Descriptive Analysis of Epidemiological Profile from Authors of Civil Claims Due to Supposed Medical Malpractice Against Neurosurgeons in Brazil

Introduction The neurosurgical practice often involves situations that require rapid and immediate decisionmaking, and a very lowmargin for error may eventually lead to an unsatisfactory clinical outcome. Thus, neurosurgery is considered as a medical specialty with high risk for the occurrence of litigation for supposed malpractice. The main objective of the present study was to identify the most prevalent epidemiological profile of the authors of civil claims for alleged malpractice against neurosurgeons, as well as to identify the legal strategies most commonly employed in this type of lawsuit. Methods This is a descriptive, retrospective and quantitative study, with review of the initials/exordials of all civil actions motivated by alleged malpractice against neurosurgeons, defended by an office specialized in Medical Law, from 2008 to 2018. Data were collected relative to the author of the action; the disease that led to the outbreak of the action; and some legal information of interest for the outcome of the litigation. Results During the period studied, 16 compensation/eviction claims were identified as being motivated by supposed neurosurgical malpractice. The average age of the authors was 51 years old; with a high school or undergraduate level of education in 75% of the cases, and especially from the Class B social extract (43%). Degenerative affections of the lumbar spine (12 cases, 75%) were the most common diseases that motivated the litigation, followed by brain tumors (2 cases, 12.5%), 1 case of carpal tunnel syndrome, and 1 case of chronic pain due to inflammatory radiculitis. The average value of the sponsored claim was 649,000.00 reais. Justice gratuity was granted in 80% of the cases and the reversal of the burden of proof by 30%. The main documentary evidence was medical reports ­ from third parties or the surgeon him/herself, and medical records.

Outcomes of Transferring a Healthy Motor Fascicle From the Radial Nerve to a Branch for the Triceps to Recover Elbow Extension in Partial Brachial Plexus Palsy.

Background: Triceps reinnervation is an important objective to pursue when repairing the brachial plexus for cases with upper roots injuries, and a number of different techniques have been developed in order to restore elbow extension in such cases. Objective: To demonstrate the surgical outcomes associated with the technique of transferring a single healthy motor fascicle from the radial nerve of the affected arm to a branch innervating 1 of the 3 heads of the triceps. Methods: A retrospective study of 13 adult patients sustaining an upper trunk syndrome associated with total elbow extension palsy who underwent the proposed technique as part of the surgical planning for reconstruction of the brachial plexus. Results: Outcomes scored as M4 for elbow extension were noted in 9 cases (70%), M3 in 3 (23%), and M1 in 1 subject (7%). No patient considered the postoperative strength for carpal or finger extension as impaired. There were no differences in outcomes by using a fascicle activating carpal or finger extension as donor, as well as regarding the use of the branch to the medial or lateral head of the triceps as the recipient. Conclusion: The technique of transferring a healthy motor fascicle from the radial nerve of the affected side to one of its nonfunctional motor branches to the triceps is an effective and safe procedure for recovering elbow extension function in patients sustaining partial injuries of the brachial plexus.

Objective Predictors of Functional Recovery Associated with Intercostal Nerves Transfer for Triceps Reinnervation in Global Brachial Plexus Palsy

Objective To evaluate the predictors of functional recovery associated with the transfer of intercostal nerves (ICNs) to the branch innervating the long head of the triceps (BLHT). Methods A retrospective analysis of 14 patients with global brachial plexus palsy for whom the surgical planning included the transfer of 2 or 3 ICNs to the BLHT. Results The effective rate of functional recovery for elbow extension was 28%. Surgical timing, severity of the injury, and number of ICNs did not show significance for functional recovery. Patients who underwent ICN transfer for reanimation of elbow extension in combination with phrenic nerve (PN) transfer for reinnervation of elbow flexion, or shoulder stability, obtained poorer results regarding triceps recovery (p < 0.01). Conclusions Intercostal nerves are reliable donors for reinnervation of the triceps in global brachial plexus injuries. However, this technique should be avoided in patients in whom the PN has been transferred for elbow flexion or shoulder abduction.

