Peripheral Nerve Stimulation for Chronic Intractable Neuropathic Pain Following a Brachial Plexus Avulsion Injury: A Case Report.

Brachial plexus avulsion injuries result in permanent motor and sensory deficits, leading to debilitating symptoms. We report the case of a 25-year-old man with chronic pain following right-sided C5-T1 nerve root avulsion without evidence of peripheral nerve injury. His pain was recalcitrant to medical and neurosurgical interventions. However, he experienced substantial (>70%) pain relief with peripheral nerve stimulation targeting the median nerve. These results agree with data suggesting collateral sprouting of sensory nerves occurs following a brachial plexus injury. Further study is needed if we are to understand the mechanisms of the peripheral nerve stimulator as a treatment option.

Origin variations and brachial plexus relationship of the dorsal scapular artery.

The dorsal scapular artery can either be a direct branch of the subclavian artery or a branch of the transverse cervical artery. Origin variation is related to its relationship with the brachial plexus. Anatomical dissection was performed on 79 sides of 41 formalin-embalmed cadavers in Taiwan. The origin of the dorsal scapular artery and the variations of its brachial plexus relationship were scrutinized and analyzed. Results showed that the dorsal scapular artery originated most frequently from the transverse cervical artery (48%), followed by the direct branch from the third part (25%) and the second part (22%) of the subclavian artery and from the axillary artery (5%). Only 3% of the dorsal scapular artery passed through the brachial plexus if its origin was the transverse cervical artery. However, 100% and 75% of the dorsal scapular artery passed through the brachial plexus when they were direct branches of the second and the third part of the subclavian artery, respectively. Suprascapular arteries were also found to pass through the brachial plexus when they were direct branches from the subclavian artery, but all passed over or under the brachial plexus if they originated from the thyrocervical trunk or transverse cervical artery. Variations in the origin and course of arteries around the brachial plexus are of immense value not only to the basic anatomical knowledge but also to clinical practices such as supraclavicular brachial plexus block and head and neck reconstruction with pedicled or free flaps.

A systematic review of brachial plexus injuries after caesarean birth: challenging delivery?

BACKGROUND: Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such injury. The objectives of this study were therefore to aggregate cases of BPI after CS, and to illuminate risk factors for BPI. METHODS: Pubmed Central, EMBASE and MEDLINE databases were searched using free text: ("brachial plexus injury" or "brachial plexus injuries" or "brachial plexus palsy" or "brachial plexus palsies" or "Erb's palsy" or "Erb's palsies" or "brachial plexus birth injury" or "brachial plexus birth palsy") and ("caesarean" or "cesarean" or "Zavanelli" or "cesarian" or "caesarian" or "shoulder dystocia"). Studies with clinical details of BPI after CS were included. Studies were assessed using the National Institutes for Healthy Study Quality Assessment Tool for Case Series, Cohort and Case-Control Studies. MAIN RESULTS: 39 studies were eligible. 299 infants sustained BPI after CS. 53% of cases with BPI after CS had risk factors for likely challenging handling/manipulation of the fetus prior to delivery, in the presence of considerable maternal or fetal concerns, and/or in the presence of poor access due to obesity or adhesions. CONCLUSIONS: In the presence of factors that would predispose to a challenging delivery, it is difficult to justify that BPI could occur due to in-utero, antepartum events alone. Surgeons should exercise care when operating on women with these risk factors.

Effect of Interscalene Brachial Plexus Block on Intracranial Pressure: Are the Measures of Optic Nerve Sheath Diameter Standardised with B-Scan?

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Recent Advances in the Treatment of Brachial Plexus Birth Injury.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation. SUMMARY: Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales.

A rat model of modified contralateral C7 transfer permitting ulnar nerve recovery.

BACKGROUND: Contralateral C7 transfer (cC7) is an important treatment for total brachial plexus avulsion (TBPA), which sacrifices the recovery of the ulnar nerve (UN). The present study aimed to introduce an animal model of modified cC7 that preserved the deep branch of ulnar nerve (dbUN) and verify its feasibility. METHODS: Anatomical study: Lengths, diameters, and axon counts of dbUN and anterior interosseous (AIN) branches in six rats were measured. In vivo surgery: 18 rats were divided into three groups. Group A: Traditional cC7. Group B: Modified cC7 finished in one stage. Group C: Modified cC7 and AIN branch anastomosed with dbUN one month after the first stage. Electrophysiological examinations, muscle wet weight, muscle cross-sectional areas, and nerve axon counts were evaluated six months postoperatively. RESULTS: Anatomical study: The distances from dbUN and AIN branches to the midpoint of the inner and outer epicondyles connection of the humerus, diameters, and axon numbers of dbUN and AIN branches were analyzed, then AIN terminal branch (tbAIN) was anastomosed with dbUN. In vivo surgery: The differences in median nerve fiber counts were not significant. There were more UN axons in group A than in groups B and C. In electrophysiological examinations, muscle wet weight and cross-sectional area of the flexor digitorum profundus showed no significant difference, but the second interosseus cross-sectional areas in groups B and C were significantly larger than in group A. CONCLUSIONS: This study established an animal model of preserving dbUN in cC7 and verified its feasibility. The possibility of restoring dbUN was established.

