Is Pseudomeningocele an Absolute Sign of Root Avulsion Brachial Plexus Injury?

BACKGROUND: The finding of pseudomeningocele from cervical myelogram is widely accepted as a pathognomonic sign for diagnosing root avulsion in brachial plexus injury. In general, motor power in this setting should be absent. However, in clinical practice, we observed that motor power in some patients was still preserved. The objective of this study is to evaluate the accuracy of pseudomeningocele from cervical myelogram for predicting root avulsion in brachial plexus injury. METHODS: We retrospectively reviewed 201 patients with brachial plexus injury from 2007-2011. Four patients were excluded due to open wound injury. Motor power of the key muscle of each nerve root was evaluated by skilled hand surgeons. All cervical myelogram was interpreted by radiologists. Sensitivities, specificities, positive predictive values and negative predictive values were calculated with 95% confidence interval. RESULTS: Thirty and 29% of pseudomeningocele occurred at C7 and C8 level, respectively. The sensitivity of pseudomeningocele of each root from C5 to T1 was low (range, 10-62%). The specificity was high only at C5 (91%) and T1 (96.2%). Over 20% of patients with pseudomeningocele at C6-8 levels had some motor function. The initial muscle power of these patients was M1 or M2 and 70% of them recovered to at least M3 at the final follow-up. CONCLUSIONS: Pseudomeningocele is not an absolute sign for diagnosing of root avulsion in brachial plexus injury due to its high false positive rate when compared with preoperative motor function of each root. Careful examination of the key muscle of each root is extremely crucial to prevent unnecessary operation on that cervical nerve root.

Randomized clinical trial comparing efficacy and safety of brand versus generic alendronate (Bonmax®) for osteoporosis treatment.

INTRODUCTION: Although the same efficacy and tolerability are anticipated due to both drugs containing the same active ingredients, comparative studies between brand and generic alendronate are limited. Accordingly, the objective of this study was to compare efficacy and safety between brand alendronate and a recently introduced generic alendronate drug. METHODS: A total of 140 postmenopausal women or men aged older than 50 years who met the indications for osteoporosis treatment were randomized to receive either generic (Bonmax®) or brand alendronate (Fosamax®) 70 mg/week over a 12-month period during the May 2014 to June 2015 study period. Endpoints included bone mineral density (BMD) changes at the lumbar spine, total hip, and femoral neck; percentage of patients with predefined levels of change in total hip and lumbar spine BMD at 12 months; and, changes in biochemical bone markers at 3, 6, and 12 months. Tolerability was evaluated by patient self-reporting of adverse experiences. RESULTS: At 12 months post-treatment, BMD significantly increased at all sites in both groups. There were no differences in BMD percentage changes or the number of patients with stable or increased BMD after 1 year between groups. No significant differences in the amount of biochemical bone marker reduction or incidence of adverse events were observed between groups. CONCLUSIONS: Generic and brand alendronate produced similar gains in BMD and reduction in bone turnover markers. Both medicadoitions were also equally well-tolerated. Based on these findings, generic alendronate (Bonmax®) is a viable alternative to the original brand of alendronate. TRIAL REGISTRATION: ClinicalTrials.gov NCT02371252.

End-to-Side Neurorrhaphy to Restore Elbow Flexion in Brachial Plexus Injury.

Background: End-to-side (ETS) neurorrhaphy is a controversial technique that is used for nerve transfer to achieve functional recovery. The advantage of this technique is the safety of donor nerve function. In this study, patients with extended upper-arm brachial plexus injury and significant hand weakness that did not meet the clinical criteria for end-to-end nerve transfer (Oberlin transfer) were treated by ETS neurorrhaphy to achieve biceps muscle reinnervation. Objective: To evaluate the outcome of ETS for biceps muscle reinnervation in brachial plexus injury patients. Material and Method: Thirteen patients with complete upper-arm and incomplete lower-arm brachial plexus injuries were treated by ETS of the motor branch of the biceps muscle to the ulnar or median nerves using the epineurial window technique. Results: Motor recovery was observed in nine of 13 patients. Good results were achieved in six patients who attained biceps motor power ≥ M3. No additional neurological deficits of the ulnar or median nerves were identified after the surgery. Conclusion: End-to-side neurorrhaphy is a viable treatment option for restoration of biceps muscle function if conventional end-to-end nerve transfer cannot be performed.

Neuropathic pain in brachial plexus injury.

BACKGROUND: In Thailand, brachial plexus injury is a common traumatic injury that affects the function of the upper extremity. The current treatments focus mainly on improving the motor and sensory function. Apart from the motor and sensory deficit, these patients usually suffer from pain. OBJECTIVE: The purpose of this study was to determine the prevalence and factors that relate to neuropathic pain in patients with brachial plexus injury. METHODS: We collected data from March 2008 to July 2011. The DN4 Questionnaire was used to diagnose neuropathic pain in 95 patients. RESULTS: The prevalence of neuropathic pain was as high as 76%. Majority of patients presented with hypoesthesia to pin prick, hypoesthesia to touch and numbness. Severity of neuropathic pain was significantly correlated with the type of brachial plexus injury. There was no difference between demographic characteristics of patients. CONCLUSION: Our study showed that the prevalence of neuropathic pain was high in brachial plexus injured patients. Therefore, surgeons should be aware of this common, yet underestimated, problem in brachial plexus injured patients.