Objetivos Avaliar os fatores preditores para recuperação funcional associados à transferência de nervos intercostais (NICs) para o ramo do nervo radial que inerva da cabeça longa do tríceps (RCLT). Métodos Análise retrospectiva de 14 pacientes com paralisia completa do plexo braquial, para os quais o planejamento cirúrgico incluiu a transferência de 2 ou 3 NICs para o RCLT. Resultados A taxa de recuperação da extensão do cotovelo foi de 28%. O intervalo cirúrgico, a gravidade da lesão e o número de NICs usados não demonstraram significância para a recuperação funcional. Os pacientes nos quais a transferência de NIC foi usada para recuperação da extensão do cotovelo concomitantemente à transferência do nervo frênico para reanimação da flexão do cotovelo ou para estabilização do ombro obtiveram piores resultados quanto a reinervação do tríceps (p < 0.01). Conclusões Os NICs podem ser utilizados como doadores para reinervação do tríceps em lesões completas do plexo braquial. No entanto, essa técnica deve ser evitada em pacientes nos quais o nervo frênico foi transferido conjuntamente visando a recuperação da flexão do cotovelo ou a estabilização do ombro.

Paravertebral abscess by Escherichia coli and melanoma metastasis in an older woman.

Paravertebral abscesses are usually caused by Staphylococcus aureus, and often affect older people with diabetes mellitus or immunosuppression. We report a huge lumbar abscess caused by Escherichia coli in an 81-year-old woman with diabetes and melanoma metastasis. Lumbar vertebra and surrounding soft tissues were involved by the Gram-negative infection, and imaging features were indicative of malignant condition. Diagnosis was established by images of magnetic resonance, histopathology, and bacterial culture from abscess fluid. This condition poses diagnosis challenges and seems to be increasing in frequency. Reports of case studies might enhance the suspicion index of primary care physicians about this entity.

Comparative Study of Nerve Grafting versus Distal Nerve Transfer for Treatment of Proximal Injuries of the Ulnar Nerve.

BACKGROUND: The prognosis for motor recovery associated with ulnar nerve injuries at a level proximal to the elbow is usually considered poor. Nerve transfers techniques were introduced as an alternative for the management of nerve lesions of the upper limb, aiming to improve the surgical results of those nerves for which direct reconstruction has not historically yielded good outcomes. METHODS: A retrospective chart review was conducted to compare the outcomes obtained using nerve grafting (20 cases) with those of distal nerve transfer (15 patients) for the treatment of proximal injuries of the ulnar nerve. Nerve transfer combined the suture of the anterior interosseous nerve to the motor branch of the ulnar nerve and the cooptation of its sensory branch to the third common digital nerve via an end-to-side suture. RESULTS: The Medical Research Council M3/M4 outcomes were observed significantly more often in the nerve transfer group (80 vs. 22%), and the mean values for handgrip strength were higher (31.3 ± 5.8 vs. 14.5 ± 7.2 kg). The groups were similar in attaining good sensory recovery (40 vs. 30%) and mean two-point-discrimination (grafting: 11 ± 2 mm; nerve transfer: 9 ± 1 mm). The mean value of the disabilities of arm, shoulder, and hand for the nerve transfer group (23.6 ± 6.7) was significantly lower than for grafting (34.2 ± 8.3). CONCLUSIONS: Distal nerve transfer resulted in better motor and functional outcomes than nerve grafting. Both techniques resulted in similar sensory outcomes, and nerve grafting was demonstrated to be a better technique for managing the painful symptoms associated with the nerve injury.

Clinical results of transferring a motor branch of the tibial nerve to the deep peroneal nerve for treatment of foot drop.

