Brain plasticity in neonatal brachial plexus palsies: quantification and comparison with adults' brachial plexus injuries.

PURPOSE: To compare two populations of brachial plexus palsies, one neonatal (NBPP) and the other traumatic (NNBPP) who underwent different nerve transfers, using the plasticity grading scale (PGS) for detecting differences in brain plasticity between both groups. METHODS: To be included, all patients had to have undergone a nerve transfer as the unique procedure to recover one lost function. The primary outcome was the PGS score. We also assessed patient compliance to rehabilitation using the rehabilitation quality scale (RQS). Statistical analysis of all variables was performed. A p ≤ 0.050 set as criterion for statistical significance. RESULTS: A total of 153 NNBPP patients and 35 NBPP babies (with 38 nerve transfers) met the inclusion criteria. The mean age at surgery of the NBPP group was 9 months (SD 5.42, range 4 to 23 months). The mean age of NNBPP patients was 22 years (SD 12 years, range 3 to 69). They were operated around sixth months after the trauma. All transfers performed in NBPP patients had a maximum PGS score of 4. This was not the case for the NNBPP population that reached a PGS score of 4 in approximately 20% of the cases. This difference was statistically significant (p < 0.001). The RQS was not significantly different between groups. CONCLUSION: We found that babies with NBPP have a significantly greater capacity for plastic rewiring than adults with NNBPP. The brain in the very young patient can process the changes induced by the peripheral nerve transfer better than in adults.

Brain plasticity and age after restoring elbow flexion with distal nerve transfers in neonatal brachial plexus palsy and nonneonatal traumatic brachial plexus injury using the plasticity grading scale.

OBJECTIVE: Ulnar and/or median nerve fascicle to musculocutaneous nerve (MCN) transfers are used to restore elbow flexion following severe neonatal and nonneonatal brachial plexus injuries (BPIs). Restoring volitional control requires plastic changes in the brain. To date, whether the potential for plasticity is influenced by a patient's age remains unknown. METHODS: Patients who had presented with a traumatic upper (C5-6 or C5-7) BPI were divided into two groups: neonatal brachial plexus palsies (NBPPs) and nonneonatal traumatic BPIs (NNBPIs). Both groups underwent ulnar or median nerve transfers to the MCN for elbow flexion restoration between January 2002 and July 2020. Only those who attained a British Medical Research Council strength rating of 4 were reviewed. The primary comparison between the two groups was the plasticity grading scale (PGS) score to determine the level of independence of elbow flexion (target) from forearm motor muscle movement (donors). The authors also assessed patient compliance with rehabilitation using a 4-point Rehabilitation Quality Scale. Bivariable and multivariable analyses were used to identify intergroup differences. RESULTS: In total, 66 patients were analyzed: 22 with NBPP (mean age at surgery 10 months) and 44 with NNBPI (age range at surgery 3-67 years, mean 30.2 years; mean time to surgery 7 months, p < 0.001). All NBPP patients obtained a PGS grade of 4 at the final follow-up versus just 47.7% of NNBPI patients (mean 3.27, p < 0.001). On ordinal regression analysis, after nature of the injury was excluded because of excessive collinearity with age, age was the only significant predictor of plasticity (ß = -0.063, p = 0.003). Median rehabilitation compliance scores were not statistically different between the two groups. CONCLUSIONS: The extent of plastic changes that occur for patients to regain volitional control over elbow flexion after upper arm distal nerve transfers following BPI is influenced by patient age, with complete plastic rewiring more likely in younger patients and virtually ubiquitous in infants. Older patients should be informed that elbow flexion after an ulnar or median nerve fascicle transfer to the MCN might require simultaneous wrist flexion.

Nerve transfers for brachial plexus injuries: grading of volitional control.

