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2.
Oper Neurosurg (Hagerstown) ; 23(5): 367-373, 2022 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-36227251

RESUMO

BACKGROUND: Nerve transfers for elbow flexion in brachial plexus injuries have been used with increasing frequency because of the higher rate of success and acceptable morbidity. This is especially true in upper and extended upper-type brachial plexus injuries. OBJECTIVE: To present the clinical outcomes of nerve transfers for elbow flexion in patients with upper and extended upper-type brachial plexus injuries. METHODS: A retrospective cohort review was done on all patients with upper and extended upper-type brachial plexus injuries from 2006 to 2017, who underwent nerve transfers for the restoration of elbow flexion. Outcome variables include Filipino version of the disability of the arm, shoulder, and hand (FIL-DASH) score, elbow flexion strength and range of motion, and pain. All statistical significance was set at P < .05. RESULTS: Fifty-six patients with nerve transfers to restore elbow flexion were included. There was a significant improvement in FIL-DASH scores in 28 patients after the nerve transfer procedure. Patients with C56 nerve root injuries and those with more than 2 years' follow-up have a higher percentage of regaining ≥M4 elbow flexion strength. Those with double nerve transfers had a higher percentage of ≥M4 elbow flexion strength, greater range of elbow flexion, and better FIL-DASH scores compared with single nerve transfers, but this did not reach statistical significance. CONCLUSION: Nerve transfer procedures improve FIL-DASH scores in upper and upper-type brachial plexus injuries. After nerve transfer, stronger elbow flexion can be expected in patients with C56 injuries, and those with longer follow-up.


Assuntos
Plexo Braquial , Articulação do Cotovelo , Transferência de Nervo , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Cotovelo/cirurgia , Articulação do Cotovelo/cirurgia , Humanos , Transferência de Nervo/métodos , Estudos Retrospectivos
3.
Curr Opin Neurol ; 35(6): 708-717, 2022 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-36302200

RESUMO

PURPOSE OF THE REVIEW: Traumatic brachial plexus injuries (BPI) are devastating life-altering events, with pervasive detrimental effects on a patient's physical, psychosocial, mental, and financial well-being. This review provides an understanding of the clinical evaluation, surgical indications, and available reconstructive options to allow for the best possible functional outcomes for patients with BPI. RECENT FINDINGS: The successful management of patients with BPI requires a multidisciplinary team approach including peripheral nerve surgeons, neurology, hand therapy, physical therapy, pain management, social work, and mental health. The initial diagnosis includes a detailed history, comprehensive physical examination, and critical review of imaging and electrodiagnostic studies. Surgical reconstruction depends on the timing of presentation and specific injury pattern. A full spectrum of techniques including neurolysis, nerve grafting, nerve transfers, free functional muscle transfers, tendon transfers, and joint arthrodesis are utilized. SUMMARY: Despite the devastating nature of BPI injuries, comprehensive care within a multidisciplinary team, open and practical discussions with patients about realistic expectations, and thoughtful reconstructive planning can provide patients with meaningful recovery.


Assuntos
Plexo Braquial , Transferência de Nervo , Humanos , Plexo Braquial/diagnóstico por imagem , Plexo Braquial/cirurgia , Plexo Braquial/lesões , Transferência de Nervo/métodos , Transferência Tendinosa/métodos , Procedimentos Neurocirúrgicos/métodos
4.
Artigo em Inglês | MEDLINE | ID: mdl-36231711

RESUMO

Surgical reconstruction and postoperative rehabilitation are both important for restoring function in patients with traumatic brachial plexus injuries (BPIs). The current study aimed to understand variations in recovery progression among patients with different injury levels after receiving the nerve transfer methods. A total of 26 patients with BPIs participated in a rehabilitation training program over 6 months after nerve reconstruction. The differences between the first and second evaluations and between C5-C6 and C5-C7 BPIs were compared. Results showed significant improvements in elbow flexion range (p = 0.001), British Medical Research Council's score of shoulder flexion (p = 0.046), shoulder abduction (p = 0.013), shoulder external rotation (p = 0.020), quantitative muscle strength, and grip strength at the second evaluation for both groups. C5-C6 BPIs patients showed a larger shoulder flexion range (p = 0.022) and greater strength of the shoulder rotator (p = 0.004), elbow flexor (p = 0.028), elbow extensor (p = 0.041), wrist extensor (p = 0.001), and grip force (p = 0.045) than C5-C7 BPIs patients at the second evaluation. Our results indicated different improvements among patients according to injury levels, with quantitative values assisting in establishing goals for interventions.


