Evaluation of Long-Term Results of Oberlin Surgery in Obstetric Brachial Paralysis / Avaliação dos resultados a longo prazo da cirurgia de Oberlin na paralisia braquial obstétrica

Abstract Objective To evaluate elbow flexion in children with obstetric brachial plexus paralysis submitted to Oberlin transfer. Methods Retrospective study with 11 patients affected by paralysis due to labor who did not present spontaneous recovery from elbow flexion until 12 months of life, operated between 2010 and 2018. Results The children were operated between 5 and 12 months of life, with a mean of 7.9 months, and the mean follow-up time was 133.2 months, ranging from 37 to 238 months. Six patients (54.5%) presented a degree of muscle strength ≥ 3, measured by the strength scale of the Medical Research Council (MRC) and, according to the active movement scale (AMS), 5 patients obtained a score of ≥ 5. A negative correlation was identified between the AMS and the Narakas classification (r = -0.509), as well as between the strength scale (MRC) and the Narakas classification (r = -0.495). A strong positive correlation was observed (r = 0.935) between the AMS and the MRC demonstrating that the higher the score on the movement scale, the higher the score on the muscle strength scale. Conclusion The Oberlin surgery is a possible option for recovery of elbow flexion in children with neonatal plexopathy, demonstrating, however, very heterogeneous results, even in the long-term follow-up.

Resumo Objetivo Avaliar a flexão do cotovelo em crianças portadoras de paralisia obstétrica do plexo braquial submetidas à transferência de Oberlin. Métodos Estudo retrospectivo com 11 pacientes acometidos por paralisia decorrente do trabalho de parto e que não apresentaram recuperação espontânea da flexão do cotovelo até os 12 meses de vida, operados entre 2010 e 2018. Resultados As crianças foram operadas entre os 5 e 12 meses de vida, com média de 7,9 meses e o tempo médio de seguimento foi de 133,2 meses, variando de 37 a 238 meses. Seis pacientes (54,5%) apresentaram grau de força muscular ≥ 3, medido pela escala de força do Medical Research Council (MRC), e, pela escala de movimentação ativa (Active Momement Scale [AMS]), 5 pacientes obtiveram pontuação ≥ 5. Foi identificada correlação negativa entre a AMS e a classificação de Narakas (r = -0,509), bem como entre a MRC e a classificação de Narakas (r = -0,495). Já entre a AMS e a MRC, foi observada forte correlação positiva (r = 0,935), demonstrando que quanto maior a pontuação na escala de movimento, maior será a pontuação na escala de força muscular. Conclusão A cirurgia de Oberlin apresenta-se como uma opção possível para a recuperação da flexão do cotovelo em crianças com plexopatia neonatal; no entanto, demonstra resultados bastante heterogêneos, mesmo no seguimento a longo prazo.

Efeito do treino de alcance combinado com estimulação elétrica em lactentes com paralisia braquial perinatal: estudo experimental de caso único / Efecto del entrenamiento de alcance combinado con electroestimulación en los lactantes con parálisis braquial perinatal: un estudio experimental de caso único / Effect of reaching training combined with electrical stimulation in infants with brachial plexus palsy: a single subject design

RESUMO O objetivo deste estudo foi avaliar o efeito do treino de alcance combinado à estimulação elétrica funcional (FES) na movimentação ativa do membro superior de lactentes com paralisia braquial perinatal (PBP). Trata-se de estudo experimental de caso único do tipo A-B com follow-up. Foram documentados semanalmente dados relativos à função do membro superior (Escala de Movimento Ativo) de dois lactentes, uma menina e um menino de 7 e 10 meses de idade, respectivamente. Após seis avaliações, três vezes por semana, durante duas semanas, na linha de base (A), a intervenção consistiu em aplicar FES Neurodyn® no músculo deltoide em combinação com treino de alcance de objetos, incentivando abdução e flexão anterior de ombro acima de 90°, durante seis semanas, totalizando 15 atendimentos (B). Os lactentes foram reavaliados duas vezes após um período de 15 e 30 dias sem intervenção (follow-up). A pontuação total obtida em cada dia de avaliação foi representada graficamente. Houve boa aceitação da eletroestimulação, sem nenhum efeito colateral. Ambos os lactentes apresentaram melhora da movimentação ativa do membro superior afetado após a intervenção e os ganhos foram mantidos no follow-up, com aumento de 9 e 7 pontos para os lactentes 1 e 2, respectivamente. Seis semanas de intervenção resultaram em mudanças individuais na função do membro superior dos lactentes, principalmente no aumento da amplitude de movimento ativo em flexão e abdução de ombro e flexão de cotovelo. Os resultados deste estudo sugerem o uso de estimulação elétrica como coadjuvante do treino do uso do membro superior afetado de lactentes com PBP.