OBJECTIVE: After brachial plexus injuries (BPIs), nerve transfers are used to restore lost muscle function. Brain plasticity underlies the process of regaining volitional control, which encompasses disconnection of the original donor nerve-related programs and reconnection to acceptor nerve programs. To the authors' knowledge, the levels of disconnection and reconnection have never been studied systematically. In this study, the authors developed a novel 4-point plasticity grading scale (PGS) and assessed the degree of volitional control achieved, identifying clinical correlations with this score. METHODS: Patients with BPI who underwent a phrenic, spinal accessory, median, and/or ulnar fascicle nerve transfer to restore biceps and deltoid function were asked to maximally contract their target muscle as follows: 1) by using only the donor nerve program, and 2) by activating the target muscle while consciously trying to avoid using the donor nerve, with assessment each time of the Medical Research Council (MRC) scale grade for muscle strength. The authors' PGS was used to rate the level of volitional control achieved. PGS grade 1 represented the lowest independent volitional control, with MRC grade 4 obtained in response to the donor command and MRC grade 0 in response to the acceptor command (minimum brain plasticity), whereas PGS grade 4 was no noticeable contraction in response to the donor command and MRC grade 4 in response to the acceptor command (maximum brain plasticity). RESULTS: In total, 153 patients were studied. For biceps restoration, the phrenic nerve was used as a donor in 44 patients, the spinal accessory nerve in 40 patients, and the median and/or ulnar fascicles in 44 patients. A triceps branch was used to restore deltoid function in 25 patients. The level of volitional control achieved was PGS grade 1 in 1 patient (0.6%), grade 2 in 21 patients (13.7%), grade 3 in 103 patients (67.3%), and grade 4 in 28 patients (18.3%). The median PGS grade did not differ significantly between the four donor nerves. No correlations were observed between age, time from BPI to surgery, duration of follow-up, or compliance with rehabilitation and PGS grade. CONCLUSIONS: Just around 20% of the authors' patients developed a complete disconnection of the donor program along with complete independent control over the reinnervated muscle. Incomplete disconnection was present in the vast majority of the patients, and the level of disconnection and control was poor in approximately 15% of patients. Brain plasticity underlies patient ability to regain volitional control after a nerve transfer, but this capacity is limited.

Use of ultrasound and targeted physiotherapy to manage nerve sutures placed under joint flexion: a case series.

BACKGROUND: Joint flexion to diminish the gap and avoid nerve grafts fell into disuse for decades, but recently attention for using this technique was regained. We report a case series of nerve suture under joint flexion, ultrasound monitoring, and physiotherapy. Our main objective was to determine how effective this multimodality treatment is. METHODS: A retrospective review of 8 patients treated with direct repair with joint flexion was done. Depending on the affected nerve, either the knee or the elbow was flexed intraoperatively to determine if direct suturing was possible. After surgery, the limb was held immobilized. Through serial ultrasounds and a physiotherapy program, the limb was fully extended. If a nerve repair rupture was observed, the patient was re-operated and grafts were used. RESULTS: Of the eight nerve sutures analyzed, four sustained a nerve rupture revealed by US at an early stage, while four did not show any sign of dehiscence. In the patients in whom the nerve suture was preserved, an early and very good response was observed. Ultrasound was 100% accurate at identifying nerve suture preservation. Early detection of nerve failure permitted early re-do surgery using grafts without flexion, ultimately determining good final results. CONCLUSIONS: We observed a high rate of dehiscence in our group of patients treated with direct repair and joint flexion. We believe this was due to an incorrect use of the immobilization device, excessive movement, or a broken device. In opposition to this, we observed that applying direct nerve sutures and joint flexion offers unusually good and fast results. If this technique is employed, it is mandatory to closely monitor suture status with US, together with physiotherapy providing progressive, US-guided extension of the flexed joint. If nerve rupture occurs, the close monitoring dictated by this protocol should ensure the timely application of a successful graft repair.

Distance Between the Corpus Callosum and the Falx Cerebri: A Little Explored Measure with Potential Surgical Implication.

OBJECTIVE: To perform measurements in normal brain imaging studies from the free edge of the falx cerebri to the genu and the body of the corpus callosum and perform a statistical analysis based on age, type of study, and sex highlighting potential surgical implication of these measurements. METHODS: In 193 normal brain imaging studies, 3 anatomical points of the corpus callosum were used to measure the distance to the falx cerebri. Horos and RadiAnt DICOM Viewer software were used to perform the measurements. Statistical analysis of data was performed with Minitab18 software. RESULTS: The results obtained in computed tomography (CT) studies were: distance A, mean 2.1065 cm; distance B, mean 2.2677 cm; distance C, mean 1.765 cm. The results obtained in magnetic resonance imaging studies were: distance A, mean 1.7148 cm; distance B, mean 2.1197 cm; distance C, mean 1.5321 cm. Statistically significant differences were obtained in measurements related to the type of study and in measurements made in CT studies related to age. CONCLUSIONS: There is a distance from the free edge of the falx cerebri to the genu and body of the corpus callosum of at least 1 cm in both CT and magnetic resonance imaging studies of normal brains. Statistically significant differences were found in the measurements in relation to the type of study and in relation to age in the measurements made in CT studies. These measurements could be important in determining the extent of bone resection in certain types of decompressive craniectomies.