Promoting Recovery Following Birth Brachial Plexus Palsy.

Neonatal brachial plexus palsies (NBPP) occur in 1.74 per 1000 live births with 20% to 30% having persistent deficits. Dysfunction can range from mild to severe and is correlated with the number of nerves involved and the degree of injury. In addition, there are several comorbidities and musculoskeletal sequelae that directly impact the overall functional development. This review addresses the nonsurgical and surgical management options and provides guidance for pediatricians on monitoring and when to refer for specialty care.

Ultrasound-Guided Perineural Vitamin B12 Injection for Brachial Plexus Injury: A Preliminary Study.

Individuals with brachial plexus injury (BPI) require upper limb function restoration, but the treatment remains controversial. Vitamin B12 may aid in pain control and nerve regeneration. We present the technical aspects of ultrasound-guided perineural vitamin B12 injection for BPI. The demonstrative case is a 50-year-old man with BPI resulting from a traffic accident. Under ultrasound guidance, vitamin B12 was injected precisely into the brachial plexus compartment around the swollen neuroma of the C6 root. Motor and sensory functions of the left upper extremity improved over 6 months. Ultrasound-guided perineural vitamin B12 injection may be an efficient and personalized intervention in cases of post-ganglionic BPI that failed to improve in the first 3 months.

Characterization of elbow flexion torque after nerve reconstruction of patients with traumatic brachial plexus injury.

BACKGROUND: The modified British Medical Research Council muscle grading system remains the primary method for assessing outcomes following surgical intervention despite its subjectivity and numerous inherent flaws. A new objective outcome measure of elbow function in patients with a brachial plexus injury is proposed. METHODS: 11 patients with a reconstructed brachial plexus (nerve reconstruction) and 10 unimpaired control subjects were evaluated. A custom apparatus measuring elbow flexion torque was developed. The subjects were asked to match their elbow flexion torque to a predefined torque. Time taken to achieve this predefined elbow flexion torque (latency) and duration of steady torque output were used as outcome measures. RESULTS: Healthy individuals were better at maintaining and regulating elbow torque. The patients with a brachial plexus injury showed similar latency while increasing their elbow torque (normalized to maximum elbow torque) but lacked the ability to modulate the latency with demand as the healthy subjects. INTERPRETATION: This novel measure provides objective information regarding the patient's ability to control elbow torque after nerve reconstruction.

Patient demographics, tumor characteristics, and outcomes following surgical treatment of benign and malignant brachial plexus tumors: a systematic review.

BACKGROUND: Various treatment options have been introduced for the management of primary tumors of the brachial plexus (BP), ranging from conservative therapy to wide local excision with/without postoperative chemoradiotherapy. However, no consensus exists regarding optimal treatment strategies based on collated and published data. OBJECTIVE: The aim of this study was to investigate the clinicopathological characteristics and outcome of patients with primary tumors of the BP who underwent surgical treatment. DATA SOURCES: A systematic search of the four main online databases, including Web of Science (WOS), PubMed, Scopus, and Google Scholar, was conducted. STUDY SELECTION: All related articles addressing the clinical outcome and role of surgical interventions for management of primary tumors of the BP. INTERVENTION: Optimal surgical and radiotherapeutic interventions for benign and malignant lesions based on the pathologic characteristics and location of primary BP tumors. RESULTS: A total of 687 patients (693 tumors) with a mean age of 41.7±8.7 years old were evaluated. In total, 629 (90.8%) tumors were benign, and 64 (9.2%) were malignant, with a mean tumor size of 5.4±3.1 cm. The location of the tumor was reported for 639 patients. For these tumors, 444 (69.5%) originated from the supraclavicular region, and 195 (30.5%) were infraclavicular. The trunks were the most common location for tumor involvement, followed by the roots, cords, and terminal branches. Gross total resection was achieved in 432 patients and subtotal resection (STR) was performed in 109 patients. With neurofibromas, STR still resulted in good outcomes. The outcomes following treatment of malignant peripheral nerve sheath tumors were poor regardless of the type of resection. In general, symptoms related to pain and sensory issues resolved rapidly postoperatively. However, the resolution of motor deficits was often incomplete. Local tumor recurrence occurred in 15 (2.2%), patients and distant metastasis was observed in only eight (1.2%) cases. The overall mortality was 21 (3.1%) patients among the study population. LIMITATIONS: The main limitation was the lack of level I and II evidence. CONCLUSIONS: The ideal management strategy for primary BP tumors is complete surgical resection. However, in some cases, particularly for neurofibromas, STR may be preferable to preserve maximal neurological function. The degree of surgical excision (total or subtotal) mainly depends on the pathological characteristics and primary location of the tumor.

