Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury.

OBJECTIVE: To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment. STUDY DESIGN: Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data. RESULTS: There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%. CONCLUSIONS: In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.

Evaluating the feasibility of implementing the Sup-ER protocol for infants with brachial plexus birth injury.

BACKGROUND: The Sup-ER protocol involves a repositioning program for infants with brachial plexus birth injury to position the shoulder in external rotation (ER) to address progressive loss in passive range of motion (PROM). The British Columbia Children's Hospital (BCCH) eligibility criteria for this protocol are infants aged 4-8 weeks with decreased shoulder ER PROM and/or Active Movement Scale (AMS) shoulder ER and/or supination scores ≤2. The resources needed to implement this protocol in large clinics have not been studied. PURPOSE: This study aims to evaluate the BCCH criteria that are used to identify appropriate candidates for the Sup-ER protocol. STUDY DESIGN: A retrospective cohort study was conducted to identify the percentage of infants who would have been recommended the Sup-ER protocol based on their PROM and AMS scores between 4 and 8 weeks of age. METHODS: A sensitivity and specificity evaluation was used to describe the BCCH criteria's ability to identify infants in this historical cohort who went on to have incomplete shoulder function (ie, true positive) vs infants who had functional shoulder outcome at 9 months of age (ie, false positive). RESULTS: At a mean of 5.8 weeks (95% confidence interval [CI] 5.3, 6.3), 46 of the 87 (53%) infants satisfied the BCCH Sup-ER protocol criteria. Forty-four (51%) were female, half (n = 45) were left side affected, and 88% had upper plexus injury. The BCCH Sup-ER protocol criteria had sensitivity of 100% and specificity of 71% to identify infants with incomplete shoulder function. Removing the AMS supination ≤2 score criterion from the criteria improves the specificity to 84%, while sensitivity remains high (97%). CONCLUSIONS: Modifying the BCCH criteria to all infants aged 4-8 weeks with AMS shoulder ER ≤2 and/or decreased shoulder ER PROM improves the precision of identifying infants who would benefit from the Sup-ER protocol.

Demyelinating polyneuropathy combined with brachial plexopathy after nivolumab therapy for hodgkin lymphoma: a case report.

BACKGROUND: Nivolumab is an immune checkpoint inhibitor that targets the programmed cell death-1 protein and is effective in treating advanced cancer. However, it is also associated with various immune-related neurological complications, including myasthenia gravis, Guillain-Barré syndrome, and demyelinating polyneuropathy. These complications can easily mimic other neurological diseases and have greatly varying therapeutic approaches depending on the underlying pathophysiology. CASE PRESENTATION: Here, we report a case of nivolumab-induced demyelinating peripheral polyneuropathy involving the brachial plexus in a patient with Hodgkin lymphoma. Approximately 7 months after nivolumab treatment, the patient experienced muscle weakness with a tightness and tingling sensation in the right forearm. Electrodiagnostic studies showed features of demyelinating peripheral neuropathy with right brachial plexopathy. Magnetic resonance imaging revealed thickening with a diffuse enhancement of both brachial plexuses. The patient was eventually diagnosed with nivolumab-induced demyelinating polyneuropathy involving the brachial plexus. Oral steroid therapy improved motor weakness and sensory abnormalities without aggravation. CONCLUSION: Our study indicates the possibility of nivolumab-induced neuropathies in cases involving muscle weakness with sensory abnormalities of the upper extremity following nivolumab administration in patients with advanced cancer. Comprehensive electrodiagnostic studies and magnetic resonance imaging are helpful in the differential diagnosis of other neurological diseases. Appropriate diagnostic and therapeutic approaches may prevent further neurological deterioration.

Diagnostic value of proximal cutaneous nerve biopsy in brachial and lumbosacral plexus pathologies.

