antiphospholipid antibody-mediated pregnancy morbidity syndrome. Copyright © 2015 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). All rights reserved.

Clinical anatomy and 3D virtual reconstruction of the lumbar plexus with respect to lumbar surgery.

PubMed

Lu, Sheng; Chang, Shan; Zhang, Yuan-zhi; Ding, Zi-hai; Xu, Xin Ming; Xu, Yong-qing

2011-04-14

Exposure of the anterior or lateral lumbar via the retroperitoneal approach easily causes injuries to the lumbar plexus. Lumbar plexus injuries which occur during anterior or transpsoas lumbar spine exposure and placement of instruments have been reported. This study aims is to provide more anatomical data and surgical landmarks in operations concerning the lumbar plexus in order to prevent lumbar plexus injuries and to increase the possibility of safety in anterior approach lumbar surgery. To study the applied anatomy related to the lumbar plexus of fifteen formaldehyde-preserved cadavers, Five sets of Virtual Human (VH) data set were prepared and used in the study. Three-dimensional (3D) computerized reconstructions of the lumbar plexus and their adjacent structures were conducted from the VH female data set. The order of lumbar nerves is regular. From the anterior view, lumbar plexus nerves are arranged from medial at L5 to lateral at L2. From the lateral view, lumbar nerves are arranged from ventral at L2 to dorsal at L5. The angle of each nerve root exiting outward to the corresponding intervertebral foramen increases from L1 to L5. The lumbar plexus nerves are observed to be in close contact with transverse processes (TP). All parts of the lumbar plexus were located by sectional anatomy in the dorsal third of the psoas muscle. Thus, access to the psoas major muscle at the ventral 2/3 region can safely prevent nerve injuries. 3D reconstruction of the lumbar plexus based on VCH data can clearly show the relationships between the lumbar plexus and the blood vessels, vertebral body, kidney, and psoas muscle. The psoas muscle can be considered as a surgical landmark since incision at the ventral 2/3 of the region can prevent lumbar plexus injuries for procedures requiring exposure of the lateral anterior of the lumbar. The transverse process can be considered as a landmark and reference in surgical operations by its relative position to the lumbar plexus. 3D

Clinical anatomy and 3D virtual reconstruction of the lumbar plexus with respect to lumbar surgery

PubMed Central

2011-01-01

Background Exposure of the anterior or lateral lumbar via the retroperitoneal approach easily causes injuries to the lumbar plexus. Lumbar plexus injuries which occur during anterior or transpsoas lumbar spine exposure and placement of instruments have been reported. This study aims is to provide more anatomical data and surgical landmarks in operations concerning the lumbar plexus in order to prevent lumbar plexus injuries and to increase the possibility of safety in anterior approach lumbar surgery. Methods To study the applied anatomy related to the lumbar plexus of fifteen formaldehyde-preserved cadavers, Five sets of Virtual Human (VH) data set were prepared and used in the study. Three-dimensional (3D) computerized reconstructions of the lumbar plexus and their adjacent structures were conducted from the VH female data set. Results The order of lumbar nerves is regular. From the anterior view, lumbar plexus nerves are arranged from medial at L5 to lateral at L2. From the lateral view, lumbar nerves are arranged from ventral at L2 to dorsal at L5. The angle of each nerve root exiting outward to the corresponding intervertebral foramen increases from L1 to L5. The lumbar plexus nerves are observed to be in close contact with transverse processes (TP). All parts of the lumbar plexus were located by sectional anatomy in the dorsal third of the psoas muscle. Thus, access to the psoas major muscle at the ventral 2/3 region can safely prevent nerve injuries. 3D reconstruction of the lumbar plexus based on VCH data can clearly show the relationships between the lumbar plexus and the blood vessels, vertebral body, kidney, and psoas muscle. Conclusion The psoas muscle can be considered as a surgical landmark since incision at the ventral 2/3 of the region can prevent lumbar plexus injuries for procedures requiring exposure of the lateral anterior of the lumbar. The transverse process can be considered as a landmark and reference in surgical operations by its relative

[Neonatal complications related to shoulder dystocia].

PubMed

Lopez, E; de Courtivron, B; Saliba, E

2015-12-01

To describe neonatal complications related to shoulder dystocia. This systematic evidence review is based on PubMed search, Cochrane library and experts' recommendations. The risks of brachial plexus birth injury, clavicle and humeral fracture, perinatal asphyxia, hypoxic-ischemic encephalopathy and perinatal mortality are increased after shoulder dystocia. The medical team should be able to provide neonatal resuscitation in the delivery room in case of perinatal asphyxia following shoulder dystocia, according to national and international guidelines. The initial clinical examination should search for complications such as brachial plexus birth injury or clavicle fracture. The risk of perinatal complications is increased in newborn after shoulder dystocia. The medical team should be able to manage these complications. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Enraged about radiotherapy.

PubMed Central

Sikora, K.

1994-01-01

The use of radiotherapy in treating breast cancer has meant that many women are able to avoid mastectomy, which is both physically and psychologically damaging. The side effects of radiotherapy, however, are given little attention. Many women have developed brachial plexus injury after radiotherapy for breast cancer, often resulting in severe pain and loss of use of the arm. There is no effective treatment for this injury and little help can be offered. In addition, many of the women did not require radiotherapy of nodal areas. A pressure group has been formed to support these women, to establish the right to compensation, and to ensure that radiotherapy regimens given to future patients will not damage the brachial plexus. Images p188-a PMID:8312773

Perinatal and maternal outcomes in planned home and obstetric unit births in women at ‘higher risk’ of complications: secondary analysis of the Birthplace national prospective cohort study

PubMed Central

Li, Y; Townend, J; Rowe, R; Brocklehurst, P; Knight, M; Linsell, L; Macfarlane, A; McCourt, C; Newburn, M; Marlow, N; Pasupathy, D; Redshaw, M; Sandall, J; Silverton, L; Hollowell, J

2015-01-01

Objective To explore and compare perinatal and maternal outcomes in women at ‘higher risk’ of complications planning home versus obstetric unit (OU) birth. Design Prospective cohort study. Setting OUs and planned home births in England. Population 8180 ‘higher risk’ women in the Birthplace cohort. Methods We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures. Main outcome measures Composite perinatal outcome measure encompassing ‘intrapartum related mortality and morbidity’ (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth. Results The risk of ‘intrapartum related mortality and morbidity’ or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31–0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure ‘intrapartum related mortality and morbidity’ (RR adjusted for parity 1.92, 95% CI 0.97–3.80). Maternal interventions were lower in planned home births. Conclusions The babies of ‘higher risk’ women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between

[Choroid plexus tumours in childhood: Experience in Sant Joan de Déu hospital].

PubMed

Del Río-Pérez, Clara Maria; Suñol-Capella, Mariona; Cruz-Martinez, Ofelia; Garcia-Fructuoso, Gemma

2016-01-01

Choroid plexus tumours are rare, with a peak incidence in the first two years of life. The most common location is the lateral ventricle in children, while in adults it is the fourth ventricle. The most common clinical manifestation is the signs and symptoms of intracranial hypertension. They are histologically classified as plexus papilloma, atypical plexus papilloma, and plexus carcinoma. A review is presented on choroid plexus tumours treated in the Hospital Sant Joan de Déu between 1980 and 2014. A total of 18 patients have been treated. An analysis was made of the demographic, clinical, histological data, treatment, and recurrences. The treatment of choice is complete resection, accompanied by adjuvant therapy in carcinomas. In atypical papillomas, the use of adjuvant therapies is controversial, reserving radiation therapy for recurrences. Papillomas have a good outcome, whereas atypical papillomas and carcinomas outcome is poor. Copyright © 2015 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.

Ultrasound-Guided Selective Versus Conventional Block of the Medial Brachial Cutaneous and the Intercostobrachial Nerves: A Randomized Clinical Trial.

PubMed

Magazzeni, Philippe; Jochum, Denis; Iohom, Gabriella; Mekler, Gérard; Albuisson, Eliane; Bouaziz, Hervé

2018-06-13

For superficial surgery of anteromedial and posteromedial surfaces of the upper arm, the medial brachial cutaneous nerve (MBCN) and the intercostobrachial nerve (ICBN) must be selectively blocked, in addition to an axillary brachial plexus block. We compared efficacy of ultrasound-guided (USG) versus conventional block of the MBCN and the ICBN. Eighty-four patients, undergoing upper limb surgery, were randomized to receive either USG (n = 42) or conventional (n = 42) block of the MBCN and the ICBN with 1% mepivacaine. Sensory block was evaluated using light-touch on the upper and lower half of the anteromedial and posteromedial surfaces of the upper arm at 5, 10, 15, 20 minutes after nerve blocks. The primary outcome was the proportion of patients who had no sensation in all 4 regions innervated by the MBCN and the ICBN at 20 minutes. Secondary outcomes were onset time of complete anesthesia, volume of local anesthetic, tourniquet tolerance, and quality of ultrasound images. In the USG group, 37 patients (88%) had no sensation at 20 minutes in any of the 4 areas tested versus 8 patients (19%) in the conventional group (P < 0.001). When complete anesthesia was obtained, it occurred within 10 minutes in more than 90% of patients, in both groups. Mean total volumes of local anesthetic used for blocking the MBCN and the ICBN were similar in the 2 groups. Ultrasound images were of good quality in only 20 (47.6%) of 42 patients. Forty-one patients (97.6%) who received USG block were comfortable with the tourniquet versus 16 patients (38.1%) in the conventional group (P < 0.001). Ultrasound guidance improved the efficacy of the MBCN and ICBN blocks. This study was registered at ClinicalTrials.gov, identifier NCT02940847.

Choroid Plexus Papilloma Expansion Over 7 Years in Aicardi Syndrome

PubMed Central

Frye, Richard E.; Polling, Jon S.; Ma, Louis C. K.

2008-01-01

Choroid plexus papillomas have been reported in Aicardi syndrome. Management of these tumors is controversial because their natural progression in Aicardi syndrome has only been rarely documented. This report describes the progression of such a tumor over 7 years in a girl with Aicardi syndrome. A magnetic resonance imaging study at 2 months of age demonstrated a right ventricular mass that was consistent with a unilateral choroid plexus papilloma. The mass enlarged over the next 7 years without causing any clinically apparent symptoms, ventricular enlargement, hydrocephalus, or mass effect. The tumor was removed without change in behavior or development. The know cases of Aicardi syndrome associated with choroid plexus papillomas are reviewed. The heterogeneous nature of this lesion is highlighted. PMID:17621535

Predicting obstetric anal sphincter injuries in a modern obstetric population.

PubMed

Meister, Melanie R L; Cahill, Alison G; Conner, Shayna N; Woolfolk, Candice L; Lowder, Jerry L

2016-09-01

Perineal lacerations are common at the time of vaginal delivery and may predispose patients to long-term pelvic floor disorders, such as urinary incontinence and pelvic organ prolapse. Obstetric anal sphincter injuries, which are the most severe form of perineal lacerations, result in disruption of the anal sphincter and, in some cases, the rectal mucosa during vaginal delivery. Long-term morbidity, including pain, pelvic floor disorders, fecal incontinence, and predisposition to recurrent injury at subsequent delivery may result. Despite several studies that have reported risk factors for obstetric anal sphincter injuries, no accurate risk prediction models have been developed. The purpose of this study was to identify risk factors and develop prediction models for perineal lacerations and obstetric anal sphincter injuries. This was a nested case control study within a retrospective cohort of consecutive term vaginal deliveries at 1 tertiary care facility from 2004-2008. Cases were patients with any perineal laceration that had been sustained during vaginal delivery; control subjects had no lacerations of any severity. Secondary analyses investigated obstetric anal sphincter injury (3rd- to 4(th)-degree laceration) vs no obstetric anal sphincter injury (0 to 2(nd)-degree laceration). Baseline characteristics were compared between groups with the use of the chi-square and Student t test. Adjusted odds ratios and 95% confidence intervals were calculated with the use of multivariable logistic regression. Prediction models were created and model performance was estimated with receiver-operator characteristic curve analysis. Receiver-operator characteristic curves were validated internally with the use of the bootstrap method to correct for bias within the model. Of the 5569 term vaginal deliveries that were recorded during the study period, complete laceration data were available in 5524 deliveries. There were 3382 perineal lacerations and 249 (4.5%) obstetric anal

[Study on the first translated obstetrics book Tai chan ju yao (Essentials in Obstetrics)].

PubMed

Wu, M

2018-01-28

In 1893, Wan Tsun-mo translated and published Tai chan ju yao ( Essentials in Obstetrics ), the first monograph of western obstetrics in modern China, symbolizing the independence of obstetrics from such maternal and child books as Fu ying xin shuo and Fu ke jing yun tu shuo , which occupies an important position in the history of the development of modern Chinese obstetrics. The book introduced anatomy, physiology, pathology, embryology, diagnostics, surgery, pharmacology and other knowledge of obstetrics in a catechismal form, and had a detailed discussion of such advanced obstetrical technologies as antiseptic, anesthesia, forceps and cesarean section for the first time.Judging from the content and translation of Tai chan ju yao , this book has already possessed the basic knowledge system of modern obstetrics, though the translation appeared to be somewhat jerky and not elegant and the terminology needing to be further improved, it was not only used as an important medium for the introduction of obstetrical knowledge, but also of great clinical value.However, its influence was so weak that later researchers seldom mentioned this book.

Injuries to the upper extremities in polytrauma: limited effect on outcome more than ten years after injury - a cohort study in 629 patients.

PubMed

Macke, C; Winkelmann, M; Mommsen, P; Probst, C; Zelle, B; Krettek, C; Zeckey, C

2017-02-01

To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients. A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients' injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion. In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC. Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255-60. ©2017 The British Editorial Society of Bone & Joint Surgery.

Association of Brachial-Ankle Pulse Wave Velocity with Asymptomatic Intracranial Arterial Stenosis in Hypertension Patients.

PubMed

Wang, Yan; Zhang, Jin; Qain, Yuesheng; Tang, Xiaofeng; Ling, Huawei; Chen, Kemin; Li, Yan; Gao, Pingjin; Zhu, Dingliang

2016-08-01

Intracranial arterial stenosis is a common cause of ischemic stroke in Asians. We therefore sought to explore the relationship of brachial-ankle pulse wave velocity and intracranial arterial stenosis in 834 stroke-free hypertensive patients. Intracranial arterial stenosis was evaluated through computerized tomographic angiography. Brachial-ankle pulse wave velocity was measured by an automated cuff device. The top decile of brachial-ankle pulse wave velocity was significantly associated with intracranial arterial stenosis (P = .027, odds ratio = 1.82; 95% confidence interval: 1.07-3.10). The patients with the top decile of brachial-ankle pulse wave velocity showed 56% higher risk for the presence of intracranial arterial stenosis to the whole population, which was more significant in patients younger than 65 years old. We also found that brachial-ankle pulse wave velocity related to both intracranial arterial stenosis and homocysteine. Our study showed the association of brachial-ankle pulse wave velocity with asymptomatic intracranial arterial stenosis in hypertension patients, especially in relative younger subjects. Brachial-ankle pulse wave velocity might be a relatively simple and repeatable measurement to detect hypertension patients in high risk of intracranial arterial stenosis. Copyright © 2016. Published by Elsevier Inc.

Brachial artery stiffness estimation using ARTSENS.

PubMed

Kiran, V Raj; Nabeel, P M; Joseph, Jayaraj; Sivaprakasam, Mohanasankar

2017-07-01

Central and peripheral arteries stiffening prominently affect hemodynamics thus increasing the risk of coronary heart disease, chronic kidney disease and end stage renal disease. There are several commercially available non-invasive measurement technologies for the evaluation of stiffness that are expensive, demand dedicated expertise and fall short for mass screening. Considering this, we have developed ARTSENS ® , a highly compact and portable image-free ultrasound device for evaluation of arterial stiffness. The capability of the device to perform accurate measurements of carotid artery stiffness has been validated through extensive in-vivo studies. In this paper we demonstrate the feasibility of using ARTSENS ® for measuring brachial artery stiffness. An inter-operator repeatability study was done based on in-vivo experiments on 9 young healthy subjects. The study included measurement of distension, end diastolic lumen diameter, arterial compliance and stiffness index performed both on carotid artery and brachial artery by two operators successively. The degree of agreement between the measurements made by operators has been investigated based on Bland-Altman plots and paired t-test. The measurements were populated within the limits of agreement. No statistically significant difference (p-values from paired t-test for end-diastolic diameter, distension, stiffness index, arterial compliance were 0.36, 0.24, 0.47 and 0.11 respectively) was seen for the brachial artery measurements performed by the two operators. The correlation between the measurement made by the operators was highly significant (r=0.86, p-value=0.003).

