Prescriptive and proscriptive lessons for managing shoulder dystocia: a technical and videographical tutorial.

This tutorial of the intrapartum management of shoulder dystocia uses drawings and videos of simulated and actual deliveries to illustrate the biomechanical principles of specialized delivery maneuvers and examine missteps associated with brachial plexus injury. It is intended to complement haptic, mannequin-based simulation training. Demonstrative explication of each maneuver is accompanied by specific examples of what not to do. Positive (prescriptive) instruction prioritizes early use of direct fetal manipulation and stresses the importance of determining the alignment of the fetal shoulders by direct palpation, and that the biacromial width should be manually adjusted to an oblique orientation within the pelvis-before application of traction to the fetal head, the biacromial width is manually adjusted to an oblique orientation within the pelvis. Negative (proscriptive) instructions includes the following: to avoid more than usual and/or laterally directed traction, to use episiotomy only as a means to gain access to the posterior shoulder and arm, and to use a 2-step procedure in which a 60-second hands-off period ("do not do anything") is inserted between the emergence of the head and any initial attempts at downward traction to allow for spontaneous rotation of the fetal shoulders. The tutorial presents a stepwise approach focused on the delivering clinician's tasks while including the role of assistive techniques, including McRoberts, Gaskin, and Sims positioning, suprapubic pressure, and episiotomy. Video footage of actual deliveries involving shoulder dystocia and permanent brachial plexus injury demonstrates ambiguities in making the diagnosis of shoulder dystocia, risks of improper traction and torsion of the head, and overreliance on repeating maneuvers that prove initially unsuccessful.

Parsonage-Turner syndrome, affecting suprascapular nerve and especially to infraspinatus muscles after COVID-19 vaccination in a professional wrestler, a case report and literature review of causes and treatments.

BACKGROUND: Acute peripheral neuropathy, also known as Parsonage-Turner syndrome or neuralgic amyotrophy, mostly affects the upper brachial plexus trunks, which include the shoulder girdle. It is typically accompanied by abrupt, intense pain, weakness, and sensory disruption. The etiology and causes of this disease are still unknown because of its low prevalence, however viral reactions-induced inflammation is one of its frequent causes. CASE PRESENTATION: Here, we introduce a professional wrestler patient who was diagnosed with PTS after vaccination and was treated, and we review some articles in this field. CONCLUSION: When it comes to shoulder-girdle complaints and pain, Parsonage-Turner syndrome can be a differential diagnosis. Corticosteroids during the acute period, followed by physical therapy, appear to be an efficient way to manage pain, inflammation, muscular atrophy, and the process of recovering to full nerve regeneration.

Surgical approach through the anterior scalene muscle resection for invasive tumours in the supraclavicular fossa (with video).

BACKGROUND: The supraclavicular fossa contains many vital organs to be preserved, such as the brachial plexus, subclavian artery and vertebral artery. Various surgical methods have been reported. However, no well-standardized surgical procedure has been established. METHODS: Between 2010 and 2020, we performed 28 surgical treatments of the superior mediastinum and supraclavicular fossa. Of these, we retrospectively reviewed seven cases of supraclavicular invasion using a unified surgical technique in which the anterior scalene muscle was resected, and the inter-scalene triangle was approached. RESULTS: We performed claviculectomy in four cases and a transmanubrial approach in three cases. In all cases, by resecting the anterior scalene muscle, the brachial plexus, subclavian artery and vertebral artery were preserved. There were no critical postoperative complications other than tracheostomy and lymphatic leakage. Median bleeding amount and operative time were 438 (range; 76-1144) ml and 328 (range; 246-615) minutes, respectively. CONCLUSIONS: The anterior scalene muscle resection method might be a safe and standardized method for preserving the brachial plexus, subclavian artery and vertebral artery.

Ethnic background as a risk factor for permanent brachial plexus birth injury: A population-based study.