Nerve Graft Length and Recovery of Elbow Flexion Muscle Strength in Patients With Traumatic Brachial Plexus Injuries: Case Series.

BACKGROUND: Traumatic brachial plexus injuries cause long-term maiming of patients. The major target function to restore in complex brachial plexus injury is elbow flexion. OBJECTIVE: To retrospectively analyze the correlation between the length of the nerve graft and the strength of target muscle recovery in extraplexual and intraplexual nerve transfers. METHODS: A total of 51 patients with complete or near-complete brachial plexus injuries were treated with a combination of nerve reconstruction strategies. The phrenic nerve (PN) was used as axon donor in 40 patients and the spinal accessory nerve was used in 11 patients. The recipient nerves were the anterior division of the upper trunk (AD), the musculocutaneous nerve (MC), or the biceps branches of the MC (BBs). An index comparing the strength of elbow flexion between the affected and the healthy arms was correlated with the choice of target nerve recipient and the length of nerve grafts, among other parameters. The mean follow-up was 4 yr. RESULTS: Neither the choice of MC or BB as a recipient nor the length of the nerve graft showed a strong correlation with the strength of elbow flexion. The choice of very proximal recipient nerve (AD) led to axonal misrouting in 25% of the patients in whom no graft was employed. CONCLUSION: The length of the nerve graft is not a negative factor for obtaining good muscle recovery for elbow flexion when using PN or spinal accessory nerve as axon donors in traumatic brachial plexus injuries.

Differences in strength fatigue when using different donors in traumatic brachial plexus injuries.

BACKGROUND: The purpose of this study was to assess the results of elbow flexion strength fatigue, rather than the maximal power of strength, after brachial plexus re-innervation with phrenic and spinal accessory nerves. We designed a simple but specific test to study whether statistical differences were observed among those two donor nerves. METHOD: We retrospectively reviewed patients with severe brachial plexus palsy for which either phrenic nerve (PN) or spinal accessory nerve (SAN) to musculocutaneous nerve (MCN) transfer was performed. A dynamometer was used to determine the maximal contraction strength. One and two kilograms circular weights were utilized to measure isometrically the duration of submaximal and near-maximal contraction time. Statistical analysis was performed between the two groups. RESULTS: Twenty-eight patients were included: 21 with a PN transfer while 7 with a SAN transfer for elbow flexion. The mean time from trauma to surgery was 7.1 months for spinal accessory nerve versus 5.2 for phrenic nerve, and the mean follow-up was 57.7 and 38.6 months, respectively. Statistical analysis showed a quicker fatigue for the PN, such that patients with the SAN transfer could hold weights of 1 kg and 2 kg for a mean of 91.0 and 61.6 s, respectively, while patients with transfer of the phrenic nerve could hold 1 kg and 2 kg weights for just a mean of 41.7 and 19.6 s, respectively. Both differences were statistically significant (at p = 0.006 and 0.011, respectively). Upon correlation analysis, endurances at 1 kg and 2 kg were strongly correlated, with r = 0.85 (p < 0.001). CONCLUSIONS: Our results suggest that phrenic to musculocutaneous nerve transfer showed an increased muscular fatigue when compared with spinal accessory nerve to musculocutaneous transfer. Further studies designed to analyze this relation should be performed to increase our knowledge about strength endurance/fatigue and muscle re-innervation.

Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series.

BACKGROUND: The phrenic nerve has been extensively reported to be a very powerful source of transferable axons in brachial plexus injuries. The most used technique used is supraclavicular sectioning of this nerve. More recently, video-assisted thoracoscopic techniques have been reported as a good alternative, since harvesting a longer phrenic nerve avoids the need of an interposed graft. OBJECTIVE: To compare grafting vs phrenic nerve transfer via thoracoscopy with respect to mean elbow strength at final follow-up. METHODS: A retrospective analysis was conducted among patients who underwent phrenic nerve transfer for elbow flexion at 2 centers from 2008 to 2017. All data analysis was performed in order to determine statistical significance among the analyzed variables. RESULTS: A total of 32 patients underwent supraclavicular phrenic nerve transfer, while 28 underwent phrenic nerve transfer via video-assisted thoracoscopy. Demographic characteristics were similar in both groups. A statistically significant difference in elbow flexion strength recovery was observed, favoring the supraclavicular phrenic nerve section group against the intrathoracic group (P = .036). A moderate though nonsignificant difference was observed favoring the same group in mean elbow flexion strength. Also, statistical differences included patient age (P = .01) and earlier time from trauma to surgery (P = .069). CONCLUSION: Comparing supraclavicular sectioning of the nerve vs video-assisted, intrathoracic nerve sectioning to restore elbow flexion showed that the former yielded statistically better results than the latter, in terms of the percentage of patients who achieve at least level 3 MRC strength at final follow-up. Furthermore, larger scale prospective studies assessing the long-term effects of phrenic nerve transfers remain necessary.