BACKGROUND: Brachial and lumbosacral plexopathies can result from numerous non-traumatic etiologies, including those of inflammatory, autoimmune, or neoplastic origin, that often require nerve biopsy for diagnosis. The purpose of this study was to evaluate the diagnostic efficacy of medial antebrachial cutaneous nerve (MABC) and posterior femoral cutaneous nerve (PFCN) nerve biopsies in proximal brachial and lumbosacral plexus pathology. METHOD: Patients undergoing MABC or PFCN nerve biopsies at a single institution were reviewed. Patient demographics, clinical diagnosis, symptom duration, intraoperative findings, post-operative complications, and pathology results were recorded. Biopsy results were classified as diagnostic, inconclusive, or negative based on the final pathology. RESULTS: Thirty patients undergoing MABC biopsies in the proximal arm or axilla and five patients with PFCN biopsies in the thigh or buttock were included. MABC biopsies were diagnostic in 70% of cases overall and 85% diagnostic in cases where pre-operative MRI also demonstrated abnormalities in the MABC. PFCN biopsies were diagnostic in 60% of cases overall and in 100% of patients with abnormal pre-operative MRIs. There were no biopsy-related post-operative complications in either group. CONCLUSIONS: In diagnosing non-traumatic etiologies of brachial and lumbosacral plexopathies, proximal biopsies of the MABC and PFCN provide high diagnostic value with low donor morbidity.

nfrared thermography as a complementary method when diagnosing birth-related brachial plexus injury.

OBJECTIVES: The main objective of this study was to determine whether infrared thermography could be used as an efficient technique to evaluate the impact of a birth-related brachial plexus injury on the temperature of the injured arm and whether it could be used as a complementary method when diagnosing this injury in clinical praxis. BACKGROUND: Clinically, the brachial plexus injury is a peripheral paresis, which occurs when nerves that send signals from the spinal cord to the shoulder, arm, and hand are stretched or compressed. In principle, the brachial plexus injury, as a long-lasting injury, should be causing hypothermia of the injured arm. METHODS: The usage of contactless infrared thermography could offer a "new view" of the diagnostic process in this case. The present study, therefore, describes a process of clinical infrared thermography examination of three patients of different age and presents results from those examinations. RESULTS AND CONCLUSION: From our results, it can be confirmed that the birth-related brachial plexus injury affects the temperature of the affected arm, especially in the area of the cubital fossa, to an extent that the thermal camera is capable of detecting significant temperature differences between the healthy and injured arms (Tab. 3, Fig. 7, Ref. 13). Text in PDF www.elis.sk Keywords: birth brachial plexus injury, upper type palsy, peripheral palsy, infrared thermography.

Implications of median sensory study to the thumb and deltoid/biceps motor unit recruitment on identifying C6 root avulsion in upper neonatal brachial plexus palsy.

INTRODUCTION/AIMS: Anatomic representation suggests that a median sensory nerve conduction study recording the thumb (median D1 NCS) may effectively assess upper neonatal brachial plexus palsy (NBPP). We sought to determine the feasibility of technique, establish reference data, and assess its ability to: (a) identify focal upper plexus lesions; and (b) identify C6 root avulsion. In a secondary analysis, we explored the association between absence/presence of motor unit action potentials (MUAPs) during needle electromyography (EMG) of the deltoid and biceps brachii muscles and C6 avulsion status. METHODS: A retrospective chart review was performed of surgical patients with severe upper NBPP who ultimately underwent surgical reconstruction (between 2017 and 2020). Median D1 sensory nerve action potential (SNAP) amplitude ranges were determined in affected and contralateral limbs and analyzed by C6 root avulsion status. Also, presence/absence of MUAPs during EMG of the deltoid and biceps brachii was compared between C6 avulsion patients and controls. RESULTS: Thirty-eight patients were included in our analysis. A median D1 NCS study was readily performed, showing a contralateral limb mean amplitude of 27.42 µV (range, 3.8-54.7 µV). Most patients had a low ipsilateral median D1 SNAP amplitude, regardless of C6 avulsion status. Detectable MUAPs in either deltoid or biceps brachii on EMG were atypical in C6 root avulsion. DISCUSSION: The median D1 NCS identifies upper NBPP, but does not distinguish C6 avulsions from post-ganglionic lesions, likely due to the frequent co-occurrence of post-ganglionic axonal disruption. The presence of MUAPs on deltoid/biceps brachii EMG suggests C6 avulsion is unlikely.

Role of electrodiagnosis in nerve transfers for focal neuropathies and brachial plexopathies.