BACKGROUND: Foot drop is a very debilitating condition affecting patients' daily activities, and its treatment has been a challenge for neurosurgeons. Grafting the peroneal or sciatic nerve usually results in poor outcomes. Our previous anatomic study demonstrated the feasibility of transferring a motor branch of the tibial nerve to the deep peroneal nerve at the level of the popliteal fossa. OBJECTIVE: To demonstrate the outcomes obtained after the transfer of a branch of the tibial nerve to the peroneal nerve for recovery of foot drop. METHODS: A retrospective review of 13 patients with foot drop caused by injuries to a lumbar root or the sciatic or peroneal nerve, who underwent a transfer of the nerve of the soleus muscle to the deep peroneal nerve. The results were evaluated using the British Medical Research Council grading system. RESULTS: Three patients were lost to follow-up. Of the remaining 10 patients, the outcomes were considered good (Medical Research Council grade M3 or M4) in 2 patients (20%) concerning ankle dorsiflexion and in 2 patients concerning toe extension (20%). One patient reported a reduced calf circumference. CONCLUSION: The transfer of the nerve of the soleus muscle to the deep peroneal nerve demonstrated poor results in most of the patients, although favorable outcomes were observed in a few subjects. Due to the inconsistency of the results, we do not favor the routine use of this technique for the treatment of foot drop.

Reanimation of elbow extension with medial pectoral nerve transfer in partial injuries to the brachial plexus.

OBJECT: Recent advancements in operative treatment of the brachial plexus authorized more extensive repairs and, currently, elbow extension can be included in the rank of desirable functions to be restored. This study aims to describe the author's experience in using the medial pectoral nerve for reinnervation of the triceps brachii in patients sustaining C5-7 palsies of the brachial plexus. METHODS: This is a retrospective study of the outcomes regarding recovery of elbow extension in 12 patients who underwent transfer of the medial pectoral nerve to the radial nerve or to the branch of the long head of the triceps. RESULTS: The radial nerve was targeted in 3 patients, and the branch to the long head of the triceps was targeted in 9. Grafts were used in 6 patients. Outcomes assessed as Medical Research Council Grades M4 and M3 for elbow extension were noted in 7 (58%) and 5 (42%) patients, respectively. CONCLUSIONS: The medial pectoral nerve is a reliable donor for elbow extension recovery in patients who have sustained C5-7 nerve root injuries.

Long-term outcomes associated to video-assisted thoracic sympathotomy for palmar-axillar subtype of the hyperhidrosis.

OBJECTIVE: Surgery for both palmar and axillar hyperhidrosis usually includes the interruption of the sympathetic chain in multiple levels. This study aimed to determine the long-term outcomes associated to video-assisted thoracic sympathotomy (VATS) of T2, T3 and T4 ganglia for these cases. METHODS: Analysis of the outcomes obtained from 36 patients regarding the rate of resolution of the symptoms and the compensatory sweating (CS). All subjects were followed-up for 36 months. RESULTS: Good outcomes were observed in 98.6% for palmar and 60% for axillary hyperhidrosis (p=0.0423), respectively. Of the subjects, 86% reported some postoperative episode of CS, however only 45% (p=0.0031) still noticed it at the end of the follow-up period. CONCLUSIONS: VATS is effective for the excessive palmar sweating, whereas it is fully efficient for only two thirds of the cases sustaining associated axillar hyperhidrosis. CS is expected as a rule following the proposed operative protocol, however it is usually self-limited.