Effectiveness and safety of home-based muscle electrical stimulator in brachial plexus injury patients.

OBJECTIVE: To evaluate the effectiveness and safety of home-based muscle electrical stimulation system in brachial plexus injury patients. MATERIAL AND METHOD: Forty brachial plexus injury patients underwent muscle electrical stimulation using a custom designed electrical stimulator. Effectiveness of the system, visual analog pain score, skin temperature, superficial skin condition, overallpatient satisfaction, and location of treatment preference were evaluated after the intervention. A follow-up telephone call was used to evaluate late-onset complications. RESULTS: Thirty-three men and seven women with an average age of 32 years were enrolled in the present study. According to our predefined definitions, 39 of 40 stimulation sessions were successfully completed, which resulted in a total system effectiveness of 97.5%. All patients tolerated the stimulation well. The average visual analog pain score was significantly decreased from 4 to 3 after the stimulation. There were no adverse incidents reported. The average patient satisfaction score was 7.8 out of 10. Thirty-five of 40 patients (88%) preferred to use home-based electrical stimulation vs. hospital-based treatment. CONCLUSION: The custom designed muscle electrical stimulator used in this study has demonstrated adequate effectiveness and safety for clinical home use for brachial plexus injury patients.

Adult brachial plexus injury: evaluation and management.

Adult traumatic brachial plexus injury involves injury of the C5-T1 spinal nerves. Common patterns of injury include "upper arm" and "total arm" types. The specific signs of preganglionic avulsion injury infer a poor prognosis for spontaneous recovery and surgery may be needed. Detailed preoperative evaluation is recommended for localization of the lesions. The treatment of upper arm type injury comprises restoration of elbow flexion and shoulder control. Good functional results may be achieved after multiple nerve transfers. The treatment of total arm type includes hand function reconstruction, in addition to shoulder and elbow treatment. Current options for hand function reconstruction include functioning free muscle transfers and nerve transfers.

Diaphragmatic height index: new diagnostic test for phrenic nerve dysfunction.

OBJECT: The diaphragmatic height index (DHI) was developed to measure the difference in diaphragm levels. The purpose of this study was to set definite DHI values and test the accuracy of these values for use as a new diagnostic test for phrenic nerve dysfunction. METHODS: All data for this study were obtained from medical charts and retrospectively reviewed. RESULTS: One hundred sixty-five patients with brachial plexus injury who had undergone nerve transfers between 2005 and 2008 were divided into Groups A and B. Group A consisted of 40 patients (mean age 28.0 years) who had sustained concomitant injury of the brachial plexus and phrenic nerves. Patients in Group A1 had right phrenic nerve injury and those in Group A2 had left phrenic nerve injury. Intraoperative direct electrical stimulation of the phrenic nerve was considered the gold standard in assessing nerve function in all patients with brachial plexus injury. Group B consisted of 125 patients (mean age 28.7 years) with brachial plexus injury and normal phrenic nerve function. Group C, the control group, consisted of 80 patients with nonbrachial plexus injury (mean age 34.0 years) who had undergone other kinds of orthopedic operations between April and June 2009. Standard posteroanterior chest radiographs were blindly interpreted using the Siriraj inhouse picture archiving and communication system in all 245 patients in the study. First, a reference line (R line) was drawn along the inferior endplate of T-10. Then, 2 lines (lines A and B) were drawn through the highest point of each diaphragm and parallel to the R line. The difference between these 2 lines divided by the height of T-10 was defined as the DHI. The cutoff points of the DHI for diagnosing right and left phrenic nerve dysfunction were analyzed with a receiver operating characteristic curve. The accuracy of these DHI values was then evaluated. The DHI in Group C was 0.64 ± 0.44, slightly higher than the DHI in Group B, with no significant difference. Diaphragmatic height indexes in Groups A1 and A2 were 2.0 ± 0.99 and -1.04 ± 0.83, respectively, which were significantly different from those in Groups B and C (p < 0.05). The cutoff point of the DHI for diagnosing right phrenic nerve dysfunction was > 1.1, and that for left phrenic nerve dysfunction was < 0.2. The sensitivity and specificity of right and left DHI values were 90.5% and 86.3%, and 94.7 and 88.3%, respectively. CONCLUSIONS: Data in this study show that diaphragm paralysis can be simply and reliably predicted by the DHI. Diaphragmatic height index values > 1.1 and < 0.2 are proposed as the new diagnostic test for right and left phrenic nerve dysfunction with a high degree of accuracy. This index is applicable in diagnosing phrenic nerve dysfunction that occurs concomitantly with brachial plexus injury or from other etiologies.

Comparison effectiveness of custom-made versus conventional aluminum splint for distal phalange injury.