Assuntos
Plexo Braquial , Articulação do Cotovelo , Transferência de Nervo , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Cotovelo/cirurgia , Humanos , Transferência de Nervo/métodos , Amplitude de Movimento Articular , Recuperação de Função Fisiológica/fisiologia , Resultado do Tratamento
5.
Rev. bras. ortop ; 57(5): 766-771, Sept.-Oct. 2022. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1407687

RESUMO

Abstract Objective The incidence of traumatic brachial plexus injuries has been increasing considerably in Brazil, mainly due to the increase in the number of motorcycle accidents. The aim of the present study is to evaluate the sensitivity and specificity of magnetic resonance imaging (MRI) in the diagnosis of brachial plexus avulsion lesions, comparing it with the findings of physical and intraoperative examination. Methods A total of 16 patients with brachial plexus injury were prospectively evaluated and treated at the hand surgery outpatient clinic from our service. All patients underwent MRI of the brachial plexus, and the findings were inserted on a table, as well as the physical examination data, and part of the patients had the plexus evaluated intraoperatively. Results In the present study, the accuracy of MRI in the identification of root avulsion was 100%, with 100% sensitivity and specificity when comparing imaging with surgical findings. Conclusion Magnetic resonance imaging showed high sensitivity and specificity, confirmed by intraoperative findings, which allows considering this test as the gold standard in the diagnosis of avulsion in traumatic brachial plexus injuries.


Resumo Objetivo A incidência de lesões traumáticas do plexo braquial vem aumentando consideravelmente no Brasil, principalmente devido ao aumento do número de acidentes de motocicleta. O objetivo do presente estudo é avaliar a sensibilidade e a especificidade da ressonância magnética (RM) no diagnóstico das lesões por avulsão do plexo braquial, comparando com os achados do exame físico e do intraoperatório. Métodos Foram avaliados prospectivamente 16 pacientes com lesão do plexo braquial atendidos no ambulatório de cirurgia da mão de nosso serviço. Todos os pacientes foram submetidos ao exame de RM do plexo braquial e os achados foram inseridos em uma tabela, assim como os dados do exame físico, e parte dos pacientes teve o plexo avaliado intraoperatoriamente. Resultados No presente estudo, a acurácia da RM na identificação de avulsão de raízes foi de 100%, com 100% de sensibilidade e especificidade comparando-se achados da imagem e cirúrgicos. Conclusão A RM mostrou alta sensibilidade e especificidade, confirmadas por achados intraoperatórios, o que permite considerar este exame como padrão outro no diagnóstico de avulsão nas lesões traumáticas do plexo braquial.


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Plexo Braquial/cirurgia , Plexo Braquial/lesões , Plexo Braquial/diagnóstico por imagem , Imageamento por Ressonância Magnética , Diagnóstico Diferencial , Traumatismos dos Nervos Periféricos
6.
Neurosurgery ; 91(6): 883-891, 2022 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-36069570

