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PubMed1990

[The blood level and a pharmacokinetic model of prilocaine during a continuous brachial plexus blockade].

Continuous brachial plexus blockade achieved by repeated injections through an axillary catheter is used increasingly often for microsurgical procedures and for postoperative pain relief. Repetitive administration, especially of long-acting agents, can cause problems with local anesthetic toxicity. Based upon a pharmacokinetic analysis of prilocaine serum concentrations after single-dose axillary plexus blockade in 14 patients, a pharmacokinetic model was established from which to predict serum concentrations after successive doses. METHODS. Each of 14 patients (ASA I-II, age 42 +/- 20 years, height 171 +/- 10 cm, body weight 72 +/- 9 kg) undergoing minor hand surgery received a single dose of 600 mg (40 ml 1.5%) prilocaine for axillary plexus blockade. Serial samples were taken from the contralateral antecubital vein and serum local anesthetic concentrations were measured by gas chromatography. Least square, non-linear regression analysis was performed to fit a triexponential curve; standard formulas were applied to develop the corresponding open two-compartment model. Computer simulation was carried out to predict the accumulation of mean local anesthetic concentrations after repetitive dosages. The kinetic model was verified with another set of 5 patients receiving a repetitive dose of prilocaine. The initial dose was 400 mg (40 ml 1%), followed by insertion of a catheter which allowed repetition at 2 and 4 h. The repetition dose was 300 mg (20 ml 1.5%). RESULTS. Maximal prilocaine serum levels of 2.32 +/- 0.80 micrograms/ml were found after 34 +/- 13 min. Mean pharmacokinetic data of the open two-compartment model with first order absorption from extravascular sites were: t alpha 1/2 = 10 min; t beta 1/2 = 139 min; V1 = 661; V dss = 254 1; Cltot = 2310 ml/min; tabs 1/2 = 35 min. The comparison of predicted and observed serum concentrations after continuous anesthesia was excellent. DISCUSSION. Pharmacokinetic data after axillary plexus blockade are comparable to those found after i.v. injection. Low serum levels were found throughout the 8 h of investigation and accumulation in serum was minimal following repetitive doses. There was no loss of action on repetition. Predicted values after pharmacokinetic modeling showed good agreement with actual measured values. Prilocaine may be a reasonable choice for repetitive use, as is appears to be toxicologically safe. Methemoglobinemia resulting from metabolites of prilocaine did not lead to complications in our study. It may, however, be a problem with repetitive dosages. Further investigations concerning this question would be useful.

Adult↗
PubMed2000

Sever-L'Episcopo tendon transfer in obstetric brachial plexus palsy.

Obstetric brachial plexus palsy produces functional and cosmetic impairment. The Sever-L'Episcopo procedure has been successfully used to improve external rotation, primarily in younger patients. Previous studies have shown steady improvement in motion and function for 1 year from the date of surgery, with little additional change beyond this period. This is a retrospective study of 7 patients who have had the procedure at the Shriners Hospital for Children in Tampa, Florida. Functional and cosmetic results have been uniformly excellent at an average follow-up of 1 year 3 months. No complications have occurred. In addition, the degree of improvement seen in our relatively older patient population has not been previously detailed in the literature.

Brachial Plexus Neuropathies↗
PubMed1988

Brachial plexus injuries and dysfunctions.

The brachial plexus and its associated structures demonstrate a propensity for certain disease processes not common to other areas of the nervous system. Brachial plexus disease produces a gait disturbance that may mimic musculoskeletal disease. When evaluating a case with possible traumatic brachial plexus disease, one relies heavily on historical, physical, and neurologic information when differentiating musculoskeletal disorders, although both may sometimes be present simultaneously in the same limb. With inflammatory disease, electromyography is extremely helpful, although an empiric dietary change may help confirm a suspicion. Brachial plexus surgery requires careful planning and meticulous technique. Attempts to remove malignant schwannomas have not been as successful as one would hope (Table 2). To a large extent, these dogs are treated late in the course of their disease because they are often treated for extended periods of time for musculoskeletal disease first. Early diagnosis and prompt surgical intervention would help many of these dogs. New histopathologic techniques, electrodiagnostic equipment, and radiographic techniques are helping to define peripheral nerve disease in the companion animal. These techniques will help us categorize and treat these diseases with greater success in the future.

