Nerve Autograft: Preservation of a Lost Art.

Nerve autografts involve the transplantation of a segment of the patient's own nerve to bridge a nerve gap. Autografts provide biological compatibility, support for axonal regeneration, and the ability to provide an anatomic scaffold for regrowth that other modalities may not match. Disadvantages of the autograft include donor site morbidity and the extra operative time needed to harvest the graft. Nevertheless, nerve autografts such as the sural nerve remain the gold standard in reconstructing nerve gaps, but a multitude of factors need to be favorable in order to garner reliable, consistent outcomes.

Biomechanical characterization of cadaveric brachial plexus microstructure.

INTRODUCTION: Peripheral nerves consist of axons and connective tissue. The amount of connective tissue in peripheral nerves such as the brachial plexus varies proximally to distally. The proximal regions of the brachial plexus are more susceptible to stretch injuries than the distal regions. A description of the mechanical behavior of the peripheral nerve components is necessary to better understand the deformation mechanisms during stretch injuries. The purpose of this study was to model the biomechanical behavior of each component of the peripheral nerves (fascicles, connective tissue) in a cadaveric model and report differences in elastic modulus, maximum stress and maximum strain. METHODS: Forty-six specimens of fascicles and epi-perineurium were subjected to cyclical uniaxial tensile tests to obtain the stress and strain histories of each specimen, using a BOSE® Electroforce® 3330 and INSTRON® 5969 materials testing machines. Maximum stress, maximum strain and elastic modulus were extracted from the load-displacement and stress-strain curves, and analyzed using Mann-Whitney tests. RESULTS: Mean elastic modulus was 6.34 MPa for fascicles, and 32.1 MPa for connective tissue. The differences in elastic modulus and maximum stress between fascicles and connective tissue were statistically significant (p < 0.001). CONCLUSIONS: Peripheral nerve connective tissue showed significantly higher elastic modulus and maximum stress than fascicles. These data confirm the greater fragility of axons compared to connective tissue, suggesting that the greater susceptibility to stretch injury in proximal regions of the brachial plexus might be related to the smaller amount of connective tissue.

Biomechanical characterization of cadaveric brachial plexus regions using uniaxial tensile tests.

INTRODUCTION: The proximal regions of the brachial plexus (roots, trunks) are more susceptible to permanent damage due to stretch injuries than the distal regions (cords, terminal branches). A better description of brachial plexus mechanical behavior is necessary to better understand deformation mechanisms in stretch injury. The purpose of this study was to model the biomechanical behavior of each portion of the brachial plexus (roots, trunks, cords, peripheral nerves) in a cadaveric model and report differences in elastic modulus, maximum stress and maximum strain. METHODS: Eight cadaveric plexi, divided into 47 segments according to regions of interest, underwent cyclical uniaxial tensile tests, using a BOSE® Electroforce® 3330 and INSTRON® 5969 material testing machines, to obtain the stress and strain histories of each specimen. Maximum stress, maximum strain and elastic modulus were extracted from the load-displacement and stress-strain curves. Statistical analyses used 1-way ANOVA with post-hoc Tukey HSD (Honestly Significant Difference) and Mann-Whitney tests. RESULTS: Mean elastic modulus was 8.65 MPa for roots, 8.82 MPa for trunks, 22.44 MPa for cords, and 26.43 MPa for peripheral nerves. Differences in elastic modulus and in maximum stress were statistically significant (p < 0.001) between proximal (roots, trunks) and distal (cords, peripheral nerves) specimens. CONCLUSIONS: Proximal structures demonstrated significantly smaller elastic modulus and maximum stress than distal structures. These data confirm the greater fragility of proximal regions of the brachial plexus.

Are Patients With Adult Traumatic Brachial Plexus Injuries Satisfied With Their Appearance?