INTRODUCTION: Brachial plexus birth injury is the most common birth injury causing permanent disability in Finland. This study aimed to assess risk factors of a permanent brachial plexus birth injury and calculate the incidence. MATERIAL AND METHODS: This is a retrospective population-based study including all deliveries between 2006 and 2022 in Southern Finland. The number of children born, obstetric data, and migrant status were gathered from the registries of the Finnish Institute for Health and Welfare, and Statistics Finland. Race of the mothers of children with a permanent brachial plexus birth injury was recorded. The severity of permanent brachial plexus birth injury was assessed using the 3-month Toronto test score. A lower score was indicative of a more severe injury (scored 0-10). RESULTS: One hundred of the 298 428 children born during the 17-year study period sustained a permanent brachial plexus birth injury (0.34 per 1000). Mothers of children with a permanent brachial plexus birth injury had a higher body mass index (29 vs. 24 kg/m2) and their pregnancies were more often complicated by diabetes (28% vs. 12%), shoulder dystocia (58% vs. 0.3%), and/or assisted deliveries (45% vs. 10%) compared with all other mothers (p < 0.001). Thirty two of the 52 725 children born to migrant mothers had a permanent brachial plexus birth injury (0.61 per 1000). The incidence of permanent brachial plexus birth injury was 5.7 times higher among children of Black migrants from Africa (18/11 738, 1.53 per 1000) compared with children of native mothers (0.27 per 1000). Black mothers had a higher body mass index at the start of pregnancy (29 vs. 26 kg/m2, p = 0.02) compared with Caucasians. Children of Black mothers had a more severe injury compared with all others (p = 0.007) with a mean 3-month Toronto test score of 4.2 (range 0.0-6.5, SD ±1.6) vs. 5.6 (range 0.0-9.3, SD ±2.2). CONCLUSIONS: Shoulder dystocia and assisted delivery are the most important risk factors for a permanent brachial plexus birth injury. Black race was associated with a higher rate and a more severe permanent brachial plexus birth injury.

Maternal and neonatal complications of shoulder dystocia with a focus on obstetric maneuvers: A case-control study of 1103 deliveries.

INTRODUCTION: Shoulder dystocia is a severe obstetric emergency that can cause substantial neonatal and maternal complications. This study aims to assess the performed obstetric maneuvers and their frequency, success, and association with maternal and neonatal complication rates. MATERIAL AND METHODS: The study population was collected among all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352) by searching for ICD-10 codes for shoulder dystocia, brachial plexus injury and clavicle fracture. Shoulder dystocia cases (n = 537) were identified by reviewing the medical records. Shoulder dystocia cases treated with one or two maneuvers were compared with those treated with at least three. Medical records of a matched control group constituting of 566 parturients without any of the forementioned ICD-10 codes were also scrutinized. RESULTS: Using the four most common obstetric maneuvers (McRoberts maneuver, suprapubic pressure, rotational maneuvers, the delivery of the posterior arm) significantly increased during the study period with individual success rates of 61.0%, 71.9%, 68.1% and 84.8%, respectively. Concurrently, the rate of brachial plexus injury and combined neonatal morbidity significantly declined from 50% to 24.2% (p = 0.02) and from 91.4% to 48.5% (p < 0.001). Approximately 75% of shoulder dystocia cases treated with maneuvers were resolved by the McRoberts maneuver and/or suprapubic pressure, but each of the four most performed maneuvers significantly increased the cumulative success rate individually and statistically (p < 0.001). The rates of brachial plexus injury and combined neonatal morbidity were at their highest (52.9% and 97.8%) when none of the maneuvers were performed and at their lowest when two maneuvers were performed (43.0% and 65.4%). The increasing number (≥3) of maneuvers did not affect the combined maternal or neonatal morbidity or brachial plexus injury but increased the risk for third- or fourth-degree lacerations (odds ratio 2.91, 95% confidence interval 1.17 to 7.24). CONCLUSIONS: The increased use of obstetric maneuvers during the study period was associated with decreasing rates of neonatal complications; conversely, the lack of obstetric maneuvers was associated with the highest rate of neonatal complications. These emphasize the importance of education, maneuver training and urgently performing shoulder dystocia maneuvers according to the international protocol guidelines.

