Preganglionic Injury of C8 Nerve Root Secondary to Shoulder Disloca tion: Diagnosis based on MRI Findings.

INTRODUCTION: Traumatic spinal root injury caused by shoulder dislocation may involve the brachial plexus or, in some cases, a single nerve. The degree of severity of the injury depends on many patient-specific factors as well as the mechanism of injury. It is essential to suspect this type of lesion by means of a thorough physical examination in order to have better patient outcomes. CASE PRESENTATION: We presented the subtle magnetic resonance imaging (MRI) findings in a 35-yearold male with left shoulder trauma and dislocation after falling off a bicycle. He complained of decreased muscle strength and sensitivity in the C8 dermatome. Atrophy of the hypothenar region and flexion deformity of the 4th and 5th digits were noted. Magnetic resonance imaging findings were consistent with a partial preganglionic C8 motor root lesion. We found T2 increased signal intensity and thinning of the intradural segment of the C8 motor nerve root and low signal in the sequence of a multi- echo gradient recalled echo (GRE). CONCLUSION: MRI is a noninvasive tool that allows a detailed anatomical characterization of the nerves. In brachial plexus injuries, the use of the GRE sequence is useful to identify the lesions, even if they are subtle; however, some lesions may go unnoticed. It is important to note that these patients require an interdisciplinary group to reach a correct diagnosis, which is vital to establish the appropriate treatment and follow-up.

Shoulder Arthrodesis for Traumatic Brachial Plexus Injuries: Functional Outcomes and Complications.

BACKGROUND: The external rotation and abduction of shoulder are considered one of the priorities of reconstruction in brachial plexus injury. The aim of this study was to evaluate the functional results and complications of shoulder arthrodesis in patients with brachial plexus injury to better comprehend the benefits of this procedure. METHODS: Between 2015 and 2019, 15 shoulder arthrodesis were performed in patients with long-standing brachial plexus injury. The main indication for arthrodesis was absent or poor recovery of shoulder abduction and external rotation. Patients presented different levels of injury. Shoulder measurements of active abduction and external rotation were made based on image records of the patients. A long 4.5-mm reconstruction plate was fit along the scapular spine, acromion, and lateral proximal third of the humerus. Structured bone graft was fit into the subacromial space. RESULTS: The mean preoperative abduction was 16°, and the mean postoperative abduction was 42°. The mean preoperative external rotation was -59°, and the mean postoperative external rotation was -13°. The mean increase in abduction and external rotation was 25° and 45°, respectively. Bone union was achieved in all cases at an average time of 5.23 months. We experienced humeral fractures in 26.66% of the cases, which were all successfully treated nonoperatively. CONCLUSIONS: Shoulder arthrodesis is a rewarding procedure for patients with brachial plexus injuries. A marked improvement in the upper limb positioning was observed in all patients. It should be considered as the main therapeutic option in cases where nerve reconstruction is no longer possible.

An alternative approach for blocking the superior trunk of the brachial plexus evaluated by a single arm clinical trial

Abstract Background Interscalene brachial plexus block is associated with phrenic nerve paralysis. The objective of this study was to evaluate an alternative approach to interscalene brachial plexus blocks in terms of efficacy, grade of motor and sensory blockade, and phrenic nerve blockade. Methods The study was prospective and interventional. The ten living patients studied were 18 to 65 years old, ASA physical status I or II, and submitted to correction of rotator cuff injury. A superior trunk blockade was performed at the superior trunk below the omohyoid muscle, without blocking the phrenic nerve. The needle was advanced below the prevertebral layer until contacting the superior trunk. In order to guarantee the correct positioning of the needle tip, an intracluster pattern of the spread was visualized. The block was performed with 5 mL of 0.5% bupivacaine in ten patients. In the six cadavers, 5 mL of methylene blue was injected. Diaphragmatic excursion was assessed by ultrasonography of the ipsilateral hemidiaphragm. In three patients, pulmonary ventilation was evaluated with impedance tomography. Pain scores and analgesic consumption were assessed in the recovery room for 6 hours after the blockade. Results In the six cadavers, methylene blue didn't reach the phrenic nerve. Ten patients underwent arthroscopic surgery, and no clinically phrenic nerve paralysis was observed. No patient reported pain during the first 6 hours. Conclusions This study suggests that this new superior trunk approach to block the superior trunk may be an alternative technique to promote analgesia for shoulder surgery in patients with impaired respiratory function.