PURPOSE: Adult traumatic brachial plexus injuries (tBPI) are devastating physically and emotionally. In addition to the physical loss of function and pervasive neuropathic pain, patients describe difficulty with negative self-image and social relationships. Our goal was to gain an initial understanding of body image and satisfaction with appearance among tBPI patients. METHODS: Among 126 patients in a prospective cohort study, 60 completed a brachial plexus injury-specific modification of the Satisfaction with Appearance survey. The survey encompasses three major domains: social discomfort because of the affected limb, interference with relationships because of the affected limb, and appearance of the affected limb. We performed a cross-sectional descriptive analysis to provide an initial understanding of these domains among brachial plexus injury patients. RESULTS: Among all 60 patients, nearly half (27/60, 45%) reported they are satisfied with their overall appearance. The appearance of their affected hand(s) was the body part with which patients expressed the most concern. Patients also reported feeling increasingly uncomfortable among those less familiar to them: 11/60 (18%) were uncomfortable around family, 18/60 (30%) were uncomfortable around friends, and 19/60 (32%) were uncomfortable around strangers. One-quarter (15/60, 25%) of brachial plexus injury patients agreed that their injury interfered with relationships and that their tBPI was unattractive (16/60, 27%) to others. CONCLUSIONS: Almost half of patients who have experienced tBPI endorse dissatisfaction with their appearance, which can subsequently interfere with their personal relationships. Further, tBPI may influence patients' comfort levels in unfamiliar social surroundings and may influence how patients feel they are perceived by others. CLINICAL RELEVANCE: The patient's perception of their affected limb and its influence on their daily social interactions should be recognized by their tBPI care team, noting opportunities for improved counseling.

Supinator to Anterior Interosseous Nerve Transfer to Restore Finger Flexion in Spinal Cord and Peripheral Nerve Injury.

PURPOSE: Restoration of pinch and grasp is a chief concern of patients with cervical spinal cord injury or peripheral nerve injury involving the anterior interosseous nerve (AIN). We hypothesize that supinator nerve-to-AIN (Sup-AIN) nerve transfer is a viable option for AIN neurotization. METHODS: We performed a retrospective review of patients who received Sup-AIN. Reported outcomes included Medical Research Council strength of the flexor digitorum profundus and flexor pollicis longus and passive range of digit motion. Patients with <12 months of follow-up were excluded. RESULTS: Eleven patients underwent Sup-AIN, eight with peripheral nerve injury, and three with spinal cord injury. Three patients were excluded because of insufficient follow-up. Average follow-up was 17 months (range: 12-25 months). Six patients had M4 recovery (75%), one patient had M3 recovery (12.5%), and one did not recover function because of severe stiffness (12.5%). We observed no complications or donor site morbidity in our patients. CONCLUSIONS: The Sup-AIN nerve transfer is an effective option to restore digital flexion in patients with peripheral nerve injury or spinal cord injury involving the AIN motor distribution. In comparison to previously described extensor carpi radialis brevis to AIN and brachialis to AIN nerve transfers, Sup-AIN offers the benefits of a more expendable donor nerve and shorter regenerative distance, respectively. The one failed Sup-AIN in our series highlights the importance of patient selection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

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.

Abnormal genes and pathways that drive muscle contracture from brachial plexus injuries: Towards machine learning approach.

In order to clarify the pathways closely linked to denervated muscle contracture, this work uses IoMT-enabled healthcare stratergies to examine changes in gene expression patterns inside atrophic muscles following brachial plexus damage. The gene expression Omnibus (GEO) database searching was used to locate the dataset GSE137606, which is connected to brachial plexus injuries. Strict criteria (|logFC|≥2 & adj.p <0.05) were used to extract differentially expressed genes (DEGs). To identify dysregulated activities and pathways in denervated muscles, gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis, and Gene Set Enrichment Analysis (GSEA) were used. Hub genes were found using Cytoscape software's algorithms, which took into account parameters like as proximity, degree, and MNC. Their expression, enriched pathways, and correlations were then examined. The results showed that 316 DEGs were predominantly concentrated in muscle-related processes such as tissue formation and contraction pathways. Of these, 297 DEGs were highly expressed in denervated muscles, whereas 19 DEGs were weakly expressed. GSEA showed improvements in the contraction of striated and skeletal muscles. In addition, it was shown that in denervated muscles, Myod1, Myog, Myh7, Myl2, Tnnt2, and Tnni1 were elevated hub genes with enriched pathways such adrenergic signaling and tight junction. These results point to possible therapeutic targets for denervated muscular contracture, including Myod1, Myog, Myh7, Myl2, Tnnt2, and Tnni1. This highlights treatment options for this ailment which enhances the mental state of patient.

