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PubMed1998

A surgical approach for concomitant spinal cord and brachial plexus surgery: an anatomical study.

Spinal cord surgery is not the current treatment for brachial plexus avulsion injuries. However, several experimental and a few clinical cases have been reported with promising results. This surgical strategy in the near future, might prove to be useful. Different simultaneous anatomical approaches to the brachial plexus and spinal cord were studied in attempt to discover the best route to be used in the surgical reconstruction of avulsion lesions of the brachial plexus by spinal cord surgery. Eleven fresh subjects were used to compare: a) simultaneous dorsal approaches to the brachial plexus and spinal cord, b) the dorsal approach to the spinal cord and the anterior approach to the brachial plexus, c) a dorsal approach to the spinal cord combined with a dorsal approach through the triceps muscle to the terminal branches of the brachial plexus and d) a purely anterior approach to the spinal cord and brachial plexus. During the study, special attention was paid to the length of the grafts needed for repair, the possibility of entire exposure of the brachial plexus and the possibility of performing concomitant nerve transfers. As a result of the anatomical findings, we would suggest a dorsal approach to the spinal cord, suprascapular nerve and sometimes to the axillary nerve, combined with an anterior exposure to the brachial plexus in order to have the whole plexus explored and routine simultaneous nerve transfers performed. In selected cases, with limited root injuries, the dorsal approach to the brachial plexus and spinal cord and the anterior approach to the brachial plexus and spinal cord might be of interest.

Brachial Plexus↗

PubMed2003

Sonographic evaluation of brachial plexus pathology.

Pre-operative US examinations of the brachial plexus were performed with the purpose of exploring the potential of this technique in recognizing lesions in the region and defining their sonographic morphology, site, extent, and relations to adjacent anatomic structures, and comparing them to the surgical findings to obtain maximal confirmation. Twenty-eight patients with clinical, electro-conductive, and imaging findings suggestive of brachial plexus pathology were included in this study. There were four main etiology groups: post-traumatic brachial plexopathies; primary tumors (benign and malignant); secondary tumors; and post irradiation injuries. Twenty-one of the 28 patients underwent surgery. Advanced imaging (mostly MRI) served as an alternative gold standard for confirmation of the findings in the non-surgically treated group of patients. The US examinations were performed with conventional US units operating at 5- to 10-MHz frequencies. The nerves were initially localized at the level of the vertebral foramina and then were followed longitudinally and axially down to the axillary region. Abnormal US findings were detected in 20 of 28 patients. Disruption of nerve continuity and focal scar tissue masses were the principal findings in the post-traumatic cases. Focal masses within a nerve or adjacent to it and diffuse thickening of the nerve were the findings in primary and secondary tumors. Post-irradiation changes presented as nerve thickening. Color Doppler was useful in detecting internal vascularization within masses and relation of a mass to adjacent vessels. The eight sonographically negative cases consisted either of traumatic neuromas smaller than 12 mm in size and located in relatively small branches of posterior location or due to fibrotic changes of diffuse nature. Sonography succeeded in depicting a spectrum of lesions of traumatic, neoplastic, and inflammatory nature in the brachial plexus. It provided useful information regarding the lesion site, extent, and anatomic relationships; thus, the principal aims of the study were therefore met. Once the technique of examination is mastered, sonography should be recommended as part of the pre-operative evaluation process post-ganglionic brachial plexus pathology. Most disadvantages are related to the restricted field of view and inability to overcome bonny obstacles particularly in evaluating pre-ganglionic region. As sonography is frequently employed for investigation of the supraclavicular region, awareness of the radiologist to the findings described may enable the early recognition of pathologies involving or threatening to involve the brachial plexus.

Adult↗

PubMed1999

Utility of vibration thresholds in patients with brachial plexus nerve compression.

