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.

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.

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.

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.

Psicoprofilaxis quirúrgica en neurocirugía: experiencia en el Hospital de Clínicas "José de San Martín" / Surgical psychoprophylaxis in neurosurgery: experience in the Hospital de Clínicas "José de San Martín"

Introducción: El presente estudio busca evaluar el rol del psicólogo en una unidad de neurocirugía a través de la psicoprofilaxis quirúrgica, una psicoterapia breve diseñada para el paciente quirúrgico durante su internación. Objetivo: Describir y analizar el trabajo realizado sobre psicoprofilaxis quirúrgica durante 8 años en la División Neurocirugía del Hospital de Clínicas José de San Martín de la Ciudad de Buenos Aires. Método: Se utilizó un protocolo de asistencia psicoterapéutica que consta de entrevistas clínicas al paciente y su familia durante la internación, asistencia del psicoterapeuta al pase de sala matinal diario, confección periódica de escalas de ansiedad, depresión y tests cognitivos, entrevistas con la familia por separado del paciente y reuniones informativas junto al equipo tratante y la familia. Se tomaron como parámetros de evaluación a la ansiedad, la depresión, la comunicación de la información, los miedos universales y la opinión de los pacientes sobre la utilidad de la misma. Resultados: Entre los años 2010 y 2018 recibieron psicoprofilaxis quirúrgica 1517 pacientes, todos ellos intervenidos quirúrgicamente por diferentes patologías. El 50% de los pacientes reportaban síntomas de ansiedad antes de la cirugía, dichos síntomas disminuyeron en un 83% después de la intervención psicológica. Lo mismo sucedió con los síntomas de depresión, del 36% del reporte inicial, un 52% mostró mejoría en sus síntomas después de recibir la psicoterapia durante la internación. En cuanto a la comunicación de la información y el tratamiento de los miedos básicos universales, el 84% de los pacientes pudieron recibir la información de forma pausada, con el tiempo suficiente para procesarla y acomodarla sumado al espacio de escucha a sus miedos universales, facilitando su procesamiento. El 82% de los pacientes asistidos calificaron como positiva la presencia de un profesional de la psicología durante la internación. Conclusión: El balance positivo entre los parámetros objetivos (ansiedad y depresión) y los subjetivos (comunicación de la información, miedos y opinión del paciente) muestran la utilidad de la presencia de un profesional de la psicología en un servicio de neurocirugía hospitalaria de alta complejidad.

Introduction: The present study evaluated the role of a psychologist in a neurosurgery unit practicing surgical psycho-prophylaxis, a brief psychotherapy intervention designed for surgical patients during hospitalization. Objective: To describe and analyze the usefulness of surgical psycho-prophylaxis over eight years in the Neurosurgery Division at Hospital de Clínicas José de San Martín. Method: A protocol of psychotherapeutic assistance was used, consisting of clinical interviews with patients and their families during hospitalization, assisting during morning rounds, evaluating patients anxiety and depression using standardized scales, cognitive testing, and arranging information meetings between the treatment team and patients' families. Evaluated parameters were anxiety, depression, how well information is communicated and universal fears addressed, and patients' opinions about the intervention's usefulness. Results: Between 2010 and 2018, 1517 patients received surgical psycho-prophylaxis, all of whom underwent surgery for different pathologies. Fifty percent of these patients reported symptoms of anxiety before surgery, which decreased by 83% post psychological intervention. Much the same transpired with symptoms of depression initially reported by 36% and improved in 52% after psychotherapy during hospitalization. Regarding information communication, 84% of patients were able to receive the information slowly, with enough time to process and accommodate it, in addition to affording them ears to hear their fears, facilitating their processing. Overall, 82% of the patients rated the presence of a psychology professional during hospitalization positively. Conclusion: Addressing both clinical parameters like anxiety and depression, and subtler parameters like the communication of information, and patients' fears and opinions, the presence of a psychology professional in the neurosurgery unit of a tertiary-care hospital was found to be both useful and appreciated by patients.

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.

