A Historical Perspective on Brachial Plexus Palsy Management: From Ancient Civilizations to the Modern Era.

Evidence of brachial plexus palsies and potential therapies have been identified by investigators across cultures and civilizations. It could be argued that there are early records of brachial plexus injuries in not only literary work but also paintings, sculptures, and ancient medical texts. The compiled ancient evidence in this review provides a historical framework of brachial plexus palsies and potential management techniques that have been utilized from ancient to modern time.

Neonatal brachial plexus palsy - early diagnosis and treatment.

Background and purpose: The incidence of brachial plexus palsy (BPP) has decreased recently, but the indivi-d-ual's quality of life is endangered. To provide better chan-ces to BPP neonates and infants, the Department of Developmental Neurology worked out, introduced, and applied a complex early therapy, including nerve point stimulation. Methods: After diagnosing the severity of BPP, early intensive and complex therapy should be started. Appro-x-imately after a week or ten days following birth, the slightest form (neurapraxia) normalizes without any intervention, and signs of recovery can be detected around this period. The therapy includes the unipolar nerve point electro-stimulation and the regular application of those elemen-tary sensorimotor patterns, which activate both extremities simultaneously. Results: With the guideline worked out and applied in the Department of Developmental Neurology, full recovery can be achieved in 50% of the patients, and even in the most severe cases (nerve root lesion), functional upper limb usage can be detected with typically developing body-scheme. Conclusion: Immediately starting complex treatment based on early diagnosis alters the outcome of BPP, providing recovery in the majority of cases and enhancing the everyday arm function of those who only partially benefit from the early treatment.

Knowledge of neonatal brachial plexus palsy among medical professionals in North America.

PURPOSE: Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. METHODS: A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. RESULTS: Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. CONCLUSIONS: Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.

Anatomy, Imaging, and Pathologic Conditions of the Brachial Plexus.

The brachial plexus is an intricate anatomic structure with an important function: providing innervation to the upper extremity, shoulder, and upper chest. Owing to its complex form and longitudinal course, the brachial plexus can be challenging to conceptualize in three dimensions, which complicates evaluations in standard orthogonal imaging planes. The components of the brachial plexus can be determined by using key anatomic landmarks. Applying this anatomic knowledge, a radiologist should then be able to identify pathologic appearances of the brachial plexus by using imaging modalities such as MRI, CT, and US. Brachial plexopathies can be divided into two broad categories that are based on disease origin: traumatic and nontraumatic. In the traumatic plexopathy group, there are distinct imaging findings and management methods for pre- versus postganglionic injuries. For nontraumatic plexopathies, having access to an accurate patient history is often crucial. Knowledge of the timing of radiation therapy is critical to diagnosing post-radiation therapy brachial plexopathy. In acute brachial neuritis, antecedent stressors occur within a specific time frame. Primary and secondary tumors of the brachial plexus are not uncommon, with the most common primary tumors being peripheral nerve sheath tumors. Direct extension and metastasis from primary malignancies such as breast and lung cancer can occur. Although diagnosing a brachial plexus anomaly is potentially perplexing, it can be straightforward if it is based on foundational knowledge of anatomy, imaging findings, and pathologic features. ©RSNA, 2020.

The Multidisciplinary Approach to the Diagnosis and Management of Nonobstetric Traumatic Brachial Plexus Injuries.

OBJECTIVE: Nonobstetric traumatic brachial plexus injuries can result in significant morbidity and chronic disability if not managed in a timely manner. Functional arm recovery is possible, but it requires a multidisciplinary approach toward the diagnosis and management of such injuries. CONCLUSION: This article provides an overview of the clinical, electrophysiology, and diagnostic imaging knowledge needed for accurate imaging interpretation and to participate in multidisciplinary discussions aimed at expediting optimal patient management.

Active Range of Motion Over Time in Patients With Obstetrical Brachial Plexus Palsy: A 10-Year Analysis.