RESUMO

BACKGROUND: Management of sporadic schwannomas is often dictated by a patient's clinical presentation and the tumor's behavior. For patients who are managed nonsurgically, there are little data available about the expected natural history. OBJECTIVE: To evaluate the natural history and growth patterns of extracranial schwannomas including tumors of the distal peripheral nerves, spine, and brachial plexus. METHODS: A retrospective review was performed to identify patients with nonsyndromic extracranial schwannomas at a single tertiary care institution diagnosed between 2002 and 2019. Patient data and tumor characteristics including volume were recorded. RESULTS: Two hundred twenty-seven patients were identified (mean age 51 years, 42% male, average of 27.8-month follow-up). Tumor location was distal peripheral nerve in 82, brachial plexus in 36, and paraspinal in 109. At the time of diagnosis, peripheral lesions were significantly larger than spinal (59 m 3 vs 13 cm 3 ) and brachial plexus lesions (15 cm 3 ). Distinct growth patterns were seen with both distal peripheral nerve and spinal lesions; 34/82 peripheral nerve lesions had fast growth (ß = 0.176%/day), and 48 had slow growth (ß = 0.021%/day; P < .01). Spinal schwannomas similarly had 30 fast-growing (ß = 0.229%/day), 16 moderate-growing (ß = 0.071%/day), and 63 slow-growing (ß = 0.022%/day; P = .03) subtypes. The brachial plexus had relatively homogeneous growth patterns (ß = 0.065%/day). Females had 2.9 times greater odds of having the fast-growing subtype. CONCLUSION: Distinct growth patterns were seen in extracranial sporadic schwannomas based on tumor location and patient demographics. Fast (>80% volume change per year) vs slow (5%-10% per year) tumor growth can often be ascertained within 2 follow-up images. Awareness of these patterns might have implications for patient counseling and therapeutic decision-making.


Assuntos
Neuropatias do Plexo Braquial , Plexo Braquial , Neurilemoma , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Plexo Braquial/cirurgia , Plexo Braquial/patologia , Neurilemoma/patologia , Neuropatias do Plexo Braquial/patologia , Nervos Periféricos/patologia , Estudos Retrospectivos
7.
Oral Oncol ; 134: 106102, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-36055126

RESUMO

Brachial plexus schwannomas are rare diseases treated by complete resection, leading to potential neurological deficits. Intracapsular enucleation is an acceptable alternative to preserve the involved nerve function. This study has examined the safety and effectiveness of intracapsular enucleation in preserving nerve function. This observational study included 19 consecutive patients with brachial plexus schwannomas originating from the roots (42 %), the trunks (37 %), and the cords (21 %). After enucleation, immediate sensory and motor weakness occurred in 21 % and 11 % of patients, and other early complications did not happen. No patients had neural deficits at postoperative one year and recurrence for a median follow-up of 72 months. In conclusion, function-preserving intracapsular enucleation via a lateral collar incision is a safe and effective treatment for brachial plexus schwannomas.


Assuntos
Plexo Braquial , Neurilemoma , Plexo Braquial/cirurgia , Humanos , Neurilemoma/complicações , Neurilemoma/cirurgia , Período Pós-Operatório , Resultado do Tratamento
8.
J Bone Joint Surg Am ; 104(22): 2008-2015, 2022 11 16.
Artigo em Inglês | MEDLINE | ID: mdl-36083976