An alternative approach for blocking the superior trunk of the brachial plexus evaluated by a single arm clinical trial.

BACKGROUND: Interscalene brachial plexus block is associated with phrenic nerve paralysis. The objective of this study was to evaluate an alternative approach to interscalene brachial plexus blocks in terms of efficacy, grade of motor and sensory blockade, and phrenic nerve blockade. METHODS: The study was prospective and interventional. The ten living patients studied were 18 to 65 years old, ASA physical status I or II, and submitted to correction of rotator cuff injury. A superior trunk blockade was performed at the superior trunk below the omohyoid muscle, without blocking the phrenic nerve. The needle was advanced below the prevertebral layer until contacting the superior trunk. In order to guarantee the correct positioning of the needle tip, an intracluster pattern of the spread was visualized. The block was performed with 5.ßmL of 0.5% bupivacaine in ten patients. In the six cadavers, 5.ßmL of methylene blue was injected. Diaphragmatic excursion was assessed by ultrasonography of the ipsilateral hemidiaphragm. In three patients, pulmonary ventilation was evaluated with impedance tomography. Pain scores and analgesic consumption were assessed in the recovery room for 6.ßhours after the blockade. RESULTS: In the six cadavers, methylene blue didn...t reach the phrenic nerve. Ten patients underwent arthroscopic surgery, and no clinically phrenic nerve paralysis was observed. No patient reported pain during the first 6.ßhours. CONCLUSIONS: This study suggests that this new superior trunk approach to block the superior trunk may be an alternative technique to promote analgesia for shoulder surgery in patients with impaired respiratory function.

Anesthesia or analgesia? New block for shoulder surgery: pericapsular nerve group block

Abstract Interscalene brachial plexus (ISB) block is considered the analgesic technique of choice for shoulder surgery. However, the hemidiaphragmatic paresis that may occur after the block has led to the search for an alternative to the ISB block. In this case report, the pericapsular nerve group (PENG) block was performed for both surgical anesthesia and postoperative analgesia in two patients who underwent shoulder surgery. It is suggested that the PENG block can be safely applied for analgesia and can be part of surgical anesthesia, but alone is not sufficient for anesthesia. The block of this area did not cause motor block or pulmonary complications, nor result in muscle laxity, blocking only the shoulder and the upper third of the humerus. It was demonstrated that the PENG block may be safely applied for both partial anesthesia and analgesia in selected shoulder surgery cases.

Origin and distribution of the brachial plexus in kinkajou (Potos flavus - Schreber, 1774).

The kinkajou (Potos flavus) is a carnivoran adapted for arboreal quadrupedal locomotion along with a prehensile tail. The thoracic limb bones and muscles of this species have been studied, but the knowledge about its nerves is still scarce. This knowledge is necessary to perform several veterinary procedures, and to review the differences among carnivoran species. Thus, the objective of this study was to describe the origin and distribution of the brachial plexus in Potos flavus. Thereby, both brachial plexuses of five specimens were dissected (10). Seven plexuses originated from C6-T2 (70%), whilst three plexuses originated from C5-T2 (30%). Additionally, C6 and C7 formed two cranial trunks, and C8, T1 and T2 formed two caudal trunks. All nerves from the brachial plexus that have been reported in carnivorans were successfully located. In addition, we found one nerve reaching the teres major muscle originating directly from the brachial plexus and not from the axillary nerve as reported in other carnivorans. The brachiocephalic nerve was found partially innervating the cleidobrachialis muscle (50%), but this muscle always was innervated by the axillary nerve. Moreover, one to three subscapular nerves were found, and the musculocutaneous nerve formed two communicating branches (proximal and distal) to the median nerve. However, the distal communicating branch of the musculocutaneous nerve was absent in two specimens (40%). In conclusion, the brachial plexus of P. flavus was differentiated mainly with other carnivorans by a higher contribution from T2, formations of trunks, and one independent nerve to the teres major muscle.