Animals↗
PubMed1998

[Comparison of transarterial technique and paresthesia technique of axillary brachial plexus block].

Axillary brachial plexus blocks were established in 40 patients using transarterial technique (n = 20) or paresthesia technique (n = 20). Sensory and motor blockades of nerves supplying the upper extremity were compared at 10, 20 and 30 minutes after the injection of local anesthetics (1.5% plain mepivacaine 40 ml). Sensory blockades of the radial nerve and axillary nerve were significantly higher with transarterial technique than paresthesia technique. The incidence of analgesia of the radial nerve at 30 min was 100% with transarterial technique and 70% with paresthesia technique. Sensory blockades of the other nerves and motor blockades of all nerves did not show any significant differences between the two techniques. Proximal and distal spreads of the local anesthetic-contrast medium mixture within the axillary neurovascular sheath were studied in 20 patients. No statistically significant difference was observed in the spread of contrast agent between the two techniques. Transarterial technique is a recommendable method for hand surgery and especially indicated for the surgery of the area supplied by the radial nerve.

Adult↗
PubMed1987

Postoperative pain relief and bupivacaine plasma levels during continuous interscalene brachial plexus block.

Interscalene brachial plexus block was performed on 40 patients for prophylactic pain relief after shoulder surgery. A dose of 1.25 mg/kg of 0.5% bupivacaine was injected for the block (Group 1) and continued with an infusion of 0.25% bupivacaine 0.25 mg/kg/h (Group 2). If the postoperative analgesia was insufficient, the patients received i.m. oxycodone 0.15 mg/kg. In Group 1, one patient managed without oxycodone supplementation during the 24-h observation period compared with eight patients in Group 2 (P less than 0.01). The rest of the patients received 3.8 +/- 1.6 doses (Group 1) and 2.5 +/- 1.2 doses (Group 2) of oxycodone (P less than 0.05). At 30 min, the mean bupivacaine plasma concentration was 1.0 microgram/ml in Group 1 and 0.9 microgram/ml in Group 2. The mean plasma level of bupivacaine increased from 0.7 microgram/ml after 180 min to 1.1 micrograms/ml (P less than 0.01) after 24 h of infusion, providing some evidence of accumulation during infusion. The dizziness and confusion experienced by three patients could be associated with the local anaesthetic, as they obtained relief after the infusion was stopped.

Adolescent↗
PubMed2006

Dermatoglyphs and brachial plexus palsy.

Perinatal brachial plexus palsy (PBPP) is a handicap quite commonly encountered in daily routine. Although birth trauma is considered to be the major cause of the defect, it has been observed that PBPP occurs only in some infants born under identical or nearly identical conditions. The aim of this study was to test the hypothesis of genetic predisposition for PBPP. It is well known that digito-palmar dermatoglyphs can be used to determine hereditary roots of some diseases. Thus, we found it meaningful to do a study analysis of digito-palmar dermatoglyphs in this disease as well, conducting it on 140 subjects (70 males and 70 females) diagnosed with PBPP. The control group was composed of fingerprints obtained from 400 adult and phenotypically healthy subjects (200 males and 200 females) from the Zagreb area. The results of multivariate and univariate analysis of variance have shown statistically significant differences between the groups observed. In spite of lower percentage of accurately classified female subjects by discriminant analysis, the results of quantitative analysis of digito-palmar dermatoglyphs appeared to suggest a genetic predisposition for the occurrence of PBPP.

Analysis of Variance↗
PubMedDate not supplied

A comparison of the lateral and posterior approach for brachial plexus block.