The clinical applicability of an automated plethysmographic determination of the ankle-brachial index after vascular surgery.

PubMed

van der Slegt, Jasper; Verbogt, Nathalie Pa; Mulder, Paul Gh; Steunenberg, Stijn L; Steunenberg, Bastiaan E; van der Laan, Lijckle

2016-10-01

An automated ankle-brachial index device could lead to potential time savings and more accuracy in ankle-brachial index-determination after vascular surgery. This prospective cross-sectional study compared postprocedural ankle-brachial indices measured by a manual method with ankle-brachial indices of an automated plethysmographic method. Forty-two patients were included. No significant difference in time performing a measurement was observed (1.1 min, 95% CI: -0.2 to +2.4; P = 0.095). Mean ankle-brachial index with the automated method was 0.105 higher (95% CI: 0.017 to 0.193; P = 0.020) than with the manual method, with limits of agreement of -0.376 and +0.587. Total variance amounted to 0.0759 and the correlation between both methods was 0.60. Reliability expressed as maximum absolute difference (95% level) between duplicate ankle-brachial index-measurements under identical conditions was 0.350 (manual) and 0.152 (automated), although not significant (p = 0.053). Finally, the automated method had 34% points higher failure rate than the manual method. In conclusion based on this study, the automated ankle-brachial index-method seems not to be clinically applicable for measuring ankle-brachial index postoperatively in patients with vascular disease. © The Author(s) 2016.

Brain iron homeostasis, the choroid plexus, and localization of iron transport proteins.

PubMed

Rouault, Tracey A; Zhang, De-Liang; Jeong, Suh Young

2009-12-01

Maintenance of appropriate iron homeostasis in the brain is important, but the mechanisms involved in brain iron uptake are incompletely understood. Here, we have analyzed where messenger RNAs that encode iron transport proteins are expressed in the brain, using the Allen Brain atlas, and we conclude that several important iron transporters are highly expressed in the choroid plexus. Based on recent estimates of the surface area of the choroid plexus and on MRI imaging studies of manganese uptake in the brain, we propose that the choroid plexus may have a much greater role than has been previously appreciated in brain iron transport.

Estimation of brachial artery volume flow by duplex ultrasound imaging predicts dialysis access maturation.

PubMed

Ko, Sae Hee; Bandyk, Dennis F; Hodgkiss-Harlow, Kelley D; Barleben, Andrew; Lane, John

2015-06-01

This study validated duplex ultrasound measurement of brachial artery volume flow (VF) as predictor of dialysis access flow maturation and successful hemodialysis. Duplex ultrasound was used to image upper extremity dialysis access anatomy and estimate access VF within 1 to 2 weeks of the procedure. Correlation of brachial artery VF with dialysis access conduit VF was performed using a standardized duplex testing protocol in 75 patients. The hemodynamic data were used to develop brachial artery flow velocity criteria (peak systolic velocity and end-diastolic velocity) predictive of three VF categories: low (<600 mL/min), acceptable (600-800 mL/min), or high (>800 mL/min). Brachial artery VF was then measured in 148 patients after a primary (n = 86) or revised (n = 62) upper extremity dialysis access procedure, and the VF category correlated with access maturation or need for revision before hemodialysis usage. Access maturation was conferred when brachial artery VF was >600 mL/min and conduit imaging indicated successful cannulation based on anatomic criteria of conduit diameter >5 mm and skin depth <6 mm. Measurements of VF from the brachial artery and access conduit demonstrated a high degree of correlation (R(2) = 0.805) for autogenous vein (n = 45; R(2) = 0.87) and bridge graft (n = 30; R(2) = 0.78) dialysis accesses. Access VF of >800 mL/min was predicted when the brachial artery lumen diameter was >4.5 mm, peak systolic velocity was >150 cm/s, and the diastolic-to-systolic velocity ratio was >0.4. Brachial artery velocity spectra indicating VF <800 mL/min was associated (P < .0001) with failure of access maturation. Revision was required in 15 of 21 (71%) accesses with a VF of <600 mL/min, 4 of 40 accesses (10%) with aVF of 600 to 800 mL/min, and 2 of 87 accesses (2.3%) with an initial VF of >800 mL/min. Duplex testing to estimate brachial artery VF and assess the conduit for ease of cannulation can be performed in 5 minutes during the initial postoperative

Uniform cell-autonomous tumorigenesis of the choroid plexus by papovavirus large T antigens.

PubMed Central

Chen, J D; Van Dyke, T

1991-01-01

The simian virus 40 (SV40) large tumor antigen (T antigen) under its natural regulatory elements induces choroid plexus papillomas in transgenic mice. Because these tumors develop focally after several months, it has been suggested that secondary cellular alterations are required to induce a tumor in this tissue. In contrast to SV40, the related lymphotropic papovavirus early region induces rapid nonfocal choroid plexus neoplasia in transgenic mice. Here, using hybrid gene constructs, we showed that T antigen from either virus in in fact sufficient to induce these tumors. Their abilities to induce proliferative abnormalities in other tissues, such as kidney and thymus, were also indistinguishable. Differences in the rate of choroid plexus tumorigenesis reflected differences in the control regions of the two viruses, rather than differences in T antigen per se. Under SV40 regulation, expression was limited to a fraction of the choroid plexus cells prior to the formation of focal tumors. When SV40 T antigen was placed under lymphotropic papovavirus control, in contrast, expression was generally uniform in the choroid plexus and rapid expansion of the tissue ensued. We found a direct relationship between T-antigen expression, morphological transformation, and proliferation of the choroid plexus epithelial cells. Analysis of mosaic transgenic mice indicated further that T antigen exerts its mitogenic effect cell autonomously. These studies form the foundation for elucidating the role of various T-antigen subactivities in tumorigenesis. Images PMID:1658622

Risk Factors for the Development of Obstetric Anal Sphincter Injuries in Modern Obstetric Practice.

PubMed

Ramm, Olga; Woo, Victoria G; Hung, Yun-Yi; Chen, Hsuan-Chih; Ritterman Weintraub, Miranda L

2018-02-01

To characterize the rate of obstetric anal sphincter injuries and identify key risk factors of obstetric anal sphincter injuries, including duration of the second stage of labor. This retrospective cohort study included all singleton, term, cephalic vaginal deliveries within Kaiser Permanente Northern California between January 2013 and December 2014 (N=22,741). Incidence of obstetric anal sphincter injuries, defined as third- or fourth-degree perineal lacerations, was the primary outcome. Multiple logistic regression models were conducted to identify obstetric anal sphincter injury risk factors and high-risk subpopulations. The overall incidence rate of obstetric anal sphincter injuries was 4.9% (3.6% of women who delivered spontaneously vs 24.0% of women who had a vacuum-assisted vaginal delivery, P<.001, CI 18.1-22.6%). In bivariate and multivariate analyses, obstetric anal sphincter injury incidence was higher among women with second stage of labor longer than 2 hours, Asian race, nulliparity, vaginal birth after cesarean delivery, episiotomy, and vacuum delivery. Women with a vacuum-assisted vaginal delivery had four times the odds of obstetric anal sphincter injury (adjusted odds ratio [OR] 4.23, 95% CI 3.59-4.98) and those whose second stage of labor lasted at least 180 minutes vs less than 60 minutes had three times the odds of incurring obstetric anal sphincter injury (adjusted OR 3.20, 95% CI 2.62-3.89). Vacuum-assisted vaginal delivery conferred the highest odds of obstetric anal sphincter injury followed by prolonged duration of the second stage of labor, particularly among certain subpopulations. Understanding these risk factors and their complex interactions can inform antepartum and intrapartum decision-making with the goal of reducing obstetric anal sphincter injury incidence.

Expression of regulatory proteins in choroid plexus changes in early stages of Alzheimer disease.

PubMed

Krzyzanowska, Agnieszka; García-Consuegra, Inés; Pascual, Consuelo; Antequera, Desiree; Ferrer, Isidro; Carro, Eva

2015-04-01

Recent studies indicate that the choroid plexus has important physiologic and pathologic roles in Alzheimer disease (AD). To obtain additional insight on choroid plexus function, we performed a proteomic analysis of choroid plexus samples from patients with AD stages I to II (n = 16), III to IV (n = 16), and V to VI (n = 11) and 7 age-matched control subjects. We used 2-dimensional differential gel electrophoresis coupled with mass spectrometry to generate a complete picture of changes in choroid plexus protein expression occurring in AD patients. We identified 6 proteins: 14-3-3 β/α, 14-3-3 ε, moesin, proteasome activator complex subunit 1, annexin V, and aldehyde dehydrogenase, which were significantly regulated in AD patient samples (p < 0.05, >1.5-fold variation in expression vs control samples). These proteins are implicated in major physiologic functions including mitochondrial dysfunction and apoptosis regulation. These findings contribute additional significance to the emerging importance of molecular and functional changes of choroid plexus function in the pathophysiology of AD.

Ulnar nerve damage (image)

MedlinePlus

The ulnar nerve originates from the brachial plexus and travels down arm. The nerve is commonly injured at the elbow because of elbow fracture or dislocation. The ulnar nerve is near the surface of the body where ...

The p75 neurotrophin receptor localization in blood-CSF barrier: expression in choroid plexus epithelium.

PubMed

Spuch, Carlos; Carro, Eva

2011-05-11

The presence of neurotrophins and their receptors Trk family has been reported in the choroid plexus. High levels of Nerve Growth Factor (NGF), Neurotrophin-4 (NT-4) and TrkB receptor were detected, while nothing was know about p75 neurotrophin receptor (p75NTR) in the choroid plexus epithelial cells. In neurons, p75NTR receptor has a dual function: promoting survival together with TrkA in response to NGF, and inducing apoptotic signaling through p75NTR. We postulated that p75NTR may also affect the survival pathways in the choroid plexus and also undergoes regulated proteolysis with metalloproteases. Here, we demonstrated the presence of p75NTR receptor in the choroid plexus epithelial cells. The p75NTR receptor would be involved in cell death mechanisms and in the damaged induced by amyloid beta (Aβ) in the choroid plexus and finally, we propose an essential role of p75NTR in the Aβ transcytosis through out choroid plexus barrier. The presence analysis reveals the new localization of p75NTR in the choroid plexus and, the distribution mainly in the cytoplasm and cerebrospinal fluid (CSF) side of the epithelial cells. We propose that p75NTR receptor plays a role in the survival pathways and Aβ-induced cell death. These data suggest that p75NTR dysfunction play an important role in the pathogenesis of brain diseases. The importance and novelty of this expression expands a new role of p75NTR.

Shoulder dystocia in primary midwifery care in the Netherlands.

PubMed

Kallianidis, Athanasios F; Smit, Marrit; Van Roosmalen, Jos

2016-02-01

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. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology.

Quantitative changes of nitrergic neurons during postnatal development of chicken myenteric plexus*

PubMed Central

Yang, Ping; Gandahi, Jameel Ahmed; Zhang, Qian; Zhang, Lin-li; Bian, Xun-guang; Wu, Li; Liu, Yi; Chen, Qiu-sheng

2013-01-01

Objective: Information regarding the development of the enteric nervous system (ENS) is important for understanding the functional abnormalities of the gut. Because fertilized chicken eggs provide easy access to embryos, chicken models have been widely used to study embryonic development of myenteric plexus; however, no study has been focused on the postnatal period. The aim of this study was to perform a qualitative and quantitative analysis of the nitrergic neurons in the myenteric plexus of developing chickens in the postnatal period. Methods: Whole-mount preparations of the myenteric plexus were made in 7-d, 15-d, and 40-d old (adult) chickens of either sex (n=15). The myenteric plexus was studied after nicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) histochemistry using light microscopy, digital photography, and Image-Pro Plus 6.0 software. The numbers of positively stained neurons and ganglia were counted in the duodenum, jejunum, ileum, caecum, and colon in the different age groups. Data were expressed as mean±standard deviation (SD), and statistical analysis was performed using a one-way analysis of variance (ANOVA) test. Results: The positively stained neurons showed various morphologies and staining intensities, and formed bead-shaped and U-shaped arrangements in the myenteric plexus. The densities of neurons and ganglia increased with age. However, the number of positive neurons per ganglion increased. The number of NADPH-d-positive neurons was highest in the colon, followed by the ileum, the jejunum, the duodenum, and the caeca in all age groups. Conclusions: Developmental changes in the myenteric plexus of chickens continue in the postnatal period, indicating that the maturation process of the gastrointestinal function is gradual. In addition, no significant difference is happening among different intestinal segments during postnatal development, suggesting that the function of different intestinal segments had been determined after

Malpractice Burden, Rural Location, and Discontinuation of Obstetric Care: A Study of Obstetric Providers in Michigan

PubMed Central

Xu, Xiao; Siefert, Kristine A.; Jacobson, Peter D.; Lori, Jody R.; Gueorguieva, Iana; Ransom, Scott B.

2011-01-01

Context It has long been a concern that professional liability problems disproportionately affect the delivery of obstetrical services to women living in rural areas. Michigan, a state with a large number of rural communities, is considered to be at risk for a medical liability crisis. Purpose This study examined whether higher malpractice burden on obstetric providers was associated with an increased likelihood of discontinuing obstetric care and whether there were rural-urban differences in the relationship. Methods Data on 500 obstetrician-gynecologists and family physicians who had provided obstetric care at some point in their career (either currently or previously) were obtained from a statewide survey in Michigan. Statistical tests and multivariate regression analyses were performed to examine the interrelationship among malpractice burden, rural location, and discontinuation of obstetric care. Findings After adjusting for other factors that might influence a physician’s decision about whether to stop obstetric care, our results showed no significant impact of malpractice burden on physicians’ likelihood to discontinue obstetric care. Rural-urban location of the practice did not modify the nature of this relationship. However, family physicians in rural Michigan had a nearly four fold higher likelihood of withdrawing obstetric care when compared to urban family physicians. Conclusions The higher likelihood of rural family physicians to discontinue obstetric care should be carefully weighed in future interventions to preserve obstetric care supply. More research is needed to better understand the practice environment of rural family physicians and the reasons for their withdrawal from obstetric care. PMID:19166559

Definition of the supraclavicular and infraclavicular nodes: implications for three-dimensional CT-based conformal radiation therapy.

PubMed

Madu, C N; Quint, D J; Normolle, D P; Marsh, R B; Wang, E Y; Pierce, L J

2001-11-01

To delineate with computed tomography (CT) the anatomic regions containing the supraclavicular (SCV) and infraclavicular (IFV) nodal groups, to define the course of the brachial plexus, to estimate the actual radiation dose received by these regions in a series of patients treated in the traditional manner, and to compare these doses to those received with an optimized dosimetric technique. Twenty patients underwent contrast material-enhanced CT for the purpose of radiation therapy planning. CT scans were used to study the location of the SCV and IFV nodal regions by using outlining of readily identifiable anatomic structures that define the nodal groups. The brachial plexus was also outlined by using similar methods. Radiation therapy doses to the SCV and IFV were then estimated by using traditional dose calculations and optimized planning. A repeated measures analysis of covariance was used to compare the SCV and IFV depths and to compare the doses achieved with the traditional and optimized methods. Coverage by the 90% isodose surface was significantly decreased with traditional planning versus conformal planning as the depth to the SCV nodes increased (P < .001). Significantly decreased coverage by using the 90% isodose surface was demonstrated for traditional planning versus conformal planning with increasing IFV depth (P = .015). A linear correlation was found between brachial plexus depth and SCV depth up to 7 cm. Conformal optimized planning provided improved dosimetric coverage compared with standard techniques.

A survey of central association members about the definition, management, and complications of shoulder dystocia.