Anesthesia or analgesia? New block for shoulder surgery: pericapsular nerve group block.

Interscalene brachial plexus (ISB) block is considered the analgesic technique of choice for shoulder surgery. However, the hemidiaphragmatic paresis that may occur after the block has led to the search for an alternative to the ISB block. In this case report, the pericapsular nerve group (PENG) block was performed for both surgical anesthesia and postoperative analgesia in two patients who underwent shoulder surgery. It is suggested that the PENG block can be safely applied for analgesia and can be part of surgical anesthesia, but alone is not sufficient for anesthesia. The block of this area did not cause motor block or pulmonary complications, nor result in muscle laxity, blocking only the shoulder and the upper third of the humerus. It was demonstrated that the PENG block may be safely applied for both partial anesthesia and analgesia in selected shoulder surgery cases.

The 2-Dimensional and 3-Dimensional Anatomy of the Adult Brachial Plexus Divisions and Cords.

Background: The objective of this work was to perform a critical review of the 2-dimensional and 3-dimensional anatomy of the adult brachial plexus divisions and cords. Methods: Twelve adult brachial plexuses from fresh cadavers were dissected. All were male and aged between 30 and 50 years. Only corpses without brachial plexus injuries were selected. The purpose of the dissections was to identify the origin of the anterior and posterior divisions of the adult brachial plexus in their respective trunks, as well as the positioning of the posterior, lateral, and medial cords. Results: The posterior division of all trunks had a cranial and dorsal origin, while the anterior division of all trunks had a caudal and ventral origin. The posterior cord was the most cranial of all, the lateral cord was central, and the medial cord was the most caudal of all cords. The posterior division of the superior trunk was always between the suprascapular nerve and the anterior division. Conclusions: Brachial plexus diagrams in most textbooks and papers are different from what was found in our dissections. Contrary to the known diagram, the posterior divisions always had a cranial origin in the superior, middle, and inferior trunks.

Functional outcome predictors after spinal accessory nerve to suprascapular nerve transfer for restoration of shoulder abduction in traumatic brachial plexus injuries in adults: the effect of time from injury to surgery.

BACKGROUND: Shoulder abduction is crucial for daily activities, and its restoration is one of the surgical priorities. We evaluated the predictive factors of shoulder abduction functional outcome after spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, with special emphasis on the effect of time from injury to the surgery, in the treatment of traumatic brachial plexus injuries. METHOD: This cohort included adult patients who underwent SAN-to-SSN transfer with a preoperative Medical Research Council strength grade 0 and a follow-up of minimum 18 months. The primary outcome was shoulder abduction function (bad, < 30°; good, 30°-60°; or excellent, > 60°). Demographics, trauma characteristics, time lapse between injury and surgery, concomitant axillary nerve reconstruction, and surgery duration were registered. Ordinal logistic regression was used to identify predictors of functional outcomes. RESULTS: The records of 83 patients (86.7% men, mean age 28.8 ± 9.8 years) were analysed. Mean body mass index was 24.1 ± 3.7 kg/m2, and 43.1% were overweight/obese. Motorcycle crashes were the most common trauma mechanism (88.0%). Excellent, good, and bad outcomes were achieved by 20.4%, 38.6%, and 41.0%, respectively. Older patients tended to have worse outcomes (p = 0.074), as well as left-sided lesions (p = 0.015) or those contralateral to manual dominance (p = 0.057). The longer the interval between injury and surgery the worse the outcome: excellent, 5.5 (4.3-7.1); good, 6.9 (5.9-8.7); and bad, 8.2 (5.7-10.1) months (p = 0.018). After multivariable analysis, longer time interval predicted lower odds of better outcomes (OR 0.823, 95% CI 0.699-0.970, p = 0.020; 17.7% lower odds of good or excellent outcome for each additional month). The odd of good or excellent outcomes was also associated with axillary nerve reconstruction (OR 2.767, 95% CI 1.016-7.536, p = 0.046), but not with age or lesion laterality. CONCLUSIONS: Excellent or good functional outcomes for shoulder abduction were achieved by almost sixty percent of adults who underwent SAN-to-SSN transfer for reconstruction of traumatic brachial plexus injuries, associated or not with axillary nerve reconstruction strategies. Longer delays from injury to surgery predicted worse outcomes, and the best time frame seemed to be less than 6 months.