RESUMEN El objetivo de este estudio fue evaluar el efecto del entrenamiento de alcance combinado con electroestimulación funcional (FES) sobre el movimiento activo de la extremidad superior de los lactantes con parálisis braquial perinatal (PBP). Este es un estudio experimental de caso único de tipo A-B con follow-up. Se registraron semanalmente datos sobre la función del miembro superior (escala de movimiento activo) de dos lactantes, una niña y un niño de 7 y 10 meses de edad, respectivamente. Después de seis evaluaciones, tres veces semanales, durante dos semanas, en la línea base (A), la intervención consistió en aplicar FES Neurodyn® en el músculo deltoides combinado con entrenamiento de alcance de objetos para estimular la abducción y la flexión anterior del hombro por encima de 90°, durante seis semanas, lo que totalizó 15 visitas (B). Se reevaluó a los lactantes dos veces tras el período de 15 y 30 días sin intervención (follow-up). El puntaje total que se obtenía en cada evaluación se representaba gráficamente. Hubo buena aceptación de la electroestimulación, sin efectos secundarios. Ambos lactantes tuvieron mejora en el movimiento activo de la extremidad superior afectada tras la intervención, y los beneficios se mantuvieron en el follow-up, con un aumento de 9 y 7 puntos para los lactantes 1 y 2, respectivamente. Seis semanas de intervención produjeron cambios individuales en la función del miembro superior de los lactantes, principalmente el aumento de la amplitud del movimiento activo en la flexión y abducción del hombro y la flexión del codo. Los resultados sugieren usar la electroestimulación como complemento en el entrenamiento de la extremidad superior afectada de lactantes con PBP.

ABSTRACT This study aimed to evaluate the effect of reaching training combined with functional electrical stimulation (FES) on active upper limb movement in infants with perinatal brachial palsy (PBP). Experimental single-case A-B design with follow-up. Two infants participated in the study, one girl of 7 months and one boy of 10 months of age. Data on infant's upper limb function (Active Movement Scale) were documented weekly. After six baseline assessments (A), 3 times per 2 weeks, intervention consisted of applying FES Neurodyn® to the deltoid muscle combined with objects reach training, encouraging abduction and anterior shoulder flexion above 90º, for six weeks, totaling 15 visits (B). The infants were reevaluated twice after a period of 15 and 30 days without intervention (follow up). The total score obtained on each evaluation day was plotted graphically. Electrostimulation was well accepted, with no side effects. Both infants showed improvement in the active movement of the affected upper limb after the intervention and the gains were maintained at follow-up, an increase of 9 and 7 points for infants 1 and 2, respectively. Six weeks of intervention resulted in individual changes in infant's upper limb function, mainly increased active range of motion in shoulder flexion and abduction and elbow flexion. The results of this study suggest the use of electrical stimulation as an adjunct to training the use of the affected upper limb of infants with PBP.

Treatment of radiation-induced brachial plexopathy with omentoplasty

Radiation-induced brachial plexus neuropathy (RIBPN) is a rare and delayed non-traumatic injury to the brachial plexus, which occurs following radiation therapy to the chest wall, neck, and/or axilla in previously treated patients with cancer. The incidence of RIBPN is more common in patients treated for carcinoma of the breast and Hodgkin lymphoma. With the improvement in radiation techniques, the incidence of injury to the brachial plexus following radiotherapy has dramatically reduced. The currently reported incidence is 1.2% in women irradiated for breast cancer. The progression of symptoms is gradual in about two-thirds of cases; the patients may initially present with paresthesia followed by pain, and later progress to motor weakness in the affected limb. We present the case of a 68-year-old female patient with breast cancer submitted to surgery, chemotherapy, and radiotherapy in the year 2000. Eighteen years later, she developed symptoms and signs compatible with RIBPN and was successfully submitted to omentoplasty for pain control. Omentoplasty is an alternative treatment for RIBPN refractory to conservative treatment, which seems to be effective in improving neuropathic pain. However, postoperative worsening of the motor strength is a real possibility, and all candidates for this type of surgery must be informed about the risk of this complication.

Prolonged brachial plexopathy following interscalene block for shoulder arthroplasty / Plexopatía braquial prolongada después de un bloqueo interescalénico en cirugía de hombro

Abstract Interscalene block (ISB) is the brachial plexus approach most frequently used in shoulder surgery, providing better postoperative analgesia and reducing the need for rescue morphine compared to general anesthesia. While it is considered a safe block, it has been associated with a relatively high rate of complications, the most serious of which are postoperative neurologic symptoms, such as paresthesia, dysesthesia, and reduced sensitivity. We present the case of a patient with prolonged neurological deficit lasting 4 months following nerve stimulation-guided ISB. Due to the multifactorial nature of postoperative neurological lesions, it can be difficult to determine their etiology. In our case, the brachial plexopathy was probably due to the administration of local anesthetic through the perineurium. We discuss possible causes and argue for the use of ultrasound associated with nerve stimulation when an ISB is performed in order to reduce the incidence of nerve puncture.

