Assessment of the usefulness of X-ray myelography and magnetic resonance myelography, performed with an open low-field device, in diagnosing perinatal preganglionic injuries of the brachial plexus.

INTRODUCTION: The goal is to assess the usefulness of diagnostic imaging in diagnosing perinatal preganglionic injuries of the brachial plexus. MATERIAL AND METHODS: The clinical material included 40 children of both genders, aged 2 to 35 months. The authors analysed the results of diagnostic imaging examinations (myelography in 20 cases and magnetic resonance [MR] myelography in 20 cases), intraoperative view and clinical course. RESULTS: In 13 out of 40 (32.5%) examined children, no evidence of avulsion of the roots of the spinal nerves was found either by diagnostic imaging or during the surgery. In 3 cases (7.5%) with avulsed roots of the spinal nerves, the diagnostic imaging and intraoperative appearance were in agreement. Total agreement of the diagnostic imaging and intraoperative view was found in 40% of cases. In 9 patients (22.5%) suspected avulsion of roots of the spinal nerves was not confirmed during the surgery. However, the further clinical course of the disease in these cases indicated high probability of avulsion of roots without their pull-out from the intervertebral foramens. In the remaining cases, the findings were as follows: false positive results - 7 (17.5%), false negative results - 1 (2.5%), results underestimating injury - 3 (7.5%), results overestimating injury - 2 (5%). CONCLUSIONS: It was determined that the usefulness of pre-operative diagnostic imaging is limited. Due to the risk of occurrence of false positive and false negative results, final decisions concerning selection of the surgical technique must be based on the analysis of the intraoperative view and preoperative clinical symptoms.

Our experience with surgical treatment of perinatal brachial plexus palsy--results in different types of lesions.

INTRODUCTION: Perinatal brachial plexus palsies can be divided into upper (C5-C6), upper-middle (C5-C6-C7) and total injuries (C5-Th1). The study aimed to evaluate the results of surgical repair in the different types of palsies. MATERIAL AND METHODS: The patient population comprised 80 children who underwent primary repair of the brachial plexus (external neurolysis, internal neurolysis, direct neurorrhaphy, nerve grafts, extraanatomical intraplexus reconstruction, extraanatomical extraplexus reconstruction). 31 patients were additionally subjected to 39 tenomioplasty procedures. Widely recognised assessment scales were used to evaluate the outcome of surgical treatment of different types of palsies in 70 patients. RESULTS: Good and very good post-operative function of the glenohumeral and elbow joints was demonstrated in all patients with upper palsy. In the group of upper-middle injuries, 61.5% of patients presented good and very good function of the shoulder joint and 76.9% had good function of the elbow. In subjects with total brachial plexus palsy, good function of the glenohumeral was demonstrated by 51.2%, good function of the elbow by 61% and 53.6% presented with a functionally useful hand. CONCLUSIONS: 1. While surgical repair may be indicated in brachial plexus injuries at all levels, it is usually inevitable in total and upper-middle palsies. 2. The surgical outcome depends on the extent of baseline damage to the brachial plexus, with the best prognosis in insolated upper palsies.

Neurolysis of the conducting neuroma-in-continuity in perinatal brachial plexus palsy - evaluation of the results of surgical treatment.

UNLABELLED: The aim of the study was to evaluate the surgical treatment results of cases of perinatal brachial plexus palsy with presence of neuroma-in-continuity. Clinical material included 21 children, aged from 3.5 to 36 months, treated surgically between 1996 and 2005. The control examination included 19 children. The shortest postoperative observation period was 4 years. After surgical treatment during clinical evaluation of function dependent on localization of neuroma-in-continuity we observed the following: in upper injury in 1 child good shoulder and elbow function; in upper-middle injuries with neuroma-in-continuity in upper trunk good elbow function in 66.6%, good shoulder function in 83.3% of cases; in upper-middle injuries with neuroma-in-continuity in upper and middle trunk in 1 examined child good function of elbow, shoulder, and wrist; in total injuries with neuroma-in-continuity in upper trunk good elbow function in 75%, and good shoulder function in 50% of cases; in total injuries with neuroma-in-continuity in upper and middle trunk good elbow function in 66.6%, good shoulder function in 33.3%, good wrist function in 66.6% of cases; in total injuries with neuroma-in-continuity in lower trunk grade 2 of motor hand function and return of sensibility to a level of S3+. CONCLUSIONS: The choice of microsurgical technique during surgical treatment of perinatal brachial plexus palsies with neuroma-in-continuity should be based on the whole clinical and intraoperative view. The best results after neurolysis should be expected when neuroma-in-continuity is localized in the upper trunk, the injury corresponds to third degree on Sunderland's scale, and during electric stimulation a normal motor response can be obtained.