BACKGROUND: Brachial plexus block by the posterior approach described by Pippa is not widely used in contrast to the lateral approach of Winnie. We compared the clinical efficacy of both approaches in a randomized prospective study. METHODS: Eighty patients, American Society of Anesthesiologists physical status I or II, scheduled for surgery of the shoulder or upper arm were randomized in 2 groups: lateral (Winnie, n = 40) or posterior approach (Pippa, n = 40). A single injection of ropivacaine 7.5 mg/mL, 0.5 mL/kg, was made after obtaining a motor response in the distribution of the axillary nerve at a current below 0.5 mA (2 Hz, 0.1 millisecond). Onset and distribution of analgesia and motor block were assessed at 5, 10, 15, 20, 30, and 60 minutes after the local anesthetic injection. Complete block was defined as anesthesia in all dermatomes C3-C6 at 60 minutes after injection. RESULTS: The posterior approach provided complete block in 36 patients (90%) and the lateral approach in 33 patients (83%). Corresponding motor block was similar in both approaches, but the block procedure time was faster in the posterior approach (6.2 [5.2-7.2] minutes v 8.4 [7.1-10.2] minutes; P < .001). Surgical success rate (posterior 95% v lateral 93%) and side effects were similar in both approaches. One complication (thoracic epidural block) was seen using the lateral approach, whereas none occurred in the posterior approach. There was no difference in patient satisfaction scores of the 2 approaches, which were equally high in both groups (posterior 98% v lateral 95%). CONCLUSION: Both approaches are comparable regarding clinical efficacy for anesthesia of the shoulder and upper arm.

Adult↗
PubMed1989

MR evaluation of brachial plexus injuries.

Ten cases of brachial plexus injury were subjected to magnetic resonance (MR) to demonstrate the roots, trunks, divisions or cord abnormalities. Both normal and abnormal brachial plexuses were imaged in sagittal, axial, coronal and axial oblique planes. Myelography, using water soluble contrast agents, was performed in seven cases. MR demonstrated one traumatic meningocele, one extradural cerebrospinal fluid (CSF) collection, trunk and/or root neuromas in four, focal root fibrosis in two and diffuse fibrosis in the remaining two cases. Results of MR were confirmed at surgery in four cases with neuromas, while myelography was normal in two and was not carried out in the remaining two. In two cases, where MR demonstrated diffuse fibrosis of the brachial plexus, myelography showed C7 and T1 traumatic meningocele in one and was normal in the other. Both these patients showed excellent clinical and electrophysiological correlation with MR findings and in one of them surgical confirmation was also obtained. In the other two cases with focal nerve root fibrosis, myelography was normal in one and showed a traumatic meningocele in another. Operative findings in these cases confirmed focal root fibrosis but no root avulsion was observed although seen on one myelogram. Focal fibrosis, however, was noted at operation in more roots than was observed with MR. Initial experience suggests that MR may be the diagnostic procedure of choice for complete evaluation of brachial plexus injuries.

Adolescent↗
PubMed2003

Sonographic mapping of the normal brachial plexus.

BACKGROUND AND PURPOSE: Mapping of the brachial plexus with MR imaging has been reported and may have potential clinical applications (eg, precise localization of traumatic or tumoral nerve lesions, selective anesthesia of the brachial plexus). We sought to demonstrate that mapping of the brachial plexus may be performed by means of sonography. METHODS: Twelve healthy adult volunteers (seven women and five men; age range, 24-38 years; mean, 31 years) underwent bilateral sonographic examination for the assessment of the nerve structures of the brachial plexus from the extraforaminal part to the axillary part. Four formolated cadavers (two male and two female; age range, 66-84 years; mean, 77.5 years) were frozen and sawed into 3-mm-thick contiguous sections in the same plane as that used for the sonographic exploration. RESULTS: A satisfactory sonographic examination was performed in 10 of 12 volunteers, leading to a good association with anatomic sections. Two volunteers were excluded from the study because a clear depiction of the brachial plexus was difficult owing to a short neck and low echogenicity at examination. The association between sonographic images and anatomic sections allowed us to map the brachial plexus. The subclavian and deep cervical arteries were useful landmarks for this mapping. The eighth cervical nerve root and the first thoracic nerve root were the most difficult part of the brachial plexus to depict because of their deep location. CONCLUSION: The brachial plexus can be mapped with sonography. However, this technique requires a good grounding in anatomy and may be impossible in short-necked individuals.

Adult↗
PubMed2000

[Obstetrical injuries of the brachial plexus].