PubMed

Gherman, Robert B; Chauhan, Suneet P; Lewis, David F

2012-04-01

To determine practice patterns for shoulder dystocia and concepts dealing with brachial plexus palsy. An Internet-based 25-question survey was electronically disseminated to all current members of the Central Association of Obstetricians and Gynecologists. For those individuals who did not respond, an additional opportunity to complete the assessment was provided during the 2009 annual meeting. Of 429 Central Association of Obstetricians and Gynecologists members, 268 (62%) responded, with 192 (78%) filling out the survey online. Nearly 90% of those queried believed that shoulder dystocia was unpredictable and unpreventable. Thirty-seven percent felt that an elective cesarean delivery should be offered for an estimated fetal weight of 4,500 g among nondiabetics. Just 40% would have allowed a trial of labor with a documented history of shoulder dystocia. Slightly more than half answered that they never used either lateral or excessive traction and obstetrician-gynecologists were more likely than maternal-fetal medicine specialists to conclude that traction applied by the clinician doing the delivery was the cause of shoulder dystocia-related brachial plexus palsy (36% compared with 12%, P=.005). Maternal-fetal medicine specialists were more likely to believe that 40-50% of brachial plexus palsies occur without concomitant shoulder dystocia (21% compared with 9%, P=.015). Differences in practice patterns exist among with regard to management recommendations of the American College of Obstetricians and Gynecologists' Practice Bulletin on shoulder dystocia. III.

Diaphragmatic height index: new diagnostic test for phrenic nerve dysfunction.

PubMed

Pornrattanamaneewong, Chaturong; Limthongthang, Roongsak; Vathana, Torpon; Kaewpornsawan, Kamolporn; Songcharoen, Panupan; Wongtrakul, Saichol

2012-11-01

The diaphragmatic height index (DHI) was developed to measure the difference in diaphragm levels. The purpose of this study was to set definite DHI values and test the accuracy of these values for use as a new diagnostic test for phrenic nerve dysfunction. All data for this study were obtained from medical charts and retrospectively reviewed. One hundred sixty-five patients with brachial plexus injury who had undergone nerve transfers between 2005 and 2008 were divided into Groups A and B. Group A consisted of 40 patients (mean age 28.0 years) who had sustained concomitant injury of the brachial plexus and phrenic nerves. Patients in Group A1 had right phrenic nerve injury and those in Group A2 had left phrenic nerve injury. Intraoperative direct electrical stimulation of the phrenic nerve was considered the gold standard in assessing nerve function in all patients with brachial plexus injury. Group B consisted of 125 patients (mean age 28.7 years) with brachial plexus injury and normal phrenic nerve function. Group C, the control group, consisted of 80 patients with nonbrachial plexus injury (mean age 34.0 years) who had undergone other kinds of orthopedic operations between April and June 2009. Standard posteroanterior chest radiographs were blindly interpreted using the Siriraj inhouse picture archiving and communication system in all 245 patients in the study. First, a reference line (R line) was drawn along the inferior endplate of T-10. Then, 2 lines (lines A and B) were drawn through the highest point of each diaphragm and parallel to the R line. The difference between these 2 lines divided by the height of T-10 was defined as the DHI. The cutoff points of the DHI for diagnosing right and left phrenic nerve dysfunction were analyzed with a receiver operating characteristic curve. The accuracy of these DHI values was then evaluated. The DHI in Group C was 0.64 ± 0.44, slightly higher than the DHI in Group B, with no significant difference. Diaphragmatic

Models of brachial to finger pulse wave distortion and pressure decrement.

PubMed

Gizdulich, P; Prentza, A; Wesseling, K H

1997-03-01

To model the pulse wave distortion and pressure decrement occurring between brachial and finger arteries. Distortion reversion and decrement correction were also our aims. Brachial artery pressure was recorded intra-arterially and finger pressure was recorded non-invasively by the Finapres technique in 53 adult human subjects. Mean pressure was subtracted from each pressure waveform and Fourier analysis applied to the pulsations. A distortion model was estimated for each subject and averaged over the group. The average inverse model was applied to the full finger pressure waveform. The pressure decrement was modelled by multiple regression on finger systolic and diastolic levels. Waveform distortion could be described by a general, frequency dependent model having a resonance at 7.3 Hz. The general inverse model has an anti-resonance at this frequency. It converts finger to brachial pulsations thereby reducing average waveform distortion from 9.7 (s.d. 3.2) mmHg per sample for the finger pulse to 3.7 (1.7) mmHg for the converted pulse. Systolic and diastolic level differences between finger and brachial arterial pressures changed from -4 (15) and -8 (11) to +8 (14) and +8 (12) mmHg, respectively, after inverse modelling, with pulse pressures correct on average. The pressure decrement model reduced both the mean and the standard deviation of systolic and diastolic level differences to 0 (13) and 0 (8) mmHg. Diastolic differences were thus reduced most. Brachial to finger pulse wave distortion due to wave reflection in arteries is almost identical in all subjects and can be modelled by a single resonance. The pressure decrement due to flow in arteries is greatest for high pulse pressures superimposed on low means.

Management of traumatic brachial artery injuries: A report on 49 patients

PubMed Central

Ekim, Hasan; Tuncer, Mustafa

2009-01-01

BACKGROUND AND OBJECTIVE: The brachial artery is the most frequently injured artery in the upper extremity due to its vulnerability. The purpose of our study was to review our experience with brachial artery injuries over a 9-year period, describing the type of injury, surgical procedures, complications, and associated injuries. PATIENTS AND METHODS: Forty-nine patients with brachial artery injury underwent surgical repair procedures at our hospital, from the beginning of May 1999 to the end of June 2008. The brachial artery injuries were diagnosed by physical examination and Doppler ultrasonography. Depending on the mode of presentation, patients were either taken immediately to the operating room for bleeding control and vascular repair or were assessed by preoperative duplex ultrasonography. RESULTS: This study group consisted of 43 males and 6 females, ranging in age from 6 to 65 years with a mean (SD) age of 27.9 (6.7) years. The mechanism of trauma was penetrating in 45 patients and blunt in the remaining 4 patients. Stab injury was the most frequent form of penetrating trauma (24 of 45). Treatment included primary arterial repair in 5 cases, end-to-end anastomosis in 28 cases, interposition vein graft in 15 cases, and interposition-ringed polytetrafluoroethylene graft in 1 case. Associated injuries were common and included venous injury (14), bone fracture (5), and peripheral nerve injury (11). Fifteen patients developed postoperative complications. One patient underwent an above-elbow amputation. CONCLUSIONS: Prompt and appropriate management of the brachial artery injuries, attention to associated injuries, and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. PMID:19318753

The choroid plexus: a comprehensive review of its history, anatomy, function, histology, embryology, and surgical considerations.

PubMed

Mortazavi, Martin M; Griessenauer, Christoph J; Adeeb, Nimer; Deep, Aman; Bavarsad Shahripour, Reza; Shahripour, Reza Bavarsad; Loukas, Marios; Tubbs, Richard Isaiah; Tubbs, R Shane

2014-02-01

The role of the choroid plexus in cerebrospinal fluid production has been identified for more than a century. Over the years, more intensive studies of this structure has lead to a better understanding of the functions, including brain immunity, protection, absorption, and many others. Here, we review the macro- and microanatomical structure of the choroid plexus in addition to its function and embryology. The literature was searched for articles and textbooks for data related to the history, anatomy, physiology, histology, embryology, potential functions, and surgical implications of the choroid plexus. All were gathered and summarized comprehensively. We summarize the literature regarding the choroid plexus and its surgical implications.

Exercise-induced brachial artery vasodilation: effects of antioxidants and exercise training in elderly men

PubMed Central

Donato, Anthony J.; Uberoi, Abhimanyu; Bailey, Damian M.; Walter Wray, D.

2010-01-01

Aging, vascular function, and exercise are thought to have a common link in oxidative stress. Of the 28 subjects studied (young, 26 ± 2 yr; old, 71 ± 6 yr), 12 took part in a study to validate an antioxidant cocktail (AOC: vitamins C, E, and α-lipoic acid), while the remaining 8 young and 8 old subjects performed submaximal forearm handgrip exercise with placebo or AOC. Old subjects repeated forearm exercise with placebo or AOC following knee-extensor (KE) exercise training. Brachial arterial diameter and blood velocity (Doppler ultrasound) were measured at rest and during exercise. During handgrip exercise, brachial artery vasodilation in the old subjects was attenuated compared with that in young subjects following placebo (maximum = ∼3.0 and ∼6.0%, respectively). In contrast to the previously documented attenuation in exercise-induced brachial artery vasodilation in the young group with AOC, in the old subjects the AOC restored vasodilation (maximum = ∼7.0%) to match the young. KE training also improved exercise-induced brachial artery vasodilation. However, in the trained state, AOC administration no longer augmented brachial artery vasodilation in the elderly, but rather attenuated it. These data reveal an age-related pro-/antioxidant imbalance that impacts vascular function and show that exercise training is capable of restoring equilibrium such that vascular function is improved and the AOC-mediated reduction in free radicals now negatively impacts brachial artery vasodilation, as seen in the young. PMID:19966056

Moro reflex

MedlinePlus

... on only one side suggests either a broken shoulder bone or an injury to the group of nerves that run from ... cases of decreased or absent reflex, may include: Shoulder x-ray Tests for disorders associated with brachial plexus injury

Genetics Home Reference: hereditary neuralgic amyotrophy

MedlinePlus

... tissues. This change in the functioning of septin proteins seems to particularly affect the brachial plexus, but the reason for this ... SH, Andermann E, Bird TD, Chance PF. SEPT9 gene sequencing analysis reveals recurrent mutations in hereditary neuralgic amyotrophy. ...

FORENSIC OBSTETRICS

PubMed Central

Russell, Keith P.

1959-01-01

Some of the more important and current aspects of forensic obstetrics are, broadly, 1. Fulfillment of basic criteria in all cases of alleged traumatic abortion. 2. Utilization of therapeutic abortion review boards, as well as sterilization committees, in all hospitals, with the active support of such committees by all those physicians interested in advancing the art and practice of obstetrics. 3. Early and active joint study of professional liability problems by combined groups of physicians and lawyers in every community. PMID:14440311

Unilateral cervical plexus block for prosthetic laryngoplasty in the standing horse.

PubMed

Campoy, L; Morris, T B; Ducharme, N G; Gleed, R D; Martin-Flores, M

2018-04-20

Locoregional anaesthetic techniques can facilitate certain surgeries being performed under standing procedural sedation. The second and third spinal cervical nerves (C2, C3) are part of the cervical plexus and provide sensory innervation to the peri-laryngeal structures in people; block of these nerves might permit laryngeal lateralisation surgery in horses. To describe the anatomical basis for an ultrasound-guided cervical plexus block in horses. To compare this block with conventional local anaesthetic tissue infiltration in horses undergoing standing prosthetic laryngoplasty. Cadaveric study followed by a double-blinded prospective clinical trial. A fresh equine cadaver was dissected to characterise the distribution of C2 and C3 to the perilaryngeal structures on the left side. A second cadaver was utilised to correlate ultrasound images with the previously identified structures; a tissue marker was injected to confirm the feasibility of an ultrasound-guided approach to the cervical plexus. In the clinical study, horses were assigned to two groups, CP (n = 17; cervical plexus block) and INF (n = 17; conventional tissue infiltration). Data collection and analyses included time to completion of surgical procedure, sedation time, surgical field conditions and surgeon's perception of block quality. We confirmed that C2 and C3 provided innervation to the perilaryngeal structures. The nerve root of C2 was identified ultrasonographically located between the longus capitis and the cleidomastoideus muscles, caudal to the parotid gland. The CP group was deemed to provide better (P<0.0002) surgical conditions with no differences in the other variables measured. Further studies with larger numbers of horses may be necessary to detect smaller differences in surgical procedure completion time based on the improved surgical filed conditions. For standing unilateral laryngeal surgery, a cervical plexus block is a viable alternative to tissue infiltration and it improves the

Quantification of the Interrelationship between Brachial-Ankle and Carotid-Femoral Pulse Wave Velocity in a Workplace Population.

PubMed

Cheng, Yi-Bang; Li, Yan; Sheng, Chang-Sheng; Huang, Qi-Fang; Wang, Ji-Guang

2016-04-01

Brachial-ankle pulse wave velocity (PWV) is increasingly used for the measurement of arterial stiffness. In the present study, we quantified the interrelationship between brachial-ankle and carotid-femoral PWV in a workplace population, and investigated the associations with cardiovascular risk factors and carotid intima-media thickness (IMT). Brachial-ankle and carotid-femoral PWV were measured using the Omron-Colin VP1000 and SphygmoCor devices, respectively. We investigated the interrelationship by the Pearson's correlation analysis and Bland-Altman plot, and performed sensitivity and specificity analyses. The 954 participants (mean ± standard deviation age 42.6 ± 14.2 years) included 630 (66.0%) men and 203 (21.3%) hypertensive patients. Brachial-ankle (13.4 ± 2.7 m/s) and carotid-femoral PWV (7.3 ± 1.6 m/s) were significantly correlated in all subjects (r = 0.75) as well as in men (r = 0.72) and women (r = 0.80) separately. For arterial stiffness defined as a carotid-femoral PWV of 10 m/s or higher, the sensitivity and specificity of brachial-ankle PWV of 16.7 m/s or higher were 72 and 94%, respectively. The area under the receiver operating characteristic curve was 0.953. In multiple stepwise regression, brachial-ankle and carotid-femoral PWV were significantly (p < 0.001) associated with age (partial r = 0.33 and 0.34, respectively) and systolic blood pressure (partial r = 0.71 and 0.66, respectively). In addition, brachial-ankle and carotid-femoral PWV were significantly (p < 0.001) associated with carotid IMT (r = 0.57 and 0.55, respectively) in unadjusted analysis, but not in analysis adjusted for cardiovascular risk factors (p ≥ 0.08). Brachial-ankle and carotid-femoral PWV were closely correlated, and had similar determinants. Brachial-ankle PWV can behave as an ease-of-use alternative measure of arterial stiffness for assessing cardiovascular risk.

Incidence of intravenous contrast extravasation: increased risk for patients with deep brachial catheter placement from the emergency department.

PubMed

Hardie, Andrew D; Kereshi, Borko

2014-06-01

Deep brachial intravenous catheter (IV) placement can be performed in emergency department patients with difficult vascular access, but the safety of deep brachial IV for iodinated contrast administration has not been assessed. This study compares the relative risk for extravasation of deep brachial IV compared with antecubital IV during power injected computed tomography (CT) examinations. A departmental practice quality improvement was performed to assess the rate of IV extravasation for all CT examinations during a 1 year period. De-identified data was analyzed with a waiver of informed consent to identify the rate and relative risk of iodinated contrast extravasation by catheter type. A total of 10,750 injections were performed, with 82 extravasation events (0.8 %). There were 51 extravasations of antecubital IV from approximately 8,599 placed (0.6 %). For 123 deep brachial IV placed, there were eight extravasations (6.5 %). The relative risk of a deep brachial IV extravasation was 9.4 compared to 0.4 for antecubital placement. Deep brachial IV demonstrated a markedly higher rate of contrast extravasation than antecubital IV. For power injected iodinated contrast administration, it is recommended to avoid the use of deep brachial IV whenever possible.

Percutaneous Coil Embolization for the Treatment of a Giant Brachial Artery Pseudoaneurym in a Child.

PubMed

Yuksel, Ahmet; Nas, Omer Fatih; Kan, Irem Iris; Tok, Mustafa; Erdogan, Cuneyt

2017-11-01

Brachial artery pseudoaneurysm is a rare phenomenon. When a diagnosis of brachial artery pseudoaneurysm is established, early and appropriate treatment should be performed as soon as possible to prevent possible complications, such as hemorrhage, rupture, and upper limb and finger losses. Open surgical repair is usually the cornerstone of treatment; however, we here report a case of giant brachial pseudoaneurysm in a 2-year-old girl, which was successfully treated with percutaneous coil embolization. Copyright © 2017 Elsevier Inc. All rights reserved.

Biochemical study of prolactin binding sites in Xenopus laevis brain and choroid plexus

DOE Office of Scientific and Technical Information (OSTI.GOV)

Muccioli, G.; Guardabassi, A.; Pattono, P.