Transfer of Motor Fascicle From the Median to the Axillary Nerve for Upper Brachial Plexus Injury: A Surgical Technique and Case Report.

Upper brachial plexus injury or isolated lesions of the axillary nerve (AN) compromise shoulder functionality significantly. Different surgical techniques have been described for selective reconstruction of the AN, with good results especially in association with repair of the suprascapular nerve. The objective of this study is to describe the transfer of motor fascicles of the median nerve to the AN by an axillary approach in cadavers and the clinical results in 2 patients. Dissections were performed on 5 cadavers, followed by identification and dissection of the AN and its divisions before entering the quadrangular space. We standardized the surgical technique in which the median nerve was first identified and then an intrafascicular dissection was performed. Then we harvested a fascicle and transferred it to the anterolateral branch of the AN. Two patients underwent an operation; at 2 years of follow-up, average abduction of 125 degrees and external rotation of 95 degrees were observed. In conclusion, the transfer of motor fascicles of the median nerve to the AN by an axillary approach could be an alternative technique for the deltoid reinnervation in upper brachial plexus injury. Some advantages are the proximity of the donor nerve to the receptor nerve and the low morbidity of the target muscles of the donor nerve. Studies with a larger number of patients are required to establish its effectiveness compared with other techniques already described.

Comparative anatomy of the brachial plexus and shoulder nerves of the Sapajus.

BACKGROUND: The capuchin is a neotropical primate that presents easy reproduction in captivity and is used in scientific research. The objective of this work was to describe the structure and the branching pattern of the brachial plexus of the capuchin and to compare the results with data from the literature for humans, chimpanzees, baboons and Callithrix. METHODS: Twelve specimens were used: eight males and four females. No animals were killed for the purpose of this study. RESULTS: The brachial plexus of Sapajus sp was constituted mainly from the ventral roots of the last four cervical spinal nerves, from C5 to C8, mainly, and the first thoracic nerve (T1). CONCLUSIONS: The pattern of formation of the brachial plexus of the capuchin monkey was more similar to that of Callithrix and baboons, perhaps because they are the only primates in this study to be essentially quadrupedal.

[Efficacy of ultrasound guided suprascapular block in patients with chronic shoulder pain: retrospective observational study]. / Eficácia do bloqueio do nervo supraescapular guiado por ultrassom em pacientes com dor crônica no ombro: estudo observacional retrospectivo.