Although birth-related brachial plexus injury (BPI) was first described more than two centuries ago, it still represents therapeutic dillemma. Incidence is 0.37-2.0 per 1000 live births. The most frequent etiologic cause is extreme lateral traction and excessive fundal pressure in a case of shoulder dystocia. However, in last decade there are reports that cite of BPIs occurring prior to delivery in up to 46% cases--intrauterine maladaptation. In 1998. and 1999. at the Rehabilitation Department of Pediatric Hospital, Clinical University Center in Sarajevo 32 children with BPI were treated. The incidence is 2.67 per 1000 live births. There were 21 cases of Erb's palsy (65.63%), 2 cases of Klumpke's palsy (6.25%). Total plexus palsy was present in 9 children (28.63%), and Horner's Syndrome in 1 case. In 25.77% of cases (8 children) there was-no evidence of shoulder dystocia at delivery. Treatment of the brachial plexus injuries in newborn is still controversial. Proper immobilization in first 7-15 days is of great importance. In this study 25 children (78.13%), in average age of 4.6 days, were brought for examination with improper immobilization. The role of widely applied electrotherapy is controversial. Complete recovery is expected in about one half, and in this study it was achieved in 75% of cases (24 children). Consensus about timing od surgical approach does not exist still. However, there is strong agreement that decision about eventual surgical treatment should be based on clinical motor testing and that MRI should precede the surgery. Although the electrodiagnostic studies have proven to be of limited prognostic value in the evaluation of children with acute obstetrical brachial plexus injuries, electromyography should be performed prior the surgery in the aim of later comparison of the results. According to our data, at this particular moment in BiH surgical treatment in this age is not available, as well as use of MRI in diagnostics of BPIs.

Birth Injuries↗
PubMed2006

Diagnostic performance of MRI and MR myelography in infants with a brachial plexus birth injury.

BACKGROUND: Detailed evaluation of a brachial plexus birth injury is important for treatment planning. OBJECTIVE: To determine the diagnostic performance of MRI and MR myelography in infants with a brachial plexus birth injury. MATERIALS AND METHODS: Included in the study were 31 children with perinatal brachial plexus injury who underwent surgical intervention. All patients had cervical and brachial plexus MRI. The standard of reference was the combination of intraoperative (1) surgical evaluation and (2) electrophysiological studies (motor evoked potentials, MEP, and somatosensory evoked potentials, SSEP), and (3) the evaluation of histopathological neuronal loss. MRI findings of cord lesion, pseudomeningocele, and post-traumatic neuroma were correlated with the standard of reference. Diagnostic performance characteristics including sensitivity and specificity were determined. RESULTS: From June 2001 to March 2004, 31 children (mean age 7.3 months, standard deviation 1.6 months, range 4.8-12.1 months; 19 male, 12 female) with a brachial plexus birth injury who underwent surgical intervention were enrolled. Sensitivity and specificity of an MRI finding of post-traumatic neuroma were 97% (30/31) and 100% (31/31), respectively, using the contralateral normal brachial plexus as the control. However, MRI could not determine the exact anatomic area (i.e. trunk or division) of the post-traumatic brachial plexus neuroma injury. Sensitivity and specificity for an MRI finding of pseudomeningocele in determining exiting nerve injury were 50% and 100%, respectively, using MEP, and 44% and 80%, respectively, using SSEP as the standard of reference. MRI in infants could not image well the exiting nerve roots to determine consistently the presence or absence of definite avulsion. CONCLUSION: In children younger than 18 months with brachial plexus injury, the MRI finding of pseudomeningocele has a low sensitivity and a high specificity for nerve root avulsion. MRI and MR myelography cannot image well the exiting nerve roots to determine consistently the presence or absence of avulsion of nerve roots. The MRI finding of post-traumatic neuroma has a high sensitivity and specificity in determining the side of the brachial plexus injury but cannot reveal the exact anatomic area (i.e. trunk or division) involved. The information obtained is, however, useful to the surgeon during intraoperative evaluation of spinal nerve integrity for reconstruction.

Birth Injuries↗
PubMed2002

Neonatal brachial plexus palsy: an unpredictable injury.