Convolutional neural network for brachial plexus segmentation at the interscalene level.

BACKGROUND: Regional anesthesia with ultrasound-guided brachial plexus block is widely used for patients undergoing shoulder and upper limb surgery, but needle misplacement can result in complications. The purpose of this study was to develop and validate a convolutional neural network (CNN) model for segmentation of the brachial plexus at the interscalene level. METHODS: This prospective study included patients who underwent ultrasound-guided brachial plexus block in the Anesthesiology Department of Beijing Jishuitan Hospital between October 2019 and June 2022. A Unet semantic segmentation model was developed to train the CNN to identify the brachial plexus features in the ultrasound images. The degree of overlap between the predicted segmentation and ground truth segmentation (manually drawn by experienced clinicians) was evaluated by calculation of the Dice index and Jaccard index. RESULTS: The final analysis included 502 images from 127 patients aged 41 ± 14 years-old (72 men, 56.7%). The mean Dice index was 0.748 ± 0.190, which was extremely close to the threshold level of 0.75 for good overlap between the predicted and ground truth segregations. The Jaccard index was 0.630 ± 0.213, which exceeded the threshold value of 0.5 for a good overlap. CONCLUSION: The CNN performed well at segregating the brachial plexus at the interscalene level. Further development could allow the CNN to be used to facilitate real-time identification of the brachial plexus during interscalene block administration. CLINICAL TRIAL REGISTRATION: The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry (ChiCTR2200055591), the site url is https://www.chictr.org.cn/ . The date of trial registration and patient enrollment is 14/01/2022.

Comparing the clinical features of lateral and medial approaches of costoclavicular technique versus traditional lateral sagittal technique as infraclavicular brachial plexus block methods: a randomized controlled trial.

BACKGROUND: It is aimed to compare the block onset times and performance features of costoclavicular techniques (medial and lateral approach) versus lateral sagittal technique. METHODS: Patients were randomized into three groups. For costoclavicular techniques, ultrasound probe was placed parallel to clavicle obtaining nerve cords, axillary artery and axillary vein visual from lateral-to-medial, respectively. The block needle was advanced from lateral (Group CLB) or medial (Group CMB) to perform costoclavicular block. For lateral sagittal technique (Group LSB), ultrasound probe was placed sagittal and perpendicular below the coracoid process to obtain sagittal artery image with the cords around. Total 20 ml of 0.5% bupivacaine and 10 ml of 2% lidocaine were deposited for all groups. Sensory and motor block onset times, block performance properties, complications, and patient/surgeon satisfactions were investigated. RESULTS: Among 56 patients, the primary outcome, sensory block onset time was shorter in Group CLB than Group CMB and Group LSB (10 [5-15], 10 [10-20], and 15 [10-15] minutes, respectively, p < 0.05). Motor block onset was also fastest in Group CLB (15 [10-20] mins for CLB, 20 [15-20] mins for LSB, and 22.5 [15-25] mins for CMB, p = 0.004). Block performance properties did not differ between the groups. The only complication observed was vascular puncture with an incidence of 28% in Group CMB. CONCLUSIONS: Lateral approach costoclavicular technique provides fastest block onset than the other techniques. Considering the success and safety profile, this technique stands as a good alternative in clinical practice. TRIAL REGISTRATION: This study is prospectively registered to clinicaltrials.gov on 20/02/2022 (NCT05260736).

Peripheral nerve decompression for pain relief in the setting of previous obstetrical brachial plexus injury: a retrospective case series.