RESUMO

BACKGROUND: A typical feature in infants with severe C5-C6 brachial plexus birth injury (BPBI) requiring nerve repair is the formation of shoulder internal rotation contracture (IRC). The underlying pathophysiological mechanism is unknown, and the sequelae can be difficult to treat. The severity of the IRC differs among children. C5-C6 lesions are heterogeneous at the root level. Our null hypothesis was that the type of root-level lesion (axonotmesis or neurotmesis versus avulsion) was not associated with the extent of IRC formation over time in children with upper-trunk BPBI. METHODS: We performed a retrospective analysis of all patients with upper-trunk BPBI who underwent primary surgery of the C5 and/or C6 spinal nerves between 1990 and 2020 and had follow-up of at least 2 years. The primary outcome was passive shoulder external rotation (ER) in adduction at 1, 3, 5, 7, and 15 years of age. The secondary outcome was whether additional shoulder surgery was performed. The relationship between the nature of the C5-C6 lesion and IRC formation was analyzed using linear mixed models. The Kaplan-Meier method was used to estimate the cumulative risk of secondary shoulder procedures. RESULTS: In total, 322 patients were analyzed; mean follow-up was 7.2 ± 4.6 years. The C5-C6 root lesion type was significantly related to the passive range of ER (overall test in linear mixed model, p = 0.007). Children with avulsion of C5 and C6 (n = 21) had, on average, 18° (95% confidence interval [CI], 6.3° to 30°) less IRC formation than those with neurotmesis of C5 and C6 (n = 175) and 17° (2.9° to 31°) less than those with neurotmesis of C5 and avulsion of C6 (n = 34). IRC formation did not differ between the neurotmesis C5-C6 and neurotmesis C5-avulsion C6 groups. Secondary shoulder procedures were performed in 77 patients (10-year risk, 28% [95%CI, 23% to 34%]). CONCLUSIONS: Shoulder IRC formation in infants with BPBI with surgically treated C5-C6 lesions occurs to a lesser degree if the C5 root is avulsed than when C5 is neurotmetic. This finding provides insight into the possible causative pathoanatomy and may ultimately lead to strategies to mitigate IRC. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Traumatismos do Nascimento , Neuropatias do Plexo Braquial , Plexo Braquial , Contratura , Transferência de Nervo , Articulação do Ombro , Criança , Lactente , Humanos , Transferência de Nervo/métodos , Ombro , Estudos Retrospectivos , Plexo Braquial/cirurgia , Plexo Braquial/lesões , Neuropatias do Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/complicações , Articulação do Ombro/cirurgia , Traumatismos do Nascimento/complicações , Traumatismos do Nascimento/cirurgia , Contratura/etiologia , Contratura/cirurgia
10.
J Hand Surg Asian Pac Vol ; 27(5): 810-815, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-36178415

RESUMO

Background: The primary objective of this study was to identify patient-related and socioeconomic factors associated with the operative treatment of adult traumatic brachial plexus injuries (BPI) at two tertiary referral centres in a single metropolitan area in the United States. The secondary objective was to assess surgeon variability in operative treatment. Methods: Adult patients with traumatic BPI at two tertiary referral centres in a single metropolitan area from 2015 to 2019 were retrospectively identified. After applying exclusion criteria, 84 adult patients with traumatic BPI treated by 22 surgeons were included. Our response variable was operative treatment of the traumatic BPI. Bi-variate screen was performed, and multi-variable logistic regression analysis was used to identify factors associated with operative treatment. Surgeon variability was separately assessed using Fisher's exact test. Results: The mean age of the study cohort was 45 years, and 69% were male. The most common BPI pattern was a global injury (39%) followed by an upper trunk injury (23%). Thirty-eight patients (45%) underwent operative treatment for the traumatic BPI. Multivariable logistic regression analysis showed that younger age and out-of-state referral were associated with operative treatment. There was significant surgeon variation in the utilisation of operative treatment. Conclusions: Out-of-state patients had more than four times higher odds of operative treatment, suggesting a regional practise pattern in which BPI requiring surgery are referred from surrounding states to our tertiary centres. Supra-regional BPI centres may facilitate timely referrals for specialty care. High-quality outcomes research in BPI is needed to mitigate surgeon treatment variation. Level of Evidence: Level IV (Therapeutic).


Assuntos
Neuropatias do Plexo Braquial , Plexo Braquial , Adulto , Humanos , Masculino , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Feminino , Centros de Atenção Terciária , Estudos Retrospectivos , Plexo Braquial/cirurgia , Plexo Braquial/lesões , Estudos de Coortes
11.
J Hand Surg Asian Pac Vol ; 27(5): 881-888, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-36178417