Long-term outcomes associated to video-assisted thoracic sympathotomy for palmar-axillar subtype of the hyperhidrosis / Resultados tardios da simpatotomia torácica vídeo-assistida para tratamento do subtipo palmar-axilar de hiperidrose

OBJECTIVE: Surgery for both palmar and axillar hyperhidrosis usually includes the interruption of the sympathetic chain in multiple levels. This study aimed to determine the long-term outcomes associated to video-assisted thoracic sympathotomy (VATS) of T2, T3 and T4 ganglia for these cases. METHODS: Analysis of the outcomes obtained from 36 patients regarding the rate of resolution of the symptoms and the compensatory sweating (CS). All subjects were followed-up for 36 months. RESULTS: Good outcomes were observed in 98.6% for palmar and 60% for axillary hyperhidrosis (p=0.0423), respectively. Of the subjects, 86% reported some postoperative episode of CS, however only 45% (p=0.0031) still noticed it at the end of the follow-up period. CONCLUSIONS: VATS is effective for the excessive palmar sweating, whereas it is fully efficient for only two thirds of the cases sustaining associated axillar hyperhidrosis. CS is expected as a rule following the proposed operative protocol, however it is usually self-limited.

OBJETIVO: A cirurgia para hiperidrose palmar e axilar usualmente inclui a interrupção da cadeia simpático-torácica em múltiplos níveis. Este estudo objetivou apresentar os resultados tardios associados à simpatectomia torácica vídeo-assistida (STVA) dos gânglios T2,T3 e T4 nesses casos. MÉTODOS: Foram analisados os resultados cirúrgicos obtidos em 36 pacientes quanto à taxa de resolução dos sintomas e à ocorrência de hiperidrose compensatória (HC). Todos os sujeitos foram acompanhados por 36 meses. RESULTADOS: Bons resultados foram observados em 98,6% dos pacientes para a forma palmar e em 60% para a forma axilar (p=0,0423). Em 86% dos casos, havia relato de algum episódio de HC, mas apenas 45% ainda notavam sua ocorrência ao final do período de acompanhamento. CONCLUSÕES: A STVA é eficaz para o tratamento da hiperidrose palmar, mas mostrou-se plenamente satisfatória em apenas dois terços dos casos associados à forma axilar. A HC deve ser considerada ocorrência esperada no protocolo cirúrgico; no entanto, evolui de maneira autolimitada na maioria dos casos.

Clinical patterns of spontaneous recovery of paralyzed triceps brachii associated with C5 to C7 injuries of the brachial plexus.

Some patients who sustain C5 to C7 nerve root injuries may demonstrate a natural recovery of elbow extension via the lower trunk; however the surgical effect of the reinnervation of the triceps brachii in such cases is still unknown. This study aims to determine the incidence of spontaneous recovery of the tricipital function and to identify the clinical and/or radiological predictors of poor spontaneous functional rehabilitation of elbow extension resulting from injuries of the upper roots of the brachial plexus. We conducted a review of the charts of 24 subjects sustaining an upper trunk syndrome with complete elbow extension palsy and who did not undergone any intervention for reinnervation of the triceps brachii in the primary brachial plexus surgery. Two years posttrauma, the muscle was scored as M0 in 12 patients (50%), M1 in 3 (12.5%), M2 in 1 (4.1%), M3 in 4 (16.6%), and M4 in 4 subjects (16.6%). The number of avulsed roots and the preoperative power of the latissimus dorsi did not demonstrate any significance in predicting the outcome of spontaneous elbow extension recovery; whereas the preoperative paralysis of the muscles for wrist extension was determined to be reliable predictive parameter for poor natural recovery of tricipital function.

The radio-radial nerve transfer for elbow extension restoration in C5 to C7 nerve root injury.

Extension of the elbow is required to oppose gravity; however, activation of the triceps brachii is frequently underestimated during the surgical planning for brachial plexus injuries. This report aims to describe a novel technique of distal nerve transfer designed for elbow extension reconstruction in patients sustaining a C5-C7 nerve root injury. We report a patient sustaining a brachial plexus injury with triceps palsy and preserved finger extension motion; after careful intraneural dissection of the radial nerve, a fascicle innervating the extensor digitorum communis muscle was sectioned, derouted and connected to a motor branch to the lateral head of the triceps. Eleven months after surgery, elbow extension strength scored MRC M4. No deficits on finger extension were observed.

Transfer of a motor fascicle from the ulnar nerve to the branch of the radial nerve destined to the long head of the triceps for restoration of elbow extension in brachial plexus surgery: technical case report.

