Interrater reliability of electrodiagnosis in neonatal brachial plexopathy.

INTRODUCTION: We investigated interrater reliability of overall assessment of nerve root lesions by electrodiagnostic testing (EDX) in neonatal brachial plexus palsy (NBPP). METHODS: Two blinded, board-certified reviewers retrospectively reviewed de-identified EDX data from 37 infants with NBPP for 2005-2012. Only nerve conduction and electromyography needle data were included. The examiners independently assigned 1 of 4 nerve root lesion categories: (1) pre-ganglionic lesion (avulsion), (2) post-ganglionic lesion (rupture), (3) normal, or (4) "unable to determine." Simple percentage agreement, the Cohen kappa statistic representing interrater reliability for each nerve root (C5-T1), and overall kappa between examiners were evaluated. RESULTS: Interrater reliabilities were substantial to almost perfect for each nerve root except C5. Considering all nerve roots, overall interrater reliability was substantial (kappa = 0.62); simple percentage agreement was 75% (138/185). CONCLUSIONS: Interrater reliability of nerve root assessment by EDX for infants with NBPP was high for C6-T1 root levels, but less reliable for C5 because of technical factors. Muscle Nerve 55: 69-73, 2017.

Prostheses and Rehabilitation Principles in Pediatric Limb Deficiency.

Pediatric limb loss or limb deficiency is uncommon in the United Sates occurring 1 per 1943 live births per year, with a ratio of 2:1 upper to lower extremity.1 Causes include congenital limb deficiency, and less frequently, limb loss secondary to trauma, cancer, or other illnesses. Vascular disruption, particularly as seen in amniotic band syndrome, stands as the leading suspect in the multifaceted and intricate causes of congenital limb loss. Children with limb difference and deficiency present unique medical and rehabilitation challenges. Physical Medicine and Rehabilitation (PM&R) physicians are uniquely equipped to navigate these complexities. Prosthetic prescription and fabrication for children require balancing scientific principles with individual needs. A "one-size-fits-all" approach is ineffective. Many diverse factors impact prosthetic prescription and fabrication, including amputation level, residual limb characteristics, cognitive/developmental age, family goals, financial resources, and medical literacy.

Comparative accuracies of electrodiagnostic and imaging studies in neonatal brachial plexus palsy.

OBJECTIVEThe incorporation of ancillary testing in the preoperative setting for patients with neonatal brachial plexus palsy (NBPP) remains controversial, but the recommendation for early nerve reconstruction when a baby has a preganglionic lesion at the lower nerve roots is generally accepted. At some specialty centers, nerve surgeons use preoperative electrodiagnostic testing (EDX) and imaging to aid in lesion localization and the preoperative planning of the nerve reconstruction. EDX and imaging have been evaluated for their abilities to detect pre- and postganglionic lesions, but their accuracies have never been compared directly in the same set of patients. The aim of the present study was to evaluate the accuracy of imaging and EDX in an NBPP population.METHODSA retrospective review was conducted of 54 patients with operative NBPP seen between 2007 and 2017. The patients underwent EDX and imaging: EDX was performed, and the results were reviewed by board-certified electrodiagnosticians, and imaging was reviewed by board-certified neuroradiologists. The gold standard was considered to be the findings at surgical exploration. Descriptive and analytical statistics were utilized to compare the accuracies of imaging and EDX.RESULTSThe mean age at surgery was 6.94 mos (± 4 mos). Fifteen patients (28%) were Narakas grade I-II, and 39 (72%) were Narakas grade III-IV. For all nerve roots, the overall accuracy of detecting preganglionic lesions was 74% for EDX and 69% for imaging. The overall sensitivity of detecting preganglionic lesions by EDX was 31%, but the specificity was 90%. The overall sensitivity of detecting preganglionic lesions by imaging was 66%, and the overall specificity was 70%. However, at C8, EDX was 37.5% sensitive and 87.5% specific, whereas imaging was 67.7% sensitive but only 29.4% specific.CONCLUSIONSEDX outperformed imaging with regard to specificity and accuracy of identifying preganglionic injuries. This finding is especially relevant in the lower nerve roots, given that lower plexus preganglionic lesions are an accepted indication for early intervention.

Clinical predictors of the medical interventions provided to patients with low back pain in the emergency department.

BACKGROUND: Low back pain is a common complaint in emergency departments (ED), where deviations from standard of care have been noted. OBJECTIVE: To relate the ordering of advanced imaging and opioid prescriptions with the presentation of low back pain in ED. METHODS: Six hundred adults with low back pain from three centers were prospectively analyzed for history, examination, diagnosis, and the ordering of tests and treatments. RESULTS: Of 559 cases the onset of pain was less than one week in 79.2%; however, most had prior low back pain, 63.5% having warning signs of a potential serious condition, and 83.9% had psychosocial risk factors. Computer tomography (CT) or magnetic resonance imaging (MRI) were ordered in 16.6%, opioids were prescribed in 52.6%, and hospital admission in 4.5%. A one-year follow-up of 158 patients found 40.8% received subsequent spine care and 5.1% had a medically serious condition. Caucasian race, age 50 years or older, warning signs, and radicular findings were associated with advanced imaging. Severe pain and psychosocial factors were associated with opioid prescribing. CONCLUSIONS: Most patients present to the ED with acute exacerbations of chronic low back pain. Risk factors for a serious condition are common, but rarely do they develop. Racial disparities and psychosocial factors had concerning relationships with clinical decision-making.

Impact of an inpatient rehabilitation facility on functional outcome and length of stay of burn survivors.

This study reviewed the use of an inpatient rehabilitation unit for burn survivors. We hypothesized that adult burn patients admitted earlier to inpatient rehabilitation have an equal or better functional outcome than those remaining in acute burn center for rehabilitation care. Functional Independence Measure (FIM) data were prospectively collected on our burn center admissions dating January 2002 to August 2003. National rehabilitation data were acquired from eRehabData and burn literature. A total of 217 adult patients survived until hospital discharge, with 21 (9.7%) discharged to inpatient rehabilitation (REHAB). REHAB had larger burn injuries, more inhalation injuries, higher incidence hand/foot burns, and longer length of stay (LOS). REHAB had lower FIM upon rehabilitation facility admission than national averages but greater FIM improvement during comparable rehabilitation LOS. Although our earlier rehabilitation admission strategy results in more frequent rehabilitation unit referrals, patients had shorter burn center LOS and greater FIM improvement compared with limited national burn patient functional outcome data currently available.