RESUMO

Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexus injury (BPI). This internally rotated posture of the limb becomes more apparent and functionally limiting once the patient recovers elbow flexion resulting in the hand striking the abdomen on attempted flexion ('tummy flexion'). This precludes hand-to-mouth reach, resulting in an inability to eat with the involved hand. The aim of this study is to present the outcomes of an external rotation osteotomy of the humerus in adult BPI. Methods: All BPI patients who underwent an external rotation osteotomy of the humerus at our institution over a 5-year period from January 2015 to December 2020 were included in this study. Data with regard to the age, gender, type of BPI, time from injury to nerve surgery and from nerve surgery till external rotation osteotomy, degree of pre- and postoperative external rotation, time to union, patient satisfaction and complications were recorded. Results: The study included 19 patients (18 men and one woman) with an average age of 30 years (range 20-58). The average time interval from the injury to the nerve surgery was 3.8 months, and between the nerve surgery and the external rotation osteotomy was 29.5 months. No patient had any preoperative external rotation and all attained a resting posture of 15°-20° of external rotation, were able to reach the mid-line of the body, and none complained of loss of internal rotation. There was an implant failure in one patient that was managed with splinting till union and removal of implants later. Conclusions: External rotation osteotomy of the humerus is a simple and effective procedure to place the limb in a better aesthetic and functional position. Level of Evidence: Level IV (Therapeutic).


Assuntos
Neuropatias do Plexo Braquial , Plexo Braquial , Adulto , Masculino , Feminino , Humanos , Adulto Jovem , Pessoa de Meia-Idade , Neuropatias do Plexo Braquial/cirurgia , Úmero/cirurgia , Plexo Braquial/cirurgia , Plexo Braquial/lesões , Osteotomia/efeitos adversos , Osteotomia/métodos , Ombro/cirurgia
12.
J Hand Surg Asian Pac Vol ; 27(5): 907-911, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-36178419

RESUMO

A complication of Kirschner (K) wire fixation is the migration of the wire. We report a patient who had undergone fixation of a right clavicle fracture associated with acromioclavicular joint (ACJ) dislocation 15 years ago. He presented with features of pain and dysaesthesia in the right ulnar nerve dermatome on the movement of the neck and shoulder. Radiographic investigations showed a broken K-wire that had migrated to the lower brachial plexus. He underwent surgical removal of the K-wire and recovered uneventfully. We summarise the literature on K-wire migration reported following clavicle and ACJ injuries. Level of Evidence: Level V (Therapeutic).


Assuntos
Articulação Acromioclavicular , Plexo Braquial , Migração de Corpo Estranho , Fratura-Luxação , Masculino , Humanos , Fios Ortopédicos/efeitos adversos , Articulação Acromioclavicular/diagnóstico por imagem , Articulação Acromioclavicular/cirurgia , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/etiologia , Migração de Corpo Estranho/cirurgia , Fratura-Luxação/diagnóstico por imagem , Fratura-Luxação/cirurgia , Fratura-Luxação/complicações , Plexo Braquial/diagnóstico por imagem , Plexo Braquial/cirurgia
13.
Pain Res Manag ; 2022: 5660462, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35958676

RESUMO

Objective: To evaluate the usefulness of surgical neurolysis for neuropathic pain relief in patients with posttraumatic brachial plexus injury (BPI). Methods: A prospective, longitudinal, nonrandomized, self-controlled before and after study was performed to evaluate the pain changes according to their intensity using the Visual Analogue Scale (VAS), and the sensory recovery after surgery using the British Medical Research Council (BMRC) scale for sensory recovery. To establish significant changes, a paired T-test was performed, and in order to determine the magnitude of these changes, an effect size was measured. α = 0.05. Results: Ten patients were included with an average follow-up of 61.9 ± 53.62 months. The main mechanism of injury was vehicular trauma (70%). A significant decrease in pain after the surgical intervention was observed resulting from an average preoperative state according to VAS of 8.4 ± 1.58, to a postoperative state of 3.4 ± 3.27 (59.52%, p = 0.005, Δ = 1.572), added to a mean sensory improvement (25%) from 2.8 ± 1.62 to 3.5 ± 0.97 after surgery according to BMRC, without statistically significant changes (p=0.062), showing a moderate effect size (Δ = 0.413). Almost all patients showed improvement in the continuous and paroxysmal pattern of pain. No postoperative complications were observed. Discussion. These results suggest that in cases of BPI that originates from a compressive syndrome secondary to the posttraumatic fibrosis that surrounds the nerve structures causing strangulation and inducing hypernociception, the use of surgical neurolysis is an appropriate alternative for patients with medically refractory neuropathic pain.