Diaphragmatic and Pulmonary Functions Following an Ultrasound-Guided Supraclavicular Approach Versus a Costoclavicular Approach of a Brachial Plexus Block: A Randomized Study.

INTRODUCTION: A costoclavicular brachial plexus block is an emerging infraclavicular approach that targets the cords lateral to the axillary artery, providing rapid onset of sensory-motor blockade. However, the incidence of hemi-diaphragmatic paralysis (HDP), a potential complication, remains unclear compared to the widely used supraclavicular (SC) approach. This study aimed to compare the incidence of HDP between ultrasound-guided costoclavicular and SC brachial plexus blocks. OBJECTIVES: To compare the influence of ultrasound-guided SC and costoclavicular brachial plexus blocks on diaphragmatic excursion, thickness, and contractility along with pulmonary function. MATERIALS AND METHODS:  This prospective, randomized, observer-blinded controlled trial included 60 patients undergoing below-shoulder surgeries. Patients were randomized to receive either ultrasound-guided SC (Group S) or costoclavicular (Group C) brachial plexus block with 0.5% levobupivacaine. The diaphragmatic function was assessed using ultrasonographic evaluation of diaphragm thickness and diaphragmatic thickness fraction (DTF) pre- and postblock. Pulmonary function tests (PFTs) (forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and peak expiratory flow rate (PEFR)) were performed preblock and two hours postblock. Block characteristics were compared. RESULTS: The SC group exhibited a significantly larger reduction in DTF from preblock to postblock compared to the costoclavicular group (mean ΔDTF: 34.38% vs. 14.01%, p<0.01). Both groups showed significant declines in FVC, FEV1, and PEFR postblock, but the magnitude of deterioration was significantly greater in the SC group, displaying no significant difference in block characteristics. CONCLUSION: The costoclavicular brachial plexus block demonstrated superior preservation of diaphragmatic contractility and lesser deterioration of PFTs compared to the SC approach while being equally effective. These findings highlight the potential benefits of the costoclavicular technique in minimizing diaphragmatic dysfunction and respiratory impairment, particularly in patients at risk for respiratory complications.

Cords of the Brachial Plexus and Their Branches Positioned Laterally to the Axillary Artery.

The brachial plexus, which supplies the upper limb, extends from the interscalene triangle in the root of the neck to the axilla and is closely related to the subclavian and axillary arteries. Variations in the formation, branching pattern, and relations are profound, and it is generally stated that variant anatomy of the plexus appears to be a rule rather than an exception. In previous studies, it was hypothesized that the anomalous development of the subclavian-axillary stem and the persistence of intersegmental arteries could induce variations in the plexus. In this study, all three cords of the brachial plexus (lateral, medial, and posterior) and their terminal branches are consistently found lateral to the third part of the axillary artery. Most of the studies reported variation in one or the other cord or its branches, but very few studies have reported about all cords lateral to the brachial plexus. The brachial plexus variations are usually also associated with the variations in the branches of the axillary artery, but in this study, no such variation is noted in the branches of the axillary artery. These differences impact the methods of surgery and the application of regional anesthesia. For successful outcomes, it is important to know how neurovascular relationships work, such as where the cords are in relation to the axillary artery. We report an interesting case of all cords and their branches positioned lateral to the axillary artery in the axilla in an adult male cadaver.

Spinal Accessory to Suprascapular Nerve Transfer in Traumatic Brachial Plexus Injury: A Comparative Study of Shoulder Recovery Outcomes in Anterior versus Posterior Approach and Surgeons' Preference.