Resumen El bloqueo Interescalénico (BIE) es el abordaje al plexo braquial usado con mayor frecuencia en cirugía de hombro, que permite una mejor analgesia postoperatoria y reduce la necesidad de morfina de rescate, en comparación con la anestesia general. Si bien es cierto que se considera un bloqueo seguro, se ha asociado a una tasa de complicaciones relativamente alta, siendo la complicación más seria los síntomas neurológicos postoperatorios (SNPO), tales como parestesia, disestesia, y pérdida de la sensibilidad. Presentamos el caso de un paciente con déficit neurológico prolongado de 4 meses de duración, luego de BIE guiado por neuroestimulación. Debido a la naturaleza multifactorial de las lesiones neurológicas postoperatorias, puede ser difícil determinar su etiología. En nuestro caso, la plexopatía braquial se debió posiblemente a la administración de anestésico local (AL) a través del perineuro. Hacemos referencia a las posible causas y la opción de ultrasonido asociado a la neuroestimulación cuando se realiza un bloqueo interescalénico, a fin de reducir la incidencia de punción del nervio.

Use of magnetic resonance imaging to diagnose brachial plexus injuries / Uso da ressonância magnética para o diagnóstico das lesões do plexo braquial

ABSTRACT Objective: To compare magnetic resonance imaging and intraoperative findings in patients diagnosed with traumatic injury to the brachial plexus. Methods: Patients with a diagnosis of traumatic injury to the brachial plexus admitted to the hand and microsurgery outpatient consult of the Hospital das Clínicas at the University of São Paulo were selected during December 2016. A total of three adult patients with up to six months of injury who underwent surgical treatment were included in the study. A diffusion-weighted sequence magnetic resonance protocol and fluid-sensitive volumetric reformatting sequence were applied. The magnetic resonance results were compared with the diagnoses obtained from the injuries observed during the surgery. The study was double-blind (surgeon and radiologist). Results: A descriptive correlation was found between the magnetic resonance imaging results and the diagnostic findings from the surgeries, for both pre- and post-ganglionic injuries. Conclusion: Magnetic resonance imaging has shown to be a promising diagnostic method in preoperative assessment of brachial plexus lesions; it is less invasive than other common methods, showing not only avulsion lesions but also localized postganglionic lesions in the supra- and infraclavicular region. Level of Evidence III; Diagnostic studies - Investigating a diagnostic test.

RESUMO Objetivo: Comparar resultados de ressonância magnética e achados intraoperatórios de pacientes com diagnóstico de lesão traumática do plexo braquial. Métodos: Foram selecionados pacientes com diagnóstico de lesão traumática do plexo braquial admitidos no ambulatório de mão e microcirurgia do Hospital das Clínicas de São Paulo no mês de dezembro de 2016. Foram incluídos pacientes adultos com até seis meses de lesão que seriam submetidos a tratamento cirúrgico, totalizando três para o estudo. Foi aplicado um protocolo de ressonância magnética com sequência ponderada em difusão e sequência com reformatação volumétrica fluido-sensível. Os resultados da ressonância magnética foram comparados com os diagnósticos das lesões obtidos na cirurgia. O estudo foi duplo-cego (cirurgião e radiologista). Resultados: Houve correlação em termos descritivos entre os laudos das ressonâncias magnéticas e os achados diagnósticos das cirurgias, tanto para as lesões pré como pós-ganglionares. Conclusão: A ressonância magnética mostrou ser um método diagnóstico promissor na avaliação pré-operatória das lesões do plexo braquial, sendo menos invasiva que os outros métodos mais utilizados, permitindo o estudo não somente das lesões por avulsão, mas também das lesões pós-ganglionares localizadas na região supra e infraclavicular. Nível de Evidência III; Estudos diagnósticos - Investigação de um exame para diagnóstico.

Augusta Marie Déjerine-Klumpke: much more than just Déjerine's wife / Augusta Marie Déjerine-Klumpke: muito mais do que apenas a esposa de Déjerine

ABSTRACT Augusta Marie Déjerine-Klumpke (1859-1927) was a formidable neurologist, neuroanatomist and researcher in France. One of the first women to be accepted for medical internship, externship and research in Paris, Augusta made her name studying and teaching anatomy, histology and dissection, attending clinical activities in neurology, obstetrics, pediatrics and neurologic trauma, performing necropsies, and writing scientific papers and book chapters. Her main research in neurology awarded her an eponym for the avulsion of the lowest root of the brachial plexus (Klumpke's palsy). Married to her professor, the remarkable Dr. Joseph Jules Déjerine, Augusta continued her career and became the first female president of the French Society of Neurology.

RESUMO Augusta Marie Déjerine-Klumpke (1859-1927) foi uma formidável neurologista, neuroanatomista e pesquisadora na França. Uma das primeiras mulheres aceitas para estágios médicos internos e externos ao hospital, e pesquisa em Paris, Augusta fez seu nome estudando e ensinando anatomia, histologia e dissecção, participando de atividades clínicas em neurologia, obstetrícia, pediatria e trauma neurológico, participando de necrópsias, e escrevendo artigos científicos e capítulos de livros. Sua principal pesquisa em neurologia lhe rendeu um epônimo para a avulsão da raiz inferior do plexo braquial (paralisia de Klumpke). Casada com seu professor, o notável Dr. Joseph Jules Déjerine, Augusta continuou sua carreira e se tornou a primeira mulher presidente da Sociedade Francesa de Neurologia.