Assuntos
Plexo Braquial , Neuralgia , Plexo Braquial/cirurgia , Humanos , Neuralgia/etiologia , Neuralgia/cirurgia , Procedimentos Neurocirúrgicos/métodos , Medição da Dor/métodos , Estudos Prospectivos , Resultado do Tratamento
14.
Artigo em Russo | MEDLINE | ID: mdl-35942840

RESUMO

BACKGROUND: Intercostobrachial neurotization is one of the few approach for partial motor recovery of extremity in patients with total trauma of brachial plexus. However, direct coaptation with musculocutaneous nerve is often impossible due to different anatomy of intercostal nerves and their functional failure at several levels. This necessitates the use of intermediate graft that deteriorates the final outcome. OBJECTIVE: To develop an alternative method for direct coaptation of musculocutaneous nerve with insufficiently long intercostal donor nerves. MATERIAL AND METHODS: The study included 26 patients with total post-traumatic plexitis. All patients underwent intercostobrachial neurotization of musculocutaneous and axillary nerves. Original technique of direct selective neurotization of motor fascicular groups of musculocutaneous and axillary nerves was used in 11 cases. RESULTS AND DISCUSSION: A modified variant of intercostobrachial neurotization of musculocutaneous and axillary nerves consists in mobilization and transposition of recipient nerves in axillary region. This makes it possible to reduce the distance to donor nerves and, in most cases, to carry out direct neurotization without autologous grafts. Among 11 patients, restoration of shoulder abduction and elbow flexion was obtained in 7 patients (77 %). CONCLUSION: The proposed adaptive technique makes it possible to avoid graft lengthening in some cases and provides satisfactory results.


Assuntos
Neuropatias do Plexo Braquial , Plexo Braquial , Transferência de Nervo , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/cirurgia , Humanos , Nervo Musculocutâneo/cirurgia , Transferência de Nervo/métodos , Ombro
15.
Hand Clin ; 38(3): 329-335, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35985757

RESUMO

Although patients with obstetric brachial plexus injuries (OBPI) have been recognized and treated for greater than 100 years there is much that is not understood or is mis-understood. I address 6 areas for discussion: the cause of OBPI and whether it matters to nerve surgeons; the value of the Narakas grading; whether surgeons should perform primary nerve surgery, especially in patients with incomplete OBPI; the cause and treatment of shoulder tightness; the cause and treatment of elbow contracture; and whether patients with OBPI need surgery in adulthood.


Assuntos
Traumatismos do Nascimento , Neuropatias do Plexo Braquial , Plexo Braquial , Contratura , Adulto , Traumatismos do Nascimento/cirurgia , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/cirurgia , Feminino , Humanos , Gravidez , Ombro
16.
J Hand Surg Asian Pac Vol ; 27(4): 599-606, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35965380

RESUMO

Background: Isolated lower (C8T1) brachial plexus injury (BPI) is uncommon and the aim of treatment is to achieve a satisfactory grasp enabling the use of the hand for daily activities. The aim of this study is to report the outcomes of the transfer of brachioradialis (BR) to flexor pollicis longus (FPL) and biceps to the flexor digitorum profundus (FDP) for an isolated lower BPI. Methods: This is a retrospective study of all patients with an isolated lower BPI who underwent a BR to FPL and biceps to FDP transfer for restoration of digital flexion over a 1-year period from May 2019 to June 2020. Patient demographic and injury data were collected at the presentation. Outcomes data included the ability to grasp and perform activities of daily living and DASH score. Results: The study included three patients (all men) with an average age of 30.3 years. All sustained an isolated lower BPI following a road traffic accident and tendon transfers were performed at a mean of 9.3 months after the initial injury. At a mean of 1-year follow-up, all three recovered grade M4 motor power of digital flexion, achieved good grasp function with pulp-to-palm distance of <1 cm. All are able to use the hand for independent as well as bimanual activities. The individual DASH scores were 36, 30 and 30. Conclusions: BR to FPL for thumb flexion and biceps to FDP using fascia lata graft to restore finger flexion is simple and effective surgeries in patients with isolated lower BPI. Level of Evidence: Level V (Therapeutic).