PROBLEM STATEMENT: Conventionally, neural transfer of SAN to SSN for shoulder abduction in traumatic brachial plexus injury is done via the anterior approach. But important advantages of the posterior approach like the proximity of neural coaptation to the muscle to be reinnervated and negating the effects of a second injury to the suprascapular nerve have made it an alternative option. METHODOLOGY: Retrospective data was collected for a total of 30 SAN to SSN transfer patients of brachial plexus injury in two groups of 15 patients each of anterior (Group A) and posterior approach (Group B) over four years. Functional outcome at the shoulder was measured as muscle power and active range of motion (ROM) at 18 months and data on patients' satisfaction levels and surgeons' perceptions were also collected. RESULTS: No statistical difference was found in the muscle strength achieved in the two groups (p-value = 0.34) but significant recovery was found in the external rotation achieved by group B (p-value = 0.02). Statistical difference was insignificant in the two groups' active ROM during abduction and external rotation. The satisfaction index of patients was 86.7% in the posterior approach compared to 68% in group A. Surgeons' perspective showed a faster speed of suprascapular nerve exploration as perceived in the posterior approach with better visibility of supraspinatus muscle contraction, and overall surgeons' preference for a posterior approach. CONCLUSION: External rotation at the shoulder is better with the posterior approach but no difference in abduction. Patients with the posterior approach were more satisfied with the recovery, and surgeons preferred the posterior approach.

Droopy Shoulder Syndrome: A Gateway to Thoracic Outlet Syndrome.

Droopy shoulder syndrome (DSS) manifests as discomfort or abnormal sensations in the neck, shoulder, chest, and upper limbs, resulting from tension on the brachial plexus caused by abnormally low shoulder positioning. This case report examines the presentation and management of a patient with DSS, a rare but crucial precursor to thoracic outlet syndrome (TOS). The patient, a 22-year-old male, presented with progressive pain and tingling in his left upper limb, shoulder, chest, and neck. Comprehensive examination and imaging studies led to a diagnosis of DSS. Physical therapy prevented progression to full-blown TOS, highlighting the importance of early recognition and intervention. This case underscores the diagnostic challenges and therapeutic strategies essential for managing this syndrome, preventing complications, and restoring patient function.

Clinical Evidence of Retrograde Axonal Growth in Chronic Brachial Plexus Injury.

Nerve axons grow from proximal to distal after axonometric injury; however, they have been seen to regenerate via alternate routes, with some also demonstrating retrograde growth in neuromas. We present the case of a 33-year-old male with a 16-year-old traumatic brachial plexus injury presenting with neuropathic pain and isolated spontaneous recovery. Following a successful pre-operative anaesthetic block, a neurectomy of the median and ulnar nerves was planned for pain relief. Intraoperatively, median nerve stimulation resulted in muscle contractions in the pectoralis major (PM) and extensor carpi radialis brevis (ECRB). This was confirmed by electrical and mechanical stimuli. Histological analysis confirmed the presence of viable axons in the median nerve despite no distal nerve function. Post-surgery motor activity was preserved. A plausible explanation for the intraoperative observations, suggesting neural connectivity between the median nerve and PM and ECRB, would be retrograde growth into various nerve pathways. Alternative explanations such as axonal bifurcation, light anaesthesia, or anatomical variations were considered but the evidence favoured retrograde axonal regrowth. These findings challenge conventional understanding and offer potential new approaches to nerve reconstruction.

Deep Cervical-thoracic Osteolipoma Near the Brachial Plexus - Case Report and Literature Review.

Osteolipoma is a rare benign variant of lipoma and constitutes less than 1% of all lipomas, presenting as a well-circumscribed painless mass. It is a tumor known to occur in several regions, usually intraosseous or adjacent to bone tissue, whose pathogenesis is still unclear. Imaging exams are useful in their evaluation and, mainly, in surgical planning, which consists of tumor excision. However, the definitive diagnosis of osteolipoma is made by histopathological examination. Although benign, osteolipomas can compress surrounding structures, leading to important symptomatology, as in this case reported in which it is in contact with the brachial plexus.

The Outcome of Spinal Accessory Nerve Transfer to the Musculocutaneous Nerve in Birth Brachial Plexus Palsy.