PURPOSE: In children with previous obstetrical brachial plexus injury (OBPI), upper extremity pain is present in 45 to 66% of patients. Recent literature reports this as musculoskeletal or neuropathic in nature. The purpose of the study is to demonstrate that peripheral nerve decompression, and neurolysis may be an effective treatment for patients with upper extremity pain in the context of previous OBPI. METHODS: A retrospective chart review was performed on patients undergoing peripheral nerve decompression and neurolysis after OBPI by senior author. The primary outcome assessed was pain, and secondary outcome measure was range of motion of the wrist and elbow. Outcome measures were assessed preoperatively as well as at their subsequent follow-up. RESULTS: Six patients were included, with a mean age of 14 years old at time of decompression. Three patients underwent median nerve, two patients underwent ulnar nerve, and one patient underwent posterior interosseous nerve decompression. There was a substantial improvement in pain post-operatively, demonstrated by reduction or resolution of subjective pain in all patients and resolution of Tinel's sign. There was a modest improvement in range of motion. CONCLUSION: This study demonstrates an improvement in subjective pain and range of motion after decompression and neurolysis in small subset of OBPI patients. It generates the hypothesis that peripheral nerve compression is a source of pain that can be addressed in this population. Future research should focus on confirming this hypothesis and assessing treatment options on a larger scale.

Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy.

PURPOSE: Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP. METHODS: This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity). RESULTS: Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7 months. Periodic clinical evaluations were performed until at least 4 years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients. CONCLUSION: Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.

Advancing glenohumeral dysplasia treatment in brachial plexus birth injury: the end-to-side spinal accessory to suprascapular nerve transfer technique.

PURPOSE: Brachial plexus birth injury (BPBI) is a common injury with the spectrum of disease prognosis ranging from spontaneous recovery to lifelong debilitating disability. A common sequela of BPBI is glenohumeral dysplasia (GHD) which, if not addressed early on, can lead to shoulder dysfunction as the child matures. However, there are no clear criteria for when to employ various surgical procedures for the correction of GHD. METHODS: We describe our approach to correcting GDH in infants with BPBIs using a reverse end-to-side (ETS) transfer from the spinal accessory to the suprascapular nerve. This technique is employed in infants that present with GHD with poor external rotation (ER) function who would not necessitate a complete end-to-end transfer and are still too young for a tendon transfer. In this study, we present our outcomes in seven patients. RESULTS: At presentation, all patients had persistent weakness of the upper trunk and functional limitations of the shoulder. Point-of-care ultrasounds confirmed GHD in each case. Five patients were male, and two patients were female, with a mean age of 3.3 months age (4 days-7 months) at presentation. Surgery was performed on average at 5.8 months of age (3-8.6 months). All seven patients treated with a reverse ETS approach had full recovery of ER according to active movement scores at the latest follow-up. Additionally, ultrasounds at the latest follow-up showed a complete resolution of GHD. CONCLUSION: In infants with BPBI and evidence of GHD with poor ER, end-to-end nerve transfers, which initially downgrade function, or tendon transfers, that are not age-appropriate for the patient, are not recommended. Instead, we report seven successful cases of infants who underwent ETS spinal accessory to suprascapular nerve transfer for the treatment of GHD following BPBI.

Brachial plexus peripheral nerve sheath tumors (PNSTs): clinical and surgical management in the pediatric population.

PURPOSE: Peripheral nerve sheath tumors (PNSTs) are rare in pediatric patients, especially in the brachial plexus. Research on PNSTs is lacking. This article presents a retrospective cohort study of pediatric patients diagnosed and treated with PNSTs, specifically brachial plexus tumors. METHODS: All pediatric patients intervened in a single center between 2007 and 2023 with brachial plexus tumors were systemically analyzed. RESULTS: Eleven pediatric patients with 14 brachial plexus PNSTs were studied. The gender distribution was 64% female and 36% male, with an average age of 10.7 years. Ninety-one percent had a previous NF-1 diagnosis. Right brachial plexus presented a higher prevalence (64%). Pain, Tinel's sign, and stiffness masses were common during diagnosis. Motor deficits were noted in 43% of the patients. Surgery was indicated for symptoms, particularly pain and rapid growth, increasing malignancy risk. Due to suspected malignancy, an en bloc resection with safety margins was performed. Among the patients, 57% received a histopathological diagnosis of MPNST (malignant peripheral nerve sheath tumor). Treatment included radiotherapy and chemotherapy. Clinical follow-up was conducted for all cases, involving clinical and oncological evaluations for all MPNSTs. CONCLUSIONS: This article present a series of pediatric brachial plexus tumors, especially in NF-1, and emphasizes the importance of thorough evaluation for this group. Swift diagnosis is crucial in pediatrics, enabling successful surgery for small lesions with limited neurological symptoms, improving long-term outcomes. Prompt referral to specialized services is urged for suspected masses, irrespective of neurological symptoms. Benign tumor postsurgical progression shows better outcomes than MPNSTs, with complete resection as the primary goal. Needle-guided biopsy is not recommended.