A Comparison of Patients from Argentina and Germany to Assess Factors Impacting Brachial Plexus and Brain Injury.

Background Traumatic brachial plexus injuries (BPIs) represent a major cause of disability in young patients. The purpose of this study was to compare two populations (from Argentina and Germany) who suffered a traumatic BPI after a motorcycle accident to identify predictors of BPI and brain injury severity. Methods Univariate and multivariable intergroup comparisons were conducted, and odds ratios were calculated to assess the associations between the different demographic, morphometric, and trauma-related variables, and the type and severity of patients' injuries. Pearson correlation coefficients were generated to identify statistically significant correlations. Results A total of 187 patients were analyzed, 139 from Argentina and 48 from Germany. The two countries differed significantly in age and several morphometric and trauma-related variables. The clinical presentation was also convincingly different in the two countries. The following three variables remained as statistically significant predictors of a complete (vs. partial) BPI: living in Argentina ( p < 0.001), presenting prior to 2015 ( p = 0.004), and greater estimated speed at the time of impact ( p = 0.074). As for BPIs, a disproportionate percentage (85.6%) of more severe brain injuries occurred in Argentinian patients ( p < 0.001) and among those whose accident involved striking a stationary vertical object. Conclusions This study identified several factors that might be considered when planning governmental policies and education initiatives to reduce BPI and brain injuries related to motorcycle use. Level of evidence II-2 (evidence obtained from case-control studies).

Treatment of neuropathic pain after peripheral nerve and brachial plexus traumatic injury.

Peripheral nerve and brachial plexus injuries typically cause severe impairment in the affected limb. The incidence of neuropathic pain is high, reaching up to 95% of cases, especially if cervical root avulsion has occurred. Neuropathic pain results from damage to the somatosensory system, and its progression towards chronicity depends upon disruptions affecting both the peripheral and central nervous system. Managing these painful conditions is complex and must be accomplished by a multidisciplinary team, starting with first-line pharmacological therapies like tricyclic antidepressants and calcium channel ligands, combined physical and occupational therapy, transcutaneous electrical stimulation and psychological support. For patients refractory to the initial measures, several neurosurgical options are available, including nerve decompression or reconstruction and ablative/modulatory procedures.

Phrenic to musculocutaneous nerve transfer for traumatic brachial plexus injuries: analyzing respiratory effects on elbow flexion control.

OBJECTIVE: In this study, the authors sought to identify the relationship between breathing and elbow flexion in patients with a traumatic brachial plexus injury (TBPI) who undergo a phrenic nerve (PN) transfer to restore biceps flexion. More specifically, the authors studied whether biceps strength and the maximal range of active elbow flexion differ between full inspiration and expiration, and whether electromyography (EMG) activity in the biceps differs between forced maximum breathing during muscular rest, normal breathing during rest, and at maximal biceps contraction. All these variables were studied in a cohort with different intervals of follow-up, as the authors sought to determine if the relationship between breathing movements and elbow flexion changes over time. METHODS: The British Medical Research Council muscle-strength grading system and a dynamometer were used to measure biceps strength, which was measured 1) during a maximal inspiratory effort, 2) during respiratory repose, and 3) after a maximal expiratory effort. The maximum range of elbow flexion was measured 1) after maximal inspiration, 2) during normal breathing, and 3) after maximal expiration. Postoperative EMG testing was performed 1) during normal breathing with the arm at rest, 2) during sustained maximal inspiration with the arm at rest, and 3) during maximal voluntary biceps contraction. Within-group (paired) comparisons, and both correlation and regression analyses were performed. RESULTS: Twenty-one patients fit the study inclusion criteria. The mean interval from trauma to surgery was 5.5 months, and the mean duration of follow-up 2.6 years (range 10 months to 9.6 years). Mean biceps strength was 0.21 after maximal expiration versus 0.29 after maximal inspiration, a difference of 0.08 (t = 4.97, p < 0.001). Similarly, there was almost a 21° difference in maximum elbow flexion, from 88.8° after expiration to 109.5° during maximal inspiration (t = 5.05, p < 0.001). Involuntary elbow flexion movement during breathing was present in 18/21 patients (86%) and averaged almost 20°. Measuring involuntary EMG activity in the biceps during rest and contraction, there were statistically significant direct correlations between readings taken during normal and deep breathing, which were moderate (r = 0.66, p < 0.001) and extremely strong (r = 0.94, p < 0.001), respectively. Involuntary activity also differed significantly between normal and deep breathing (2.14 vs 3.14, t = 4.58, p < 0.001). The degrees of involuntary flexion were significantly greater within the first 2.6 years of follow-up than later. CONCLUSIONS: These results suggest that the impact of breathing on elbow function is considerable after PN transfer for elbow function reconstruction following a TBPI, both clinically and electromyographically, but also that there may be some waning of this influence over time, perhaps secondary to brain plasticity. In the study cohort, this waning impacted elbow range of motion more than biceps muscle strength and EMG recordings.