INTRODUCTION: Painful shoulder syndrome is a frequent condition among the elderly and an important cause of functional disability. As the conservative is not always effective, ultrasound guided suprascapular nerve blockade presents as an important alternative treatment. OBJECTIVE: To evaluate the efficacy and safety of the use of 0.25% levobupivacaine and 40 mg of triamcinolone in the suprascapular nerve blockade in patients with chronic pain in the shoulder. METHODS: A retrospective, descriptive and analytical study of 71 patients submitted to suprascapular nerve infiltration between August 2014 and March 2017. Surveys were carried out to patients before the technique was performed, after 72 hours, at 1, 3 and 6 months. Pain intensity was assessed using a numeric pain scale (NPS). RESULTS: Out of the 71 patients who underwent a blockade of the suprascapular nerve, 81.2% reported a decrease in pain at 72 hours. In the first, third and sixth month, respectively, 89.8%, 76.1% and 61.8% of the patients presented pain relief. A statistically significant difference (p<0.001) was verified between NPS and the 4 moments assessed after the technique. 43.7% had total pain remission (NPS=0) at six months. Global effectiveness of suprascapular nerve blockade was 60.6% and for the subgroup of patients with rotators' cuff patology was 62.2%. No complications were reported regarding the suprascapular nerve block. CONCLUSION: The results show that ultrasound-guided blockade of the suprascapular nerve using 0.25% levobupivacaine and 40 mg of triamcinolone is a safe and effective treatment in patients with chronic shoulder pain.

Efficacy of ultrasound guided suprascapular block in patients with chronic shoulder pain: observational, retrospective study / Eficácia do bloqueio do nervo supraescapular guiado por ultrassom em pacientes com dor crônica no ombro: estudo observacional retrospectivo

Abstract Introduction: Painful shoulder syndrome is a frequent condition among the elderly and an important cause of functional disability. As the conservative treatment is not always effective, ultrasound guided suprascapular nerve blockade presents as an important alternative treatment. Objective: To evaluate the efficacy and safety of the use of 0.25% levobupivacaine and 40 mg of triamcinolone in the suprascapular nerve blockade in patients with chronic pain in the shoulder. Methods: A retrospective, descriptive and analytical study of 71 patients submitted to suprascapular nerve infiltration between August 2014 and March 2017. Surveys were carried out to patients before the technique was performed, after 72 hours and at 1, 3 and 6 months. Pain intensity was assessed using a numeric pain scale (NPS). Results: Out of the 71 patients who underwent a blockade of the suprascapular nerve, 81.2% reported a decrease in pain at 72 hours. In the first, third and sixth month, respectively, 89.8%, 76.1% and 61.8% of the patients presented pain relief. A statistically significant difference (p < 0.001) was verified between NPS and the 4 moments assessed after the technique. 43.7% had total pain remission (NPS = 0) at six months. Global effectiveness of suprascapular nerve blockade was 60.6% and for the subgroup of patients with rotators' cuff patology was 62.2%. No complications were reported regarding the suprascapular nerve block. Conclusion: The results show that ultrasound-guided blockade of the suprascapular nerve using 0.25% levobupivacaine and 40 mg of triamcinolone is a safe and effective treatment in patients with chronic shoulder pain.

Resumo Introdução: A síndrome do ombro doloroso é uma condição frequente entre os idosos e uma causa importante de incapacidade funcional na população em geral. O tratamento conservador nem sempre é eficaz, pelo que o bloqueio do nervo supraescapular guiado por ecografia apresenta-se como uma opção de tratamento válida. Objetivo: Avaliação da eficácia e segurança do uso de levobupivacaína a 0,25% e 40 mg de triancinolona no bloqueio do nervo supraescapular ecoguiado em doentes com dor crônica no ombro. Métodos: Realizou-se um estudo retrospectivo observacional, descritivo e analítico com 71 doentes submetidos à infiltração do nervo supraescapular entre agosto de 2014 e março de 2017. Foram aplicados questionários antes da realização da técnica, após 72 horas; 1, 2 e 6 meses. A intensidade da dor foi avaliada usando a Escala de Avaliação Numérica (EAN). Resultados: Dos 71 doentes submetidos ao bloqueio do nervo supraescapular; 81,2% referiram diminuição da dor às 72 horas. Aos primeiro, terceiro e sexto mês, respectivamente 89,8%; 76,1% e 61,8% apresentaram melhoria da dor. Verificou-se uma diferença estatisticamente significativa (p < 0,001), entre a EAN inicial e os 4 momentos após a realização da técnica. 43,7% dos doentes tiveram remissão total da dor (EAN = 0) aos seis meses. A eficácia global do bloqueio do nervo supraescapular foi de 60,6% e, para o subgrupo com patologia da coifa dos rotadores, de 62,2%. Nenhuma complicação do bloqueio do NSE foi registrada. Conclusão: Este estudo mostra que o bloqueio eco-guiado do NSE usando levobupivacaína a 0,25% e 40 mg de triancinolona é um procedimento seguro e eficaz em doentes com dor crônica no ombro.