PURPOSE: In our experience, and from the personal report of others, children with obstetrical brachial plexus palsy appear to lose some of their initially recovered active range of motion over the time in both operated and nonsurgical patients. This study investigates whether such a diminution of active movement occurs over time. METHODS: We performed a retrospective analysis of data from our obstetrical brachial plexus clinic. Between 1991 and 2000, 139 patients with a minimum follow-up of 10 years were included in the study. Patients were divided into a nonsurgical group (n = 42) and a group who underwent either primary or secondary brachial plexus reconstruction or both (n = 97). Fifteen joint movements were assessed at 2, 4 to 6, and 9 to 11 years of age and at later final follow-up using the Active Movement Scale. Repeated measures analysis using age at each visit as the repeated measures covariate was undertaken. RESULTS: Active movement scores were not diminished when patients were evaluated at the 10-year follow-up visit. CONCLUSIONS: The suggested loss of active range of motion over time is not demonstrated at 10-year follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Ultrasound-guided peripheral nerve stimulation for neuropathic pain after brachial plexus injury: two case reports.

Brachial plexus injury (BPI) often causes severe neuropathic pain that becomes chronic and difficult to treat pharmacologically or surgically. Here, we describe two cases of successful treatment of BPI with peripheral nerve stimulation (PNS). Both patients had experienced severe neuropathic pain after incomplete BPI for a long time (32 and 17 years) and did not response to medication, radiofrequency neuroablation, or spinal cord stimulation. After PNS using ultrasound, their pain was relieved by more than 50% over the course of 1 year. Both patients were satisfied with their improved sleep and quality of life. We conclude that PNS could be an alternative therapeutic modality for neuropathic pain after BPI as it provides direct nerve stimulation, has few complications, and is easy to perform.

Axillary Artery Injury Associated with Proximal Humeral Fractures: Review of Long-Term Vascular, Orthopedic, and Neurologic Outcomes.

BACKGROUND: Fracture and dislocation of the proximal humerus is common. It is associated with a number of vascular, neurologic, and orthopedic complications; these include brachial plexopathy and avascular necrosis (AVN) of the humeral head. These complications are rare but can potentially cause severe disability to patients; however, they remain poorly described in the literature. To describe vascular, orthopedic, and neurologic outcomes after axillary artery repair, in patients with proximal humeral fractures or dislocations. METHODS: We conducted a retrospective review of patients admitted to 2 tertiary trauma centers in Victoria, Australia, with fracture or dislocation of the proximal humerus and associated axillary artery injury. Patients were selected according to guidelines for trauma call or alert and the presence of high-risk mechanism of injury. Data on vascular, orthopedic, and neurologic complications were collected. RESULTS: Twenty-one patients were identified. Injury to the first part of the axillary artery was noted in 11 patients (52%). Brachial plexus exploration was performed in 17 patients (81%). Four patients (19%) underwent nerve repair. Long-term neurologic recovery was universally poor. Major orthopedic complications included AVN of the humeral head, delayed union, and the need for prosthesis or arthrodesis. Eleven patients (52%) received upper limb fasciotomy. Five patients (24%) underwent delayed secondary upper limb amputation. CONCLUSIONS: There was an unusually high rate of injuries to the first part of the axillary artery. Close clinical observation is recommended for such patients. AVN of the humeral head and brachial plexopathy remain significant and debilitating complications.

A Thematic Analysis of Online Discussion Boards for Brachial Plexus Injury.

PURPOSE: Patients with brachial plexus injury (BPI) and their family members contribute to Internet discussion groups dedicated to BPI. We hypothesized that a thematic analysis of posts from BPI Internet discussion groups would reveal common themes related to the BPI patient experience, providing topics for patient education and counseling. METHODS: Internet discussion boards were identified using the search term "brachial plexus injury support group" in Google, Bing, and Yahoo! search engines. Two discussion boards had substantially more posts than other Web sites and were chosen for analyses. Posts from January 1, 2015, through January 1, 2016, were examined. Using an iterative and established process, 2 investigators (M.T.M. and C.J.D) independently analyzed each post using thematic analysis in 3 steps (open coding, axial coding, and selective coding) to determine common themes. In this process, each post was reviewed 3 times. RESULTS: A total of 328 posts from the 2 leading discussion boards were analyzed. Investigators reached a consensus on themes for all posts. One central theme focused on emotional aspects of BPI. Four other central themes regarding information support were identified: BPI disease, BPI treatment, recovery after BPI treatment, and process of seeking care for BPI. CONCLUSIONS: Examination of posts on Internet support groups for BPI revealed recurring concerns, questions, and opinions of patients and their family members. The most common themes related to disease information, treatment, recovery, and the emotional element of BPI. CLINICAL RELEVANCE: These findings provide a helpful starting point in refining topics for patient education and support that are targeted on patients' interests and concerns.