Age as a Predictor of Long-Term Results in Patients with Brachial Plexus Palsies Undergoing Surgical Repair.

BACKGROUND: Among other factors, like the time from trauma to surgery or the number of axons that reach the muscle target, a patient's age might also impact the final results of brachial plexus surgery. OBJECTIVE: To identify (1) any correlations between age and the 2 outcomes: elbow flexion strength and shoulder abduction range; (2) whether childhood vs adulthood influences outcomes; and (3) other baseline variables associated with surgical outcomes. METHODS: Twenty pediatric patients (under age 20 yr) who had sustained a traumatic brachial plexus injury were compared against 20 patients, 20 to 29 yr old, and 20 patients, 30 yr old or older. Univariate, univariate trend, and correlation analyses were conducted with patient age, time to surgery, type of injury, and number of injured roots included as independent variables. RESULTS: A statistically significant trend toward decreasing mean strength in elbow flexion, progressing from the youngest to oldest age group, was observed. This linear trend persisted when subjects were subdivided into 4 age groups (<20, 20-29, 30-39, ≥40). There were no differences by age group in final shoulder abduction range or the percentage achieving a good shoulder outcome. CONCLUSION: Our data suggest that age is somehow linked to the outcomes of brachial plexus surgery with respect to elbow flexion, but not shoulder abduction strength. Increasing age is associated with steadily worsening elbow flexion outcomes, perhaps indicating the need for earlier surgery and/or more aggressive repairs in older patients.

Treatment of complete facial palsy in adults: comparative study between direct hemihypoglossal-facial neurorrhaphy, hemihipoglossal-facial neurorrhaphy with grafts, and masseter to facial nerve transfer.

BACKGROUND: The hypoglossal (with or without grafts) and masseter nerves are frequently used as axon donors for facial reinnervation when no proximal stump of the facial nerve is available. We report our experience treating facial nerve palsies via hemihypoglossal-to-facial nerve transfers either with (HFG) or without grafts (HFD), comparing these outcomes against those of masseteric-to-facial nerve transfers (MF). METHOD: A total of 77 patients were analyzed retrospectively, including 51 HFD, 11 HFG, and 15 MF nerve transfer patients. Both the House-Brackmann (HB) scale and our own, newly-designed scale to rate facial reanimation post nerve transfer (quantifying symmetry at rest and when smiling, eye occlusion, and eye and mouth synkinesis when speaking) were used to enumerate the extent of recovery. RESULTS: With both the HB and our own facial reanimation scale, the HFD and MF procedures yielded better outcome scores than HFG, though only the HGD was statistically superior. HGD produced slightly better scores than MF for everything but eye synkinesis, but these differences were generally not statistically significant. Delaying surgery beyond 2 years since injury was associated with appreciably worse outcomes when measured with our own but not the HB scale. The only predictors of outcome were the surgical technique employed and the duration of time between the initial injury and surgery. CONCLUSIONS: HFD appears to produce the most satisfactory facial reanimation results, with MF providing lesser but still satisfactory outcomes. Using interposed grafts while performing hemihypoglossal-to-facial nerve transfers should likely be avoided, whenever possible.

The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis.