BACKGROUND AND IMPORTANCE: Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks. CLINICAL PRESENTATION: Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases. CONCLUSION: The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.

The importance of the preoperative clinical parameters and the intraoperative electrophysiological monitoring in brachial plexus surgery.

OBJECTIVE: The study aims to demonstrate the impact of some preoperative clinical parameters on the functional outcome of patients sustaining brachial plexus injuries, and to trace some commentaries about the use of intraoperative monitoring techniques. METHOD: A retrospective study one hundred cases of brachial plexus surgery. The analysis regarding postoperative outcomes was performed by comparing the average of the final result of the surgery for each studied cohort. RESULTS: Direct electrical stimulation was used in all patients, EMG in 59%, SEPs in 37% and evoked NAPs in 19% of the cases. Patients in whom the motor function of the hand was totally or partially preserved before surgery, and those in whom surgery was delayed less than 6 months demonstrated significant (p<0.05) better outcomes. CONCLUSION: The preoperative parameters associated to favorable outcomes in reconstruction of the brachial plexus are a good post-traumatic status of the hand and a short interval between injury and surgery.

Brachial plexus surgery: the role of the surgical technique for improvement of the functional outcome.

OBJECTIVE: The study aims to demonstrate the techniques employed in surgery of the brachial plexus that are associated to evidence-based improvement of the functional outcome of these patients. METHOD: A retrospective study of one hundred cases of traumatic brachial plexus injuries. Comparison between the postoperative outcomes associated to some different surgical techniques was demonstrated. RESULTS: The technique of proximal nerve roots grafting was associated to good results in about 70% of the cases. Significantly better outcomes were associated to the Oberlin's procedure and the Sansak's procedure, while the improvement of outcomes associated to phrenic to musculocutaneous nerve and the accessory to suprascapular nerve transfer did not reach statistical significance. Reinnervation of the hand was observed in less than 30% of the cases. CONCLUSION: Brachial plexus surgery renders satisfactory results for reinnervation of the proximal musculature of the upper limb, however the same good outcomes are not usually associated to the reinnervation of the hand.

The importance of the preoperative clinical parameters and the intraoperative electrophysiological monitoring in brachial plexus surgery / A importância dos parâmetros clínicos pré-operatórios e da monitoração eletrofisiológica intra-operatória para a cirurgia do plexo braquial

OBJECTIVE: The study aims to demonstrate the impact of some preoperative clinical parameters on the functional outcome of patients sustaining brachial plexus injuries, and to trace some commentaries about the use of intraoperative monitoring techniques. METHOD: A retrospective study one hundred cases of brachial plexus surgery. The analysis regarding postoperative outcomes was performed by comparing the average of the final result of the surgery for each studied cohort. RESULTS: Direct electrical stimulation was used in all patients, EMG in 59 percent, SEPs in 37 percent and evoked NAPs in 19 percent of the cases. Patients in whom the motor function of the hand was totally or partially preserved before surgery, and those in whom surgery was delayed less than 6 months demonstrated significant (p<0.05) better outcomes. CONCLUSION: The preoperative parameters associated to favorable outcomes in reconstruction of the brachial plexus are a good post-traumatic status of the hand and a short interval between injury and surgery.

OBJETIVO: Apresentar o impacto de alguns parâmetros clínicos pré-operatórios sobre o prognóstico de pacientes com lesões traumáticas do plexo braquial e tecer comentários a respeito da monitorização eletrofisiológica intraoperatória. MÉTODO: Estudo retrospectivo de cem cirurgias de plexo braquial, incluindo apenas os casos que atingiram um tempo de seguimento em que poderia se assumir que o resultado final da cirurgia foi obtido. RESULTADOS: Pacientes apresentando função motora da mão normal ou parcialmente preservada após o trauma, além daqueles nos quais o intervalo entre trauma e cirurgia foi menor do que de seis meses, apresentaram os melhores resultados (p<0,05). CONCLUSÃO: Os parâmetros clínicos mais fortemente associados à obtenção de melhores resultados cirúrgicos são o estado neurológico pré-operatório da mão e um curto intervalo entre o trauma e a cirurgia. A estimulação elétrica simples é um método útil em casos de lesões associadas à tração; EMG e NAP são úteis para lesões infraclaviculares de nervos longos.