PURPOSE: Patients with brachial plexus birth injury with limited intraplexal donors require the use of extraplexal donors. Concern regarding the potential for respiratory problems resulting from the harvest of intercostal nerves or the phrenic nerve suggests the need for other options. Transfer of the spinal accessory nerve (SAN) is one option for restoring elbow flexion in adult patients; however, there are few reports of the results of this transfer in brachial plexus birth injury. This study aimed to report the result of SAN transfer to the musculocutaneous nerve (MCN) in brachial plexus birth injury. METHODS: Patients who had undergone SAN to MCN nerve transfer were included in this study. Patients were classified according to Narakas classification. The chart was reviewed for the time for recovery of elbow flexion according to the Active Movement Scale (AMS). RESULTS: Eleven patients underwent SAN to MCN transfers with interpositional sural nerve grafts. Mean birthweight was 4,070 grams (range: 3,300-4,670). Mean time to operation was 6.5 months (range: 4-10). Of the 11 patients, two were of Narakas type 3, whereas the others were of type 4. One patient did not recover elbow flexion and underwent later tendon transfer, whereas the other 10 patients reached AMS grade M6 recovery. The median time for AMS grade M1 elbow flexion recovery was eight months (interquartile range: 6.2-8.8) and for AMS grade M5 was 26 months (interquartile range: 14.2-36.5). CONCLUSIONS: Spinal accessory nerve to MCN transfer with an interposition nerve graft is a viable option for restoring elbow flexion. However, long-term outcomes of this procedure have yet to be fully demonstrated. TYPE OF STUDY/LEVEL OF EVIDENCE: Case series IV.

Long-Term Hand and Shoulder Function in Children following Early Surgical Intervention for a Birth-Related Upper Brachial Plexus Injury.

Purpose To better understand the long-term hand and shoulder outcomes of upper brachial plexus birth injuries. Methods We evaluated shoulder and hand function in 32 patients (13 males; 19 females) with a C5/C6 birth injury history). All patients had undergone primary nerve surgery as infants, and 12 underwent a simultaneous shoulder procedure as they presented with a fixed internal rotation contracture of the shoulder. On average, all patients were evaluated and examined 15 years postoperatively. The shoulder function was evaluated using the Miami Shoulder Scale. Hand function was measured by the 9-hole peg test (9-HPT) and statistical analysis included comparison of 9-HPT time against normative data using the Student's t -test. Results The cohort includes 22 right-hand-dominant and 10 left-hand-dominant patients. Mean age at surgery was 10 months; mean age at follow-up was 15 years ± 2 years 2 months. Cumulative shoulder function was "good" or "excellent" (Miami score) in 23 patients. For 9-HPT, 23 out of 32 patients seen had an involved hand with a significant alteration in function. Conclusion Early nerve surgery in cases of upper brachial plexus birth injuries result in the desired outcome. To ensure timely and targeted therapy for any residual deficits, it is imperative that limitations in hand function among children with an Erb's palsy.

The efficacy of ultrasound-guided upper thoracic erector spinae plane block for postoperative analgesia in proximal shoulder surgery and its effect on phrenic nerve function: A prospective exploratory study.

Background and Aims: The upper thoracic (T2) erector spinae plane block (UT-ESPB) has been proposed as an alternative to interscalene brachial plexus block for postoperative analgesia in shoulder surgery. The current study was conducted to evaluate the same. Material and Methods: Patients scheduled for shoulder surgery under general anesthesia (GA) received ultrasound-guided UT-ESPB. The outcomes measured were diaphragmatic movements, block characteristics, and quality of recovery at 24 h. Results: A total of 43 patients were recruited. The incidence of phrenic nerve palsy was 0%. The sensory level achieved by the maximum number of patients at the end of 30 min was C7-T5 level, and none had a motor block. Forty-two percent of patients did not require rescue analgesia till 24 h postoperative. In the rest of the patients, the mean (SD) duration of analgesia was 724.2 ± 486.80 min, and the mean postoperative requirement of fentanyl was 98.80 ± 47.02 µg. The median pain score (NRS) during rest and movement is 2 to 3 and 3 to 4, respectively. The median quality of recovery score at the end of 24 h after the block was 14 (15-14). Conclusion: The upper thoracic ESPB resulted in a sensory loss from C7-T5 dermatomes without any weakness of the diaphragm and upper limb. However, the block was moderately effective in terms of the total duration of analgesia, postoperative pain scores, analgesic requirement, and quality of recovery in patients undergoing proximal shoulder surgeries under GA. Further studies are required to establish its role due to its poor correlation with sensory spread.