Axillary Artery Transection and Brachial Plexus Injury After Open Inferior Glenohumeral Dislocation: A Case Report.

CASE: A judo athlete presented with an open inferior shoulder dislocation that occurred during competition. Examination revealed a transection of the axillary artery and neuropraxia of the posterior cord. Neuropraxia was resolved within 2 weeks. The axillary artery was repaired with a femoral vein graft. He regained full strength, range of motion, and function at 8 months. CONCLUSION: Inferior glenohumeral dislocations are rare, and their management can be complicated by vascular and neurological injuries. We emphasize the importance of examination, diagnosis, and treatment of neurovascular pathologies to avoid catastrophic outcomes.

Diagnostic value of proximal cutaneous nerve biopsy in brachial and lumbosacral plexus pathologies.

BACKGROUND: Brachial and lumbosacral plexopathies can result from numerous non-traumatic etiologies, including those of inflammatory, autoimmune, or neoplastic origin, that often require nerve biopsy for diagnosis. The purpose of this study was to evaluate the diagnostic efficacy of medial antebrachial cutaneous nerve (MABC) and posterior femoral cutaneous nerve (PFCN) nerve biopsies in proximal brachial and lumbosacral plexus pathology. METHOD: Patients undergoing MABC or PFCN nerve biopsies at a single institution were reviewed. Patient demographics, clinical diagnosis, symptom duration, intraoperative findings, post-operative complications, and pathology results were recorded. Biopsy results were classified as diagnostic, inconclusive, or negative based on the final pathology. RESULTS: Thirty patients undergoing MABC biopsies in the proximal arm or axilla and five patients with PFCN biopsies in the thigh or buttock were included. MABC biopsies were diagnostic in 70% of cases overall and 85% diagnostic in cases where pre-operative MRI also demonstrated abnormalities in the MABC. PFCN biopsies were diagnostic in 60% of cases overall and in 100% of patients with abnormal pre-operative MRIs. There were no biopsy-related post-operative complications in either group. CONCLUSIONS: In diagnosing non-traumatic etiologies of brachial and lumbosacral plexopathies, proximal biopsies of the MABC and PFCN provide high diagnostic value with low donor morbidity.

Restoring musculocutaneous nerve function in 146 brachial plexus operations - A retrospective analysis.

INTRODUCTION: A brachial plexus lesion is a devastating injury often affecting young, male adults after traffic accidents. Therefore, surgical restoration of elbow flexion is critical for establishing antigravity movement of the upper extremity. We analyzed different methods for musculocutaneous reconstruction regarding outcome. METHODS: We conducted a retrospective analysis of 146 brachial plexus surgeries with musculocutaneous reconstruction performed at our department from 2013 to 2017. Demographic data, surgical method, donor and graft nerve characteristics, body mass index (BMI) as well as functional outcome of biceps muscle based on medical research council (MRC) strength grades before and after surgery were analyzed. Multivariate analysis was performed using SPSS. RESULTS: Oberlin reconstruction was the procedure performed most often (34.2%, n = 50). Nerve transfer and autologous repair showed no significant differences regarding outcome (p = 0.599, OR 0.644 CI95% 0.126-3.307). In case of nerve transfers, we found no significant difference whether reconstruction was performed with or without a nerve graft (e.g. sural nerve) (p = 0.277, OR 0.619 CI95% 0.261-1.469). Multivariate analysis identifies patient age as a strong predictor for outcome, univariate analysis indicates that nerve graft length > 15 cm and BMI of > 25 could lead to inferior outcome. When patients with early recovery (n = 19) are included into final evaluation after 24 months, the general success rate of reconstructions is 62,7% (52/83). CONCLUSION: Reconstruction of musculocutaneous nerve after brachial plexus injury results in a high rate of clinical improvement. Nerve transfer and autologous reconstruction both show similar results. Young age was confirmed as an independent predictor for better clinical outcome. Prospective multicenter studies are needed to further clarify.