Functional outcome of spinal accessory nerve transfer to the suprascapular nerve to restore shoulder function: Results in upper and complete traumatic brachial plexus palsy in adults.

BACKGROUND: Shoulder stability, abduction and external rotation are vital for the performance of usual daily tasks. AIMS: To compare the functional outcomes in the shoulder following spinal accessory to suprascapular nerve transfer (SASNT). PATIENTS AND METHODS: Comparison of the outcome of adult patients with upper traumatic brachial plexus palsy undergoing SASNT with patients with complete palsy submitted to the same procedure. STATISTICAL ANALYSIS: Ranges of motion were compared via the Mann-Whitney U test. The percentages of patients with a favorable outcome were compared by the chi-square test. All tests were two-tailed and P values <0.05 were considered statistically significant. RESULTS: SASNT was performed in 76 patients: 23 cases (30.2%) of upper-plexus injuries and 53 cases (69.7%) of complete brachial plexus palsy. Good shoulder abduction was achieved in 15 patients (65.2%) with upper plexus palsy and a good external rotation in 5 (21.7%). In those patients with a good recovery, the average range of motion (ROM) was 53° for shoulder abduction and 71.2° for external rotation. Thirty-six patients (67.9%) with complete palsy had a good shoulder abduction recovery with 30.7° of average ROM, but only 3 patients (5.6%) recovered a good shoulder external rotation with 68.3° of average ROM. There was no statistical difference for the abduction outcome, but the external rotation outcome was superior in the upper plexus palsy group. CONCLUSION: SASNT is a consistent procedure to achieve functional recovery of shoulder abduction after a partial or complete plexus injury, but the outcomes of external rotation were quite disappointing in both the groups.

Safety zone for posterosuperior shoulder access: study on cadavers / Zona de segurança no acesso posterossuperior do ombro: estudo em cadáver

ABSTRACT OBJECTIVE: The posterosuperior shoulder access used in surgical treatment for acromioclavicular dislocation was constructed through dissection of 20 shoulders from 10 recently chilled adult cadavers, and the distances from this route to the nearby neurovascular structures were analyzed. METHODS: A Kirschner wire was introduced into the top of the base of the coracoid process through the posterosuperior shoulder access, in the area of the origin of the conoid and trapezoid ligaments, thus reproducing the path for inserting two anchors for anatomical reconstruction of the coracoclavicular ligaments. The smallest distance from the insertion point of the Kirschner wire to the suprascapular nerve and artery/vein was measured. RESULTS: The mean distance from the suprascapular nerve to the origin of the coracoclavicular ligaments at the top of the base of the coracoid process was 18.10 mm (range: 13.77-22.80) in the right shoulder and 18.19 mm (range: 12.59-23.75) in the left shoulder. The mean distance from the suprascapular artery/vein to the origin of the coracoclavicular ligaments was 13.10 mm (range: 9.28-15.44) in the right shoulder and 14.11 mm (range: 8.83-18.89) in the left shoulder. Comparison between the contralateral sides did not show any statistical difference. CONCLUSION: The posterosuperior shoulder access route for anatomical reconstruction of the coracoclavicular ligaments in treating acromioclavicular dislocation should be performed respecting the minimum limit of 8.83 mm medially.