Pediatric fibromyxoid brachial plexus tumor with YWHAZ::PLAG1 gene fusion: a case report.

Pediatric fibromyxoid soft tissue tumors may be associated with gene fusions such as YHWAZ::PLAG1, with only three reported cases in the literature. We present the fourth case, a 13-year-old male with a pediatric fibromyxoid brachial plexus tumor with YWHAZ::PLAG1 gene fusion. This is also the first case to be reported in an adolescent, in the brachial plexus, and in the Philippines. The patient presented with a 10-year history of a slowly growing left supraclavicular mass and a 1-year history of intermittent dysesthesia in the left upper extremity. Neurologic examination was unremarkable. Imaging revealed a large left supraclavicular lesion with intrathoracic extension. Surgical excision was performed, and histopathology revealed a fibromyxoid tumor with YWHAZ::PLAG1 gene fusion. Although previous examples of this gene fusion pointed toward lipoblastoma as their primary pathology, our tumor does not completely fulfill the current diagnostic criteria for a lipoblastoma and may represent an intermediate form of the disease. Our case is unique not only because it is the first reported adolescent patient harboring such a lesion but also because of the relatively lengthy natural history exhibited by the tumor prior to its resection. This provided us with valuable information about its behavior, which suggests a more indolent growth pattern. This case also highlights the clinical importance of molecular testing of tumors, where recognition of disease entities can assist clinicians in deciding and advocating for the proper management.

Ultrasound guided costoclavicular block in pediatric population: A prospective observational study.

BACKGROUND: The costoclavicular space serves as an alternative approach to the infraclavicular brachial plexus block, and numerous studies in adults have demonstrated promising outcomes for distal upper limb surgery. Blocking the brachial plexus at this level is potentially advantageous because the cords are relatively superficial, located in close proximity to each other and easily identified using ultrasound. AIMS: This study aimed to assess the success rate and feasibility of costoclavicular block in children undergoing unilateral below elbow upper limb surgery. METHODS: Thirty children aged 2-12 years scheduled for unilateral below elbow surgery under general anesthesia were included. Costoclavicular block was performed under ultrasound and nerve stimulator guidance with 0.5% ropivacaine, 0.5 mL/kg. Success was evaluated based on the absence of significant hemodynamic response to skin incision made 20 min after the block. The sono-anatomy of costoclavicular space, ease of needling, complications, and the post-operative pain scores were assessed. RESULTS: The mean age and weight of the children were 6.5 ± 3.8 years and 19.7 ± 9.1 kg, respectively. The success rate of costoclavicular block in our cohort is 100%. Sonographic visualization was graded as excellent (Likert Scale 2) in 90% of cases. The plexus was located at a depth of 1.4 ± 0.3 cm from the skin, the lateral extent of cords from the artery was 0.8 ± 0.4 cm and they were observed inferior and lateral to the artery. The mean needling time was 3.6 ± 1.1 min. None of the children experienced complications such as vascular or pleural puncture, hematoma, Horner's syndrome or diaphragmatic palsy. Postoperative pain scores were low, and no rescue analgesia was required. CONCLUSIONS: In conclusion, the costoclavicular block exhibited a notably high success rate in pediatric population. This study substantiates that the three cords of the brachial plexus are consistently visible and superficial during ultrasound examination using this approach, confirming their separation from vascular structures and the reliable achievement of blockade without observed complications.