Tenomyoplastic procedures to improve shoulder function in the treatment of perinatal brachial plexus palsy.

BACKGROUND: A contracture of the shoulder joint in the course of perinatal brachial plexus palsy significantly affects the function of the upper limb as a whole. The aim of this paper is to present the authors' experience in surgical procedures carried out to improve shoulder joint function impaired as a result of perinatal brachial plexus palsy and evaluate the treatment outcomes. MATERIAL AND METHODS: The study involved 36 patients who underwent 37 tenomyoplastic procedures (subscapular release, teres major transfer, transfer of a portion of the trapezius). Pre- and postoperative shoulder joint function was assessed with the Gilbert scale. RESULTS: Surgical release of the subscapular muscle improved shoulder function in all patients, usually by 1 degree in the Gilbert scale. Teres major transfer improved shoulder function in all 4 patients (grade IV - 3 children, grade V - 1 child). One patient benefited from tenomyoplasty involving the trapezius. CONCLUSIONS: 1. Indications for tenomyoplasty procedures in the region of the shoulder joint may be present both in children who had previously undergone microsurgery and in those in whom rehabilitation had led to a good outcome of perinatal brachial plexus palsy. 2. The fact that most patients improved following tenomyoplastic procedures justifies their advisability. A visible functional improvement of the upper limb can be achieved with a relatively low risk of complications.

Preganglionic injuries in perinatal brachial plexus palsies - results of surgical treatment.

BACKGROUND AND PURPOSE: The authors report their experience in surgical treatment of preganglionic injuries in perinatal brachial plexus palsies. MATERIAL AND METHODS: Clinical material consisted of 16 children, of both sexes, aged from 2.5 to 33 months (mean 6.2 months), treated surgically between 1994 and 2006. The clinical view of the injury and location of preganglionic lesions was analysed and the description of the performed microsurgical techniques is provided. Control clinical examinations included a group of 14 children. The shortest postoperative observation period was 3 years. The currently accepted scales of evaluation of function of particular joints of the upper limb were used. RESULTS: The following outcome was noted after surgical treatment of perinatal brachial plexus palsies with signs of pre- and postganglionic injuries: good shoulder function in 6 cases, and average in 2 others; good elbow function in 4 cases, and average in 7 patients; functional position of the forearm in 9 cases, and good range of pronation and supination in 1 patient; useful function of wrist (flexion/extension) in 4 cases; good motor hand function in 3 cases, and fair in 6 patients. CONCLUSIONS: In preganglionic perinatal brachial plexus injuries located in the upper-middle part, spinal nerve C7 roots avulsion is the most frequently observed, and in the lower part of the brachial plexus, spinal nerve C8 roots avulsion is the most frequently observed. In preganglionic injuries of the brachial plexus, the number of avulsed spinal nerves has an influence on technical possibilities of performing reconstruction procedures, and then the results of the surgical treatment.

[The employment of synthetic biodegradable polymers in reconstructions of the peripheral nerves]. / Zastosowanie syntetycznych polimerów ulegajqcych biodegradacji w rekonstrukcjach nerwów obwodowych.