Elective amputation of the upper limb is an option in the treatment of traumatic injuries of the brachial plexus? / A amputação eletiva do membro superior é uma opção no tratamento das lesões traumáticas do plexo braquial?

ABSTRACT The treatment of complete post-traumatic brachial plexus palsy resulting in a flail shoulder and upper extremity remains a challenge to peripheral nerve surgeons. The option of upper limb amputation is controversial and scarcely discussed in the literature. We believe that elective amputation still has a role in the treatment of select cases. The pros and cons of the procedure should be intensely discussed with the patient by a multidisciplinary team. Better outcomes are usually achieved in active patients who strongly advocate for the procedure.

RESUMO O tratamento das paralisias completas após lesões traumáticas do plexo braquial que resultam em um membro superior completamente paralisado permanecem como um desafio aos cirurgiões de nervos periféricos. A opção de amputar o membro superior é controversa e raramente discutida na literatura. Acreditamos que a amputação eletiva ainda tem utilidade no tratamento de casos selecionados. Os prós e contras do procedimento devem ser intensamente discutidos com o paciente por uma equipe multidisciplinar. Os melhores resultados são geralmente obtidos em pacientes atuantes que reivindicam vigorosamente o procedimento.

Correlation between the elbow flexion and the hand and wrist flexion after neurotization of the fascicles of the ulnar nerve to the motor branch to the biceps / Correlação da flexão do cotovelo com a flexão da mão e do punho após neurotização dos fascículos do nervo ulnar para ramo motor do bíceps

ABSTRACT OBJECTIVE: Gain in elbow flexion in patients with brachial plexus injury is extremely important. The transfer of a fascicle from the ulnar nerve to the motor branch of the musculocutaneous nerve (Oberlin surgery) is a treatment option. However, in some patients, gain in elbow flexion is associated with wrist and finger flexion. This study aimed to assess the frequency of this association and the functional behavior of the limb. METHODS: Case-control study of 18 patients who underwent the Oberlin surgery. Group 1 included patients without disassociation of range of elbow flexion and that of the fingers and wrist; Group 2 included patients in whom this disassociation was present. In the functional evaluation, the Sollerman and DASH tests were used. RESULTS: It was observed that 38.89% of the patients did not present disassociation of elbow flexion with flexion of the wrist and fingers. Despite the existence of a favorable difference in the group with disassociation of the movement, when the Sollerman protocol was applied to the comparison between both groups, this difference was not statistically significant. With the DASH test, however, there was a statistically significant difference in favor of the group of patients who managed to disassociate the movement. CONCLUSION: The association of elbow flexion with flexion of the wrist and fingers, in the group studied, was shown to be a frequent event, which influenced the functional result of the affected limb.

RESUMO OBJETIVO: O ganho da flexão do cotovelo em pacientes com lesão no plexo braquial é de suma importância. A cirurgia de transferência de fascículo do nervo ulnar para ramo motor do nervo musculocutâneo (cirurgia de Oberlin) é uma opção de tratamento. Contudo, o ganho da flexão do cotovelo, em alguns pacientes, vem associado à flexão do punho e dos dedos. O objetivo deste trabalho é avaliar a frequência dessa associação e o comprometimento funcional do membro. MÉTODOS: Estudo tipo caso-controle de 18 pacientes submetidos à cirurgia de Oberlin. No Grupo 1 foram incluídos os pacientes que não apresentavam dissociação do ganho da flexão do cotovelo com a dos dedos e do punho; no Grupo 2, os pacientes em que havia dissociação. Os testes de Sollerman e Disabilities of the Arm, Shoulder and Hand (Dash) foram usados na avaliação funcional. RESULTADOS: Observou-se que 38,89% dos pacientes não dissociavam flexão de cotovelo de flexão de punho e dos dedos. Apesar de existir uma diferença favorável ao grupo que dissociava o movimento quando aplicado o protocolo de Sollerman na comparação entre os pacientes dos dois grupos, essa não se mostrou estatisticamente significante. Já no teste Dash, observou-se diferença estatisticamente significante, favorável ao grupo de pacientes que consegue dissociar o movimento. CONCLUSÃO: A associação da flexão do cotovelo com a flexão de punho e dos dedos no grupo estudado mostrou ser um evento frequente, teve influência no resultado funcional do membro acometido.

The optimal visualization of brachial plexus with utilization of nerve-sheath signal increased with inked rest-tissue rapid acquisition of relaxation imaging MR neurography and initial dignostic application / 中华放射学杂志