BACKGROUND: Controversy exists surrounding the use of the phrenic nerve for transfer in severe brachial plexus injuries. The objectives of this study are: (1) to present the experience of the authors using the phrenic nerve in a single institution; and (2) to thoroughly review the existing literature to date. METHODS: Adult patients with C5-D1 and C5-C8 lesions and a phrenic nerve transfer were retrospectively included. Patients with follow-up shorter than 18 months were excluded. The MRC muscle strength grading system was used to rate the outcome. Clinical repercussions relating to sectioning of the phrenic nerve were studied. An intense rehabilitation program was started after surgery, and compliance to this program was monitored using a previously described scale. Statistical analysis was performed with the obtained data. RESULTS: Fifty-one patients were included. The mean time between trauma and surgery was 5.7 months. Three-quarters of the patients had C5-D1, with the remainder C5-C8. Mean post-operative follow-up was 32.5 months A MRC of M4 was achieved in 62.7% patients, M3 21.6%, M2 in 3.9%, and M1 in 11.8%. The only significant differences between the two groups were in graft length (9.8 vs. 15.1 cm, p = 0.01); and in the rehabilitation compliance score (2.86 vs. 2.00, p = 0.01). CONCLUSIONS: Results of phrenic nerve transfer are predictable and good, especially if the grafts are short and the rehabilitation is adequate. It may adversely affect respiratory function tests, but this rarely correlates clinically. Contraindications to the use of the phrenic nerve exist and should be respected.

Influence of body mass index on the outcome of brachial plexus surgery: are there any differences between elbow and shoulder results?

BACKGROUND: Body mass index (BMI) has recently been identified as a predictor of outcomes following reconstructive surgery of shoulder palsies. In this study, we sought to determine if the same holds true for the reconstruction of elbow flexion. METHODS: Forty patients who had undergone partial ulnar-to-biceps nerve transfer (Oberlin's procedure) for shoulder palsy were assessed and compared against 18 previously reported patients who had undergone reconstruction for elbow palsies. The British Medical Research Council (BMRC) scale and an index dividing shoulder abduction strength in the affected arm by healthy arm were recorded. All patients had undergone surgery within 12 months of injury and had ≥ 12 months of follow-up. RESULTS: M4 or M3 biceps strength was obtained in 90 % of patients. Final strength on the affected side averaged 5.8 kg, versus 20.2 kg on the normal side, for a mean recovery index score of 0.30. In this sample of 40 patients, BMI did not predict percentage strength or BMRC grade recovery. Neither did age, number of roots involved, the affected side, nor time to surgery. Comparing patients with elbow versus shoulder reconstruction, there were no differences, except that patients undergoing Oberlin's procedure had a statistically longer duration of time between injury and surgical repair (7.4 vs 5.1 months, p < 0.006). CONCLUSIONS: Our data suggest that proximal muscle re-innervation is functionally more dependent upon BMI than distal re-innervation, likely because proximal muscles must support the weight of the entire extremity, while more distal muscles do not. BMI should be taken into consideration when planning surgery.

Transferencia tendinosa de tibial posterior en parálisis del nervio peróneo común: ¿El fin del pie caído? / Tendinous transfer of posterior tibial in paralysis of the common peroneal nerve: The end of the fallen foot?

INTRODUCCIÓN: la lesión del nervio peróneo común es la más frecuente del miembro inferior, resultando en pie caído y marcha en steppage. La reconstrucción nerviosa tiene un resultado desfavorable en la mayoría de las series. Una alternativa terapéutica a dicha reconstrucción es la transferencia del tendón del músculo tibial posterior, cuyo objetivo es lograr la dorsiflexión activa del pie. El objetivo de este trabajo es analizar los resultados obtenidos con esta cirugía. MATERIAL Y MÉTODOS: se analizaron una serie de pacientes a los que se realizó una transferencia de tendón de tibial posterior por pie caído, entre los meses de enero 2008 y junio 2012. Sólo se incluyeron en el análisis aquellos que presentaban un seguimiento de al menos 12 meses. La técnica empleada en todos los procedimientos fue la vía subcutánea, circunferencial, con fijación tendón-tendón, y usando como blanco los tendones del tibial anterior, extensor propio del hallux, extensor común de los dedos y peróneos laterales. La escala de Stanmore fue empleada para analizar los resultados. RESULTADOS: en el período analizado, fueron realizadas 22 transferencias de tibial posterior, de los cuales 19 poseían un seguimiento adecuado. Diez de esos 19 pacientes mostraron un resultado excelente (52,3%), cinco bueno (26,7%), dos pacientes regular (10,5%) y dos malo (10,5 %), de acuerdo a la escala mencionada. Sólo una complicación se verificó en un caso, la pérdida de tensión de la sutura tendinosa, que requirió una nueva cirugía. CONCLUSIÓN: la transferencia tendinosa de tibial posterior es un procedimiento con una alta tasa de éxito, tanto es nuestra serie como en otras publicadas en la literatura. Atento a los resultados generalmente pobres que posee la reconstrucción nerviosa primaria directa, consideramos que en casos seleccionados la técnica de transferencia tendinosa es la primera elección en el pie caído