Assuntos
Atividades Cotidianas , Plexo Braquial , Adulto , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Mãos , Humanos , Masculino , Estudos Retrospectivos , Transferência Tendinosa
17.
J Bone Joint Surg Am ; 104(16): 1475-1482, 2022 08 17.
Artigo em Inglês | MEDLINE | ID: mdl-35976186

RESUMO

BACKGROUND: A cohort of patients with traumatic brachial plexus injuries (BPIs) underwent elective amputation following unsuccessful surgical reconstruction or delayed presentation. The results of amputation with and without a myoelectric prosthesis (MEP) using nonintuitive controls were compared. We sought to determine the benefits of amputation, and whether fitting with an MEP was feasible and functional. METHODS: We conducted a retrospective review of patients with BPI who underwent elective upper-extremity amputation at a single institution. Medical records were reviewed for demographics, injury and reconstruction details, amputation characteristics, outcomes, and complications. Prosthesis use and MEP function were assessed. The minimum follow-up for clinical outcomes was 12 months. RESULTS: Thirty-two patients with BPI and an average follow-up of 53 months underwent elective amputation between June 2000 and June 2020. Among the cases were 18 transhumeral amputations, 12 transradial amputations, and 2 wrist disarticulations. There were 29 pan-plexus injuries, 1 partial C5-sparing pan-plexus injury, 1 lower-trunk with lateral cord injury, and 1 lower-trunk injury. Amputation occurred, on average, at 48.9 months following BPI and 36.5 months following final reconstruction. Ten patients were fitted for an MEP with electromyographic signal control from muscles not normally associated with the intended function (nonintuitive control). Average visual analog scale pain scores decreased post-amputation: from 4.8 pre-amputation to 3.3 for the MEP group and from 5.4 to 4.4 for the non-MEP group. Average scores on the Disabilities of the Arm, Shoulder and Hand questionnaire decreased post-amputation, but not significantly: from 35 to 30 for the MEP group and from 43 to 40 for the non-MEP group. Patients were more likely to be employed following amputation than they were before amputation. No patient expressed regret about undergoing amputation. All patients in the MEP group reported regular use of their prosthesis compared with 29% of patients with a traditional prosthesis. All patients in the MEP group demonstrated functional terminal grasp/release that they considered useful. CONCLUSIONS: Amputation is an effective treatment for select patients with BPI for whom surgical reconstruction is unsuccessful. Patients who underwent amputation reported decreased mechanical pain, increased employment rates, and a high rate of satisfaction following surgery. In amputees with sufficient nonintuitive electromyographic signals, MEPs allow for terminal grasp/release and are associated with high rates of prosthesis use. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Amputação Traumática , Amputados , Membros Artificiais , Plexo Braquial , /métodos , Amputação Traumática/cirurgia , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Humanos , Dor
18.
J Shoulder Elbow Surg ; 31(11): e545-e561, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-35963513