Objective To assess the optimal visiualization capacity of brachial plexus with three-dimensional nerve-sheath signal increased with inked rest-tissue rapid acquisition of relaxation imaging (3D SHINKEI), exploring the feasibility of preliminary diagnostic value on brachial plexus diseases. Methods MRI scans were performed on 24 healthy volunteers with no history of brachial plexus injury, and 46 patients whose outcomes of lesions had been verified as post-ganglionic brachial plexus injuries by surgery or clinical follows-up . The scan series consist 3D SHINKEI, STIR in the coronal plane as well as DW-MRN in the axial plane using a 3.0 T MR system. The source and post-processed images of 3D SHINKEI and DW-MRN were scored according to the optimal visibility on brachial plexus, in the meanwhile, contrast-to-noise ratio of the original images in the 3D SHINKEI and STIR sequences were calculated separately. Two radiologists blindly compared the detection rate of positive brachial plexus injuries between 3D SHINKEI and STIR in 46 patients. And then analyze the outcomes by means of Kappa test, Mann-Whitney test , independent sample t test, and Chi-square test. Results Post-ganglionic brachial plexus showed high intensity in the 3D SHINKEI sequence. In the 24 healthy volunteers, the scores by the two radiologists were 3.6 ± 0.6, 3.5 ± 0.6, 3.0 ± 0.2, 2.9 ± 0.1, respectively. There was statistical difference between the two sequences (Z=2.667,P=0.008,P<0.05). And the Kappa was 0.8 and 0.6 with favorable consistency. The CNR of 3D SHINKEI and STIR were 0.61 ± 0.07, 0.42 ± 0.03 (t=12.78, P=0.001, P<0.05). The positive detection rates of post-ganglionic brachial plexus injuries on 3D SKINKEI and STIR were, 78.3%, 52.2%(χ2=9.421, P<0.05). Conclusions 3D SHINKEI sequence demonstrates robust visibility consistently and can clearly display the structures and signals of post-ganglionic abnormality, compared with DW-MRN and STIR. This technique can be helpful to provide more complementary information to further confirm the diagnosis of brachial plexus injuries.

Imaging assessment of glenohumeral dysplasia secondary to brachial plexus birth palsy / Avaliação de imagens de displasia glenoumeral secundária a paralisia obstétrica do plexo braquial

Abstract Objective: To assess imaging parameters related to the morphology of the glenohumeral joint in children with unilateral brachial plexus birth palsy (BPBP), in comparison with those obtained for healthy shoulders. Materials and Methods: We conducted a retrospective search for cases of unilateral BPBP diagnosed at our facility. Only patients with a clinical diagnosis of unilateral BPBP were included, and the final study sample consisted of 10 consecutive patients who were assessed with cross-sectional imaging. The glenoid version, the translation of the humeral head, and the degrees of glenohumeral dysplasia were assessed. Results: The mean diameter of the affected humeral heads was 1.93 cm, compared with 2.33 cm for those of the normal limbs. In two cases, there was no significant posterior displacement of the humeral head, five cases showed posterior subluxation of the humeral head, and the remaining three cases showed total luxation of the humeral head. The mean glenoid version angle of the affected limbs (90-α) was -9.6º, versus +1.6º for the normal, contralateral limbs. Conclusion: The main deformities found in this study were BPBP-associated retroversion of the glenoid cavity, developmental delay of the humeral head, and posterior translation of the humeral head.

Resumo Objetivo: Avaliar os parâmetros de imagem relacionados com a morfologia da articulação glenoumeral em crianças com paralisia obstétrica do plexo braquial (POPB) unilateral, comparando-os com os observados em ombros saudáveis. Materiais e Métodos: Foi realizada uma busca retrospectiva de casos de POPB unilateral diagnosticados em nossa instituição. Somente foram incluídos os pacientes com diagnóstico clínico de POPB unilateral, e a amostra final do estudo consistiu em 10 pacientes consecutivos avaliados por meio de imagens transversais. Foram avaliados a retroversão da cavidade glenoide, a translação da cabeça do úmero e o grau de displasia glenoumeral. Resultados: A média do diâmetro da cabeça do úmero foi 1,93 cm nos membros afetados e 2,33 cm nos membros normais. Em dois casos, não houve deslocamento posterior significativo da cabeça do úmero, cinco casos apresentaram subluxação posterior da cabeça do úmero, e os três casos restantes apresentaram luxação total da cabeça do úmero. A média do ângulo de retroversão glenoide dos membros afetados (90-α) foi -9,6º, ao passo que a dos membros contralaterais normais foi +1,6º. Conclusão: As principais deformidades encontradas neste estudo foram retroversão da cavidade glenoide relacionada com POPB, atraso no desenvolvimento da cabeça do úmero e translação posterior da cabeça do úmero.

Chordata method combined with electrotherapy in functional recovery after brachial plexus injury: report of three clinical cases / Método Chordata combinado com eletroterapia na recuperação funcional após lesão do plexo braquial: relato de três casos clínicos

AIMS: To report three clinical cases of complex brachial plexus injury treated with an innovative physical therapy program, the Chordata Method, combined with electrotherapy. CASE DESCRIPTION: Three patients suffered a complex brachial plexus injury. They were submitted to surgery and to long-term rehabilitation with the Chordata method (including suspension and tilting exercises) combined with electrotherapy. All patients exhibited significant signs of recovery in post-treatment electroneuromyography. Moreover, improvements in muscle strength and in the range of motion of the injured upper limb were also observed, leading to better posture and gains in activities of daily living (e.g., driving a modified car, holding objects, performing household chores, and doing leisure activities). CONSLUSIONS: There was great functional recovery after the physical therapy program with the Chordata Method combined with electrotherapy, with an impact on patients' daily lives as well as on electroneuromyography findings. Randomized clinical trials are needed to confirm or refute this new non-pharmacological strategy for the treatment of brachial plexus injuries.