1990-03-01

The occurrence of prolactin binding sites in some brain structures (telencephalon, ventral hypothalamus, myelencephalon, hypophysis, and choroid plexus) from Xenopus laevis (anuran amphibian) was studied by the in vitro biochemical technique. The higher binding values were obtained at the level of the choroid plexus and above all of the hypothalamus. On the bases of hormonal specificity and high affinity, these binding sites are very similar to those of prolactin receptors of classical target tissues as well as of those described by us in other structures from Xenopus. To our knowledge, the present results provide the first demonstration of the occurrencemore » of prolactin specific binding sites in Xenopus laevis choroid plexus cells.« less

Vascular patterns of upper limb: an anatomical study with accent on superficial brachial artery

PubMed Central

Kachlik, David; Konarik, Marek; Baca, Vaclav

2011-01-01

The aim of the study was to evaluate the terminal segmentation of the axillary artery and to present four cases of anomalous branching of the axillary artery, the superficial brachial artery (arteria brachialis superficialis), which is defined as the brachial artery that runs superficially to the median nerve. Totally, 130 cadaveric upper arms embalmed by classical formaldehyde technique from collections of the Department of Anatomy, Third Faculty of Medicine, Charles University in Prague, were macroscopically dissected with special focus on the branching arrangement of the axillary artery. The most distal part of the axillary artery (infrapectoral part) terminated in four cases as a bifurcation into two terminal branches: the superficial brachial artery and profunda brachii artery, denominated according to their relation to the median nerve. The profunda brachii artery primarily gave rise to the main branches of the infrapectoral part of the axillary artery. The superficial brachial artery descended to the cubital fossa where it assumed the usual course of the brachial artery in two cases and in the other two cases its branches (the radial and ulnar arteries) passed superficially to the flexors. The incidence of the superficial brachial artery in our study was 5% of cases. The reported incidence is a bit contradictory, from 0.12% to 25% of cases. The anatomical knowledge of the axillary region is of crucial importance for neurosurgeons and specialists using the radiodiagnostic techniques, particularly in cases involving traumatic injuries. The improved knowledge would allow more accurate diagnostic interpretations and surgical treatment. PMID:21342134

Erb-Duchenne and Dejerine-Klumpke Palsies

MedlinePlus

... the U.S. and Worldwide NINDS Clinical Trials Related Information Patient Organizations March of Dimes National Organization for Rare Disorders (NORD) National Rehabilitation Information Center (NARIC) United Brachial Plexus Network See all related ... Publications Parálisis de Erb-Duchenne y Dejerine-Klumpke ...

Peripheral Nerve Disorders

MedlinePlus

... outlet syndrome. In some cases, like complex regional pain syndrome and brachial plexus injuries, the problem begins after an injury. Some people are born with peripheral nerve disorders. Symptoms often start gradually, and then ... Burning or tingling Muscle weakness Sensitivity to touch ...

Real-time mapping of the corneal sub-basal nerve plexus by in vivo laser scanning confocal microscopy

NASA Astrophysics Data System (ADS)

Guthoff, Rudolf F.; Zhivov, Andrey; Stachs, Oliver

2010-02-01

The aim of the study was to produce two-dimensional reconstruction maps of the living corneal sub-basal nerve plexus by in vivo laser scanning confocal microscopy in real time. CLSM source data (frame rate 30Hz, 384x384 pixel) were used to create large-scale maps of the scanned area by selecting the Automatic Real Time (ART) composite mode. The mapping algorithm is based on an affine transformation. Microscopy of the sub-basal nerve plexus was performed on normal and LASIK eyes as well as on rabbit eyes. Real-time mapping of the sub-basal nerve plexus was performed in large-scale up to a size of 3.2mm x 3.2mm. The developed method enables a real-time in vivo mapping of the sub-basal nerve plexus which is stringently necessary for statistically firmed conclusions about morphometric plexus alterations.

In situ cephalic vein bypasses from axillary to the brachial artery after catheterization injuries.

PubMed

Hudorovic, Narcis; Lovricevic, Ivo; Ahel, Zaky

2010-07-01

The need to bypass to the brachial artery is rare. Over a five-year period, 16 patients had suffered iatrogenic post-catheterization injuries of the upper extremity. We have performed 16 bypasses, in 16 patients, mean age was 65 years (range 47-75), to the brachial artery originating from an artery proximal to the shoulder joint. In all cases, the axillary artery was the donor artery. All bypasses were created by using the cephalic vein with the in situ technique and distal anastomoses were made to a distance-free section of brachial artery. No operative mortality, neurological complications or major upper-extremity amputation was associated with the procedure. Life-long-conduit analysis showed 75% patency in the five-year period. After iatrogenic post-catheterization trauma of arterial system of upper extremity, bypasses from axillary to brachial artery with the cephalic vein with the in situ technique is a safe operation with satisfactory long-term patency.

Arrangement of the myenteric plexus throughout the gastrointestinal tract of the opossum.

PubMed

Christensen, J; Rick, G A; Robison, B A; Stiles, M J; Wix, M A

1983-10-01

Silver impregnation of the myenteric plexus of the opossum gut was used to find differences among various regions. In the esophagus, the plexus was sparse and ganglia were spaced irregularly, many being parafascicular. Ganglia were sparse in the striated-muscle region, but more frequent in the smooth-muscle region. In the stomach, uniformly spaced ganglia were large and intrafascicular; ganglia were larger in the distal stomach than in the proximal stomach. The proximal stomach contained thick fascicles, called shunt fascicles, radiating from the lesser to the greater curvatures and bypassing ganglia. A thick nerve bundle encircled the pylorus. In the small intestine, the regularly spaced ganglia were large and intrafascicular. In the cecum, they were small and intrafascicular. In the colon, they were large and intrafascicular. Shunt fascicles, like those of the proximal stomach, extended from the rectum into the distal colon. In the rectum, the plexus was sparse, and ganglia were small and distributed irregularly. Many ganglia were parafascicular. Unique knots of tangled fascicles were frequent in the rectum; these were called labyrinthine nodes. The least densely innervated regions of the gut are the lower esophageal sphincter and the rectum. Major differences in the anatomy of the plexus characterize the different regions of the gut.

Pathological alteration in the choroid plexus of Alzheimer's disease: implication for new therapy approaches.

PubMed

Krzyzanowska, Agnieszka; Carro, Eva

2012-01-01

Morphological alterations of choroid plexus in Alzheimer's disease (AD) have been extensively investigated. These changes include epithelial atrophy, thickening of the basement membrane, and stroma fibrosis. As a result, synthesis, secretory, and transportation functions are significantly altered resulting in decreased cerebrospinal fluid (CSF) turnover. Recent studies discuss the potential impacts of these changes, including the possibility of reduced resistance to stress insults and slow clearance of toxic compounds from CSF with specific reference to the amyloid peptide. Here, we review new evidences for AD-related changes in the choroid plexus. The data suggest that the significantly altered functions of the choroid plexus contribute to the multiparametric pathogenesis of late-onset AD.

Proteomic analysis of trans-hemispheric motor cortex reorganization following contralateral C7 nerve transfer

PubMed Central

Yuan, Yin; Xu, Xiu-yue; Lao, Jie; Zhao, Xin

2018-01-01

Nerve transfer is the most common treatment for total brachial plexus avulsion injury. After nerve transfer, the movement of the injured limb may be activated by certain movements of the healthy limb at the early stage of recovery, i.e., trans-hemispheric reorganization. Previous studies have focused on functional magnetic resonance imaging and changes in brain-derived neurotrophic factor and growth associated protein 43, but there have been no proteomics studies. In this study, we designed a rat model of total brachial plexus avulsion injury involving contralateral C7 nerve transfer. Isobaric tags for relative and absolute quantitation and western blot assay were then used to screen differentially expressed proteins in bilateral motor cortices. We found that most differentially expressed proteins in both cortices of upper limb were associated with nervous system development and function (including neuron differentiation and development, axonogenesis, and guidance), microtubule and cytoskeleton organization, synapse plasticity, and transmission of nerve impulses. Two key differentially expressed proteins, neurofilament light (NFL) and Thy-1, were identified. In contralateral cortex, the NFL level was upregulated 2 weeks after transfer and downregulated at 1 and 5 months. The Thy-1 level was upregulated from 1 to 5 months. In the affected cortex, the NFL level increased gradually from 1 to 5 months. Western blot results of key differentially expressed proteins were consistent with the proteomic findings. These results indicate that NFL and Thy-1 play an important role in trans-hemispheric organization following total brachial plexus root avulsion and contralateral C7 nerve transfer. PMID:29557385

Effect of Load Carriage on Upper Limb Performance.

PubMed

Hadid, Amir; Katz, Inbar; Haker, Tal; Zeilig, Gabi; Defrin, Ruth; Epstein, Yoram; Gefen, Amit

2017-05-01

Carrying heavy backpacks are often associated with shoulder discomfort or pain, loss of sensorimotor functions, and brachial plexus injuries that might hamper performance. On the basis of previous research, the cause of these symptoms could be tissue deformations of the brachial plexus and the subclavian artery caused by the shoulder straps. This study aimed to evaluate the changes in the upper extremity hemodynamic and neural function and to assess how they are associated with brachial plexus tissue deformation during heavy load carriage. Ten young healthy adults carried for 45 min a backpack load (40% of their body weight) while standing freely, followed by 15 min of recovery (unloaded). Index-finger microvascular flow and sensorimotor function were measured before and after carrying the load, and after recovery. The following sensorimotor functions were measured: light touch thresholds by the index finger and little finger, forearm thermal sensation thresholds, and gross motor function. In addition, marksmanship accuracy, as an indication for fine motor function, was tested. Load carriage resulted in an average decrease of ~40% in microvascular flow and a significant decrement in light touch sensation (P < 0.05), but not in thermal sensation and gross motor functions. An increase in the light touch threshold was highly correlated with a reduced index-finger microvascular blood flow (r = 0.79, P = 0.007). These physiological effects were associated with a functional 34% decrement in the accuracy of target acquisition. Heavy load carriage resulted in impaired light touch sensitivity and fine motor function, which were associated with reduced finger microvascular blood flow.

Quantification of the Interrelationship between Brachial-Ankle and Carotid-Femoral Pulse Wave Velocity in a Workplace Population

PubMed Central

Cheng, Yi-Bang; Li, Yan; Sheng, Chang-Sheng; Huang, Qi-Fang; Wang, Ji-Guang

2016-01-01

Background Brachial-ankle pulse wave velocity (PWV) is increasingly used for the measurement of arterial stiffness. In the present study, we quantified the interrelationship between brachial-ankle and carotid-femoral PWV in a workplace population, and investigated the associations with cardiovascular risk factors and carotid intima-media thickness (IMT). Methods Brachial-ankle and carotid-femoral PWV were measured using the Omron-Colin VP1000 and SphygmoCor devices, respectively. We investigated the interrelationship by the Pearson's correlation analysis and Bland-Altman plot, and performed sensitivity and specificity analyses. Results The 954 participants (mean ± standard deviation age 42.6 ± 14.2 years) included 630 (66.0%) men and 203 (21.3%) hypertensive patients. Brachial-ankle (13.4 ± 2.7 m/s) and carotid-femoral PWV (7.3 ± 1.6 m/s) were significantly correlated in all subjects (r = 0.75) as well as in men (r = 0.72) and women (r = 0.80) separately. For arterial stiffness defined as a carotid-femoral PWV of 10 m/s or higher, the sensitivity and specificity of brachial-ankle PWV of 16.7 m/s or higher were 72 and 94%, respectively. The area under the receiver operating characteristic curve was 0.953. In multiple stepwise regression, brachial-ankle and carotid-femoral PWV were significantly (p < 0.001) associated with age (partial r = 0.33 and 0.34, respectively) and systolic blood pressure (partial r = 0.71 and 0.66, respectively). In addition, brachial-ankle and carotid-femoral PWV were significantly (p < 0.001) associated with carotid IMT (r = 0.57 and 0.55, respectively) in unadjusted analysis, but not in analysis adjusted for cardiovascular risk factors (p ≥ 0.08). Conclusions Brachial-ankle and carotid-femoral PWV were closely correlated, and had similar determinants. Brachial-ankle PWV can behave as an ease-of-use alternative measure of arterial stiffness for assessing cardiovascular risk. PMID:27195246

The blind pushing technique for peripherally inserted central catheter placement through brachial vein puncture.

PubMed

Lee, Jae Myeong; Cho, Young Kwon; Kim, Han Myun; Song, Myung Gyu; Song, Soon-Young; Yeon, Jae Woo; Yoon, Dae Young; Lee, Sam Yeol

2018-03-01

The objective of this study was to conduct a prospective clinical trial evaluating the technical feasibility and short-term clinical outcome of the blind pushing technique for placement of pretrimmed peripherally inserted central catheters (PICCs) through brachial vein access. Patients requiring PICC placement at any of the three participating institutions were prospectively enrolled between January and December 2016. The review boards of all participating institutions approved this study, and informed consent was obtained from all patients. PICC placement was performed using the blind pushing technique and primary brachial vein access. The following data were collected from unified case report forms: access vein, obstacles during PICC advancement, procedure time, and postprocedural complications. During the 12-month study period, 1380 PICCs were placed in 1043 patients. Of these, 1092 PICCs placed in 837 patients were enrolled, with 834 PICCs (76%) and 258 PICCs (34%) placed through brachial vein and nonbrachial vein access, respectively. In both arms, obstacles were most commonly noted in the subclavian veins (n = 220) and axillary veins (n = 94). Successful puncture of the access vein was achieved at first try in 1028 PICCs (94%). The technical success rate was 99%, with 1055 PICCs (97%) placed within 120 seconds of procedure time and 1088 PICCs (99%) having the tip located at the ideal position. Follow-up Doppler ultrasound detected catheter-associated upper extremity deep venous thrombosis (UEDVT) for 18 PICCs in 16 patients and late symptomatic UEDVT for 16 PICCs in 16 patients (3.1%). Catheter-associated UEDVT was noted for 28 PICCs (82%) and 6 PICCs (18%) placed through brachial vein and nonbrachial vein access, respectively. The incidence of obstacles and the procedure time (<120 seconds) differed significantly between brachial vein and nonbrachial vein access (P = .001). There was no statistically significant difference between brachial vein and

Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study.

PubMed

Brocklehurst, Peter; Hardy, Pollyanna; Hollowell, Jennifer; Linsell, Louise; Macfarlane, Alison; McCourt, Christine; Marlow, Neil; Miller, Alison; Newburn, Mary; Petrou, Stavros; Puddicombe, David; Redshaw, Maggie; Rowe, Rachel; Sandall, Jane; Silverton, Louise; Stewart, Mary

2011-11-23

To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies. Prospective cohort study. England: all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units. 64,538 eligible women with a singleton, term (≥37 weeks gestation), and "booked" pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded. A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units). There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. Interventions during labour were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%). The results support a policy

Shoulder Problems in Athletes.

ERIC Educational Resources Information Center

Clancy, William G., Jr.

A description is given of typical sport-related injuries to the shoulder area. These include: (1) brachial plexus injuries; (2) peripheral nerve injuries about the shoulder; (3) acromioclavicular injuries; (4) sternoclavicular injuries; (5) shoulder dislocations; (6) recurrent traumatic subluxation/dislocations; and (7) overuse injuries.…

National Rehabilitation Hospital Assistive Technology Research Center

DTIC Science & Technology

1995-10-01

methods of assembly by orthotists. Because of this, efforts have been made to overcome these challenges but have proved fruitless thus far. Becker ...people including those with muscular dystrophy , multiple sclerosis, brachial plexus injuries, and those who work in jobs requiring them to hold their

[Obstetric hysterectomy. Incidence, indications and complications].