[SUPRASCAPULAR NEUROPATHY]. / ATTEINTES DU NERF SUPRA-SCAPULAIRE.

Supra-scapular nerve (SSN) damage is a rare, but classical diagnosis that can often be overlooked since the nonspecific clinical history and examination commonly lead to the misdiagnosis of another shoulder disorder. This article details the etiopathology, the patients at risk, the reasons for consultation and the clinical aspects of suprascapular neuropathy; it also outlines its diagnostic and therapeutic approaches.

TREATMENT OF LOCAL RADIATION LESIONS IN BREAST CANCER PATIENTS.

The purpose of this paper is the demonstration and analysis of the effectiveness of spinal cord stimulation in treatment of chronic drug-resistant neuropathy pain in a patient with radiation-induced plexopathy. She underwent radiation therapy for cancer of the right breast in 2000. Ten years later she complained with pain and weakness her right arm. After physical examination and investigation right-side brachial plexopathy was diagnosed. Antidepressant and anticonvulsant had positive effect during one year but then pain appeared again. That is why the patient has been implanted the system of epidural electrostimulation of thickening of the cervical spinal cord. During the post-operative period significant improvement of pain relief was noted. The doses of analgesics were decreased. Spinal cord stimulation efficacy for treatment of chronic pain was repeatedly proved in clinical investigation and meta-analyses. Nevertheless spinal cord stimulation effects on radiation-induced neurological disorders and possible pathophysiological mechanisms are not enough examined. All these facts require further investigation.

Extensive motor axonal misrouting after conservative treatment of obstetric brachial plexus lesions.

AIM: The aim of this cross-sectional study was to assess systematically motor function and motor misrouting in adults with conservatively treated obstetric brachial plexus lesion (OBPL). METHOD: Seventeen adults with OBPL (median age 38y; five males, 12 females) and 16 comparison participants (median age 26y; eight males, eight females) were investigated. Motor function in the group with OBPL was assessed through passive and active motion, muscle strength of the deltoid, biceps, and triceps muscles, and Mallet aggregate score and five subscores. Motor misrouting was quantified by electrically stimulating each of 10 arm muscles and recording activity from the other nine in response to this. Motor function and motor misrouting were statistically analysed using the Mann-Whitney U test and Spearman's correlation coefficient. RESULTS: Motor function testing showed excellent strength but poor functional Mallet scores. Participants with OBPL had significantly more motor misrouting than comparison participants (Mann-Whitney U=31.5 [df=28], p<0.001, median difference=-4.00, 95% confidence interval [CI]=-7.00 to -1.00). Most misrouting was observed when stimulating the biceps (Mann-Whitney U=38.5 [df=31], p<0.001, median difference=-3.00, 95% CI -3.00 to -1.00), deltoid (Mann-Whitney U=68.5 [df=31], p=0.003, median difference=-1.0, 95% CI=-4.00 to 0.00 <0.001) and brachioradialis muscles (Mann-Whitney U=72.0 [df=31], p=0.002, median difference <0.001, 95% CI=-3.00 to 0.00 <0.001). There were no significant correlations between the presence of motor misrouting and impairment of motor function. INTERPRETATION: There is extensive motor misrouting in conservatively treated OBPL. The presence of this, in addition to motor functional impairment, suggests that motor misrouting should be further studied in OBPL.

Chronic post-traumatic neuropathic pain of brachial plexus and upper limb: a new technique of peripheral nerve stimulation.