OBJETIVOS: Descrever três casos clínicos em que os indivíduos tiveram lesão de plexo braquial complexa, tratada com um programa inovador de fisioterapia, o Método Chordata, associado à eletroterapia. DESCRIÇÃO DOS CASOS: Três pacientes sofreram lesões complexas do plexo braquial. Os três sujeitos foram submetidos à intervenção cirúrgica e a um longo período de reabilitação com o emprego do método Chordata (envolvendo exercícios de suspensão e pendulação corporal), combinada com a eletroterapia. Todos os pacientes apresentaram sinais significativos de recuperação na eletroneuromiografia pós-tratamento. Além disso, os três também apresentaram melhora na força muscular e nas amplitudes de movimento do membro superior acometido. Observou-se melhor postura e ganhos importantes nas atividades de vida diária (tais como dirigir um carro modificado, segurar objetos, realizar tarefas domésticas e atividades de lazer). CONCLUSÕES: Os resultados revelaram uma importante recuperação funcional após o programa de fisioterapia com o Método Chordata associado à eletroterapia, com impacto na vida diária dos pacientes, bem como nos achados eletroneuromiográficos. Ensaios clínicos randomizados são necessários para confirmar ou refutar esta nova estratégia terapêutica não farmacológica nas lesões de plexo braquial.

Risk factors and clinical prediction of shoulder dystocia in non-macrosomia / 中华妇产科杂志

Objective To investigate the risk factors,clinical prediction and intrapartum management of shoulder dystocia in non-macrosomia.Methods Totally 7 811 cases of vaginal delivery were retrospectively reviewed from Juanary 2009 to December 2013 in Shengjing Hospital.Shoulder dystocia was found in 11 cases (0.14％,11/7 811),including 1 case of macrosomia and l0 cases of non-macrosomia (shoulder dystocia group).Each non-macrosomia shoulder dystocia case was matched with 10 cases of normal delivery in the same week,which were selected randomly as the control group.The tendency and risk factors of shoulder dystocia in macrosomia and non-macrosomia were analyzed,and the following data between the two groups were compared,including the height of uterus fundus,abdominal circumference of the pregnant woman,the increasing of body mass index(BMI),fetal biparietal diameter (BPD),fetal femur length (FL),duration of every stage of labor,birth weight of the newborn,head circumference and chest circumference of the newborn,Apgar score.Results (1) There were 213 macrosomias among the 7 811 vaginal deliveries,with the incidence of 2.73％ (213/7 811).Only 1 shoulder dystocia was macrosomia (0.46％,1/213); while the other 10 cases were non-macrosomia (0.13％,10/7 598).(2) From 2009 to 2013,the macrosomia happened by 24 cases (2.32％,24/1 034),42 cases (3.61％,42/1 164),46 cases (2.60％,46/1 772),62 cases (3.01％,62/2 060),39 cases (2.19％,39/1781),respectively.The incidence of macrosomia had no significant difference among these 5 years (P＞0.05).The shoulder dystosia occurrence without macrosia in these 5 years were 1 case (0.10％,1/1 034),3 cases (0.26％,3/1 164),2 eases (0.11％,2/1 172),2 cases (0.10％,2/2 060),2 cases (0.11％,1/1 781),respectively.The incidence of shoulder dystocia without macrosomia had no significant difference among these 5 years (P＞0.05).(3) In the should dystocia group,5 cases were complicated with premature rupture of membrane (5/10),4 cases were mother≥ 35 years old (4/10),3 cases were multipara(3/10),3 cases had gestational diabetes mellitus(3/10),3 cases were occiput posterior during the first stage of labor(3/10),3 cases had prolonged second stage of labor (3/10) and 6 cases had routine lateral incision (6/10).In the control group,3 cases were complicated with premature rupture of membrane(3/10); 1 case was mother≥35 years old (1/10); 2 cases were multipara(2/10),3 cases had gestational diabetes mellitus (3/10),1 case had prolonged second stage (1/10) and 7 cases had routine lateral incision (7/10).(4) There were no significant difference in the height of uterus fundus,BMI,BPD,FL,and duration of the first stage of labor between the shoulder dystocia group and the control group (P＞0.05).Compared with the control group,the increasing of BMI [(6.8±3.1) vs (4.8± 1.4) kg/m2],the time of the second stage of labor[(86±65) vs (38±28) minutes] and abdominal circumference[(108±8) vs (101±7) cm] were significantly higher in the shoulder dystosia group (P＜0.05).(5)There were significant difference in the chest circumference of the newborn [(34.0±1.6) vs (32.2±1.9) cm] and the ratio of chest circumference to head circumference of the newborn [(0.99±0.03) vs (0.97±0.03)] between the two groups(P＜0.05).The 1-minute Apgar score of the newborn (7.4±2.8) was significantly lower than the control group (10.0±0.0) (P＜0.01).Clavicular fracture occurred in 3 newborns and brachial plexus injury occurred in 4 newborns in the shoulder dystosia group.Conclusion It is difficult to predict shoulder dystocia in non-macrosomia.Shoulder dystocia of non-macrosomia could be predicted by measurement of the head circumference,chest circumference,the ratio of chest circunfference to head circumference by using prenatal ultrasound.The risk factors may complicated with premature rupture of membrane,abnormal occiput position during the first stage of labor and prolonged second stage of labor.