PubMed

Vázquez, Juan A Reveles; Rivera, Geannyne Villegas; Higareda, Salvador Hernández; Páez, Fernando Grover; Vega, Carmen C Hernández; Segura, Agustin Patiño

2008-03-01

Obstetric hysterectomy is indicated when patient's life is at risk, and it is a procedure that requires a highly experienced and skilled medical team to solve any complication. To identify incidence, indications, and complications of obstetric hysterectomy within a high-risk population. Transversal, retrospective study from July 1st 2004 to June 30 2006 at Unidad Medica de Alta Especialidad, Hospital de Ginecoobstetricia, Centro Medico Nacional de Occidente, IMSS. There were reviewed 103 patient' files with obstetric hysterectomy. Incidence was calculated, and clinical and socio-demographic characteristics, indications, and complications of obstetric hysterectomy identified and expressed in frequency, percentages, and central tendency measurements. Incidence of obstetric hysterectomy was 8 cases within every 1,000 obstetric consultation. Age average was 31.1 +/- 5.1 years. 72.8% had cesarean surgery history. Main indication was placenta previa associated with placenta accreta (33%), followed by uterine hypotony (22.3%). Complications were hypovolemic shock (56.3%), and vesical injuries (5.8%). There were no maternal deaths. Cesarean history induces higher obstetric hysterectomy incidence in women with high-risk pregnancy, due to its relation to placentation disorders, as placenta previa that increases hemorrhage possibility, and thus, maternal morbidity and mortality.

Injury to the Lumbar Plexus and its Branches After Lateral Fusion Procedures: A Cadaver Study.

PubMed

Grunert, Peter; Drazin, Doniel; Iwanaga, Joe; Schmidt, Cameron; Alonso, Fernando; Moisi, Marc; Chapman, Jens R; Oskouian, Rod J; Tubbs, Richard Shane

2017-09-01

Neurologic deficits from lumbar plexus nerve injuries commonly occur in patients undergoing lateral approaches. However, it is not yet clear what types of injury occur, where anatomically they are located, or what mechanism causes them. We aimed to study 1) the topographic anatomy of lumbar plexus nerves and their injuries in human cadavers after lateral transpsoas approaches to the lumbar spine, 2) the structural morphology of those injuries, and 3) the topographic anatomy of the lumbar plexus throughout the mediolateral approach corridor. Fifteen adult fresh frozen cadaveric torsos (26 sides) underwent lateral approaches (L1-L5) by experienced lateral spine surgeons. The cadavers were subsequently opened and the entire plexus dissected and examined for nerve injuries. The topographic anatomy of the lumbar plexus and its branches, their injuries, and the morphology of these injuries were documented. Fifteen injuries were found with complete or partial nerve transections (Sunderland IV and V). Injuries were found throughout the mediolateral approach corridor. At L1/2, the iliohypogastric, ilioinguinal, and subcostal nerves were injured within the psoas major muscle, the retroperitoneal space, or the outer abdominal muscles and subcutaneous tissues. Genitofemoral nerve injuries were found in the retroperitoneal space. Nerve root injuries occurred within the retroperitoneal space and psoas muscle. Femoral nerve injuries were found only within the psoas major muscle. No obturator nerve injuries occurred. Lateral approaches can lead to structural nerve damage. Knowledge of the complex plexus anatomy, specifically its mediolateral course, is critical to avoid approach-related injuries. Copyright © 2017 Elsevier Inc. All rights reserved.

Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise.

PubMed

Hankins, Gary D V; Clark, Shannon M; Munn, Mary B

2006-10-01

The purpose of this analysis was to determine the impact on specific forms of neonatal morbidity and mortality by allowing women to opt for delivery by elective cesarean section at 39 weeks of gestation (EGA). According to the National Vital Statistics Reports, over 70% of deliveries in the U.S. annually are at gestational ages>or=39 weeks EGA. Estimating that over 4 million deliveries occur annually in the United States, this would yield approximately 3 million pregnancies wherein the woman may exercise her choice for either primary or repeat cesarean section at 39 weeks EGA or at the point when labor is established. A search was conducted using Ovid Medline spanning the past 10 years using the following key words: fetal trauma, shoulder dystocia, brachial plexus palsy, neonatal skull fracture, obstetrical trauma, traumatic delivery, intrauterine fetal demise, stillbirth, fetal demise, and neonatal encephalopathy. Using this search technique, over 2100 articles were identified. The abstracts were reviewed and pertinent articles were chosen for further consideration. The identified articles and their applicable references were obtained for inclusion in this review. Preference was given to publications on or after the year 2000 with the exception of classical or sentinel articles, which were included without regard to year of publication. Four major categories of neonatal morbidity and mortality are discussed: Shoulder dystocia: Accepting that we do not have a successful method for the prediction or prevention of shoulder dystocia, the question becomes, "What is the chance that a baby will sustain a permanent brachial plexus injury at delivery?" Additionally, is there a significant protective effect of cesarean section in reducing the risk of such injury? Currently, the occurrence rate of brachial plexus palsy at the time of vaginal delivery ranges from 0.047% to 0.6% and for cesarean section from 0.0042% to 0.095%. Using a composite estimate of the risk of 0

Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment with Ankle Brachial Index in Adults

MedlinePlus

... Force Recommendations Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment with Ankle Brachial Index in Adults ... on Screening for Peripheral Artery Disease (PAD) and Cardiovascular Disease (CVD) Risk Assessment with Ankle Brachial Index (ABI) ...

Obstetric fistula: what about gender power?

PubMed

Roush, Karen; Kurth, Ann; Hutchinson, M Katherine; Van Devanter, Nancy

2012-01-01

Despite over 40 years of research there has been little progress in the prevention of obstetric fistula and women continue to suffer in unacceptable numbers. Gender power imbalance has consistently been shown to have serious implications for women's reproductive health and is known to persist in regions where obstetric fistula occurs. Yet, there is limited research about the role gender power imbalance plays in childbirth practices that put women at risk for obstetric fistula. This information is vital for developing effective maternal health interventions in regions affected by obstetric fistula.

The malpractice premium costs of obstetrics.

PubMed

Norton, S A

1997-01-01

This study examined, in 1992, the variation in the level of malpractice premiums, and the incremental malpractice premium costs associated with the practice of obstetrics for family practitioners and obstetricians. On average, in 1992 obstetricians and family practitioners providing obstetric services paid malpractice premiums of roughly $44,000 and $16,000, respectively. The incremental increase in malpractice premium costs represented roughly 70% of the premium the physicians would have paid had they not provided obstetric services. These results suggest that for both family practitioners and obstetricians, there is a considerable premium penalty associated with providing obstetric services which may have implications for women's access to obstetric services. Moreover, the results make it clear that physicians practicing in different states, and different specialists within a state, may face very different malpractice premium costs.

A novel combination of peripheral nerve blocks for arthroscopic shoulder surgery.

PubMed

Musso, D; Flohr-Madsen, S; Meknas, K; Wilsgaard, T; Ytrebø, L M; Klaastad, Ø

2017-10-01

Interscalene brachial plexus block is currently the gold standard for intra- and post-operative pain management for patients undergoing arthroscopic shoulder surgery. However, it is associated with block related complications, of which effect on the phrenic nerve have been of most interest. Side effects caused by general anesthesia, when this is required, are also a concern. We hypothesized that the combination of superficial cervical plexus block, suprascapular nerve block, and infraclavicular brachial plexus block would provide a good alternative to interscalene block and general anesthesia. Twenty adult patients scheduled for arthroscopic shoulder surgery received a combination of superficial cervical plexus block (5 ml ropivacaine 0.5%), suprascapular nerve block (4 ml ropivacaine 0.5%), and lateral sagittal infraclavicular block (31 ml ropivacaine 0.75%). The primary aim was to find the proportion of patients who could be operated under light propofol sedation, without the need for opioids or artificial airway. Secondary aims were patients' satisfaction and surgeons' judgment of the operating conditions. Nineteen of twenty patients (95% CI: 85-100) underwent arthroscopic shoulder surgery with light propofol sedation, but without opioids or artificial airway. The excluded patient was not comfortable in the beach chair position and therefore received general anesthesia. All patients were satisfied with the treatment on follow-up interviews. The surgeons rated the operating conditions as good for all patients. The novel combination of a superficial cervical plexus block, a suprascapular nerve block, and an infraclavicular nerve block provides an alternative anesthetic modality for arthroscopic shoulder surgery. © 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

A Monte Carlo model for the internal dosimetry of choroid plexuses in nuclear medicine procedures.

PubMed

Amato, Ernesto; Cicone, Francesco; Auditore, Lucrezia; Baldari, Sergio; Prior, John O; Gnesin, Silvano

2018-05-01

Choroid plexuses are vascular structures located in the brain ventricles, showing specific uptake of some diagnostic and therapeutic radiopharmaceuticals currently under clinical investigation, such as integrin-binding arginine-glycine-aspartic acid (RGD) peptides. No specific geometry for choroid plexuses has been implemented in commercially available software for internal dosimetry. The aims of the present study were to assess the dependence of absorbed dose to the choroid plexuses on the organ geometry implemented in Monte Carlo simulations, and to propose an analytical model for the internal dosimetry of these structures for 18 F, 64 Cu, 67 Cu, 68 Ga, 90 Y, 131 I and 177 Lu nuclides. A GAMOS Monte Carlo simulation based on direct organ segmentation was taken as the gold standard to validate a second simulation based on a simplified geometrical model of the choroid plexuses. Both simulations were compared with the OLINDA/EXM sphere model. The gold standard and the simplified geometrical model gave similar dosimetry results (dose difference < 3.5%), indicating that the latter can be considered as a satisfactory approximation of the real geometry. In contrast, the sphere model systematically overestimated the absorbed dose compared to both Monte Carlo models (range: 4-50% dose difference), depending on the isotope energy and organ mass. Therefore, the simplified geometric model was adopted to introduce an analytical approach for choroid plexuses dosimetry in the mass range 2-16 g. The proposed model enables the estimation of the choroid plexuses dose by a simple bi-parametric function, once the organ mass and the residence time of the radiopharmaceutical under investigation are provided. Copyright © 2018 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.

Diagnostic value of MR imaging in the Lewis-Sumner syndrome: a case series.

PubMed

Rajabally, Yusuf A; Knopp, Michael J; Martin-Lamb, Darren; Morlese, John

2014-07-15

Lewis-Sumner syndrome (LSS) is considered a variant of chronic inflammatory demyelinating polyneuropathy (CIDP), which is more frequently described with exclusive upper limb involvement. The diagnosis of LSS is clinical and electrophysiological. However, these are not always obvious and in view of its rarity, the diagnosis may be missed and patients denied effective immunomodulatory therapy. We herein describe the magnetic resonance imaging (MRI) findings in a series of five consecutive patients with a clinical diagnosis of LSS, using T2 STIR (Short Tau Inversion recovery) images without contrast. We demonstrated hyperintensity with or without hypertrophy of cervical roots and/or brachial plexus on the affected side and/or controlaterally which aided diagnostic confirmation. This helped therapeutic decision making regarding immunotherapy in all cases. MR imaging of the cervical spine/brachial plexus with T2 STIR may be helpful in suspected cases of LSS as it represents a very useful additional diagnostic tool. Copyright © 2014 Elsevier B.V. All rights reserved.

[Combined surgical and physical treatment in traumatic painful syndromes of the cervical spine].

PubMed

Stachowski, B; Kaczmarek, J; Nosek, A; Kocur, L

1976-01-01

Clinical observations suggest the need for changing therapeutic management to a more active one in cases of cervical spine injury with damage to the spinal cord and nerve roots or brachial plexus. In 248 patients with these injuries treated initially conservatively the incidence of cervicobrachial pain was analysed. Neuralgic pains were present in 31.5% of cases, causalgic pains in 2.4% and sympathalgic pains in 2%. Conservative treatment conducted in these patients (89 cases) during many months after trauma had no effect on return of mobility. Long-term application of physioterapy prevented only temporarily the development of trophic changes and only partially relieved pains. Only surgical decompression of the spinal cord or spinal nerves with stabilization of damaged vertebrae caused disappearance of painful syndromes and improvement in the motor activity of the extremities. These observations show that early surgical intervention for decompression of the spinal cord, roots or brachial plexus should be advocated in these cases.

The scalene reflex: relationship between increased median or ulnar nerve pressure and scalene muscle activity.

PubMed

Monsivais, J J; Sun, Y; Rajashekhar, T P

1995-07-01

Neck pain, headaches, upper thoracic pain, and dystonic scalene muscles are common findings in patients who have severe entrapment neuropathies of the upper extremities. This problem was taken to the laboratory in an attempt to discover the correlation between distal entrapment neuropathies, brachial plexus entrapments, and prominent scalenus muscles. When increased pressure (over 40 mmHg) was applied to the median and ulnar nerves in the forelimbs of eight goats, increased electromyographic activity was noted in the ipsilateral scalenus muscle. Pressures ranging from 100 to 150 mmHg caused increased electromyographic activity on the contralateral scalene muscle, and the authors postulate that it is mediated by the gamma afferent and efferent system. This relationship may explain the commonly found neck pain and muscle spasm in patients with peripheral neuropathies, and it represents a link between the somatic efferent nerves and the gamma motor neuron system. At present, the same phenomenon has been documented in 30 humans with the diagnosis of brachial plexus entrapment.

HRV analysis in local anesthesia using Continuous Wavelet Transform (CWT).

PubMed

Shafqat, K; Pal, S K; Kumari, S; Kyriacou, P A

2011-01-01

Spectral analysis of Heart Rate Variability (HRV) is used for the assessment of cardiovascular autonomic control. In this study Continuous Wavelet Transform (CWT) has been used to evaluate the effect of local anesthesia on HRV parameters in a group of fourteen patients undergoing axillary brachial plexus block. A new method which takes signal characteristics into account has been presented for the estimation of the variable boundaries associated with the low and the high frequency band of the HRV signal. The variable boundary method might be useful in cases when the power related to respiration component extends beyond the traditionally excepted range of the high frequency band (0.15-0.4 Hz). The statistical analysis (non-parametric Wilcoxon signed rank test) showed that the LF/HF ratio decreased within an hour of the application of the brachial plexus block compared to the values fifteen minutes prior to the application of the block. These changes were observed in thirteen of the fourteen patients included in this study.

Mechanisms of 5-aminolevulinic acid uptake at the choroid plexus.

PubMed

Novotny, A; Xiang, J; Stummer, W; Teuscher, N S; Smith, D E; Keep, R F

2000-07-01

5-Aminolevulinic acid (5-ALA) is a precursor of porphyrins and heme that has been implicated in the neuropsychiatric symptoms associated with porphyrias. It is also being used clinically to delineate malignant gliomas. The blood-CSF barrier may be an important interface for 5-ALA transport between blood and brain as in vivo studies have indicated 5-ALA is taken up by the choroid plexuses whereas the normal blood-brain barrier appears to be relatively impermeable. This study examines the mechanisms of 5-[(3)H]ALA uptake into isolated rat lateral ventricle choroid plexuses. Results suggest that there are two uptake mechanisms. The first was a Na(+)-independent uptake system that was pH dependent (being stimulated at low pH). Uptake was inhibited by the dipeptide Gly-Gly and by cefadroxil, an alpha-amino-containing cephalosporin. These properties are the same as the proton-dependent peptide transporters PEPT1 and PEPT2, which have recently been shown to transport 5-ALA in frog oocyte expression experiments. Choroid plexus uptake was not inhibited by captopril, a PEPT1 inhibitor, suggesting PEPT2-mediated uptake. The presence of PEPT2 and absence of PEPT1 in the choroid plexus were confirmed by western blotting. The second potential mechanism was both Na(+) and HCO(3)(-) dependent and appears to be an organic anion transporter, although it is possible that removal of Na(+) and HCO(3)(-) may indirectly affect PEPT2 by affecting intracellular pH. The presence of PEPT2 and a putative Na(+)/HCO(3)(-)-dependent organic anion transporter is important not only for an understanding of 5-ALA movement between blood and brain but also because these transporters may affect the distribution of a number of drugs between blood and CSF.

Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District.