INTRODUCTION: common peroneal nerve injury is the most frequent nerve deficit affecting the lower limbs, resulting in foot drop and stepagge. Primary surgical nerve repair has an unfavorable outcome in most series. An alternative is posterior tibial tendon transfer, a procedure designed to achieve active dorsiflexion. The aim of this paper is to analyze the results obtained with this surgery. METHODS: between January 2008 and June 2012, all patients submitted for posterior tibial tendon transfer with a minimum follow-up of 12 months, were analyzed. Subcutaneous route was used for the transfer, and tendon-to-tendon suture was employed, using as targets the anterior tibial, extensor hallucis longus, extensor digitorum longus and peroneal tendons. Stanmore scale was used for analysis. RESULTS: a total of 22 patients were operated in the studied period, but 19 who had a minimum follow-up were included in these analysis. The results were excellent in 10 patients (52,3%), good in 5 (26,7%), fair in in 2 patients (10,5%) and poor in 2 (10,5%), according to Stanmore scale. CONCLUSIONS: this tendon transfer has a high rate of success, both in our series and in the literature. Considering the poor results that primary nerve repairs has, we believe that posterior tibial tendon transfer is the first choice for the treatment of foot drop in selected cases

Spinal to accessory nerve transfer in traumatic brachial plexus palsy: is body mass index a predictor of outcome?

INTRODUCTION: Several factors that affect functional recovery after surgery in severe brachial plexus lesions have been identified, i.e., time to surgery and presence of root avulsions. The body mass index (BMI) of the patient could be one of these possible factors. The objective of the present paper is to systematically study the relationship between BMI and the outcome of abduction following spinal accessory to suprascapular nerve transfer. METHODS: We retrospectively studied 18 cases that followed these inclusion criteria: (1) Male patients with a spinal accessory to suprascapular nerve transfer as the only procedure for shoulder function reanimation; (2) at least C5-C6 root avulsion; (3) interval between trauma and surgery less than 12 months; (4) follow-up was at least 2 years; (5) no concomitant injury of the shoulder girdle. Pearson correlation analysis and linear regression was performed for BMI versus shoulder abduction. RESULTS: The mean range of post-operative abduction obtained across the entire series was 49.7° (SD ± 30.2). Statistical evaluation revealed a significant, negative moderately strong correlation between BMI and post-operative range of shoulder abduction (r = -0.48, p = 0.04). Upon simple linear regression, time to surgery (p = 0.04) was the only statistically significant predictor of abduction range negatively correlated. CONCLUSIONS: Analysis of this series suggests that a high BMI of patients undergoing brachial plexus surgery is a negative predictor of outcome, albeit less important than others like time from trauma to surgery. Nevertheless, the BMI of patients should be taken into consideration when planning surgical strategies for reconstruction.

Artrodesis de hombro vs cirugía primaria de reconstrucción en pacientes con lesiones graves de plexo braquial: estudio comparativo / Shoulder arthrodesis vs. primary reconstruction surgery in patients with serious brachial pexus injuries: comparative study

Objetivo: La cirugía de reparación nerviosa es la primera elección en lesiones del plexo braquial. La artrodesis de hombro estabiliza y otorga cierta abducción por desplazamiento de la escápula. El objetivo del presente trabajo es: comparar la artrodesis de hombro versus la transferencia del nervio espinal accesorio al supraescapular. Materiales y métodos: se analizaron en forma retrospectiva 20 pacientes con parálisis completa del miembro superior y avulsión radicular de al menos 4 raíces. Diez fueron artrodesados, y en los otros 10 se realizó una única transferencia nerviosa para el hombro, antes citada. El seguimiento mínimo fue de 2 años. Se determinó la abducción en grados y se describió una escala para estudiar los resultados de ambas técnicas. Los resultados fueron comparados estadísticamente. Resultados: en los pacientes artrodesados el promedio, según la escala, fue 4,5 puntos, mientras que en los transferidos fue 4,8. La media de abducción en grados fue de 37 en artrodesados y 43,5 en transferidos. No se encontraron diferencias estadísticamente significativas entre ambos grupos. Conclusiones: los resultados de ambas técnicas son semejantes. La artrodesis escápulo-humeral es una posibilidad terapéutica aceptable del hombro paralizado en los pacientes con lesiones muy graves del plexo braquial y escasez de donantes nerviosos.