OBJECTIVE: Brachial plexus paralysis is a serious form of neonatal morbidity. We determined its incidence and persistence of disability and evaluated whether its occurrence could be predicted by maternal characteristics or partographic analysis in a large cohort of recent cases. STUDY DESIGN: During the years 1994 through 1998, all infants with neonatal evidence of obstetric brachial plexus injury were identified and followed 14;>or=1 year. Obstetric details in these maternal-infant pairs were compared with 108 control pairs, matched for maternal and gestational age, parity, and birth weight. Partographs of cases and control subjects were reviewed, in a blinded manner, by 3 obstetricians who were asked to identify likely cases of nerve injury. A risk score comprising eight recognized associated clinical features was assigned. RESULTS: Fifty-four of 35,796 infants (1.5/1000) had evidence of brachial plexus injury; in 10 cases (19%), neurologic deficit persisted to 1 year. Although the risk factor profile was relatively higher in cases compared with control subjects, the highest score was 5 of 8 in six cases (2 cases, 4 control subjects). Obstetricians' partographic assessment identified "likely brachial plexus injury" in 13 of 54 cases (24%) and 16 of 108 control subjects (15%), and in only 3 cases (6%) did the assessors concur (positive predictive value, 7%-17%; negative predictive value, 5%-12%; sensitivity, 24%-50%; specificity, 66%-68%). Risk scores were similar among persistently and transiently injured cases. CONCLUSION: Our results indicate that brachial plexus injury is not predictable before delivery, either by risk factor scoring or by partographic analysis.

Birth Injuries↗
PubMed2006

Etiological risk factors for brachial plexus palsy.

AIM: To investigate risk factors for brachial plexus palsy in newborns. We analyzed 45 544 live-born children, born over a nine-year period from January 1, 1996 to December 31, 2004. METHODS: The analysis was retrospective and based on the medical documentation of the Clinic for Gynecology and Obstetrics, Clinic for Neurology, and Clinic for Physical Medicine and Rehabilitation of the University Clinical Center Tuzla. We compared study and control groups of newborns. Rates among groups were compared using Chi-square, with significance at p < 0.05, and with significance at p < 0.01. RESULTS: Examining epidemiological characteristics, 86 newborns with brachial plexus palsy had been recorded, thus, the prevalence was 1.86 per 1000 live-born children. Analyzing maternal and neonatal factors, and the labor pattern itself, it was found that the highest factors of risk for brachial plexus injury were birth weight of over 4000 g, a precipitous second stage of labor (<15 minutes), and vacuum-extractor assisted labor. Brachial plexus palsy was more frequent when the mothers were overweight, with a body mass index >or=29 kg/m2. None of the parturient women, whose newborns were diagnosed with brachial plexus palsy, had external conjugate diameter <18 cm. Newborns delivered vaginally were not diagnosed with a higher frequency of brachial plexus palsy when compared to newborns who were delivered by cesarean section, but newborns who were vaginal breech-delivered were diagnosed to have a higher incidence of brachial plexus palsy. Newborns whose mothers were older than 35 years were diagnosed to have brachial plexus palsy more frequently, but a statistically significant difference between primiparas and multiparas was not found. A total of 39 newborns (45.2%) were diagnosed with a fracture of the clavicle, which was the most frequently combined damage with brachial plexus injury. Forty-two newborns (48.8%) had an Apgar score of <or=7 in the first minute after delivery, which indicates intrapartal fetal distress and is an indication of the traumatic nature of these deliveries. The average birth weight of newborns with brachial plexus damage was 3858.1+/-587.7 g, which for an average gestational age of 38.8+/-1.8 weeks, corresponds to eutrophic newborns. Both male and female newborns were diagnosed to have brachial plexus palsy comparably frequently, and almost all deliveries (97.7%) were initiated spontaneously. The majority of newborns were born between the hours of 02:00 and 03:00 and between the hours of 14:00-15:00.

Adolescent↗
PubMed2005

Applying cervical spine anatomy to interscalene brachial plexus blocks.

BACKGROUND: The interscalene brachial plexus block (ISBPB) is a most reliable and commonly performed technique for regional anesthesia of the upper extremity. It has widespread clinical applicability, ranging from use for shoulder surgery as well as diagnostic and therapeutic uses in pain management. Traditional methods described for performing the ISBPB involve identifying surface anatomy landmarks. Unfortunately, in patients with less than ideal landmarks (those with short, thick necks and those lacking adequate muscle tone in the neck area) it becomes increasingly challenging to identify these landmarks. As a result there is greater uncertainty in accurately locating the brachial plexus, and consequently greater risk in performing the block. METHODS: A simple new approach to the interscalene brachial plexus block is described, utilizing the bony anatomy of the cervical spine as a landmark for directing the needle to the correct position, a nerve stimulator, and a confirmatory injection of a test dose of anesthetic solution to enhance accuracy. In addition, by correctly implementing this technique, the block may be performed by a sole operator. RESULTS: This simple approach has proven to be clinically effective in more than 2,000 blocks of the brachial plexus during the past 4 years. CONCLUSION: It is concluded that this technique represents a safe, reproducible, and highly successful method for use by anesthesiologists and pain physicians alike.