Clinical evaluation of augmented reality-based 3D navigation system for brachial plexus tumor surgery.

BACKGROUND: Augmented reality (AR), a form of 3D imaging technology, has been preliminarily applied in tumor surgery of the head and spine, both are rigid bodies. However, there is a lack of research evaluating the clinical value of AR in tumor surgery of the brachial plexus, a non-rigid body, where the anatomical position varies with patient posture. METHODS: Prior to surgery in 8 patients diagnosed with brachial plexus tumors, conventional MRI scans were performed to obtain conventional 2D MRI images. The MRI data were then differentiated automatically and converted into AR-based 3D models. After point-to-point relocation and registration, the 3D models were projected onto the patient's body using a head-mounted display for navigation. To evaluate the clinical value of AR-based 3D models compared to the conventional 2D MRI images, 2 senior hand surgeons completed questionnaires on the evaluation of anatomical structures (tumor, arteries, veins, nerves, bones, and muscles), ranging from 1 (strongly disagree) to 5 (strongly agree). RESULTS: Surgeons rated AR-based 3D models as superior to conventional MRI images for all anatomical structures, including tumors. Furthermore, AR-based 3D models were preferred for preoperative planning and intraoperative navigation, demonstrating their added value. The mean positional error between the 3D models and intraoperative findings was approximately 1 cm. CONCLUSIONS: This study evaluated, for the first time, the clinical value of an AR-based 3D navigation system in preoperative planning and intraoperative navigation for brachial plexus tumor surgery. By providing more direct spatial visualization, compared with conventional 2D MRI images, this 3D navigation system significantly improved the clinical accuracy and safety of tumor surgery in non-rigid bodies.

Diagnosis of obstetric brachial plexus injury in a 2-year-old girl using high­frequency ultrasonography.

We describe an unusual case of infant obstetric brachial plexus injury located in the cervical (C)5-C6 brachial plexus nerve, which was preoperatively diagnosed using high-frequency ultrasonography (US) at 2 years of age. The girl was diagnosed with a right clavicular fracture because of shoulder dystocia. She had been showing movement limitations of her entire right upper limb after fracture healing and was then referred to our hospital at 2 years of age. High-frequency US showed that the roots of the right brachial plexus ran continuously, but the diameter of C6 was thinner on the affected side than on the contralateral side (right 0.12 cm vs. left 0.20 cm). A traumatic neuroma had formed at the upper trunk, which was thicker (diameter: right 0.35 cm vs. left 0.23 cm; cross-sectional area: right 0.65 cm2 vs. left 0.31 cm2) at the level of the supraclavicular fossa. Intraoperative findings were consistent with ultrasound findings. Postoperative pathology confirmed brachial plexus traumatic neuroma.

Dorsal root entry zone lesioning for brachial plexus avulsion - technical evolution and long-term follow-up.

BACKGROUND: Brachial plexus avulsion (BPA) injuries can cause severe deafferentation pain. This has been successfully treated with dorsal root entry zone (DREZ) lesioning. Distortions in anatomy following a BPA injury can make identifying neural structures challenging. We describe a modification to the operative technique that improves the surgical view and the advanced intraoperative neuromonitoring (IONM) employed to identify DREZ. We have analysed the long-term outcomes for pain, quality of life, and complications in patients undergoing DREZ lesioning. METHODS: This is a single-centre retrospective case series including patients who underwent DREZ lesioning with IONM for brachial plexus avulsion between 2012 and 2022. Analysed data included pre- and postoperative pain (VAS), quality of life score for chronic pain, and complications. The evolution of the surgical approach is discussed. RESULTS: 44 consecutive patients underwent a DREZ lesioning procedure with intraoperative monitoring and mapping. In these patients the mean VAS score improved from 8.9 (7-10) to 1.87 (0-6) (p < 0.0001) at the time of discharge. 31 patients were followed-up for more than 12 months with a mean duration of follow-up of 41 months and their results were as follows: the mean VAS improved from 9.0 (7-10) to 4.1 (0-9) (p < 0.0001) at the last follow-up and the mean QOL values improved from 3.7 (2-6) to 7.4 (4-10) (p < 0.0001). The long-term outcomes were 'good' in 39%, 'fair' in 29% and 'poor' in 32% of patients. 55% of the patients were able to stop or reduce pain medications. CONCLUSIONS: Modifications of surgical technique provide better exposure of DREZ, and IONM aids in identifying DREZ in the presence of severe intra-dural changes. Long-term outcomes of DREZ lesioning indicate not only a reduction in pain but also a significant improvement in quality of life.