Over the past 2 decades, the surgical treatment of brachial plexus and peripheral nerve injuries has advanced considerably. Nerve transfers have become an important surgical tool in addition to nerve repair and grafting. Electrodiagnosis has traditionally played a role in the diagnosis and localization of peripheral nervous system injuries, but a different approach is needed for surgical decision-making and monitoring recovery. When patients have complete or severe injuries they should be referred to surgical colleagues early after injury, as outcomes are best when nerve transfers are performed within the first 3 to 6 mo after onset. Patients with minimal recovery of voluntary activity are particularly challenging, and the presence of a few motor unit action potentials in these individuals should be interpreted on the basis of timing and evidence of ongoing reinnervation. Evaluation of potential recipient and donor muscles, as well as redundant muscles, for nerve transfers requires an individualized approach to optimize the chances of a successful surgical intervention. Anomalous innervation takes on new importance in these patients. Communication between surgeons and electrodiagnostic medicine specialists (EMSs) is best facilitated by a joint collaborative clinic. Ongoing monitoring of recovery post-operatively is critical to allow for decision making for continued surgical and rehabilitation treatments. Different electrodiagnostic findings are expected with resolution of neurapraxia, distal axon sprouting, and axonal regrowth. As new surgical techniques become available, EMSs will play an important role in the assessment and treatment of these patients with severe nerve injuries.

Idiopathic brachial plexopathy after pacemaker implant.

A middle-aged woman presented with symptomatic complete heart block and underwent an uneventful dual chamber pacemaker implantation. Three weeks post procedure, she developed left arm pain and weakness, with neurological localization to the lower trunk of left brachial plexus. Possibilities of traumatic compression by the device/leads or postoperative idiopathic brachial plexopathy were considered. After ruling out traumatic causes, she was started on oral steroids, to which she responded remarkably. This case highlights the importance of recognizing this rare cause of brachial plexopathy following pacemaker implantation, because not only does an expedited diagnosis and medical treatment lead to prompt recovery with minimal neurological deficits, but it also circumvents an unnecessary surgical re-exploration.

Neonatal brachial plexus palsy - early diagnosis and treatment.

Background and purpose: The incidence of brachial plexus palsy (BPP) has decreased recently, but the indivi-d-ual's quality of life is endangered. To provide better chan-ces to BPP neonates and infants, the Department of Developmental Neurology worked out, introduced, and applied a complex early therapy, including nerve point stimulation. Methods: After diagnosing the severity of BPP, early intensive and complex therapy should be started. Appro-x-imately after a week or ten days following birth, the slightest form (neurapraxia) normalizes without any intervention, and signs of recovery can be detected around this period. The therapy includes the unipolar nerve point electro-stimulation and the regular application of those elemen-tary sensorimotor patterns, which activate both extremities simultaneously. Results: With the guideline worked out and applied in the Department of Developmental Neurology, full recovery can be achieved in 50% of the patients, and even in the most severe cases (nerve root lesion), functional upper limb usage can be detected with typically developing body-scheme. Conclusion: Immediately starting complex treatment based on early diagnosis alters the outcome of BPP, providing recovery in the majority of cases and enhancing the everyday arm function of those who only partially benefit from the early treatment.

Severe brachial plexopathy secondary to shingles (herpes zoster).

Varicella zoster reactivation ("shingles" or "herpes zoster") usually presents as a self-limiting, unilateral, dermatomal vesicular rash in older adults. We present the case of a 73 year-old woman with unilateral brachial plexopathy, an unusual but debilitating complication of shingles. Despite treatment with intravenous acyclovir and immunoglobulin she had a marked residual motor paresis that required an upper limb rehabilitation program after discharge.

Knowledge of neonatal brachial plexus palsy among medical professionals in North America.

PURPOSE: Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. METHODS: A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. RESULTS: Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. CONCLUSIONS: Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.

A novel instrumented shoulder functional test using wearable sensors in patients with brachial plexus injury.

BACKGROUND: Because nerve injury of muscles around the shoulder can be easily disguised by "trick movements" of the trunk, shoulder dysfunction following brachial plexus injury is difficult to quantify with conventional clinical tools. Thus, to evaluate brachial plexus injury and quantify its biomechanical consequences, we used inertial measurement units, which offer the sensitivity required to measure the trunk's subtle movements. METHODS: We calculated 6 kinematic scores using inertial measurement units placed on the upper arms and the trunk during 9 functional tasks. We used both statistical and machine learning techniques to compare the bilateral asymmetry of the kinematic scores of 15 affected and 15 able-bodied individuals (controls). RESULTS: Asymmetry indexes from several kinematic scores of the upper arm and trunk showed a significant difference (P < .05) between the affected and control groups. A bagged ensemble of decision trees trained with trunk and upper arm kinematic scores correctly classified all controls. All but 2 patients were also correctly classified. Upper arm scores showed correlation coefficients ranging from 0.55-0.76 with conventional clinical scores. CONCLUSIONS: The proposed wearable technology is a sensitive and reliable tool for objective outcome evaluation of brachial plexus injury and its biomechanical consequences. It may be useful in clinical research and practice, especially in large cohorts with multiple follow-ups.