RESUMO

Thoracic outlet syndrome (TOS) is a rare condition (1-3 per 100,000) caused by neurovascular compression at the thoracic outlet and presents with arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand. TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s). Patients develop TOS secondary to congenital abnormalities such as cervical ribs or fibrous bands originating from a cervical rib leading to an objectively verifiable form of TOS. However, the diagnosis of TOS is often made in the presence of symptoms with physical examination findings (disputed TOS). TOS is not a diagnosis of exclusion, and there should be evidence for a physical anomaly that can be corrected. In patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression, diagnosis of TOS can be established through history, a physical examination maneuvers, and imaging. Neck trauma or repeated work stress can cause scalene muscle scaring or dislodging of a congenital cervical rib that can compress the brachial plexus. Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections. The most common surgical treatments include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection. Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder. By 8 weeks postoperatively, patients can begin resistance strength training. Surgical treatment complications include injury to the subclavian vessels potentially leading to exsanguination and death, brachial plexus injury, hemothorax, and pneumothorax. In this review, we outline the diagnostic tests and treatment options for TOS to better guide clinicians in recognizing and treating vascular TOS and objectively verifiable forms of neurogenic TOS.


Assuntos
Toxinas Botulínicas , Plexo Braquial , Síndrome do Desfiladeiro Torácico , Humanos , Síndrome do Desfiladeiro Torácico/diagnóstico , Síndrome do Desfiladeiro Torácico/etiologia , Síndrome do Desfiladeiro Torácico/terapia , Costelas/cirurgia , Plexo Braquial/cirurgia , Descompressão Cirúrgica/métodos
19.
J Hand Surg Eur Vol ; 47(11): 1103-1113, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-35833214

RESUMO

A multidisciplinary brachial plexus clinic has been a relatively new concept, offering different surgical speciality perspectives on the treatment of brachial plexus injuries. The resulting collaborative effort has proven to be greater than the sum of its parts. In this review, the history, philosophy of care, development/implementation and impact of a creation of a multidisciplinary brachial plexus team at the Mayo Clinic are detailed.


Assuntos
Neuropatias do Plexo Braquial , Plexo Braquial , Humanos , Plexo Braquial/cirurgia , Plexo Braquial/lesões , Neuropatias do Plexo Braquial/cirurgia
20.
Oper Neurosurg (Hagerstown) ; 23(2): 125-132, 2022 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-35838452

RESUMO

BACKGROUND: Optimal management of recurrent neurogenic thoracic outlet syndrome (NTOS) remains a considerable challenge. OBJECTIVE: To assess the safety and effectiveness of reoperative brachial plexus neurolysis in patients with recurrent NTOS. METHODS: From 2009 to 2019, 85 patients underwent reoperative supraclavicular brachial plexus neurolysis for recurrent NTOS after a previous anatomically complete supraclavicular decompression. Data from a prospectively maintained database were analyzed retrospectively. RESULTS: The mean patient age at reoperation was 36.9 ± 1.3 (range 15-64) years, 75% were female, and the interval after previous primary operation was 2.5 ± 0.2 years. Intervening injury had precipitated recurrent NTOS in 14 patients (16%), and the mean Disability of the Arm, Shoulder, and Hand (QuickDASH) score before reoperation was 65.2 ± 2.6, reflecting substantial disability. Operative findings consisted of dense fibrous scar tissue surrounding/encasing the brachial plexus. Compared with the previous primary operations, reoperations had a shorter operative time (198 ± 4 vs 161 ± 5 minutes, P < .01) and hospital stay (4.4 ± 0.2 vs 3.6 ± 0.1 days, P < .01), but there were no significant differences in the frequency of prolonged hospitalization (7.1% vs 4.7%), early reoperation (3.5% vs 1.2%), or 30-day hospital readmission (8.2% vs 7.1%). During a median follow-up of 4.8 years, QuickDASH scores improved by 23.3 ± 2.6 (34.2% ± 3.6%; P < .01) and patient-rated outcomes were excellent in 24%, good in 42%, fair in 26%, and poor in 8%. CONCLUSION: Reoperative supraclavicular brachial plexus neurolysis is technically challenging but safe and effective treatment for recurrent NTOS, with significant improvements in symptoms and function. Diminishing perineural scar tissue development and avoiding secondary injury would likely decrease the need for reoperations.


Assuntos
Plexo Braquial , Síndrome do Desfiladeiro Torácico , Adolescente , Adulto , Plexo Braquial/cirurgia , Cicatriz/cirurgia , Descompressão Cirúrgica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto Jovem
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