The aim of the study was to evaluate the effect on pain relief in patients with peripheral neuropathic pain after brachial plexus injuries using an implanted peripheral nerve stimulator applied directly to the nerve branch involved into the axillary cavity. Seven patients with post-traumatic brachial plexus lesions or distal peripheral nerve complaining of severe intractable chronic pain were enrolled in a single-centre, open-label trial. Conventional drugs and traditional surgical treatment were not effective. Patients underwent careful neurological evaluation, pain questionnaires and quantitative sensory testing (QST). Surgical treatment consists of a new surgical technique: a quadripolar electrode lead was placed directly on the sensory peripheral branch of the main nerve involved, proximally to the site of lesion, into the axillary cavity. To assess the effect, we performed a complete neuroalgological evaluation and QST battery after 1 week and again after 1, 6 and 12 weeks. All patients at baseline experienced severe pain with severe positive phenomena in the median (5) and/or radial (2) territory. After turning on the neuro-stimulator system, all patients experienced pain relief within a few minutes (>75 % and >95 % in most), with long-lasting pain relief with a reduction in mean Numerical Rating Scale (NRS) of 76.2 % after 6 months and of 71.5 % after 12 months. No significant adverse events occurred. We recommend and encourage this surgical technique for safety reasons; complications such as dislocation of electrocatheters are avoided. The peripheral nerve stimulation is effective and in severe neuropathic pain after post-traumatic nerve injuries of the upper limbs.

The effect of perinatal brachial plexus lesion on upper limb development.

BACKGROUND: Deficiency in upper limb development is a sequel of the perinatal brachial plexus palsy. The purpose of this study was to evaluate the effect of brachial plexus birth lesion on upper limb development. METHODS: Forty-four patients with unilateral obstetric brachial plexus palsy underwent measurements of both upper extremities. The average age at the time of evaluation was 6.8 years. Active motion was assessed using Gilbert-Raimondi, the modified MRC, and Al-Qattan scales. Paired t test was used for statistical analysis. Correlation between limb length / circumference discrepancy and age / time of surgery was assessed using Pearson correlation coefficient. RESULTS: A decrease in the circumference and length was observed in all limbs with brachial plexus lesion. We found a statistically significant difference between degree of hand length and width decrease and its useful and useless function. We observed a statistically significant difference in measurement: forearm length, hand length and width dependent on the type of surgical procedure (neurolysis, reconstruction). We observed no correlation between age and limb length / circumference discrepancy. We also observed no correlation between time of surgery and limb length / circumference discrepancy. CONCLUSIONS: The decrease in dimensions of the affected limbs occurred predominantly during the period of early childhood. Disparities in dimensions are observed in both cases of deficiency of useful function of upper limb and cases in which functional efficiency appears.

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

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

Activation of astrocytes and microglia in the C3-T4 dorsal horn by lower trunk avulsion in a rat model of neuropathic pain.

PURPOSE: Brachial plexus pain is thought to be generated not by avulsed roots but rather by nonavulsed roots, because avulsed roots could not transmit action potentials to central nerves. The aim of this study was to evaluate pain-related behavior and the extent of glial activation in a model of brachial plexus avulsion (BPA). METHODS: We used 24 male Wistar rats. For rats in the BPA group, the C8-T1 roots were avulsed from the spinal cord at the level of the lower trunk (n = 10). Rats in a sham-surgery group had a similar surgery without the root avulsion (n = 7). Rats in an untreated group had no surgery (n = 7). Mechanical hyperalgesia of the forelimb plantar surfaces corresponding to C6 and C7 dermatomes was evaluated using a Semmes-Weinstein monofilament test every third day for 3 weeks (n = 15). Activation of astrocytes and microglia was examined immunohistochemically using anti-glia fibrillary acidic protein and anti-Iba1 antibodies 3 days after surgery (n = 9). RESULTS: When compared with rats in the sham-surgery and naive control groups, rats in the BPA group displayed significant mechanical hyperalgesia in the dermatome innervated by uninjured nerves both ipsilaterally and contralaterally and continuing through day 21. Iba1-immunoreactive microglia and glia fibrillary acidic protein-immunoreactive astrocytes were significantly activated on the ipsilateral side in the BPA group from levels C3 to T3 compared with the sham-surgery and untreated groups of rats. CONCLUSIONS: Activation of glia at uninjured levels of the dorsal horn may facilitate pain transmission following BPA injury. Consequently, spared spinal glial cells may represent therapeutic targets for treatment of pain related to BPA injury. CLINICAL RELEVANCE: Our findings may indicate why neuropathic pain is so frequent and intense following BPA injury.