Neurophysiological Evaluation of Neural Transmission in Brachial Plexus Motor Fibers with the Use of Magnetic versus Electrical Stimuli.

The anatomical complexity of brachial plexus injury requires specialized in-depth diagnostics. The clinical examination should include clinical neurophysiology tests, especially with reference to the proximal part, with innovative devices used as sources of precise functional diagnostics. However, the principles and clinical usefulness of this technique are not fully described. The aim of this study was to reinvestigate the clinical usefulness of motor evoked potential (MEP) induced by a magnetic field applied over the vertebrae and at Erb's point to assess the neural transmission of brachial plexus motor fibers. Seventy-five volunteer subjects were randomly chosen to participate in the research. The clinical studies included an evaluation of the upper extremity sensory perception in dermatomes C5-C8 based on von Frey's tactile monofilament method, and proximal and distal muscle strength by Lovett's scale. Finally, 42 healthy people met the inclusion criteria. Magnetic and electrical stimuli were applied to assess the motor function of the peripheral nerves of the upper extremity and magnetic stimulus was applied to study the neural transmission from the C5-C8 spinal roots. The parameters of compound muscle action potential (CMAP) recorded during electroneurography and MEP induced by magnetic stimulation were analyzed. Because the conduction parameters for the groups of women and men were comparable, the final statistical analysis covered 84 tests. The parameters of the potentials generated by electrical stimulus were comparable to those of the potentials induced by magnetic impulse at Erb's point. The amplitude of the CMAP was significantly higher following electrical stimulation than that of the MEP following magnetic stimulation for all the examined nerves, in the range of 3-7%. The differences in the potential latency values evaluated in CMAP and MEP did not exceed 5%. The results show a significantly higher amplitude of potentials after stimulation of the cervical roots compared to potentials evoked at Erb's point (C5, C6 level). At the C8 level, the amplitude was lower than the potentials evoked at Erb's point, varying in the range of 9-16%. We conclude that magnetic field stimulation enables the recording of the supramaximal potential, similar to that evoked by an electric impulse, which is a novel result. Both types of excitation can be used interchangeably during an examination, which is essential for clinical application. Magnetic stimulation was painless in comparison with electrical stimulation according to the results of a pain visual analog scale (3 vs. 5.5 on average). MEP studies with advanced sensor technology allow evaluation of the proximal part of the peripheral motor pathway (between the cervical root level and Erb's point, and via trunks of the brachial plexus to the target muscles) following the application of stimulus over the vertebrae.

Double Fascicular Nerve Transfer Restored Nearly Normal Functional Movements in a Completely Paralyzed Upper Extremity Resulting from an ACDF Surgery: A Case Report and Review of Recent Literature.

BACKGROUND Cervical spine deformities can occur because of genetic, congenital, inflammatory, degenerative, or iatrogenic causes. CASE REPORT We report a 45-year-old woman who presented to our clinic with complete paralysis of the left upper extremity 5 months after C4-C6 discectomy and fusion surgery. The electrodiagnostic and EMG reports 3 months after her previous surgery revealed left C5-C7 polyradiculopathy involving the upper trunk, lateral and posterior cords, and atrophy of the left deltoids, triceps, and biceps muscles. She underwent the following nerve transfer procedures with the senior author (RKN): The median nerve fascicles were transferred to the biceps and brachialis branches of the musculocutaneous nerve. Radial nerve triceps branches were transferred to the deltoid and teres minor branches of the axillary nerve. The patient could fully abduct her left shoulder to 170°, and the LUE functions were restored to nearly normal 17 months after the surgery. CONCLUSIONS Neurolysis combined with nerve transfer might be the most effective treatment for cervical spinal root injuries. Advances in peripheral nerve rewiring, transcranial magnetic stimulation, brain-computer interface robotic technologies, and emerging rehabilitation will undoubtedly increase the possibility of reviving the extremities in patients with central pathology by restoring the descending motor signals through the residual neural network connections.

Brachial Plexus Nerve Injuries and Disorders: MR Imaging-Ultrasound Correlation.

Multimodality imaging of the brachial plexus is essential to accurately localize the lesion and characterize the pathology and site of injury. A combination of computed tomography (CT), ultrasound, and MR imaging is useful along with clinical and nerve conduction studies. Ultrasound and MR imaging in combination are effective to accurately localize the pathology in most of the cases. Accurate reporting of the pathology with dedicated MR imaging protocols in conjunction with Doppler ultrasound and dynamic imaging provides practical and useful information to help the referring physicians and surgeons to optimize medical or surgical treatment regimens.