RESUMO OBJETIVO: Os autores fizeram o acesso posterossuperior do ombro usado no tratamento cirúrgico da luxação acromioclavicular, a partir da dissecção de 20 ombros de 10 cadáveres adultos recém-resfriados, e analisaram as distâncias da via às estruturas neurovasculares próximas. MÉTODOS: Introduziu-se um fio de Kirschner no topo da base do processo coracoide pelo acesso posterossuperior do ombro, na área de origem dos ligamentos conoide e trapezoide, para reproduzir o trajeto da inserção de duas âncoras para reconstrução anatômica dos ligamentos coracoclaviculares. Mediu-se a menor distância do ponto de inserção do fio de Kirschner ao nervo e à artéria/veia supraescapular. RESULTADOS: A média da distância do nervo supraescapular até a origem dos ligamentos coracoclaviculares no topo da base do processo coracoide foi de 18,10 mm (13,77 a 22,80) no ombro direito e 18,19 mm (12,59 a 23,75) no ombro esquerdo. A média da distância da artéria/veia supraescapular até a origem dos ligamentos coracoclaviculares foi de 13,10 mm (09,28 a 15,44) no ombro direito e 14,11 mm (08,83 a 18,89) no ombro esquerdo. Não houve diferença estatística comparativa entre os lados contralaterais. CONCLUSÃO: A via de acesso posterossuperior do ombro para reconstrução anatômica dos ligamentos coracoclaviculares no tratamento das luxações acromioclaviculares deve ser feita com respeito ao limite de 08,83 mm medialmente.

Neurologic Outcomes After Low-Volume, Ultrasound-Guided Interscalene Block and Ambulatory Shoulder Surgery.

BACKGROUND AND OBJECTIVES: Postoperative neurologic symptoms after interscalene block and shoulder surgery have been reported to be relatively frequent. Reports of such symptoms after ultrasound-guided block have been variable. We evaluated 300 patients for neurologic symptoms after low-volume, ultrasound-guided interscalene block and arthroscopic shoulder surgery. METHODS: Patients underwent ultrasound-guided interscalene block with 16 to 20 mL of 0.5% bupivacaine or a mix of 0.2% bupivacaine/1.2% mepivacaine solution, followed by propofol/ketamine sedation for ambulatory arthroscopic shoulder surgery. Patients were called at 10 days for evaluation of neurologic symptoms, and those with persistent symptoms were called again at 30 days, at which point neurologic evaluation was initiated. Details of patient demographics and block characteristics were collected to assess any association with persistent neurologic symptoms. RESULTS: Six of 300 patients reported symptoms at 10 days (2%), with one of these patients having persistent symptoms at 30 days (0.3%). This was significantly lower than rates of neurologic symptoms reported in preultrasound investigations with focused neurologic follow-up and similar to other studies performed in the ultrasound era. There was a modest correlation between the number of needle redirections during the block procedure and the presence of postoperative neurologic symptoms. CONCLUSIONS: Ultrasound guidance of interscalene block with 16- to 20-mL volumes of local anesthetic solution results in a lower frequency of postoperative neurologic symptoms at 10 and 30 days as compared with investigations in the preultrasound period.

Winged scapula incidence and upper limb morbidity after surgery for breast cancer with axillary dissection.