Neurological and Dexterity Assessments in a Woman with Radiation-Induced Brachial Plexopathy After Breast Cancer.

The aim of this case report is to inform clinicians about radiation-induced brachial plexopathy, a rare complication that often presents well after treatment with inconsistent symptoms and manifestations. It is often a diagnosis of exclusion when a neoplastic or other cause cannot be identified. Electrodiagnostic testing is particularly useful. Here, the results of a standardized grip and pinch strength assessment and dexterity test are presented in a woman whose symptoms first appeared 20 years after completing treatments for stage IIIA breast cancer.

Primary cancer location predicts predominant level of brachial plexopathy.

BACKGROUND: Changes in radiation therapy practice and cancer incidence bring into question prior evidence suggesting that radiation therapy predominantly injures the brachial plexus upper trunk, while tumor invasion typically injures the lower trunk. METHODS: We reviewed electrodiagnostic brachial plexopathy reports in cancer survivors for predominant trunk involvement, injury mechanism (tumor invasion vs radiation), and primary cancer location. RESULTS: Fifty-six cases of cancer-associated brachial plexopathy were identified. There was no relationship between injury mechanism and brachial plexus injury level. However, primary cancer location superior/inferior to the clavicle increased the odds of predominantly upper/lower trunk involvement by a factor of 60.0 (95% confidence interval: 7.9, 1401, respectively). CONCLUSIONS: Cancers superior/inferior to the clavicle increase the likelihood of predominantly upper/lower trunk plexopathy, respectively, regardless plexus injury mechanism. These findings contrast with older work, possibly due to more precise radiation therapy techniques and increased incidence of radiosensitive head and neck cancers.

Examination of the human motor endplate after brachial plexus injury with two-photon microscopy.

INTRODUCTION: After traumatic nerve injury, neuromuscular junction remodeling plays a key role in determining functional outcomes. Immunohistochemical analyses of denervated muscle biopsies may provide valuable prognostic data regarding clinical outcomes to supplement electrodiagnostic studies. METHODS: We performed biopsies on nonfunctioning deltoid muscles in two patients after gunshot wounds and visualized the neuromuscular junctions using two-photon microscopy with immunohistochemistry. RESULTS: Although the nerves in both patients showed evidence of acute Wallerian degeneration, some of the motor endplates were intact but exhibited significantly decreased surface area and volume. Both patients exhibited substantial recovery of motor function over several weeks postinjury. DISCUSSION: Two-photon microscopic assessment of neuromuscular junction integrity and motor endplate morphometry in muscle biopsies provided evidence of partial sparing of muscle innervation. This finding supported the clinical judgment that eventual recovery would occur. With further study, this technique may help to guide operative decisionmaking after traumatic nerve injuries.

Early electrodiagnosis in the management of neonatal brachial plexus palsy: A systematic review.

Neonatal brachial plexus palsy (NBPP) is a prominent form of newborn morbidity with a potentially disabling persistence. Neurosurgical intervention is indicated in select NBPP patients. Early prognostic assessment would facilitate rational selection of those infants for surgery. We conducted a systematic literature review to determine the prognostic value of early electrodiagnosis (EDx) in NBPP. We included 16 observational studies with a total sample size of 747 children. Risk of bias and quality of evidence were rated. Wide variation was found in EDx techniques, outcome algorithms, and decisionmaking. Nevertheless, the most methodologically sound studies support the use of EDx, at standardized time-frames, as a key prognostic modality for complementing clinical judgment and neuroimaging. An accurate knowledge of the underlying anatomy of the nerve injury helps to counsel families and to guide reconstructive strategy.

Contralateral lumbosacral plexopathy following lumbar microdiscectomy.

We describe the unique case of a 51-year-old lady who developed a contralateral lumbosacral plexopathy two days after a lumbar microdiscectomy. This is the first report to date of this complication occurring following this procedure. We review the literature regarding lumbosacral plexopathy and discuss the evidence base behind investigating and managing this condition and the potential pathophysiological mechanisms which underlie its development. We draw comparisons with the more widely recognised post-operative brachial neuritis, characterised by delayed onset brachial plexopathy developing after cervical decompression, and propose an immune-mediated inflammatory mechanism linking the two conditions.