In this study we presented the possibility of using a synthetic biodegradable polymers to production a conduits employ in reconstructions of the peripheral nerves in experimental studies and medical practice. The aliphatic polyesters are most common used to this purpose. The poly(phosphoesters) and polyurethanes are used rather rare. In study we presented experiences of many authors in employment of the following polymers in experimental conditions. The obtained results were also described. The cases of clinical using of artificial nerve conduits from PGA--polyglycolic acid and PLCL--poly(DL-lactide-epsilon-caprolactone) were also described. Only PGA and PLCL marked as GEM Neurotube and Neurolac were approved to commercial production. The basic aspects of operating technique during reconstructions with artificial nerve conduits and causes of potential failure in microsurgical reconstructions were described. Still existing limitations in employment of artificial nerve tubes were emphasized and the directions of future progress in studies were presented. The possibility of establish of molecular weight of polymers building a tube scaffold and porosity and degradability of the wall create a chance to production an optimal in clinical applications artificial nerve tube.

Comparison of the results of surgical treatment after direct neurorrhaphy and reconstruction with sural nerve grafts in perinatal brachial plexus lesions.

The neurotmesis of elements of the brachial plexus in perinatal lesions requires microsurgical reconstruction. In this study we present our own experiences in surgical treatment of postganglionic lesions in the fifth degree of injury in Sunderland's scale. The clinical material consisted of 14 children aged from 2.5 to 6 months treated surgically due to neurotmesis of the neural elements of the brachial plexus. In 8 cases direct neurorrhaphy and in 6 cases reconstruction with sural nerve grafts were performed. During the operations material from the proximal stumps of the brachial plexus trunks was collected for histopathological examination. The analysis of the material comprised: clinical type of injury, location of postganglionic lesion and type of surgical procedure. The results of surgical treatment were evaluated using generally accepted scales (Gilbert's, Raimondi's, Al-Qattan's and British Medical Research Council scales). Comparison of the results of treatment between the surgical methods was also performed. Better results of surgical treatment were observed after direct neurorrhaphy. In our opinion the indications for these two methods are different and both operative techniques are useful in surgical treatment of perinatal brachial plexus palsy.

[Outcome treatment of pseudoarthrosis of long bones with decortication method depends on osteosynthesis]. / Wyniki leczenia stawów rzekomych kosci dlugich konczyny górnej metoda dekortykacji w zaleznosci od rodzaju osteosyntezy.

Purpose of work was estimation of the results of treatment of pseudoarthrosis of the long bone with the method of decortication, with use of autogenic bone depends on kind of pseudoarthrosis and kind of osteosynthesis. In the years 1995-2005 56 patients were treated because of pseudoarthrosis of long bone in our Clinic. Pseudoarthrosis is classified according to Weber-Cech classification. In the methodology of clinical estimation and subjective estimation of the patient Stewart and Hundley and Anderson classification were used. Union was achieved in 51 cases. Time of bone union achievement was 5 months. The results of treatment are depends on morfology of pseudoartrosis and are independs of kind of osteosynthesis.

Experience with surgery for entrapment syndrome of the suprascapular nerve.

BACKGROUND: The suprascapular nerve entrapment syndrome accounts for about 1-2% of all causes of shoulder pain and dysfunction. Entrapment may occur at different levels and a frequent site of compression is the suprascapular notch, the upper border of which is the superior transverse scapular ligament. MATERIAL AND METHODS: We studied 5 patients with entrapment of the suprascapular nerve at the suprascapular notch, analyzing the pathomechanism of the compression syndrome. The outcome of the surgical treatment was evaluated by examining the improvement in strength of the supraspinatus and infraspinatus muscles based on the Narakas method. The degree of recovery of atrophy of the muscles and pain was also evaluated. RESULTS: Following surgical treatment, pain subsided in 4 patients (80%), muscle strength improved in three (60%) and in 1 patients (20%) there was recovery of muscle mass. CONCLUSIONS: The outcomes of surgery for suprascapular entrapment depend on appropriate differential diagnosis, early detection and prompt referral for operative treatment whenever such is necessary.

Evaluation of the dynamics of sensory improvement in the hand after surgical treatment of carpal tunnel syndrome.