Journal Article↗
PubMed2003

Imaging tumours of the brachial plexus.

Tumours of the brachial plexus are rare lesions and may be classified as benign or malignant. Within each of these groups, they are further subdivided into those that are neurogenic in origin (schwannoma, neurofibroma and malignant peripheral nerve sheath tumour) and those that are non-neurogenic. Careful pre-operative diagnosis and staging is essential to the successful management of these lesions. Benign neurogenic tumours are well characterized with pre-operative MRI, appearing as well-defined, oval soft-tissue masses, which are typically isointense on T1-weighted images and show the "target sign" on T2-weighted images. Differentiation between schwannoma and neurofibroma can often be made by assessing the relationship of the lesion to the nerve of origin. Many benign non-neurogenic tumours, such as lipoma and fibromatosis, are also well characterized by MRI. This article reviews the imaging features of brachial plexus tumours, with particular emphasis on the value of MRI in differential diagnosis.

Brachial Plexus↗
PubMed2006

Botulinum toxin as an adjunct to motor learning therapy and surgery for obstetrical brachial plexus injury.

Following obstetrical brachial plexus injury, infants are unable to learn specific patterns of movement due to the disruption of neural pathways. Even with successful reinnervation (spontaneously or post surgical reconstruction), function can be suboptimal due to overactivity in antagonist muscles preventing movement of reinnervated muscles. Botulinum toxin type A (BTX-A) was used to temporarily weaken antagonistic muscles early in the reinnervation process following brachial plexus injury, with the aim of facilitating functional improvement. A case series of eight children (five females, three males; mean age 12.5mo [SD 6.43]; range 5-22mo) with significant muscle imbalances but evidence of reinnervation were given BTX-A injections into the triceps, pectoralis major, and/or latissimus dorsi muscles. After a single injection, all parents reported improvement in function. Active Movement Scale total score changed significantly between pre BTX-A and 1 month (p=0.014), and 4 months (p=0.022) post BTX-A injection. It is proposed that BTX-A facilitated motor learning through improved voluntary relaxation of antagonist muscles while allowing increased activity in reinnervated muscles.

Biomechanical Phenomena↗
PubMedDate not supplied

[Brachial plexus tumors--neurosurgical treatment].

Tumours of the brachial plexus according to present classification are included to soft tissue tumours. Because of rare occurrence of these tumours diagnostic and operative experience is relatively small. There is also a few number of publications regarding tumours of the brachial plexus. Therefore the aim of the study was to present our experience in the surgical treatment of tumours of the brachial plexus basing on the material of 5 cases treated in the years 1997-2001. There were 4 males and 1 female, age from 17 to 58 years old. Four patients were under 27 years old. In 3 cases tumours of the brachial plexus invaded the spinal canal through the intervertebral foramen and caused spinal cord compression (type A). In 2 cases tumours involved only plexus elements (type B). In 2 cases tumours were associated with neurofibromatosis type II. Five cases of neural sheath tumours included 2 schwannomas, 2 neurofibromas and 1 schwannoma malignum. All patients underwent surgery. In case of schwannomas and neurofibromas the surgical removal was radical without impairment of brachial plexus function. In case of a giant schwannoma malignum tumor, which caused flaccid paresis and symptoms of insufficient blood, supply with severe pain in the upper limb radical extirpation was also possible. In type A tumours in the first stage intraspinal part of the tumor was removed. Follow up observation lasted from 3 months to 4 years. The result of treatment of benign tumours was very good with complete function recovery of the upper limb, pain disappearance and no symptoms of recurrence in the long postoperative period. In case of malignant schwannoma in the early postoperative period both pain and symptoms of blood supply disturbances completely disappeared. The patient died 12 months after the operation because of tumor dissemination. Benign tumours of the brachial plexus can be effectively surgically treated using microsurgical techniques and, if necessary, nerve grafting. In case of malignant tumours many authors also recommend surgery with optimal sparing of the brachial plexus function and subsequent radio and chemotherapy. Low number A few cases in our series makes impossible to draw any epidemiological conclusions.

Adult↗