Brachial plexus surgery: the role of the surgical technique for improvement of the functional outcome / Cirurgia do plexo braquial: o papel da técnica cirúrgica para a obtenção de melhores resultados funcionais

OBJECTIVE: The study aims to demonstrate the techniques employed in surgery of the brachial plexus that are associated to evidence-based improvement of the functional outcome of these patients. METHOD: A retrospective study of one hundred cases of traumatic brachial plexus injuries. Comparison between the postoperative outcomes associated to some different surgical techniques was demonstrated. RESULTS: The technique of proximal nerve roots grafting was associated to good results in about 70 percent of the cases. Significantly better outcomes were associated to the Oberlin's procedure and the Sansak's procedure, while the improvement of outcomes associated to phrenic to musculocutaneous nerve and the accessory to suprascapular nerve transfer did not reach statistical significance. Reinnervation of the hand was observed in less than 30 percent of the cases. CONCLUSION: Brachial plexus surgery renders satisfactory results for reinnervation of the proximal musculature of the upper limb, however the same good outcomes are not usually associated to the reinnervation of the hand.

OBJETIVO: Análise de resultados das técnicas que comprovadamente melhoraram o prognóstico funcional de pacientes com lesões traumáticas do plexo braquial. MÉTODO: Estudo retrospectivo de cem casos de lesões traumáticas do plexo braquial. Foi realizada comparação dos resultados pós-operatórios obtidos com as diferentes técnicas utilizadas. RESULTADOS: A técnica de enxertia a partir de raízes proximais resultou em bons graus de reinervação em 70 por cento dos casos. Bons resultados (p<0,05) também foram relacionados à técnica de Oberlin e de Sansak, enquanto que a transferência frênico-musculocutâneo e acessório-suprascapular não resultaram em melhora que atingisse significância estatística. Reinervação motora da mão foi observada em menos de 30 por cento dos casos. CONCLSUÃO: A cirurgia de reinervação do plexo braquial em geral resulta em boa recuperação da função proximal do membro, porém esses mesmos bons resultados não são observados em termos de reinervação da mão.

Distal anterior interosseous nerve transfer to the deep ulnar nerve and end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve for treatment of high ulnar nerve injuries: experience in five cases.

OBJECTIVE: To demonstrate the results of a double nerve transfer at the level of the hand for recovery of the motor and sensory function of the hand in cases of high ulnar nerve injuries. METHOD: Five patients underwent a transfer of the distal branch of the anterior interosseous nerve to the deep ulnar nerve, and an end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve. RESULTS: Two patients recovered strength M3 and three cases were graded as M4; recovery of protective sensation (S3+ in three patients and S4 in two) was observed in the fourth and fifth fingers, and at the hypothenar region. The monofilament test showed values of 3.61 or less in all cases and the two-point discrimination test demonstrated values of 7 mm in three cases and 5 mm in two. CONCLUSION: This technique of double nerve transfer is effective for motor and sensory recovery of the distal ulnar-innervated side of the hand.

Triceps brachii reinnervation in primary reconstruction of the adult brachial plexus: experience in 25 cases.