PubMed

Ng'anjo Phiri, Selia; Fylkesnes, Knut; Moland, Karen Marie; Byskov, Jens; Kiserud, Torvid

2016-01-01

Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district. A cross-sectional survey was conducted in 2011 as part of the 'Response to Accountable priority setting for Trust in health systems' (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas. A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71-75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60-2.71%) than in rural areas 0.4% (95% CI 0.27-0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55-8.76). Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

Transmigration of macrophages across the choroid plexus epithelium in response to the feline immunodeficiency virus

PubMed Central

Meeker, Rick B.; Bragg, D. C.; Poulton, Winona; Hudson, Lola

2013-01-01

Although lentiviruses such as human, feline and simian immunodeficiency viruses (HIV, FIV, SIV) rapidly gain access to cerebrospinal fluid (CSF), the mechanisms that control this entry are not well understood. One possibility is that the virus may be carried into the brain by immune cells that traffic across the blood–CSF barrier in the choroid plexus. Since few studies have directly examined macrophage trafficking across the blood–CSF barrier, we established transwell and explant cultures of feline choroid plexus epithelium and measured trafficking in the presence or absence of FIV. Macrophages in co-culture with the epithelium showed significant proliferation and robust trafficking that was dependent on the presence of epithelium. Macrophage migration to the apical surface of the epithelium was particularly robust in the choroid plexus explants where 3-fold increases were seen over the first 24 h. Addition of FIV to the cultures greatly increased the number of surface macrophages without influencing replication. The epithelium in the transwell cultures was also permissive to PBMC trafficking, which increased from 17 to 26% of total cells after exposure to FIV. Thus, the choroid plexus epithelium supports trafficking of both macrophages and PBMCs. FIV significantly enhanced translocation of macrophages and T cells indicating that the choroid plexus epithelium is likely to be an active site of immune cell trafficking in response to infection. PMID:22281685

True Brachial Artery Aneurysm in a Patient with Vascular Access for Haemodialysis and Kidney Graft.

PubMed

Correia, Mafalda; Marinho, André; Mendes, Carolina; Antunes, Luís; Gonçalves, Óscar

2017-01-01

True brachial artery aneurysms are rare and some of them have been described as a late complication in patients with vascular access for haemodialysis and kidney graft. The purpose of this paper is to present a clinical case of a patient with a true brachial artery aneurysm and its following treatment. This case concerns a caucasian male patient with 43 years old who had vesicoureteral reflux at 7 years old, and subsequent end-stage renal disease, and started on haemodialysis at the age of twelve. The patient had homolateral radial and brachiocephalic arteriovenous fistulas (AVF), two sequential kidney grafts and was under immunosuppressant therapy for several years. As part of the medical history he also had bilateral amaurosis, Hepatitis B and C and was submitted to total parathyroidectomy and a following auto-transplant. In the latest years the patient presented with several aneurysms related to the vascular access. After the finding of an anastomotic false aneurysm and venous aneurysms complicating the AVF, the patient had removal of the aneurysms and ligation of the AVF. Later, he was diagnosed, in different times, with two true brachial artery aneurysms. At the time of the diagnosis of the first true aneurysm, the patient presented with local pain and occasional paraesthesias relative to compression symptoms. At physical examination the patient had a brachial pulsatile mass and a palpable radial pulse. The Doppler ultrasound exam revealed a true brachial artery aneurysm with 4,5 cm diameter. After two years, the patient was once again diagnosed with a true brachial artery aneurysm with 3,1 cm diameter. At this time the patient was asymptomatic and had palpable brachial mass and radial pulse. At the time of the diagnosis of the first true brachial aneurysm the patient was submitted to partial aneurysmectomy and brachiobrachial graft with PTFE 8. The patency of the graft persisted until the diagnosis of the second aneurysm. After two years, the patient was

Swelling in the upper arm: the presentation and management of an isolated brachial artery aneurysm

PubMed Central

Alagaratnam, S; Lau, T; Munro, M; Loh, A

2011-01-01

True aneurysms of the brachial artery are uncommon. We describe the presentation and surgical management of an isolated, brachial artery aneurysm in a 64-year-old woman. Excision of the aneurysm and long saphenous venous interposition grafting was performed with no postoperative complications and histology demonstrated true aneurysmal degeneration. PMID:21943445

Pathological Alteration in the Choroid Plexus of Alzheimer’s Disease: Implication for New Therapy Approaches

PubMed Central

Krzyzanowska, Agnieszka; Carro, Eva

2012-01-01

Morphological alterations of choroid plexus in Alzheimer’s disease (AD) have been extensively investigated. These changes include epithelial atrophy, thickening of the basement membrane, and stroma fibrosis. As a result, synthesis, secretory, and transportation functions are significantly altered resulting in decreased cerebrospinal fluid (CSF) turnover. Recent studies discuss the potential impacts of these changes, including the possibility of reduced resistance to stress insults and slow clearance of toxic compounds from CSF with specific reference to the amyloid peptide. Here, we review new evidences for AD-related changes in the choroid plexus. The data suggest that the significantly altered functions of the choroid plexus contribute to the multiparametric pathogenesis of late-onset AD. PMID:22563316

Echogenicity and ultrasound visibility of peripheral nerves of the upper extremity.

PubMed

Stolz, Lori A; Acuna, Josie Galarza; Gaskin, Kevin; Murphy, Amanda M; Friedman, Lucas; Stears-Ellis, Summer; Javedani, Parisa; Stolz, Uwe; Adhikari, Srikar

2018-05-02

Regional anesthesia with ultrasound-guidance is an excellent option for pain control if nerves are adequately visualized. Gender, body mass index (BMI), history of diabetes, neck and forearm circumference may affect echotexture and visualization. This study evaluates patient characteristics for their ability to predict the echogenicity or visibility of upper extremity peripheral nerves. This is a prospective observational study. A convenience sample of adult emergency department patients were enrolled. Gender, BMI, history of diabetes, neck circumference and arm circumference were recorded. Sonographic images of the brachial plexus at interscalene and supraclavicular levels, the median, the radial and ulnar nerves were recorded. Three reviewers independently graded the echogenicity and visibility using subjective scales. 395 peripheral nerves were included. Nerves of the forearm (median, ulnar, radial nerves) were found to be more echogenic (OR=9.3; 95% CI: 5.7, 15.3) and visible (OR=10.0; 6.3, 16.0) than more proximal nerves (brachial plexus at interscalene and supraclavicular levels). Gender, BMI, and history of diabetes mellitus were not significantly related to nerve visibility (p=0.9, 0.2, 0.2, respectively) or echogenicity (p=0.3, 0.8, 0.3). Neck circumference was not related to visibility or echogenicity of proximal nerves. Increased forearm circumference improved echogenicity (OR=1.25; 1.09, 1.43) but not visibility of forearm nerves. Gender, BMI and presence of diabetes were not related to echogenicity or visibility of upper extremity nerves. Increasing forearm circumference was associated with increased echogenicity of the adjacent nerves, but not visibility. Neck circumference was not associated with either nerve visibility or echogenicity of brachial plexus nerve bundles.

Shoulder dystocia in diabetic and non-diabetic pregnancies.

PubMed

Malinowska-Polubiec, Aneta; Romejko-Wolniewicz, Ewa; Szostak, Oksana; Dobrowolska-Redo, Agnieszka; Tolloczko, Justyna; Zareba-Szczudlik, Julia; Smolarczyk, Roman; Czajkowski, Krzysztof

2014-01-01

Shoulder dystocia remains an obstetric emergency. Maternal diabetes is considered to be one of the major risk factors for shoulder dystocia. The aim of this study was to analyze antepartum and peripartum risk factors and complications of shoulder dystocia in diabetic and non-diabetic women. We performed a retrospective analysis of 48 shoulder dystocia cases out of 28,485 vaginal deliveries of singleton, live-born infants over a 13 year period: 13 cases were diagnosed in diabetic women and 35 cases in non-diabetic women. The study was conducted in the 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, Poland, from January 2000 to December 2012. Compared to non-diabetic women, diabetic patients had significantly higher pre-pregnancy body weight (83.4±23.8 kg vs. 62.5±10.9 kg, p=0.002), higher pre-pregnancy BMI (30.2±6.8 kg/m2 vs. 22.9±4.3 kg/m2, p=0.0003), and lower gestational weight gain (11.4±6.2 kg vs. 16.0±4.7 kg, p=0.01). Diabetic women with shoulder dystocia were more likely to deliver before completion of the 38th week of gestation (30.8% vs. 5.7%, p=0.02) and had a higher incidence of 1st and 2nd stage perineal tears compared with the non-diabetic group (23.1% vs. 0%, p=0.02). There were two cases of symphysis pubis dehiscence in non-diabetic women. Children of diabetic mothers had a significantly higher birth weight (4,425.4±561.6 g vs. 4,006.9±452.8 g, p=0.03). Children of diabetic mothers with dystocia were at significantly higher risk of peripartum injuries (92.3% vs. 45.7%). A significant difference was observed in the percentage of brachial plexus palsy (61.5% vs. 17.1%). Children of diabetic women experiencing shoulder dystocia were more frequently affected by Erb's brachial plexus palsy and respiratory disturbances. These children had an increased likelihood of birth weights above the 90th percentile (not necessarily reaching 4,000 g) compared to children born to non-diabetic mothers. Shoulder dystocia in women with

Comparison of two automatic methods for the assessment of brachial artery flow-mediated dilation.

PubMed

Faita, Francesco; Masi, Stefano; Loukogeorgakis, Stavros; Gemignani, Vincenzo; Okorie, Mike; Bianchini, Elisabetta; Charakida, Marietta; Demi, Marcello; Ghiadoni, Lorenzo; Deanfield, John Eric

2011-01-01

Brachial artery flow-mediated dilation (FMD) is associated with risk factors providing information on cardiovascular prognosis. Despite the large effort to standardize the methodology, the FMD examination is still characterized by problems of reproducibility and reliability that can be partially overcome with the use of automatic systems. We developed real-time software for the assessment of brachial FMD (FMD Studio, Institute of Clinical Physiology, Pisa, Italy) from ultrasound images. The aim of this study is to compare our system with another automatic method (Brachial Analyzer, MIA LLC, IA, USA) which is currently considered as a reference method in FMD assessment. The agreement between systems was assessed as follows. Protocol 1: Mean baseline (Basal), maximal (Max) brachial artery diameter after forearm ischemia and FMD, calculated as maximal percentage diameter increase, have been evaluated in 60 recorded FMD sequences. Protocol 2: Values of diameter and FMD have been evaluated in 618 frames extracted from 12 sequences. All biases are negligible and standard deviations of the differences are satisfactory (protocol 1: -0.27 ± 0.59%; protocol 2: -0.26 ± 0.61%) for FMD measurements. Analysis times were reduced (-33%) when FMD Studio is used. Rejected examinations due to the poor quality were 2% with the FMD Studio and 5% with the Brachial Analyzer. In conclusion, the compared systems show a optimal grade of agreement and they can be used interchangeably. Thus, the use of a system characterized by real-time functionalities could represent a referral method for assessing endothelial function in clinical trials.

Comparison of brachial artery vasoreactivity in elite power athletes and age-matched controls.

PubMed

Welsch, Michael A; Blalock, Paul; Credeur, Daniel P; Parish, Tracie R

2013-01-01

Elite endurance athletes typically have larger arteries contributing to greater skeletal muscle blood flow, oxygen and nutrient delivery and improved physical performance. Few studies have examined structural and functional properties of arteries in power athletes. To compare the size and vasoreactivity of the brachial artery of elite power athletes to age-matched controls. It was hypothesized brachial artery diameters of athletes would be larger, have less vasodilation in response to cuff occlusion, but more constriction after a cold pressor test than age-matched controls. Eight elite power athletes (age = 23 ± 2 years) and ten controls (age = 22 ± 1 yrs) were studied. High-resolution ultrasonography was used to assess brachial artery diameters at rest and following 5 minutes of forearm occlusion (Brachial Artery Flow Mediated Dilation = BAFMD) and a cold pressor test (CPT). Basic fitness measures included a handgrip test and 3-minute step test. Brachial arteries of athletes were larger (Athletes 5.39 ± 1.51 vs. 3.73 ± 0.71 mm, p<0.05), had greater vasodilatory (BAFMD%: Athletes: 8.21 ± 1.78 vs. 5.69 ± 1.56%) and constrictor (CPT %: Athletes: -2.95 ± 1.07 vs. -1.20 ± 0.48%) responses, compared to controls. Vascular operating range (VOR = Peak dilation+Peak Constriction) was also greater in athletes (VOR: Athletes: 0.55 ± 0.15 vs. 0.25 ± 0.18 mm, p<0.05). Athletes had superior handgrip strength (Athletes: 55.92 ± 17.06 vs. 36.77 ± 17.06 kg, p<0.05) but similar heart rate responses at peak (Athletes: 123 ± 16 vs. 130 ± 25 bpm, p>0.05) and 1 minute recovery (Athletes: 88 ± 21 vs. 98 ± 26 bpm, p>0.05) following the step test. Elite power athletes have larger brachial arteries, and greater vasoreactivity (greater vasodilatory and constrictor responses) than age-matched controls, contributing to a significantly greater VOR. These data extend the existence of an 'athlete's artery' as previously shown for elite endurance athletes to elite power athletes

Brachial-Ankle PWV: Current Status and Future Directions as a Useful Marker in the Management of Cardiovascular Disease and/or Cardiovascular Risk Factors.

PubMed

Tomiyama, Hirofumi; Matsumoto, Chisa; Shiina, Kazuki; Yamashina, Akira

2016-01-01

Since 2001, brachial-ankle pulse wave velocity (brachial-ankle PWV) measurement has been applied for risk stratification of patients with atherosclerotic cardiovascular disease and/or its risk factors in Japan. Measurement of the brachial-ankle PWV is simple and well standardized, and its reproducibility and accuracy are acceptable. Several cross-sectional studies have demonstrated a significant correlation between the brachial-ankle PWV and known risk factors for cardiovascular disease; the correlation is stronger in subjects with cardiovascular disease than in those without cardiovascular disease. We conducted a meta-analysis, which demonstrated that the brachial-ankle PWV is an independent predictor of future cardiovascular events. Furthermore, the treatment of cardiovascular risk factors and lifestyle modifications have been shown to improve the brachial-ankle PWV. Thus, at present, brachial-ankle PWV is close to being considered as a useful marker in the management of atherosclerotic cardiovascular disease and/or its risk factors.

21 CFR 884.5100 - Obstetric anesthesia set.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Obstetric anesthesia set. 884.5100 Section 884.5100 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES OBSTETRICAL AND GYNECOLOGICAL DEVICES Obstetrical and Gynecological Therapeutic Devices...

21 CFR 884.5100 - Obstetric anesthesia set.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Obstetric anesthesia set. 884.5100 Section 884.5100 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES OBSTETRICAL AND GYNECOLOGICAL DEVICES Obstetrical and Gynecological Therapeutic Devices...

21 CFR 884.5100 - Obstetric anesthesia set.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Obstetric anesthesia set. 884.5100 Section 884.5100 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES OBSTETRICAL AND GYNECOLOGICAL DEVICES Obstetrical and Gynecological Therapeutic Devices...

Exercise during pregnancy: the role of obstetric providers.

PubMed

May, Linda E; Suminski, Richard R; Linklater, Emily R; Jahnke, Sara; Glaros, Alan G

2013-08-01

Obstetric providers are logical choices for conveying information about physical activity to their pregnant patients. However, research regarding obstetric providers counseling pregnant patients about physical activity is sparse. To investigate the association between obstetric providers discussing exercise with their pregnant patients and patients' exercise behaviors and to explore factors related to obstetric providers discussing exercise and other health behaviors (tobacco use, alcohol use, and nutrition) with their patients. We received completed surveys from 238 pregnant women and 31 obstetric providers at 12 obstetrician offices. The offices were located throughout the United States and were heterogeneous in regards to patient insurance coverage, number of patients treated per month, and percentage of patients with complications. Women who were "more careful about eating healthy" (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.2-8.0) and who discussed exercise with their obstetric provider (OR, 2.2; 95% CI, 1.1-4.3) were more likely to "maintain or increase exercise" during pregnancy than those who were not conscientious about their diets and those who did not discuss exercise with their obstetric provider, respectively. The odds of obstetric providers discussing exercise with pregnant patients increased 7-fold (OR, 7.1; 95% CI, 1.4-37.3) for each health behavior the obstetric provider discussed with the patient. Patient discussions with obstetric providers about exercise and patient attention to eating habits are associated with exercising during pregnancy. A more multibehavioral approach by obstetric providers may improve the likelihood that patients exercise during pregnancy.