The diagnosis of brachial plexus nerve compression is controversial due to the subjective nature of patient symptoms and the lack of objective, quantifiable tests. It has been hypothesized that quantitative sensory evaluation of sensory threshold is the most sensitive method of evaluating nerve compression, particularly in the early stages. This study evaluated the sensitivity and specificity of vibration thresholds for detection of brachial plexus nerve compression. A multiple-frequency vibrometer was used to evaluate 40 control subjects and 35 patients with brachial plexus nerve compression. Calculated sensitivity values were modest (0.49 at 63, 250, and 500 cps) with high specificity values (0.98 at 8 cps) for individual frequencies using a fifth percentile criterion. The low sensitivity values indicate that this instrument is not adequate as a screening device.

Adult↗

PubMed1992

[Vessels of the brachial plexus].

The blood supply of brachial plexus is described by means of lightened injected specimens of older human fetus. The following arteries have direct branches to brachial plexus: the aortic arch/brachiocephalica trunk, subclavia a., thyrocervical trunk, ascending cervical a., transverse cervical a., suprascapular a., and the acromial network. Secondary branches leave them that partly anastomose and also return from distal to proximal. The blood supply is luxurious.

Brachial Plexus↗

PubMed1994

[Pathogenesis of thoracic outlet syndrome: diagnosis with neurography of the brachial plexus].

From 1985 to 1992, the brachial plexus in 130 cases with thoracic outlet syndrome (TOS) was examined by neurography. We found evidence of stretching in patients with severe symptoms who were examined with their arm at their side. We studied the relationship between the evidence we found and the clinical symptoms and signs, to investigate the pathogenesis of TOS. The compression and stretching of the brachial plexus were evaluated visually. The TOS cases were classified into four types: (I) Compression only, (II) Compression > Stretching, (III) Compression < Stretching, and (IV) Stretching only. We confirmed that there were characteristic clinical features for each type of TOS. From these results, both compression and stretching of the brachial plexus were suggested pathogenetic factors of TOS. Conservative treatment using a scapular band was effective for the stretching types III and IV, while surgical treatment was indicated for the compression types I and II.

Adolescent↗

PubMed2002

Ultrasonographic assessment of topographic anatomy in volunteers suggests a modification of the infraclavicular vertical brachial plexus block.

BACKGROUND: The infraclavicular vertical brachial plexus block, first described by Kilka and coworkers, offers a more proximal spread of anaesthesia for the upper extremity than the classic axillary approach. In this technique, the puncture site is defined as lying at the exact centre of an infraclavicular line (k) between the jugular fossa and the ventral process of the acromion. Our study was designed to determine whether the point so defined (P) corresponds with the optimal puncture site determined sonographically (S) and to develop an improved prediction model. METHOD: High-resolution ultrasonography was carried out in 59 volunteers to visualize the plexus. Sonography-derived distances and morphometric measurements were used to test accuracy and calculate multiple regressions. RESULTS: We found a clear trend towards a more lateral puncture site. In women, S was significantly (P<0.001) lateral (8 mm) to P. The overall accuracy of the infraclavicular vertical brachial plexus block technique was not sufficient to predict the optimal puncture site reliably. Our resulting improved prediction model is valid for both sexes and is based not just on the centre point but on the absolute length of k (22-22.5 cm). We found that for every 1 cm decrease in k the optimal puncture site moved 2 mm laterally from the exact centre of k, and for every 1 cm increase in k it moved 2 mm medially. CONCLUSIONS: The suggested modification should help to increase the success rate of the infraclavicular vertical brachial plexus block while decreasing the rate of potentially severe complications, although individual ultrasonographic guidance is to be recommended whenever possible.

Adolescent↗

PubMed2000

The communicating branch of the 4th cervical nerve to the brachial plexus: the double constitution, anterior and posterior, of its fibers.