Clinical application of ultrasound-guided radiofrequency thermocoagulaion in the brachial plexus nerve roots block / 中华医学超声杂志（电子版）

ObjectiveTo explore the clinical application of ultrasound-guided radiofrequency thermocoagulaion in brachial plexus block.MethodsC5-C7 brachial plexus block was performed by 6-13 MHz high-frequency ultrasound probe in 65 patients with cervical spondylotic radiculopathy. Visual analogue scale (VAS) score were compared before and after treatment.ResultsThe brachial plexus was showed clearly in 62 patients; however, 3 patients had to be confi rmed by nerve stimulation positioning. The percentage of successful rate is 100%. There was no operation related nerve injury and other complications. The VAS score of preoperation and 1st, 4th and 12nd week after treatment was 8.67±0.76, 3.58±0.62, 2.46±0.2 and 1.77±0.28, respectively. There were significantly difference between before and after treatment (t=58.71, 6.23, 107.72, allP<0.01).ConclusionThe brachial plexus block using radiofrequency thermocoagulaion combined with ultrasound guidance is a safe and radiation-free treatment and warrants to be promoted in clinical practices.

Parálisis obstétrica del plexo braquial. Revisión del estado actual de la enfermedad / Current concepts concerning obstetric brachial plexus palsy

El presente documento hace una revisión actual de la parálisis obstétrica del plexo braquial; se observan la etiología, aspectos demográficos, diagnóstico, cuándo deben ser observada sin cirugía y cuándo es el momento de operar. La clave de indicación de cirugía está dada cuando no ha habido recuperación del bíceps contra gravedad entre los tres y seis meses de edad. La cirugía está dirigida a la resección del neuroma y la utilización de injertos nerviosos. También tiene cabida en el tratamiento quirúrgico el uso de las transferencias nerviosas o neurotizaciones. La recuperación es lenta y se observaran resultados hasta los dos o tres años después de la cirugía. En los niños mayores de 18 meses, el tratamiento se enfoca, no en la microcirugía, sino en la reconstrucción mediante liberaciones, transferencias tendinosas y osteotomías.

This article presents a review of current concepts in obstetric brachial plexus palsy (OBPP) looking at its aetiology, demographic aspects, diagnosis and when patients should be observed without surgery and when it is time to operate. Surgery is indicated when there has been no recovery of biceps against gravity (active elbow flexion) against gravity between 3 to 6 months of age. Surgery is focused on neuroma resection and the use of nerve grafts. Nerve transfer or neurotisation also has a place in surgical treatment. Recovery is slow and results are usually observed 2 to 3 years after surgery. Treatment in children aged over 18 months will not consist of microsurgery reconstruction but rather tendon transfer, release and osteotomy.

Brachial Plexus Injury as a Complication after Nerve Block or Vessel Puncture

Brachial plexus injury is a potential complication of a brachial plexus block or vessel puncture. It results from direct needle trauma, neurotoxicity of injection agents and hematoma formation. The neurological presentation may range from minor transient pain to severe sensory disturbance or motor loss with poor recovery. The management includes conservative treatment and surgical exploration. Especially if a hematoma forms, it should be removed promptly. Comprehensive knowledge of anatomy and adept skills are crucial to avoid nerve injuries. Whenever possible, the patient should not be heavily sedated and should be encouraged to immediately inform the doctor of any experience of numbness/paresthesia during the nerve block or vessel puncture.

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

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.

Brachial Plexus Neuritis Associated With Streptococcus agalactiae Infection: A Case Report

Brachial plexus neuritis is reportedly caused by various factors; however, it has not been described in association with Streptococcus agalactiae. This is a case report of a patient diagnosed with brachial plexus neuritis associated with pyogenic arthritis of the shoulder. A 57-year-old man visited the hospital complaining of sudden weakness and painful swelling of the left arm. The diagnosis was pyogenic arthritis of the left shoulder, and the patient was treated with open irrigation and debridement accompanied by intravenous antibiotic therapy. S. agalactiae was isolated from a wound culture, and an electrodiagnostic study showed brachial plexopathy involving the left upper and middle trunk. Nine weeks after onset, muscle strength improved in most of the affected muscles, and an electrodiagnostic study showed signs of reinnervation. In conclusion, S. agalactiae infection can lead to various complications including brachial plexus neuritis.