A pilot study of the relationship between Doppler-estimated carotid and brachial artery flow and cardiac index.

PubMed

Weber, U; Glassford, N J; Eastwood, G M; Bellomo, R; Hilton, A K

2015-10-01

We measured carotid and brachial artery blood flow by Doppler ultrasound in 11 human volunteers, and related these to cardiac index and to each other. The median (IQR [range]) carotid arterial blood flow was 0.334 (0.223-0.381 [0.052-0.563]) l.min(-1) on the right and 0.315 (0.223-0.369 [0.061-0.690]) l.min(-1) on the left. The brachial arterial blood flow was 0.049 (0.033-0.062 [0.015-0.204]) l.min(-1) on the right and 0.039 (0.027-0.054 [0.011-0.116]) on the left. Cardiac index was 3.2 (2.8-3.5 [1.9-5.4]) l.min(-1) .m(-2) . There was a moderate to good correlation between right-and left-sided flows (brachial: ρ = 0.45; carotid: ρ = 0.567). Brachial and carotid flow had no or a negative correlation with cardiac index (right brachial: ρ = -0.145, left brachial: ρ = -0.349; right carotid: ρ = -0.376, left carotid: ρ = -0.285). In contrast to some previous studies, we found that Doppler-estimated peripheral arterial blood flows only show a weak correlation with cardiac index and cannot be used to provide non-invasive estimates of cardiac index in man. © 2015 The Association of Anaesthetists of Great Britain and Ireland.

Bilateral transit time assessment of upper and lower limbs as a surrogate ankle brachial index marker.

PubMed

Foo, Jong Yong Abdiel

2008-01-01

Ankle brachial index is useful in monitoring the pathogenesis of peripheral arterial occlusive diseases. Sphygmomanometer is the standard instrument widely used but frequent prolonged monitoring can be less comfortable for patients. Pulse transit time is known to be inversely correlated with blood pressure and a ratio-based pulse transit time measurement has been proposed as a surrogate ankle brachial index marker. In this study, 17 normotensive adults (9 men; aged 25.4 +/- 3.9 years) were recruited. Two postural change test activities were performed to induce changes in the stiffness of the arterial wall of the moved periphery. Results showed that only readings from the limbs that adopted a new posture registered significant blood pressure and pulse transit time changes (P < .05). Furthermore, there was significant correlation between the ankle brachial index and pulse transit time ratio measure for both test activities (R(2) > or = 0.704). The findings herein suggest that pulse transit time ratio is a surrogate and accommodating ankle brachial index marker.

Association of the Duration of Active Pushing With Obstetric Outcomes.

PubMed

Grobman, William A; Bailit, Jennifer; Lai, Yinglei; Reddy, Uma M; Wapner, Ronald J; Varner, Michael W; Caritis, Steve N; Prasad, Mona; Tita, Alan T N; Saade, George; Sorokin, Yoram; Rouse, Dwight J; Blackwell, Sean C; Tolosa, Jorge E

2016-04-01

To estimate the associations between the duration of active pushing during the second stage of labor and maternal and neonatal outcomes. We performed an observational study in which data were obtained by trained abstractors from maternal and neonatal charts of deliveries at 25 hospitals over a 3-year period. In this secondary analysis, women with no prior cesarean delivery who had a term, singleton, cephalic gestation and reached complete dilation were analyzed. The duration of pushing, defined as the time from initiation of pushing to either vaginal delivery or the decision to proceed with a cesarean delivery, was determined. The primary maternal outcome was cesarean delivery and the primary neonatal outcome was a composite that included: mechanical ventilation, proven sepsis, brachial plexus palsy, clavicular fracture, skull fracture, other fracture, seizures, hypoxic-ischemic encephalopathy, or death. Nulliparous and parous women were analyzed separately in univariable and then multivariable analyses. A total of 53,285 women were analyzed. In both nulliparous and parous women, longer duration of pushing was associated with increased odds of both cesarean delivery and the neonatal adverse outcome composite. Nevertheless, even after 4 hours of pushing, approximately 78% of nulliparous women who continued with active pushing had a vaginal delivery and more than 97% did not have the composite adverse neonatal outcome. Similarly, after more than 2 hours of pushing, approximately 82% of parous women who continued active pushing delivered vaginally and more than 97% did not have the adverse neonatal outcome. A longer duration of pushing is associated with an increased relative risk, but small absolute difference in risk, of neonatal complications. Approximately 78% of nulliparous women delivered vaginally even after 4 hours of pushing.

Composite redesign of obstetrical forceps

NASA Technical Reports Server (NTRS)

Lawson, Seth W.; Smeltzer, Stan S.

1994-01-01

Due to the increase in the number of children being born recently, medical technology has struggled to keep pace in certain areas. In these areas, particular needs have arisen to which the subject of this paper is directed. In the area of obstetrics, the forceps design and function has remained relatively unchanged for a number of years. In an effort to advance the technology, NASA Marshall Space Flight Center has been asked by the obstetrical community to help in a redesign of the obstetric forceps. Traditionally the forceps design has been of tubular stainless steel, constructed in two halves which interlock and hinge to provide the gripping force necessary to aid in the delivery of an infant. The stainless steel material was used to provide for ease of cleaning and sterilization. However, one of the drawbacks of the non-flexible steel design is that excessive force can be placed upon an infants head which could result in damage or injury to the infant. The redesign of this particular obstetric tool involves applying NASA's knowledge of advanced materials and state of the art instrumentation to create a tool which can be used freely throughout the obstetrics community without the fear of injury to an infant being delivered.

Rehabilitation of brachial plexus and peripheral nerve disorders.

PubMed

Scott, Kevin R; Ahmed, Aiesha; Scott, Linda; Kothari, Milind J

2013-01-01

Peripheral nerve lesions are common and can present in a variety of ways. Peripheral nerve injury can result from a broad spectrum of causes. For the majority of patients, rehabilitation is generally indicated regardless of etiology. Evaluation and treatment by a multidisciplinary team including neurologists, psychiatrists, surgeons, occupational and physical therapists, and therapists with specialized training in orthotics maximizes the potential for recovery. This chapter will focus on those upper and lower extremity neuropathies that are most commonly seen in clinical practice. In addition, we discuss various rehabilitative strategies designed to improve function and quality of life. Copyright © 2013 Elsevier B.V. All rights reserved.

Association of left ventricular structural and functional abnormalities with aortic and brachial blood pressure variability in hypertensive patients: the SAFAR study.

PubMed

Chi, C; Yu, S-K; Auckle, R; Argyris, A A; Nasothimiou, E; Tountas, C; Aissopou, E; Blacher, J; Safar, M E; Sfikakis, P P; Zhang, Y; Protogerou, A D

2017-10-01

Both brachial blood pressure (BP) level and its variability (BPV) significantly associate with left ventricular (LV) structure and function. Recent studies indicate that aortic BP is superior to brachial BP in the association with LV abnormalities. However, it remains unknown whether aortic BPV better associate with LV structural and functional abnormalities. We therefore aimed to investigate and compare aortic versus brachial BPV, in terms of the identification of LV abnormalities. Two hundred and three participants who underwent echocardiography were included in this study. Twenty-four-hour aortic and brachial ambulatory BP was measured simultaneously by a validated BP monitor (Mobil-O-Graph, Stolberg, Germany) and BPV was calculated with validated formulae. LV mass and LV diastolic dysfunction (LVDD) were evaluated by echocardiography. The prevalence of LV hypertrophy (LVH) and LVDD increased significantly with BPV indices (P⩽0.04) in trend tests. After adjustment to potential confounders, only aortic average real variability (ARV), but not brachial ARV or weighted s.d. (wSD, neither aortic nor brachial) significantly associated with LV mass index (P=0.02). Similar results were observed in logistic regression. After adjustment, only aortic ARV significantly associated with LVH (odds ratio (OR) and 95% confidence interval (CI): 2.28 (1.08, 4.82)). As for LVDD, neither the brachial nor the aortic 24-hour wSD, but the aortic and brachial ARV, associated with LVDD significantly, with OR=2.28 (95% CI: (1.03, 5.02)) and OR=2.36 (95% CI: (1.10, 5.05)), respectively. In summary, aortic BPV, especially aortic ARV, seems to be superior to brachial BPV in the association of LV structural and functional abnormalities.

21 CFR 884.5100 - Obstetric anesthesia set.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Obstetric anesthesia set. 884.5100 Section 884... § 884.5100 Obstetric anesthesia set. (a) Identification. An obstetric anesthesia set is an assembly of... anesthetic drug. This device is used to administer regional blocks (e.g., paracervical, uterosacral, and...

21 CFR 884.5100 - Obstetric anesthesia set.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Obstetric anesthesia set. 884.5100 Section 884... § 884.5100 Obstetric anesthesia set. (a) Identification. An obstetric anesthesia set is an assembly of... anesthetic drug. This device is used to administer regional blocks (e.g., paracervical, uterosacral, and...

[Prophylactic plexus catheter treatment in operations following complex regional pain syndrome (CRPS)].

PubMed

Neubrech, Florian; Pronk, Roderick Franciscus; Bigdeli, Amir Khosrow; Tapking, Christian; Kneser, Ulrich; Harhaus, Leila

2017-08-01

Background  This paper investigates and discusses the effect of perioperative plexus catheter treatment in former CRPS patients. Patients and Methods A retrospective matched-pair analysis was conducted on 10 CRPS patients with comparable injuries, who underwent surgery in the disease-free interval. In 10 cases, the procedure was performed with perioperative plexus catheter treatment (intervention group), whereas 10 patients did not receive perioperative plexus catheter treatment (control group). Results  In the intervention group, after a follow-up time of 105 (20-184) days after the last surgical procedure, pain intensity on the visual analogue scale (VAS; 0 to 10) was 6.4 (4-8), fingertip-to-palm distance averaged 3.2 (0-7.6) cm, active range of wrist motion was 47.5 (0-95), and grip strength was 9.2 (2.1-16.6) kg. In the control group, after a follow-up time of 129 (19-410) days since the last surgical procedure, pain intensity on the visual analogue scale was 6 (3-10), fingertip-to-palm distance averaged 2.7 (0-4.5) cm, active range of wrist-motion was 64 (0-125), and grip strength was 12.4 (0.8-23.8) kg. There was no significant difference between the groups. There was no recurrence of CRPS disease in either group after surgery. Conclusion  There is no evidence so far for perioperative plexus catheter treatment to prevent recurrence in former CRPS patients. Georg Thieme Verlag KG Stuttgart · New York.

21 CFR 884.2050 - Obstetric data analyzer.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Obstetric data analyzer. 884.2050 Section 884.2050... § 884.2050 Obstetric data analyzer. (a) Identification. An obstetric data analyzer (fetal status data analyzer) is a device used during labor to analyze electronic signal data obtained from fetal and maternal...

21 CFR 884.2050 - Obstetric data analyzer.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Obstetric data analyzer. 884.2050 Section 884.2050... § 884.2050 Obstetric data analyzer. (a) Identification. An obstetric data analyzer (fetal status data analyzer) is a device used during labor to analyze electronic signal data obtained from fetal and maternal...

21 CFR 884.2050 - Obstetric data analyzer.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Obstetric data analyzer. 884.2050 Section 884.2050... § 884.2050 Obstetric data analyzer. (a) Identification. An obstetric data analyzer (fetal status data analyzer) is a device used during labor to analyze electronic signal data obtained from fetal and maternal...

21 CFR 884.2050 - Obstetric data analyzer.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Obstetric data analyzer. 884.2050 Section 884.2050... § 884.2050 Obstetric data analyzer. (a) Identification. An obstetric data analyzer (fetal status data analyzer) is a device used during labor to analyze electronic signal data obtained from fetal and maternal...

Ultrasound-guided fine needle aspiration in the diagnosis of peripheral nerve sheath tumors in 4 dogs

PubMed Central

da Costa, Ronaldo C.; Parent, Joane M.; Dobson, Howard; Ruotsalo, Kristiina; Holmberg, David; Duque, M. Carolina; Poma, Roberto

2008-01-01

Ultrasound-guided fine needle aspiration was used in establishing the diagnosis in 4 cases of malignant peripheral nerve sheath tumor. Sonographic and cytologic characteristics are discussed. Because of its availability and ease of use, axillary ultrasonography with fine needle aspiration can be an initial diagnostic step for suspected brachial plexus tumors. PMID:18320983

Is Personalized Medicine Achievable in Obstetrics?

PubMed Central

Quinney, Sara K; Flockhart, David A; Patil, Avinash S

2014-01-01

Personalized medicine seeks to identify the right dose of the right drug for the right patient at the right time. Typically, individualization of therapy is based on the pharmacogenomic make-up of the individual and environmental factors that alter drug disposition and response. In addition to these factors, during pregnancy a woman’s body undergoes many changes that can impact the therapeutic efficacy of medications. Yet, there is minimal research regarding personalized medicine in obstetrics. Adoption of pharmacogenetic testing into the obstetrical care is dependent on evidence of analytical validity, clinical validity, and clinical utility. Here, we briefly present information regarding the potential utility of personalized medicine for treating the obstetric patient for pain with narcotics, hypertension, and preterm labor and discuss the impediments of bringing personalized medicine to the obstetrical clinic. PMID:25282474

Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES): Promoting Patient Safety in Obstetrics with Teamwork-Focused Interprofessional Simulations

ERIC Educational Resources Information Center

Freeth, Della; Ayida, Gubby; Berridge, Emma Jane; Mackintosh, Nicola; Norris, Beverley; Sadler, Chris; Strachan, Alasdair

2009-01-01

Introduction: We describe an example of simulation-based interprofessional continuing education, the multidisciplinary obstetric simulated emergency scenarios (MOSES) course, which was designed to enhance nontechnical skills among obstetric teams and, hence, improve patient safety. Participants' perceptions of MOSES courses, their learning, and…

Relationship of the lumbar plexus branches to the lumbar spine: anatomical study with application to lateral approaches.

PubMed

Tubbs, Richard Isaiah; Gabel, Brandon; Jeyamohan, Shiveindra; Moisi, Marc; Chapman, Jens R; Hanscom, R David; Loukas, Marios; Oskouian, Rod J; Tubbs, Richard Shane

2017-07-01

Injuries to the lumbar plexus during lateral approaches to the spine are not uncommon and may result in permanent deficits. However, the literature contains few studies that provide landmarks for avoiding the branches of the lumbar plexus. The present anatomical study was performed to elucidate the course of these nerves in relation to lateral approaches to the lumbar spine. This is a quantitative anatomical cadaveric study. The lumbar plexus and its branches were dissected on 12 cadaveric sides. Metal wires were laid on the nerves along their paths on the posterior abdominal wall. Fluoroscopy was performed in the anteroposterior and lateral positions. The relationships between regional bony landmarks and the branches of the lumbar plexus were observed. When viewed laterally, the greatest concentration of nerves occurred from the posteroinferior aspect of L4, inferior along the posterior one-third of the body of L5, then at the level of the sacral promontory. On the basis of our study, approaches to the anterior two-thirds of the L4 vertebra and anterior third of L5 will result in the lowest chance of lumbar plexus nerve injury. In addition, lateral muscle dissection through the psoas major should be in a superior to inferior direction in order to minimize nerve injury. Laterally, the widest corridor between branches in the abdominal wall was between the subcostal and iliohypogastric nerves. The findings of our cadaveric study provide surgeons who approach the lateral lumbar spine with data that could decrease injuries to the branches of the lumbar plexus, thus lessening patient morbidity. Copyright © 2017 Elsevier Inc. All rights reserved.

Vascular entrapment of the sciatic plexus causing catamenial sciatica and urinary symptoms.