[Facial paralysis surgery. Current concepts]. / Cirugía de la parálisis facial. Conceptos actuales.

Facial palsy is a relatively common condition, from which most cases recover spontaneously. However, each year, there are 127,000 new cases of irreversible facial paralysis. This condition causes aesthetic, functional and psychologically devastating effects in the patients who suffer it. Various reconstructive techniques have been described, but there is no consensus regarding their indication. While these techniques provide results that are not perfect, many of them give a very good aesthetic and functional result, promoting the psychological, social and labour reintegration of these patients. The aim of this article is to describe the indications for which each technique is used, their results and the ideal time when each one should be applied.

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.

[Thoracic Outlet Syndrome: is it always a surgical condition? Analysis of a series of 31 cases operated by the supraclavicular route]. / Síndrome del Outlet Torácico: ¿Una Patología Siempre Quirúrgica? Análisis de una Serie de 31 Cirugías Realizadas por Vía Supraclavicular Serie clínica.

BACKGROUND: Thoracic Outlet Syndrome is a compression of the brachial plexus that remains highly controversial. Classification in True or Neurogenic Outlet (TTO) and Disputed or Non-neurogenic Outlet (DTO) is becoming very popular. The former is characterized by a muscular atrophy of the intrinsic muscles of the hand, while the latter has only sensitive symptoms. The purpose of this article is to analyze the results obtained in a series of 31 patients. METHODS: All patients with diagnosis of Thoracic Outlet operated between January 2003 and December 2012 with a minimum follow-up of six months where included. Age, sex, symptoms, classification, preoperative studies results, complications and recurrences were analyzed. RESULTS: 31 surgeries performed in 30 patients, 9 with TTO (8 women, mean age 24.3 years) and 21 with DTO (18 women, mean age 37.4 years, 1 recurrence) were included. Ninety percent of patients presented neurophysiological and 66.6% imagenological preoperative disturbances. All TTO and only 36.7% of DTO showed clear pathological findings during surgical exploration. A high percentage (87,5% sensitive and 77.7% motor) of TTO ameliorated after surgical decompression. Only 45.5% of DTO showed permanent positive changes, 13.6% temporary, 36.6% no changes, and 4.5%(one case) showed deterioration after decompresive surgery. Complications after surgery were more frequent ­but temporary- in TTO cases (33.3%), than in DTO (13.6%). CONCLUSIONS: TTO showed a favorable outcome after surgery. DTO showed a worst ­but still positive- postoperative result if patients are selected properly. These data are in concordance with other recent reports.

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.

Surgical treatment of typical peripheral schwannomas: the risk of new postoperative deficits.

BACKGROUND: Although peripheral schwannomas can be resected without postoperative neurological complications, surgeons must anticipate the possibility that new neurological deficits could develop. In order to evaluate the risk of neurological complications in the surgical treatment of these tumours, we performed a retrospective review of cases involving schwannomas in the extremities, as well as an analysis of the related literature. METHOD: We reviewed a combined series of 72 schwannomas from the extremities presenting for surgical excision. Meticulous analysis of the files was undertaken, searching for pre-operative findings that could be more frequent in patients with surgical complications. The incidence, severity, and transitory nature of post-operative complications in our series was observed and compared against the literature. RESULTS: Eleven patients (15.2 %) developed new neurological deficits after surgery: sensory disturbance in seven cases, motor weakness in three, and a single wound hematoma. Most of these complications were temporary. Statistical analysis demonstrated a positive relationship between the presence of complications and both patient age under 50 years (p = 0.02) and tumours greater than 3 cm in greatest diameter (p = 0.02). CONCLUSIONS: Although relatively infrequent, the potential for novel post-operative deficits after the surgical treatment of peripheral schwannomas does exist and should be included during pre-operative counseling.

Síndrome del outlet torácico: una patología siempre quirúrgica? / Thoracic outlet syndrome: an always surgical entity?