PATTERN OF A PRIMARY B-CELL LYMPHOMA IN ULNAR NERVE: INTRANEURAL OR EXTRANEURAL.

Primary lymphomas of peripheral nerves (PLPNs) are extremely rare and most commonly reported in lumbar nerves and have been found in only five cases in the upper extremities. We describe two patterns of presentation focusing on clinical, radiological, and pathological findings of two patients affected by primary multifocal lymphoma of the ulnar nerve without systemic involvement or other medical conditions. We report a case of extraneural lymphoma in a 72-years-old (patient #1) and a case of intraneural lymphoma in a 45-years old woman (Patient #2). Magnetic resonance imaging and ultrasound findings were similar to Peripheral Nerve Sheath Tumors (PNST). Surgical exploration and excision were performed. Morpho pathological results revealed in both cases a diffuse large B-cell non-Hodgkin lymphoma. In patient #1, the disease relapsed after only 4 months with brachial plexus involvement. The patient died about 10 months after the onset of symptoms. Patient #2 did not have post-surgical sensory or motor deficit and follow up at 6 years did not show recurrence or any other localizations. PLPN is a rare and challenging condition and is frequently misdiagnosed. PLPNs could have an intraneural or an extraneural pattern. As peripheral neuropathy may be caused by a nervous involvement by a lymphoma, in patients with atypical lesions, a complete preoperative imaging should be acquired.

Management of Adult Traumatic Brachial Plexus Injury.

Brachial plexus injury is not uncommon in our country like Bangladesh and it causes functional damage and physical disability of the upper limbs. Most of the cases were caused by motor vehicle accident. We have conducted a prospective study for the operative treatment of 105 adult traumatic brachial plexus injury cases in Hand unit in the department of Orthopaedics, Bangabandhu Sheikh Mujib Medial University (BSMMU) during January 2012 to July 2019. The main surgical options for brachial plexus injury include primary reconstructive surgery such as neurolysis, direct repair, nerve graft, nerve transfer (neurotization) and possibly free functioning (gracilis) muscle transfer and secondary reconstructive procedure such as tendon transfer, arthrodesis, FFMT and bony procedure. Each of these procedures is used either alone or in combination for particular clinical scenarios. Aims and objectives of this study was to restoration of shoulder abduction and external rotation, elbow flexion and hand function are goal of treatment of adult traumatic brachial plexus injury. Age range was from 14 years to 55 years (mean age 26 years). Male were 95 and female were 10 cases. Time from trauma to surgery was valid 3 months to 9 months. Motor cycle accident was most common mechanism of injury. Upper plexus (C5, C6) injury was 52 cases, extended upper plexus (C5, C6 & C7) injury was 19 cases and global brachial plexus injury was 34 cases. When there is high suspicion of root avulsions, early exploration and reconstruction is indicated. Operate these patients 2-3 months after their injury. In other patients without high suspicion of root avulsion, we routinely perform exploration between 3 to 6 months after injury when no adequate sign of recovery are present. Common reconstructive options are any injury with neuroma in continuity with conductive nerve action potential (NAP): only neurolysis or any injury with nerve rupture or postganglionic neuroma not conducting nerve Action potential (NAP) and good proximal nerve: Direct repair or repair with nerve graft or nerve transfer if possible. Follow up period from 6 months to 6 years. The best results were obtained in C5, C6 and C5, C6 & C7 brachial plexus injury cases. SAN to SSN, Oberlin II and long head triceps motor branch to anterior division of axillary nerve transfer for C5 & C6 injury or upper plexus injury and in addition intercostals nerve to anterior division of axillary nerve and AIN branch of median nerve to ECRB for C5, C6 & C7 (extended upper plexus injury). Extra-plexus and intra-plexus neurotization was done in global brachial plexus injury cases and 5 cases by contra-lateral C7 to median nerve by vascularised ulnar nerve graft and only 2 cases contra-lateral C7 to lower trunk through pre spinal or pre tracheal route were done and only one case by FFMT. Few cases gain shoulder abduction and elbow flexion but no improvement of hand function and most cases even by FFMT still in follow up. Results of surgical treatment of upper and extended upper brachial plexus injury cases were satisfactory on the other hand recovery of shoulder abduction and elbow flexion was acceptable and comparable to other study in global brachial plexus injury and recovery of hand function were poor.