BACKGROUND: Finger splint is a simple and common method for finger immobilization. The flexible aluminum foam-padded splint is a convenient off-the-shelf inexpensive splint. But there're some studies favor expensively custom-made thermoplastic splint due to its less likely result in treatment failure. Therefore the authors have modified the conventional aluminum finger splint in the foam-padded part to improve the fitting and compliance of the patients. OBJECTIVE: To compare the fitting of custom-made aluminum finger splint with conventional aluminum finger splint. MATERIAL AND METHOD: Sixty volunteers were randomized to apply 30 conventional or custom-made aluminum splints on 4th digit in non dominated hand for one week. The fitting of each splint was measured by displacement of the splint between initial placement and one week later. Patient satisfaction and pain was measured by visual analog score (VAS). RESULTS: The slip and deviation in custom-made group were less than the conventional group significantly (mean of slip 0.86 mm vs. 2.23 mm, p < 0.001, mean of deviation 1.1 degrees vs. 2.23 degrees,p < 0.001) but the longitudinal migration was not significantly difference between both groups (mean 1.6 mm in custom-made group vs. 1.46 mm in conventional group, p = 0.67). The patient satisfaction demonstrated no significant difference between both groups (mean VAS 7.76 in custom-made group vs. 7.3 in conventional group, p = 0.31). Two patients terminated from the present study before one week in custom-made group and one patient in the conventional group (6.67% vs. 3.33%, p = 0.554). CONCLUSION: The custom-made aluminum finger splint can improve the fitting to the finger pulp. However, patient satisfaction and compliance are not significantly different between both groups.

Technique of closed unlocked femoral nailing using ultrasound guidance.

We report a method of closed femoral nailing, without locking, using only ultrasound guidance from the beginning to end of the operation. The method was evaluated as a prospective study in 150 cases of unilateral femoral mid-shaft fracture that underwent surgery within 1 week. There were 132 males and 18 females aged from 16 to 70 years (mean 26). The interval from injury to operation averaged 2.3 days (range 1-7). Twenty-seven cases had Winquist I comminution and 123 cases had no comminution. In 145 cases (97%), we were successful using this method, with an average operation time of 35.8 min (range 30-50). In five cases, we had to change to using fluoroscopic control. Of these, in one case the fracture could not be reduced under ultrasound monitoring, one had nail incarceration, in one there was breakage of the flexible reamer and in two cases we were unable to pass the guide-wire across the fracture within 10 min. Ultrasound is readily available in most hospitals and can be used as an alternative method for monitoring the fracture alignment in closed unlocked femoral nailing.

Radiation scattering to the primary surgeon during closed locked femoral nailing.

A prospective study of the radiation exposure to the primary surgeon during closed static locked femoral nailing was performed in 50 cases. There were 44 males and 6 females whose ages ranged from 15 to 70 years (average, 32). The degree of fracture comminution was classified by Winquist. The cases included 1 Winquist (WQ)1, 9 WQ2, 27 WQ3 and 13 WQ4. The Grosse-Kempf femoral nail was used in 40 cases and the AO interlocking femoral nail was used in 10 cases. The C-arm image intensifier model Phillip BV212 and BV 300 were used during the present study. The average operation time was 52 minutes (range, 30 to 120). The fluoroscopic time for the entire procedure average 132 seconds (range, 23 to 366). The radiation exposure to the primary surgeon ranged from 2 to 231 micro-Sv with an average of 30 micro-Sv per procedure. From the present study, it was found that radiation scattered to the primary surgeon during current practice for closed static femoral nailing using the recent model of C-arm image intensifier was minimal and far below the permissible dose. It was also found that the group using the C-arm model BV 300 (n = 16) had significant lesser fluoroscopic time and less radiation scattering to the primary surgeon than the group with model BV 212 (n = 34).

Brachial plexus injuries in the adult. nerve transfers: the Siriraj Hospital experience.

A strategy that uses the selective combination of neurotizations can yield a moderate degree of shoulder and elbow control. Even though some wrist and finger movement can occasionally be achieved by the current methods of neurotization,the results in terms of restoration of useful hand function are still far from satisfactory. The use of intraplexal and contralateral plexal neurotization combined with free-functioning muscle transfer and the better understanding of central-peripheral function integration may provide more purposeful hand function in the future.

A protector for retrograde femoral nailing using proctoscope.

An improvised method of using a proctoscope as a protector during the reaming procedure for closed retrograde femoral nailing is described. This protector is easy to handle and can be effectively used to protect the intra-articular structures, patellar cartilage and patellar tendon during the reaming process. The protector can also help minimise the reaming bone dust spilling out into the joint cavity.

Capture of the screw during percutaneous screw insertion.

The simple technique to maintain the engagement of the screw and the screw driver during percutaneous locking screw insertion is presented. The method can capture the screw when the screw becomes disengaged. This will be helpful when percutaneous screw insertion is performed in the narrow and deep location of the bone such as a locking screw at the upper part of the femur during retrograde femoral nailing.