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.

A randomised trial comparing block characteristics of a mixture versus sequential injections of lignocaine and ropivacaine for supraclavicular brachial plexus nerve block in patients undergoing upper limb surgery.

Background and Aim: There is no consensus on the appropriate use of mixtures of local anaesthetic drugs in various combinations for nerve blocks. We intended to compare short-acting lignocaine and long-acting ropivacaine as a mixture versus undiluted sequential injections on block characteristics of ultrasound-guided (USG) supraclavicular brachial plexus block for upper limb surgeries. Methods: A double-blinded randomised study was conducted on 64 adult patients scheduled for upper limb surgery who received 15 mL each of 2% lignocaine with adrenaline and 0.75% ropivacaine as a 1:1 mixture in the mixed group (Group M) or sequential injections in the sequential group (Group S) by using a USG technique. The primary outcome was the percentage of participants with complete four nerve sensory blocks at 10 minutes post block injection. Secondary outcomes were sensory and motor block characteristics till 30 minutes, total duration of analgesia, sensory and motor block, and complications. Results: Demographic characteristics and time taken for the procedure were similar. The percentage of participants with a complete four-nerve sensory block at 10 minutes was higher in Group S (69%) versus Group M (41%) (P = 0.04). Complete sensory and motor block rates were similar at 30 minutes. The block procedure time, total duration of analgesia, and sensory and motor block were similar in both groups. There were no major complications. Conclusion: Sequential lignocaine-ropivacaine, compared to the mixed injection technique, has a higher initial rate of sensory and motor block onset with a similar total block duration.

Axillary Brachial Plexus Block Compared with Other Regional Anesthesia Techniques in Distal Upper Limb Surgery: A Systematic Review and Meta-Analysis.

Background: Several regional anesthesia (RA) techniques have been described for distal upper limb surgery. However, the best approach in terms of RA block success rate and safety is not well recognized. Objective: To assess and compare the surgical anesthesia and efficacy of axillary brachial plexus block with other RA techniques for hand and wrist surgery. The attainment of adequate surgical anesthesia 30 min after block placement was considered a primary outcome measure. Additionally, successful block outcomes were required without the use of supplemental local anesthetic injection, systemic opioid analgesia, or the need to convert to general anesthesia. Methods: We performed a systematic search in the following databases: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and CENTRAL. RCTs comparing axillary blocks with other brachial plexus block techniques, distal peripheral forearm nerve block, intravenous RA, and the wide-awake local anesthesia no tourniquet (WALANT) technique were included. Results: In total, 3070 records were reviewed, of which 28 met the inclusion criteria. The meta-analysis of adequate surgical anesthesia showed no significant difference between ultrasound-guided axillary block and supraclavicular block (RR: 0.94 [0.89, 1.00]; p = 0.06; I2 = 60.00%), but a statistically significant difference between ultrasound-guided axillary block and infraclavicular block (RR: 0.92 [0.88, 0.97]; p < 0.01; I2 = 53.00%). Ultrasound-guided infraclavicular blocks were performed faster than ultrasound-guided axillary blocks (SMD: 0.74 [0.30, 1.17]; p < 0.001; I2 = 85.00%). No differences in performance time between ultrasound-guided axillary and supraclavicular blocks were demonstrated. Additionally, adequate surgical anesthesia onset time was not significantly different between ultrasound-guided block approaches: ultrasound-guided axillary blocks versus ultrasound-guided supraclavicular blocks (SMD: 0.52 [-0.14, 1.17]; p = 0.12; I2 = 86.00%); ultrasound-guided axillary blocks versus ultrasound-guided infraclavicular blocks (SMD: 0.21 [-0.49, 0.91]; p = 0.55; I2 = 92.00%). Conclusions: The RA choice should be individualized depending on the patient, procedure, and operator-specific parameters. Compared to ultrasound-guided supraclavicular and infraclavicular block, ultrasound-guided axillary block may be preferred for patients with significant concerns of block-related side effects/complications. High heterogeneity between studies shows the need for more robust RCTs.