PURPOSE: The aim of this study was to determine the incidence of winged scapula after breast cancer surgery, its impact on shoulder morbidity and difference in incidence according to surgery type. METHODS: Patients with breast cancer and surgical indication for axillary dissection were included. A total of 112 patients were surveyed with one physical evaluation before the surgery and others 15, 30, 90, and 180 days after. Winged scapula was assessed with test proposed by Hoppenfeld. Shoulder range of motion (ROM) was assessed with goniometer for flexion, extension, adduction, abduction, internal rotation, and external rotation. A verbal scale from 0 to 10 was used to assess pain. RESULTS: Winged scapula incidence was 8.0 % 15 days after surgery. Two patients recovered from winged scapula 90 days after surgery and four more 180 days after surgery, while three patients still had winged scapula at this time. The incidence after 15 days from surgery was 20.9 and 22.6 % among patients submitted to sentinel node biopsy or axillary lymphadenectomy (AL), respectively (p < 0.01). There was no statistical difference of incidence according to breast surgery type. Operated side shoulder flexion, adduction, and abduction ROM changes were statistically different in patients with or without winged scapula. The mean reduction was higher in patients with winged scapula. Both groups showed the same pattern over time in pain. CONCLUSION: Winged scapula incidence was 8.0 % and was higher in AL, and prevalence decreased during 6 months after surgery. Patients who developed winged scapula had more shoulder flexion, adduction, and abduction limitation.

A cadaveric study to determine the minimum volume of methylene blue to completely color the nerves of brachial plexus in cats. An update in forelimb and shoulder surgeries.

PURPOSE: To determine the minimum volume of methylene blue (MB) to completely color the brachial plexus (BP) nerves, simulating an effective anesthetic block in cats. METHODS: Fifteen adult male cat cadavers were injected through subscapular approach with volumes of 2, 3, 4, 5 and 6 ml in both forelimbs, for a total of 30 brachial plexus blocks (BPB). After infusions, the specimens were carefully dissected preserving each nervous branch. The measurement of the effective area was indicated by the impregnation of MB. Nerves were divided into four segments from the origin at the spinal level until the insertion into the thoracic limb muscles. The blocks were considered effective only when all the nerves were strongly or totally colored. RESULTS: Volumes of 2, 3 and 4 ml were considered insufficient suggesting a failed block, however, volumes of 5 and 6 ml were associated with a successful block. CONCLUSIONS: The injection of methylene blue, in a volume of 6 ml, completely colored the brachial plexus. At volumes of 5 and 6 ml the brachial plexus blocks were considered a successful regional block, however, volumes of 2, 3 and 4 ml were considered a failed regional block.

A cadaveric study to determine the minimum volume of methylene blue to completely color the nerves of brachial plexus in cats. An update in forelimb and shoulder surgeries

PURPOSE: To determine the minimum volume of methylene blue (MB) to completely color the brachial plexus (BP) nerves, simulating an effective anesthetic block in cats. METHODS: Fifteen adult male cat cadavers were injected through subscapular approach with volumes of 2, 3, 4, 5 and 6 ml in both forelimbs, for a total of 30 brachial plexus blocks (BPB). After infusions, the specimens were carefully dissected preserving each nervous branch. The measurement of the effective area was indicated by the impregnation of MB. Nerves were divided into four segments from the origin at the spinal level until the insertion into the thoracic limb muscles. The blocks were considered effective only when all the nerves were strongly or totally colored. RESULTS: Volumes of 2, 3 and 4 ml were considered insufficient suggesting a failed block, however, volumes of 5 and 6 ml were associated with a successful block. CONCLUSIONS: The injection of methylene blue, in a volume of 6 ml, completely colored the brachial plexus. At volumes of 5 and 6 ml the brachial plexus blocks were considered a successful regional block, however, volumes of 2, 3 and 4 ml were considered a failed regional block. .

Lesiones del nervio torácico largo de Bell. Revisión de conceptos terapéuticos / Long thoracic nerve of Bell. Review of therapeutic management

Las lesiones del nervio torácico producen parálisis del serrato anterior y originan una deformidad característica (escápula alata), que genera debilidad y alteraciones importantes en la movilidad del hombro. En esta revisión, se analizan conceptos sobre anatomía, etiología, presentación clínica y alternativas terapéuticas. (AU)

The long thoracic nerve injuries are manifested by a characteristic deformity called scapula alata, causing weakness, and impaired shoulder mobility. In this review current concepts of the anatomy, etiology, clinical presentation and therapeutic management are analyzed. (AU)