The medial cord to musculocutaneous (MCMc) nerve transfer: a new method to reanimate elbow flexion after C5-C6-C7-(C8) avulsive injuries of the brachial plexus--technique and results.

The aim of this paper is to report on our ample experience with the medial cord to musculocutaneous (MCMc) nerve transfer. The MCMc technique is a new type of neurotization which is able to reanimate the elbow flexion in multilevel avulsive injuries of the brachial plexus provided that at least the T1 root is intact. A series of 180 consecutive patients, divided into four classes according to the quality of hand function, is available for a long-term follow-up after brachial plexus surgery. The patients enrolled for the study have in common a brachial plexus palsy showing multiple cervical root avulsive injuries at two (C5-C6), three (C5-C6-C7) and four (C5-C6-C7-C8) levels. The reinnervation of the musculocutaneous nerve is obtained via an end-to-end transfer from two donor fascicles located in the medial cord. The selected fascicles are those directed principally to the flexor carpi radialis, ulnaris and, to a lesser degree, the flexor digitorum profundus. Under normal anatomic conditions, they are located in the medial cord, and their site corresponds to the inverted V-shaped bifurcation between the internal contribution of the median nerve and the ulnar nerve. The technique has no failure and no complications when the hand shows a normal wrist and finger flexion and a normal intrinsic function. In case of suboptimal conditions of the hand, the technique has proved technically more challenging, but still with 67% satisfactory results. In the four-root avulsive injuries, however, this method shows its limitations and an alternative strategy should be preferred when possible. EMG analysis shows a reinnervation in both the biceps and the brachialis muscles, explaining the high quality of the observed results. Moreover, this technique theoretically offers the possibility of a "second attempt" at a more distal level in case of failure of the first surgery. This procedure is quick, safe, extremely effective and easily feasible by an experienced plexus surgeon. The ideal candidate is a patient harbouring a C5-C6 avulsive injury of the upper brachial plexus with a normally functioning hand.

Comparison of A-mode ultrasound and computed tomography: detection of secretion in maxillary and frontal sinuses in ventilated patients.

OBJECTIVE: To study the accuracy of A-mode ultrasonography (A-MU) in detecting secretion in maxillary and frontal sinuses in critically ill, intubated patients undergoing mechanical ventilation. DESIGN: Open study in mechanically ventilated, comatose patients. SETTING: Medical-surgical intensive care unit in the General Hospital of Rovigo. PATIENTS: 50 consecutive, mechanically ventilated, critically ill patients. All patients were in a coma and needed cerebral computed tomography (CT) for a diagnosis. MEASUREMENTS AND RESULTS: The A-MU technique gave 100 images of maxillary and frontal sinuses. The images were read blindly and classified into five categories: definitely normal, definitely abnormal, probably normal, questionable, and probably abnormal. CT findings were considered to be the "gold standard". The specificity of echo images varied from 72 to 98% and the sensitivity from 63 to 86% for maxillary sinuses. For frontal sinuses, the specificity varied from 96 to 99% and the sensitivity from 14 to 57%. The area under the receiver-operating characteristic curve was found to be 0.89 and 0.76 for maxillary and frontal sinuses, respectively. CONCLUSIONS: The A-MU technique is an accurate tool for detecting secretion in the maxillary sinuses in intubated patients. More investigations are necessary in order to evaluate its usefulness in the frontal sinuses.