The prerequisites and clinical outcomes of ipsilateral C7 nerve root transfer to the upper trunk for adult C5-C6 brachial plexus injuries.

PURPOSE: Although ipsilateral C7 nerve transfer is used for the treatment of C5-C6 brachial plexus injuries, accurately evaluating the functional quality of the donor nerve (ipsilateral C7 nerve root) is difficult, especially when the C7 nerve root is slightly injured. The purpose of this study was to determine the indicators to evaluate the quality of the ipsilateral C7 nerve and assess the clinical outcomes of this procedure. METHODS: This study employed the following three indicators to assess the quality of the ipsilateral C7 nerve: (1) the muscle strength and electrophysiological status of the latissimus dorsi, triceps brachii, and extensor digitorum communis; (2) the sensibility of the radial three digits, especially the index finger; and (3) the intraoperative appearance, feel and electrophysiological status of the ipsilateral C7 nerve root. Transfer of the ipsilateral C7 nerve root to the upper trunk was implemented only when the following three tests were conducted, the criteria were met, and the clinical outcomes were assessed in eight patients with C5-C6 brachial plexus injuries. RESULTS: Patients were followed-up for an average of 90 ± 42 months. At the final follow-up, all eight patients achieved recovery of elbow flexion, with five and three patients scoring M4 and M3, respectively, according to the Medical Research Council scoring. The shoulder abduction range of motor recovery averaged 86 ± 47° (range, 30°-170°), whereas the shoulder external rotation averaged 51 ± 26° (range, 15°-90°). CONCLUSION: Ipsilateral C7 nerve transfer is a reliable and effective option for the functional reconstruction of the shoulder and elbow after C5-C6 brachial plexus injuries when the three prerequisites are met.

Anatomical damages in the spinal nerve roots and the spinal cord after brachial plexus injury: descriptive study from a cohort of consecutive patients who underwent DREZ-lesioning for pain-practical implications.

BACKGROUND: Systematic descriptions of anatomical damage after brachial plexus injury (BPI) at the intradural level have been scarcely reported in detail. However, considering these damages, not only in the spinal nerve roots but also in the spinal cord itself, is crucial in determining the appropriate surgical approach to restore upper limb function and address refractory pain. Therefore, the authors present a descriptive study focusing on intradural findings observed during microsurgical DREZ-lesioning. METHODS: This study enrolled 19 consecutive patients under the same protocol. Microsurgical observation through exposure of C4 to Th1 medullary segments allowed to describe the lesions in spinal nerve roots, meninges, and spinal cord. Electrical stimulation of the ventral roots checked the muscle responses. RESULTS: Extensive damage was observed among the 114 explored roots (six roots per patient), with only 21 (18.4%) ventral (VR) and 17 (14.9%) dorsal (DR) roots retaining all rootlets intact. Damage distribution varied, with the most frequent impairments in C6 VRs (18 patients) and the least in Th1 VRs (14 patients), while in all the 19 patients for the C6 DRs (the most frequently impaired) and in 14 patients for Th1 DRs (the less impaired). C4 roots were found damaged in 12 patients. Total or partial avulsions affected 63.3% and 69.8% of DRs and VRs, respectively, while 15.8% and 14.0% of the 114 DRs and VRs were atrophic, maintaining muscle responses to stimulation in half of those VRs. Pseudomeningoceles were present in 11 patients but absent in 46% of avulsed roots. Adhesive arachnoiditis was noted in 12 patients, and dorsal horn parenchymal alterations in 10. CONCLUSIONS: Knowledge of intradural lesions post-BPI helps in guiding surgical indications for repair and functional neurosurgery for pain control.