Three dimensional sampling perfection with application-optimized contrasts by using different flip angle evolutions-short time of the inversion recovery sequence for the post-ganglionic segments of the brachial plexus / 中华放射学杂志

Objective To evaluate the contrast-enhanced 3D sampling perfection with application-optimized contrasts by using different flip angle evolutions-short TI inversion recovery sequence (SPACE-STIR) for the imaging of the post-ganglionic segments of the brachial plexus.Methods Forty-three patients with suspected brachial plexus lesions were examined with 3D SPACE-STIR and contrast-enhanced 3D SPACE-STIR prospectively.Signal-to-noise ratios (SNR),contrast-to-noise ratios (CNR),and the conspicuousness of roots,trunks,divisions and cords of the brachial plexus of the two 3D sequences were retrospectively compared.Statistical analysis was performed by using student t-test and Wilcoxon rank sum test.Results Compared with 3D SPACE-STIR,contrast-enhanced 3D SPACE-STIR provided the similar SNRs (left,37.41 ±7.34 vs 36.27 ±7.66,t =1.574,P =0.123,right,43.85 ±9.56 vs 42.34 ±9.74,t =1.937,P =0.073),but significantly higher nerve-to-muscle CNRs (left,24.01 ± 6.31 vs 26.39 ± 6.95,right,29.31 ± 7.84 vs 31.77 ± 8.85,t =-3.278,-3.278,both P ＜ 0.01) and nerve-to-lymph gland CNRs(left,-0.84 ± 10.51 vs 15.35 ±8.02,right,-8.47 ± 10.85 vs 19.30 ± 10.35,t =-15.984,-15.651,both P ＜0.01).The conspicuousness of roots and trunks on contrast-enhanced 3D SPACE-STIR was significantly better than that on 3D SPACE-STIR (Z =-3.606,-4.472,P ＜ 0.01),while the conspicuousness of divisions and cords was similar(Z =-1.732,-1.414,P =0.083,0.157).The signal intensity of neoplastic lesions on contrast-enhanced 3D SPACE-STIR tended to decrease rapidly,thus the lesion conspicuousness was worse than that on 3D SPACE-STIR.Conclusions Contrast-enhanced 3D SPACE-STIR has obvious advantages in displaying normal brachial plexus and revealing non-neoplastic lesions of the brachial plexus,but may be insufficient for the diagnosis of neoplastic lesions of the brachial plexus.

Application of MRI in common non-traumatic brachial plexopathies / 中华放射学杂志

Objective To evaluate the MRI application in the common non-traumatic brachial plexopathies.Methods Twenty-seven patients with non-traumatic brachial plexopathies were retrospectively analyzed,which consisted of 10 males and 17 females with age range from 22 to 70 years old.Among the patients,2 were neurofibromatosis,8 were schwannoma,3 were metastases,2 were radiation plexopathy,1 was multifocal motor neuropathy (MMN),and 11 were typical thoracic outlet syndrome (TOS).Before treatment,all patients underwent MRI of brachial plexus,in which 8 patients underwent Gd-DTPA enhanced MRI.Results In 2 cases of neurofibromatosis,the tumors appeared as fusiform,bead-like masses,growing along the course of brachial plexus with involvement of rootlets in vertebral canal,and iso-to little hypointensity on T1WI,inhomogeneous hyperintensity on T2WI and inhomogeneously enhanced.Schwannoma of 8 cases displayed as fusiform mass,eccentric to the original nerve with sharply defined edge,and hypointensity or inhomogeneous hyperintensity on T1WI,inhomogeneous hyperintensity on T2WI with cystic necrosis in 3 cases which was inhomogeneously enhanced.Two of the 3 cases of metastases manifested as multiple masses besides brachial plexus,the other one appeared as widespread lesion infiltrating brachial plexus and surrounding structures.Two cases of radiation plexopathy displayed as diffused thickened nerves,with increased signal intensity on short time inversion recovery (STIR),clear structure and no mass surrounding the plexus.One case of MMN showed thickened nerves with increased signal intensity on STIR.Eleven cases of typical TOS manifested as arched elevation of C8,T1 and inferior trunk,with thickened nerves and increased signal intensity on STIR.Elevated subclavian artery could be seen in 8 cases.And in one case of TOS,a mass in the end of cervical rib compressed the local brachial plexus.Conclusions MRI can clearly show the location,involved scope and the relationship with adjacent structures.So MRI can provide reliable information for clinical diagnosis and treatment.

Percutaneous T2 and T3 Radiofrequency Sympathectomy for Complex Regional Pain Syndrome Secondary to Brachial Plexus Injury: A Case Series

Complex regional pain syndrome secondary to brachial plexus injury is often severe, debilitating and difficult to manage. Percuteneous radiofrequency sympathectomy is a relatively new technique, which has shown promising results in various chronic pain disorders. We present four consecutive patients with complex regional pain syndrome secondary to brachial plexus injury for more than 6 months duration, who had undergone percutaneous T2 and T3 radiofrequency sympathectomy after a diagnostic block. All four patients experienced minimal pain relief with conservative treatment and stellate ganglion blockade. An acceptable 6 month pain relief was achieved in all 4 patients where pain score remained less than 50% than that of initial score and all oral analgesics were able to be tapered down. There were no complications attributed to this procedure were reported. From this case series, percutaneous T2 and T3 radiofrequency sympathectomy might play a significant role in multi-modal approach of CRPS management.