PubMed

Lemos, Nucelio; Marques, Renato Moretti; Kamergorodsky, Gil; Ploger, Christine; Schor, Eduardo; Girão, Manoel J B C

2016-02-01

Pelvic congestion syndrome is a well-known cause of cyclic pelvic pain (Ganeshan et al., Cardiovasc Intervent Radiol 30(6):1105-11, 2007). What is much less well known is that dilated or malformed branches of the internal or external iliac vessels can entrap the nerves of the sacral plexus against the pelvic sidewalls, producing symptoms that are not commonly seen in gynecological practice, such as sciatica, or refractory urinary and anorectal dysfunction (Possover et al., Fertil Steril 95(2):756-8. 2011). The objective of this video is to explain and describe the symptoms suggestive of vascular entrapment of the sacral plexus, as well as the technique for the laparoscopic decompression of these nerves. Two anecdotal cases of intrapelvic vascular entrapment are used to review the anatomy of the lumbosacral plexus and demonstrate the laparoscopic surgical technique for decompression at two different sites, one on the sciatic nerve and one on the sacral nerve roots. After surgery, the patient with the sciatic entrapment showed full recovery of the sciatica and partial recovery of the myofascial pain. The patient with sacral nerve root entrapment showed full recovery with resolution of symptoms. The symptoms suggestive of intrapelvic nerve entrapment are: perineal pain or pain irradiating to the lower limbs in the absence of a spinal disorder, and lower urinary tract symptoms in the absence of prolapse of a bladder lesion. In the presence of such symptoms, the radiologist should provide specific MRI sequences of the intrapelvic portion of the sacral plexus and a team and equipment to expose and decompress the sacral nerves should be prepared.

Migrants and obstetrics in Austria--applying a new questionnaire shows differences in obstetric care and outcome.

PubMed

Oberaigner, Willi; Leitner, Hermann; Oberaigner, Karin; Marth, Christian; Pinzger, Gerald; Concin, Hans; Steiner, Horst; Hofmann, Hannes; Wagner, Teresa; Mörtl, Manfred; Ramoni, Angela

2013-01-01

Immigration plays a major role in obstetrics in Austria, and about 18 % of the Austrian population are immigrants. Therefore, we aimed to (1) test the feasibility of a proposed questionnaire for assessment of migrant status in epidemiological research and (2) assess some important associations between procedures and outcomes in obstetrics and migration in selected departments in Austria. We adapted a standardized questionnaire to the main immigration groups in Austria. Information on country of origin, length of residence in Austria and German-language ability was collected from eight selected obstetrics departments. Of the 1,971 questionnaires, 1,873 questionnaires of singleton births were selected and included in the analysis. We analyzed a total of 1,873 parturients with singleton births, of which 35 % had migrant status, 12 % were from ex-Yugoslavia, 12 % were from Turkey, and 12 % were from other countries. The proportion of parturients having their first care visit after the 12th week of pregnancy was higher in migrant groups (19 %). Smoking was highest in the migrants from ex-Yugoslavia (21 %). Vaginal delivery was more frequent in migrants from ex-Yugoslavia (78 %) and Turkey (83 %) than in nonmigrants (71 %) and episiotomy was more frequently performed in migrants from other countries. All differences are statistically significant. Administration of a standardized questionnaire for assessment of migrant status in obstetric departments in Austria was shown to be feasible. We assessed differences in obstetric care and outcome and consequently recommend that action should be initiated in Austria toward harmonizing obstetric procedures among the migrant and the nonmigrant groups and toward minimizing risk factors.

Phrenic palsy and analgesic quality of continuous supraclavicular vs. interscalene plexus blocks after shoulder surgery.

PubMed

Wiesmann, T; Feldmann, C; Müller, H H; Nentwig, L; Beermann, A; El-Zayat, B F; Zoremba, M; Wulf, H; Steinfeldt, T

2016-09-01

Hemidiaphragmatic palsy is a common consequence of the interscalene brachial plexus block. It occurs less commonly with the supraclavicular approach. Register data suggest that the analgesic quality of a supraclavicular blockade is sufficient for arthroscopic shoulder surgery, although data on the post-operative analgesic effect are lacking. After approval by the ethics committee, patients having arthroscopic shoulder surgery under general anaesthesia were randomized to receive a continuous interscalene or supraclavicular blockade. Phrenic nerve function was evaluated through ultrasound examination of the diaphragm in combination with spirometry. Pain scores at rest and activity etc. were determined before catheter insertion, during observation in the post- anaesthesia care unit (PACU) and on post-operative day 1 (POD1). The initial application of 10 ml of ropivacaine 0.2% was followed by continuous application of 4 ml of ropivacaine 0.2%, plus a patient controlled analgesia (PCA) bolus of 4 ml/h. One hundred and twenty patients were randomized, of which 114 data sets were analysed. Complete hemidiaphragmatic paresis occurred in 43% of the interscalene group vs. 24% in the supraclavicular group during PACU stay. Rates of dyspnoea and hoarseness were similar. Horner's syndrome occurred in 21% of the interscalene but only 3% of the supraclavicular group on POD1. Pain scores were comparable for pain at rest and during stress at each time point. This trial showed a significantly greater incidence of phrenic nerve palsy of the interscalene group in PACU, but not on POD1. Post-operative analgesic quality was similar in both groups. Continuous supraclavicular blockade is a suitable alternative to the continuous interscalene technique. © 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Brachial artery endothelial function is unchanged after acute sprint interval exercise in sedentary men and women.

PubMed

Shenouda, Ninette; Skelly, Lauren E; Gibala, Martin J; MacDonald, Maureen J

2018-05-03

What is the central question of this study? What is the acute brachial artery endothelial function response to sprint interval exercise and are there sex-based differences? What is the main finding and its importance? Brachial artery endothelial function did not change in either men or women following an acute session of SIT consisting of 3 × 20 s 'all-out' cycling sprints. Our findings suggest this low-volume protocol may not be sufficient to induce functional changes in the brachial artery of sedentary, but otherwise healthy adults. Sprint interval training (SIT) is a potent metabolic stimulus, but studies examining its acute effects on brachial artery endothelial function are limited. The influence of oestradiol on the acute arterial response to this type of exercise is also unknown. We investigated the brachial artery endothelial function response to a single session of SIT in sedentary healthy men (n = 8; 22 ± 4 years) and premenopausal women tested in the mid-follicular phase of the menstrual cycle (n = 8; 21 ± 3 years). Participants performed 3 × 20 s 'all-out' cycling sprints interspersed with 2 min of active recovery. Brachial artery flow-mediated dilatation (FMD) and haemodynamic parameters were measured before and 1 and 24 h post-exercise. Despite attenuations in some haemodynamic parameters at 1 h post-exercise, there were no changes in absolute (P = 0.23), relative (P = 0.23) or allometrically scaled FMD (P = 0.38) following a single session of SIT. Resting and peak dilatory diameters did not change in men or women (P > 0.05 for all) and there were no interactions between time and sex for any measure (P > 0.05). Oestradiol was not correlated with relative FMD at baseline (r = -0.22, P = 0.42) or with the change in relative FMD from baseline to 1 h post-exercise (r = 0.24, P = 0.40). Overall, brachial artery FMD appears to be unchanged in men and women following an acute session of SIT, and the higher oestradiol

Is personalized medicine achievable in obstetrics?

PubMed

Quinney, Sara K; Patil, Avinash S; Flockhart, David A

2014-12-01

Personalized medicine seeks to identify the right dose of the right drug for the right patient at the right time. Typically, individualization of therapy is based on the pharmacogenomic makeup of the individual and environmental factors that alter drug disposition and response. In addition to these factors, during pregnancy, a woman's body undergoes many changes that can impact the therapeutic efficacy of medications. Yet, there is minimal research regarding personalized medicine in obstetrics. Adoption of pharmacogenetic testing into the obstetrical care is dependent on evidence of analytical validity, clinical validity, and clinical utility. Here, we briefly present information regarding the potential utility of personalized medicine for treating the obstetric patient for pain with narcotics, hypertension, and preterm labor, and discuss the impediments of bringing personalized medicine to the obstetrical clinic. Copyright © 2014 Elsevier Inc. All rights reserved.

Preterm birth by vacuum extraction and neonatal outcome: a population-based cohort study.

PubMed

Åberg, Katarina; Norman, Mikael; Ekéus, Cecilia

2014-01-22

Very few studies have investigated the neonatal outcomes after vacuum extraction delivery (VE) in the preterm period and the results of these studies are inconclusive. The objective of this study was to describe the use of VE for preterm delivery in Sweden and to compare rates of neonatal complications after preterm delivery by VE to those found after cesarean section during labor (CS) or unassisted vaginal delivery (VD). Data was obtained from Swedish national registers. In a population-based cohort from 1999 to 2010, all live-born, singleton preterm infants in a non-breech presentation at birth, born after onset of labor (either spontaneously, by induction, or by rupture of membranes) by VD, CS, or VE were included, leaving a study population of 40,764 infants. Logistic regression analyses were used to calculate adjusted odds ratios (AOR), using unassisted vaginal delivery as reference group. VE was used in 5.7% of the preterm deliveries, with lower rates in earlier gestations. Overall, intracranial hemorrhage (ICH) occurred in 1.51%, extracranial hemorrhage (ECH) in 0.64%, and brachial plexus injury in 0.13% of infants. Infants delivered by VE had higher risks for ICH (AOR = 1.84 (95% CI: 1.09-3.12)), ECH (AOR = 4.48 (95% CI: 2.84-7.07)) and brachial plexus injury (AOR = 6.21 (95% CI: 2.22-17.4)), while infants delivered by CS during labor had no increased risk for these complications, as compared to VD. While rates of neonatal complications after VE are generally low, higher odds ratios for intra- and extracranial hemorrhages and brachial plexus injuries after VE, compared with other modes of delivery, support a continued cautious use of VE for preterm delivery.

Cortical Reorganization in Dual Innervation by Single Peripheral Nerve.

PubMed

Zheng, Mou-Xiong; Shen, Yun-Dong; Hua, Xu-Yun; Hou, Ao-Lin; Zhu, Yi; Xu, Wen-Dong

2017-09-21

Functional recovery after peripheral nerve injury and repair is related with cortical reorganization. However, the mechanism of innervating dual targets by 1 donor nerve is largely unknown. To investigate the cortical reorganization when the phrenic nerve simultaneously innervates the diaphragm and biceps. Total brachial plexus (C5-T1) injury rats were repaired by phrenic nerve-musculocutaneous nerve transfer with end-to-side (n = 15) or end-to-end (n = 15) neurorrhaphy. Brachial plexus avulsion (n = 5) and sham surgery (n = 5) rats were included for control. Behavioral observation, electromyography, and histologic studies were used for confirming peripheral nerve reinnervation. Cortical representations of the diaphragm and reinnervated biceps were studied by intracortical microstimulation techniques before and at months 0.5, 3, 5, 7, and 10 after surgery. At month 0.5 after complete brachial plexus injury, the motor representation of the injured forelimb disappeared. The diaphragm representation was preserved in the "end-to-side" group but absent in the "end-to-end" group. Rhythmic contraction of biceps appeared in "end-to-end" and "end-to-side" groups, and the biceps representation reappeared in the original biceps and diaphragm areas at months 3 and 5. At month 10, it was completely located in the original biceps area in the "end-to-end" group. Part of the biceps representation remained in the original diaphragm area in the "end-to-side" group. Destroying the contralateral motor cortex did not eliminate respiration-related contraction of biceps. The brain tends to resume biceps representation from the original diaphragm area to the original biceps area following phrenic nerve transfer. The original diaphragm area partly preserves reinnervated biceps representation after end-to-side transfer. Copyright © 2017 by the Congress of Neurological Surgeons

Non-invasive assessment of peripheral arterial disease: Automated ankle brachial index measurement and pulse volume analysis compared to duplex scan.

PubMed

Lewis, Jane Ea; Williams, Paul; Davies, Jane H

2016-01-01

This cross-sectional study aimed to individually and cumulatively compare sensitivity and specificity of the (1) ankle brachial index and (2) pulse volume waveform analysis recorded by the same automated device, with the presence or absence of peripheral arterial disease being verified by ultrasound duplex scan. Patients (n=205) referred for lower limb arterial assessment underwent ankle brachial index measurement and pulse volume waveform recording using volume plethysmography, followed by ultrasound duplex scan. The presence of peripheral arterial disease was recorded if ankle brachial index <0.9; pulse volume waveform was graded as 2, 3 or 4; or if haemodynamically significant stenosis >50% was evident with ultrasound duplex scan. Outcome measure was agreement between the measured ankle brachial index and interpretation of pulse volume waveform for peripheral arterial disease diagnosis, using ultrasound duplex scan as the reference standard. Sensitivity of ankle brachial index was 79%, specificity 91% and overall accuracy 88%. Pulse volume waveform sensitivity was 97%, specificity 81% and overall accuracy 85%. The combined sensitivity of ankle brachial index and pulse volume waveform was 100%, specificity 76% and overall accuracy 85%. Combining these two diagnostic modalities within one device provided a highly accurate method of ruling out peripheral arterial disease, which could be utilised in primary care to safely reduce unnecessary secondary care referrals.

Intra- and interobserver agreement among obstetric experts in court regarding the review of abnormal fetal heart rate tracings and obstetrical management.

PubMed

Sabiani, Laura; Le Dû, Renaud; Loundou, Anderson; d'Ercole, Claude; Bretelle, Florence; Boubli, Léon; Carcopino, Xavier

2015-12-01

The objective of the study was to evaluate the intra- and interobserver agreement among obstetric experts in court regarding the retrospective review of abnormal fetal heart rate tracings and obstetrical management of patients with abnormal fetal heart rate during labor. A total of 22 French obstetric experts in court reviewed 30 cases of term deliveries of singleton pregnancies diagnosed with at least 1 hour of abnormal fetal heart rate, including 10 cases with adverse neonatal outcome. The experts reviewed all cases twice within a 3-month interval, with the first review being blinded to neonatal outcome. For each case reviewed, the experts were provided with the obstetric data and copies of the complete fetal heart rate recording and the partogram. The experts were asked to classify the abnormal fetal heart rate tracing and to express whether they agreed with the obstetrical management performed. When they disagreed, the experts were asked whether they concluded that an error had been made and whether they considered the obstetrical management as the cause of cerebral palsy in children if any. Compared with blinded review, the experts were significantly more likely to agree with the obstetric management performed (P < .001) and with the mode of delivery (P < .001) when informed about the neonatal outcome and were less likely to conclude that an error had been made (P < .001) or to establish a link with potential cerebral palsy (P = .003). The experts' intraobserver agreement for the review of abnormal fetal heart rate tracing and obstetrical management were both mediocre (kappa = 0.46-0.51 and kappa = 0.48-0.53, respectively). The interobserver agreement for the review of abnormal fetal heart rate tracing was low and was not improved by knowledge of the neonatal outcome (kappa = 0.11-0.18). The interobserver agreement for the interpretation of obstetrical management was also low (kappa = 0.08-0.19) but appeared to be improved by knowledge of the neonatal outcome

A survey of Australasian obstetric anaesthesia audit.

PubMed

Smith, S J; Cyna, A M; Simmons, S W

1999-08-01

In order to develop a minimal obstetric anaesthesia dataset based on current Australasian clinical audit best practice, we carried out a postal survey of 69 Australasian anaesthetic departments covering an obstetric service. We asked about data being collected, specifically concerning the high risk obstetric patient, epidural analgesia and postoperative anaesthetic review. Examples of any data collection forms were requested. Of the 66 responses, 35 departments (53%) were not collecting any audit data. Twenty-six of the 31 departments (84%) performing obstetric anaesthesia audit responded to our follow-up telephone survey. Eighteen departments believed that there had been an improvement in patient care as a result of their audit and 13 felt that the benefits outweighed the costs involved. However, only six departments (9%) had performed an audit cycle. The importance of feedback to patients or hospital staff and the incidence of post dural puncture headache (PDPH) were cited by some as priorities for obstetric anaesthesia audit. There was however no consistency as to what data should be collected. Many responses suggested a perceived need to collect clinical data without knowing what to do with it. Our survey has highlighted confusion between three distinct objectives; a dataset for obstetric anaesthesia record keeping, data required for continuing patient management in hospital and, a specific minimal dataset for clinical audit purposes. We conclude that current Australasian obstetric anaesthesia audit strategies are inadequate to develop a minimal dataset for cost-effective clinical audit.

Indirect carotid cavernous fistula mimicking ocular myasthenia.

PubMed

Leishangthem, Lakshmi; Satti, Sudhakar Reddy

2017-10-19