Objective: Primary nerve reconstruction surgery is the gold standard in brachial plexus injuries. Shoulder arthrodesis stabilizes and abducts the shoulder by the movement of the scapula. The goal of the present study is to compare shoulder arthrodesis versus spinal nerve transfer to supraescapular nerve. Materials y methods: 20 patients with complete brachial plexus palsy (flail arm) and at least 4 roots avulsions were analyzed retrospectively. Ten were submitted to shoulder arthrodesis, while in the other 10, only one nerve transfer was performed to reinervate the shoulder. Minimum follow-up was 2 years. The results were determined in degrees of abduction, also measured in a scale, and compared statistically. Results: the mean result in the patients with shoulder arthrodesis was 4.5, and 4.8 in the nerve transferred. Mean final abduction was 37 degrees in arthrodesis and 43.5 in nerve transfer. No statistical significant difference was found between groupsConclusions: the results of both techniques are similar. Shoulder arthrodesis is a viable option in severely injured brachial plexus patients where donor nerve are scarce.

Forámenes craneales en abordajes a base de cráneo / Skull foramina in surgical approaches to the skull base

Introducción: el objetivo del presente trabajo es determinar la distancia entre los abordajes neuroquirúrgicos ás utilizados y los forámenes de base de cráneo. Estos datos pueden ser de utilidad tanto para el planeamiento prequirúrgico como para navegaión intraoperatoria. Materiales y métodos: se estudiaron 72 hemicráneos secos, 36 derechos y 36 izquierdos, 7 bases de cráneo formolizadas y 14 hemicráneos. Se emplearon calibradores y las medidas se expresan en mm. Resultados: La distancia entre el abordaje Ptrerional y el punto de salida dural del III par fue d 55 mm en promedio. La distancia entre el abordaje Petrosectomía Presignmoidea Posterior y el punto de salida dural del IV par fue 57.3 mm. LA distancia entre el abordaje de la Petrosectomía Presigmoidea Posterior y el punto de salida dural del V par fue 33.71 mm e promedio. LA distancia entre el abordaje Subtemporal y los amos del nervio trigémino fue en promedio de 61 mm para V1 (mínimo 56 mm y máximo 67 mm), 57 mm para V2 mínimo 50 mm y máximo 63 mm) y 48 mm para V3 (mínimo 35 mm y máximo 56 mm). La distancia entre el abordaje de la petrosectomía Presigmoide Posterior y el punto de saluda dural del VI par fue 59.85 mm en promedio. La distancia entre ewl abordaje suboccipital lateral superior y el punto de saluda dural de los pares VII y VIII fue 34. 5 mm. La distancia entre el abordaje de la Petrosectomía Presigmoidea Posterior y el punto de salida dural de los pares IX, X y XI fue 2179 mm. La distancia entre el abordaje Transcondilar y el XII par fue de 50.58 mm en promedio. Conclusión: se describió la anatomía de los forámenes de base de cráneo y su relación con los abordajes, con el objetivo de brindar el conocimiento necesario para el planeamiento de las complejas estrategias neuroquirúrgicas.

Introduction: This paper aims at establishing the distance between the most frequently used neurosurgical approaches and the skull base foramina. These data can be useful both for presurgical planning and for intrasurgical navigation. Materials and methods: 72 dried skull halves were examined, 36 right and 36 left halves, 7 in formaldehyde solution skull bases and 14 skull halves. Gages were used and measurements are expressed in mm.Results: The distance between the Pterional approach and the dural opening of the III pair was 55mm in average. The distance between the posterior Petrosectomy with presigmoidal approach and the dural opening of the IV pair was 57.3mm. The distance between the posterior Petrosectomy with presigmoidal approach and the dural opening of the V pair was 33.71mm in average. The distance between the Subtemporal approach and the trigeminal nerve branches was 61mm, in average, for V1 (56mm minimum and 67mm maximum), 57mm for V2 (50mm minimum and 63mm maximum) and 48mm for V3 (35mm minimum and 56mm maximum). The distance between the posterior Petrosectomy with presigmoidal approach and the dural opening of the VI pair was 59.85mm in average. The distance between the upper lateral suboccipital approach and the dural opening of the VII and VIII pairs was 34.5mm. The distance between the posterior Petrosectomy with presigmoidal approach and the dural opening of pairs IX, X and XI was 21.79mm. The distance between the Transcondilar approach and the XII pair was 50.58mm in average.Conclusion: The anatomy of skull base foramina was described together with their relation to the different approaches, with the aim of providing the necessary knowledge for planning the complex neurosurgical strategies.