BACKGROUND: Elbow flexion and shoulder abduction are the primary goals in brachial plexus surgery; however, reinnervation of the triceps is also an objective to be considered, as restoration of elbow extension improves the stabilization of the elbow and can provide a more powerful grasp. This study aims to demonstrate the author's experience with restoration of elbow extension function in cases of brachial plexus surgery in adults. METHODS: Records of 25 patients sustaining traumatic brachial plexus injuries who were treated surgically with reinnervation of the triceps were reviewed. Nine techniques were employed, including posterior cord reconstruction and nerve transfers using donors such as the ipsilateral C7 root, phrenic nerve, medial pectoral nerve, intercostal nerves, the spinal accessory nerve, and a motor fascicle of the ulnar nerve. The targeted structure was the radial nerve or the branch to the long head of the triceps. FINDINGS: Twenty-one subjects (83%) obtained triceps reinnervation, and good results (M3 or better) were observed in 19 cases (76%). M4 grade was noted in 36% of the cases, M3 grade in 40%, M2 grade in 8%, M1 grade in 8%, and M0 grade in 8% of the patients. The best outcomes were observed in the cases presenting a C5 to C7 palsy and those in which the nerve to the triceps was chosen as the transfer target. CONCLUSIONS: Reinnervation of the triceps can be achieved in most patients if adequate donor and recipient nerves are carefully selected based on an individual case-specific decision.

Distal anterior interosseous nerve transfer to the deep ulnar nerve and end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve for treatment of high ulnar nerve injuries: experience in five cases / Transferência do nervo interósseo anterior distal para o ramo profundo do nervo ulnar e sutura término-lateral do nervo ulnar superficial ao terceiro nervo digital comum para tratamento de lesões altas do nervo ulnar: experiência em cinco casos

OBJECTIVE: To demonstrate the results of a double nerve transfer at the level of the hand for recovery of the motor and sensory function of the hand in cases of high ulnar nerve injuries. METHOD: Five patients underwent a transfer of the distal branch of the anterior interosseous nerve to the deep ulnar nerve, and an end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve. RESULTS: Two patients recovered strength M3 and three cases were graded as M4; recovery of protective sensation (S3+ in three patients and S4 in two) was observed in the fourth and fifth fingers, and at the hypothenar region. The monofilament test showed values of 3.61 or less in all cases and the two-point discrimination test demonstrated values of 7 mm in three cases and 5 mm in two. CONCLUSION: This technique of double nerve transfer is effective for motor and sensory recovery of the distal ulnar-innervated side of the hand.

OBJETIVO: Demonstrar os resultados obtidos com uma dupla transferência nervosa ao nível da mão para tratamento de lesões do nervo ulnar localizadas acima do cotovelo. MÉTODO: Cinco pacientes foram submetidos à transferência do nervo interósseo anterior para o ramo profundo do nervo ulnar, associado à sutura término-lateral do nervo ulnar superficial ao terceiro nervo digital comum. RESULTADOS: Dois pacientes recuperaram força M3 e os outros três casos foram graduados como M4. Recuperação de sensibilidade protetora (S3+ em três pacientes e S4 em dois) foi observada nos quarto e quinto dedos, além da região hipotenar. O teste de monofilamentos demonstrou valores iguais ou menores do que 3,61 em todos os casos e o teste de discriminação de dois pontos apresentou valores de 7 mm em três casos e 5 mm em dois. CONCLUSÃO: A técnica de dupla transferência nervosa é eficaz como modalidade de tratamento para lesões altas do nervo ulnar.

ACUTE LESION OF THE MOTOR BRANCH OF THE ULNAR NERVE IN THE WRIST AFTER TUG-OF-WAR TRAINING.

Papers correlating clinical and electrophysiological findings relating to ulnar nerve lesions in the wrist are uncommon in the literature, if compared with elbow injuries. We present the case of a patient with atrophy of the intrinsic musculature of the hand, secondary to injury only of the motor branch of the ulnar nerve, which is located in Guyon's canal close to the hamate hook. We review the anatomical, clinical and neurophysiological aspects of distal ulnar nerve injuries and we emphasize the importance of multidisciplinary approaches. Specifically in relation to the mechanism of injury of this patient (tug-of-war), we did not find any similar cases in the literature. We issue an alert regarding the risks during military physical training.