Reliability of Various Predictors for Preoperative Diagnosis of Infraclavicular Brachial Plexus Lesions with Shoulder and/or Elbow Paresis.

BACKGROUND: The distinction between supraclavicular and infraclavicular acute brachial plexus injuries (BPIs) could be challenging in cases of combined shoulder and elbow paresis. The reliability of several preoperative predictors was investigated to avoid unnecessary dissection, prolonged operation time, increased postoperative morbidity, and long scars. METHODS: Between 2004 and 2013, 75 patients, who sustained acute BPI and presented with motor paresis of shoulder and elbow with preservation of hand function, were included and studied retrospectively. Various predictors including muscles function, sensation, fractures, Tinel's sign and nerve conduction velocity (NCV) studies were reviewed. RESULTS: The highest odds ratio (OR) values for infraclavicular BPI were healthy clavicular head of pectoralis major and biceps, presenting with OR = 36.5 and 31.76, respectively, which were identified the most important predictors. CONCLUSION: A combination of functioning pectoralis major or biceps, scapular fracture, an infraclavicular Tinel's sign, and normal NCV in the musculocutaneous nerve was highly predictive of an infraclavicular level.

Suprascapular neuropathy: A review of 87 cases.

INTRODUCTION: Suprascapular neuropathy (SSN) is rare, with an estimated prevalence of 4.3% in patients with shoulder pain. METHODS: This retrospective chart review included patients with SSN seen during a 16-year period. Demographics and clinical information were recorded. Descriptive statistics, including percentages, means, and standard deviations, were computed for the variables of interest for all patients. RESULTS: Of 87 patients included in this study, trauma (n = 27) was the most common cause of SSN, followed by neuralgic amyotrophy (n = 21). Fifty-seven patients had isolated SSN. Others had SSN associated with axillary neuropathy (23 patients), brachial plexopathy (3 patients), and long thoracic, radial, or spinal accessory neuropathy (1 patient each). DISCUSSION: SSN is commonly associated with axillary neuropathy. Trauma remains the most common cause of SSN. Electrodiagnostic findings aid in the initial diagnosis and may indicate the need for close clinical follow-up based on the severity of the axonal injury.

Radiation-induced brachial plexus toxicity after SBRT of apically located lung lesions.

Purpose: To evaluate the rate and dose response of brachial plexus toxicity post stereotactic body radiation therapy (SBRT) of apically situated lung lesions. Material/methods: We retrospectively identified all patients with apically located tumors, defined by the epicenter of the tumor being located superiorly to the aortic arch, and treated with SBRT between 2008 and 2013. Patients with a shorter follow-up than 6 months were excluded. Primary aim was to evaluate radiation-induced brachial plexopathy (RIBP). Dose to the plexus was assessed by a retrospective delineation of the brachial plexus on the CT used for treatment planning. Then, Dmax, D0.1cc, D1cc and D3.0cc of the brachial plexus were collected from the dose-volume histograms (DVH) and recalculated to the biologically effective dose (BED) using α/ß = 3 Gy. A normal tissue complication probability (NTCP) model, based on four different dose-volume parameters (BED3,max, BED3,0.1cc, BED3,1.0cc, BED3,3.0cc) was fitted to the data. Results: Fifty-two patients with 56 apically located tumors were identified. Median prescription dose per fraction was 15 Gy (range 6-17) and median number of fractions was 3 (3-10). With a median follow-up of 30 months (6.1-72) seven patients experienced maximum grade 2 (scored 3 times) or 3 (scored 4 times) RIBP after a median of 8.7 months (range 4.0-31). Three patients had combined symptoms with pain, sensory and motor affection and four patients had isolated pain. Median BED3,max for the patients experiencing RIBP was 381 Gy (range 30-524) versus BED3,max of 34 Gy (range 0.10-483) for the patients without RIBP. The NTCP models showed a very high predictive ability (area under the receiver operating characteristic curve (AUC) 0.80-0.88). Conclusion: SBRT of apically located lung lesions may cause severe neurological symptoms; for a three-fraction treatment, we suggest that the maximum dose to the plexus should be kept ≤30 Gy (130 Gy BED3).