Objetivo: el objetivo de este trabajo es analizar los resultados obtenidos en una serie de cirugías realizadas en esta patología. Material y métodos: se analizaron todos los casos de cirugías de nervios efectuados en el período 2003-2012, separando los casos con diagnóstico de outlet torácico operados con un período de seguimiento postoperatorio mínimo de 6 meses. Se buscaron los siguientes datos: edad, sexo, presencia de síntomas sensitivos y/o motores, tipo de outlet (verdadero o disputado), resultado de los estudios neurofisiológicos y de imágenes, resultado de la cirugía, complicaciones postoperatorias y recidivas. Resultados: se incluyeron 31 cirugías realizadas en 30 pacientes, 9 con diagnóstico de OTV (8 mujeres) con un promedio de edad fue de 24.3 años, y 21 con OTD (18 mujeres) de 37.4 años en promedio. Un 90% de todos los casos de outlet presentaron alteraciones neurofisiológicas preoperatorios, y los estadios imagenológicos fueron anormales en 66.6%. Una vez realizada la exploración, el 100% de los OTV presentó una alteración anatómica claramente relacionada con la sintomatología, hecho observado sólo en el 36.7% de los OTD operados. El 87.5% de los OTV mejoraron sus síntomas sensitivos luego de la cirugía, mientras que 77.7% mejoraron desde el punto de vista motor. Por el contrario, 45.4% de los OTD mejoraron permanentemente, 36.3% no tuvieron cambios, 13.6% mejoraron transitoriamente y 405% (un caso) empeoró. Las complicaciones postoperatorias fueron más frecuentes aunque transitorias en el grupo de OTV (3 casos sobre 9 operados, 33.3%) que en los OTD (3 casos sobre 22, un 13.6%). Conclusión: el OTV es una patología infrecuente cuyo tratamiento quirúrgico suele evolucionar favorablemente. En cambio, el OTD constituye un diagnóstico de exclusión y su tratamiento quirúrgico da un resultado bueno aunque inferior al del OTV. (AU)

Síndrome del outlet torácico: una patología siempre quirúrgica? / Thoracic outlet syndrome: an always surgical entity?

Objetivo: el objetivo de este trabajo es analizar los resultados obtenidos en una serie de cirugías realizadas en esta patología. Material y métodos: se analizaron todos los casos de cirugías de nervios efectuados en el período 2003-2012, separando los casos con diagnóstico de outlet torácico operados con un período de seguimiento postoperatorio mínimo de 6 meses. Se buscaron los siguientes datos: edad, sexo, presencia de síntomas sensitivos y/o motores, tipo de outlet (verdadero o disputado), resultado de los estudios neurofisiológicos y de imágenes, resultado de la cirugía, complicaciones postoperatorias y recidivas. Resultados: se incluyeron 31 cirugías realizadas en 30 pacientes, 9 con diagnóstico de OTV (8 mujeres) con un promedio de edad fue de 24.3 años, y 21 con OTD (18 mujeres) de 37.4 años en promedio. Un 90% de todos los casos de outlet presentaron alteraciones neurofisiológicas preoperatorios, y los estadios imagenológicos fueron anormales en 66.6%. Una vez realizada la exploración, el 100% de los OTV presentó una alteración anatómica claramente relacionada con la sintomatología, hecho observado sólo en el 36.7% de los OTD operados. El 87.5% de los OTV mejoraron sus síntomas sensitivos luego de la cirugía, mientras que 77.7% mejoraron desde el punto de vista motor. Por el contrario, 45.4% de los OTD mejoraron permanentemente, 36.3% no tuvieron cambios, 13.6% mejoraron transitoriamente y 405% (un caso) empeoró. Las complicaciones postoperatorias fueron más frecuentes aunque transitorias en el grupo de OTV (3 casos sobre 9 operados, 33.3%) que en los OTD (3 casos sobre 22, un 13.6%). Conclusión: el OTV es una patología infrecuente cuyo tratamiento quirúrgico suele evolucionar favorablemente. En cambio, el OTD constituye un diagnóstico de exclusión y su tratamiento quirúrgico da un resultado bueno aunque inferior al del OTV.