BACKGROUND AND PURPOSE: The aim of the study was to evaluate the dynamics of improvement of tactile sensory threshold and two-point discrimination in fingers innervated by the median nerve after surgical treatment of carpal tunnel syndrome (CTS), to assess differences between improvements of both aforementioned sensory measures, as well as to estimate the time taken to achieve ultimate sensory improvement in the hand. MATERIAL AND METHODS: The study included 87 patients (78 females and 9 males) operated on at the Department of Traumatology and Hand Surgery, Medical Academy in Wroclaw between July 2002 and August 2004 because of carpal tunnel syndrome. Mean age of patients was 51.8 years. The study included evaluation of tactile sensory (pressure) threshold and two-point discrimination. Measurements were performed seven times in each patient, that is, before the surgery, and then on the second, fifth and tenth postoperative day as well as one, three and six months after the surgery. RESULTS: There were only minor differences in improvement of tactile sensory threshold and two-point discrimination between particular fingers, but in each case less favourable results were achieved in the thumb and the middle finger and the best results in the ring finger. Over time the observed degree of sensory improvement decreased, and during the last follow-up mean values of tactile sensory threshold and two-point discrimination in each of the studied fingers were within the normal range. CONCLUSIONS: After surgical treatment of CTS normalisation of two-point discrimination occurs earlier than normalisation of tactile sensory threshold. The highest degree of improvement of two-point discrimination is observed during the first two days after surgery, while the highest degree of improvement of tactile sensory threshold is noted between the 10th and 30th postoperative day. No further significant improvement of tactile sensory threshold or two-point discrimination is observed following an initial period of three months after surgery.

[Lower extremity nerves injuries in bone fractures and joint dislocations--etiopathogenesis, treatment]. / Uszkodzenia nerwów konczyn dolnych w zlamaniach kosci i zwichnieciach stawów--etiopatogeneza, leczenie.

Lower extremity nerve injuries accompanying bone fractures and joint dislocations lead to serious disturbances at the lower limbs and caused significant prolongation of the treatment time. Clinical material consisted of 73 patients treated surgically with lower extremity nerve injuries due to bone fractures and joint dislocation. Based on this material we analysed the most frequent localisations of the nerves lesions and the mechanism of injury. The indications to surgical treatment were also described.

[Iatrogenic lesions of the lower extremity nerves--causes, prevention and indications to the surgical treatment]. / Jatrogenne uszkodzenia nerwów koniczyn dolnyc--przyczyny, zapobieganie, wskazania do leczenia operacyjnego.

Iatrogenic lesions of the nerve might be of a deliberate or unintentional character. The clinical material consisted of 73 patients treated surgically with unintentional injuries of the lower limbs nerves. Based on this material we analysed the causes of iatrogenic lesions of the lower limbs nerves and the probably mechanism of injury. The methods of prevention of these complications and the indication to surgical treatment were also described.

[The use of the fibrin glue in the peripheral nerves reconstructions]. / Wykorzystanie kleju fibrynowego w rekonstrukcjach nerwów obwodowych.

In this study we presented essential historical data about application of the fibrin glue in microsurgical reconstructions of the peripheral nerves. The technique of the preparation of the fibrin glue and the most important aspects of the clinical practice were described. We presented also our own experience in the use of the fibrin glue (Tissucol Kit firmy Baxter AG, Beriplast P firmy Behring), in microsurgical reconstructions of the brachial plexus and peripheral nerves. The basic principles of management were emphasized and a few clinical cases were presented. Microsurgical reconstructions of the nerves with using of the fibrin glue are atraumatic and don't cause inflammation and granuloma formation. These methods allowed to while away the time of surgical procedure and allowed to perform a microsurgical reconstruction in difficult conditions. Microsurgical reconstructions of the nerves with fibrin glue application may be used individually or in connection with suture materials.

[Self-mutilation as a consequence of the perinatal brachial plexus palsy]. / Samookaleczenie dloni jako nastepstwo okoloporodowego uszkodzenia splotu ramiennego.

In this study we presented 2 cases of the self-mutilation of the hand following obstetrical brachial plexus palsy. The mechanism of this behaviour was also discussed.