Face presentation at term: incidence, risk factors and influence on maternal and neonatal outcomes.

OBJECTIVES: The incidence, diagnosis, management and outcome of face presentation at term were analysed. METHODS: A retrospective, gestational age-matched case-control study including 27 singletons with face presentation at term was conducted between April 2006 and February 2021. For each case, four women who had the same gestational age and delivered in the same month with vertex position and singletons were selected as the controls (control group, n = 108). Conditional logistic regression was used to assess the risk factors of face presentation. The maternal and neonatal outcomes of the face presentation group were followed up. RESULTS: The incidence of face presentation at term was 0.14‰. After conditional logistic regression, the two factors associated with face presentation were high parity (adjusted odds ratio [aOR] 2.76, 95% CI 1.19-6.39)] and amniotic fluid index > 18 cm (aOR 2.60, 95% CI 1.08-6.27). Among the 27 cases, the diagnosis was made before the onset of labor, during the latent phase of labor, during the active phase of labor, and during the cesarean section in 3.7% (1/27), 40.7% (11/27), 11.1% (3/27) and 44.4% (12/27) of cases, respectively. In one case of cervical dilation with a diameter of 5 cm, we innovatively used a vaginal speculum for rapid diagnosis of face presentation. The rate of cesarean section and postpartum haemorrhage ≥ 500 ml in the face presentation group was higher than that of the control group (88.9% vs. 13.9%, P < 0.001, and 14.8% vs. 2.8%, P = 0.024), but the Apgar scores were similar in both sets of newborns. Among the 27 cases of face presentation, there were three cases of adverse maternal and neonatal outcomes, including one case of neonatal right brachial plexus injury and two cases of severe laceration of the lower segment of the uterus with postpartum haemorrhage ≥ 1000 ml. CONCLUSIONS: Face presentation was rare. Early diagnosis is difficult, and thus easily neglected. High parity and amniotic fluid index > 18 cm are risk factors for face presentation. An early diagnosis and proper management of face presentation could lead to good maternal and neonatal outcomes.

Evaluation of Upper Extremity Reachable Workspace in Children With Brachial Plexus Birth Injury.

PURPOSE: Brachial plexus birth injury (BPBI) results in upper extremity (UE) movement limitations. Current assessments of UE function used to inform clinical decision-making only evaluate a limited set of static postures and/or movements and have been criticized for being insensitive to certain meaningful differences in function. Reachable workspace provides a numeric and visual assessment of global UE movement ability by quantifying the regions in space that patients can reach with their hands, and it can be collected using real-time feedback to elicit a best-effort acquisition of function. This study evaluated the ability of a real-time feedback reachable workspace tool to assess UE movement in BPBI. METHODS: Twenty-two children with BPBI participated. Reachable workspace data were collected with three-dimensional motion capture using real-time visual feedback to measure UE reaching ability in all regions surrounding the body. All outer, far-from-body points reached by the hand were recorded and analyzed by region. A two-way, within-subjects analysis of variance was used to assess interlimb differences in percentage workspace reached and median reach distance for each of the six regions. RESULTS: The affected limb had significantly less percentage workspace reached than the unaffected limb for all six regions (mean interlimb differences by region, 5.7%-38.6%). The affected limb had significantly less median reach distance than the unaffected limb for all six regions (mean interlimb differences by region, 3.1%-36.8%). CONCLUSIONS: The workspace approach was capable of detecting UE movement impairments of the BPBI-affected limb. The reported deficits in workspace on the affected limb correspond to common movement impairments in BPBI, such as limitations in shoulder elevation, external rotation, extension, and elbow extension. CLINICAL RELEVANCE: The real-time feedback reachable workspace tool is sufficiently robust for assessing UE movement impairments in children with BPBI.