Twenty-four adult cadavers (48 sides) were used to investigate the incidence of a branch arising from the ventral ramus of the fourth cervical nerve (C4) with the phrenic nerve and subsequently joining the brachial plexus. Six brachial plexuses with spinal cords and phrenic nerves were dissected under a surgical microscope to investigate localization of fibers contained in the C4 branch to the brachial plexus. The incidence of the C4 branch was 23% (11/48 sides). Branches from C4 to the brachial plexus divided into anterior and posterior divisions on four sides (4/6 sides). On two sides, the branch did not divide but consisted entirely of an anterior division (2/6 sides). In the brachial plexus, anterior division fibers of the C4 branch were intertwined with fibers from the anterior divisions of the ventral rami of the fifth and sixth cervical nerves. They then passed to the suprascapular nerve and the anterior division of the superior trunk (6/6 sides). On the other hand, posterior division fibers of the C4 branch were intertwined with fibers from the posterior divisions of the ventral rami of the fifth and sixth cervical nerves. They then passed to the suprascapular nerve (2/6 sides) and the posterior division of the superior trunk (4/6 sides). The anterior division of the C4 branch received fibers from the ventral rootlets of the entire fourth cervical segment, whereas the posterior division received fibers from the ventral rootlets of the caudal half of the fourth cervical segment only. The fact that the suprascapular nerve received fibers from both the anterior and posterior divisions of the C4 branch was considered to support our claim that the human suprascapular nerve belongs to both the anterior and posterior divisions of the brachial plexus.

Adult↗

PubMed2004

Neuromuscular hamartoma arising in the brachial plexus.

We report a case brachial plexus neuromuscular hamartoma (choristoma) in a 28-year-old man who complained of numbness of the left hand and forearm for several years. MRI revealed a circumscribed, rounded mass in the left brachial plexus. The patient is well 2 years after surgery, with no neurological deficit.

Adult↗

PubMedDate not supplied

Bilateral brachial plexus compressive neuropathy (crutch palsy).

Brachial plexus compressive neuropathy following the use of axillary crutches (crutch palsy) is a rare but well-recognized entity. Most reported cases involve the posterior cord of the brachial plexus in children and have resolved spontaneously within 8-12 weeks. We recently treated a 36-year-old man who was using axillary crutches for mobilization after a supracondylar femoral fracture. Bilateral posterior cord (predominantly radial nerve) compressive neuropathy subsequently developed, with lesser involvement of the ulnar and median nerves. The patient had little to no improvement clinically 8 weeks after the estimated onset of the palsy, and an electromyogram at that time confirmed the presence of a severe axonotmesis lesion of the radial, median, and ulnar nerves bilaterally. The patient was treated with static cock-up wrist splinting and discontinuation of the axillary crutches. Return of sensory and motor function was delayed but occurred within 9 months.

Adult↗

PubMedDate not supplied

The anatomic relationship of the brachial plexus and axillary artery to the glenoid. Implications for anterior shoulder surgery.

Iatrogenic brachial plexus injury is an uncommon but potentially severe complication of shoulder reconstruction for instability that involves dissection near the subscapularis muscle and potentially near the brachial plexus. We examined the relationship of the brachial plexus to the glenoid and the subscapularis muscle and evaluated the proximity of retractors used in anterior shoulder surgical procedures to the brachial plexus. Eight fresh-frozen cadaveric shoulders were exposed by a deltopectoral approach. The subscapularis muscle was split in the middle and dissected to reveal the capsule beneath it. The capsule was split at midline, and a Steinmann pin was placed in the equator of the glenoid rim under direct visualization. The distance from the glenoid rim to the brachial plexus was measured with calipers with the arm in 0 degrees, 60 degrees, and 90 degrees of abduction. The brachial plexus and axillary artery were within 2 cm of the glenoid rim, with the brachial plexus as close as 5 mm in some cases. There was no statistically significant change in the distance from the glenoid rim to the musculocutaneous nerve, axillary artery, medial cord, or posterior cord with the arm in various degrees of abduction. Retractors placed superficial to the subscapularis muscle or used along the scapular neck make contact with the brachial plexus in all positions tested.

Aged↗

PubMed1997

Gunshot injuries to the brachial plexus.

OBJECTIVE: Gunshot wounds to the brachial plexus present a specific problem in peripheral nerve surgery. The purpose of this study is to analyze the characteristics of these injuries and the possibilities for functional recovery after their surgical treatment. DESIGN: Retrospective analysis of nerve lesions and results of surgery. MATERIALS AND METHODS: The series consists of 54 patients operated on, with 148 injured nerve elements, i.e., with 163 injured nerve elements when individual components of complex brachial plexus structures are included. Surgical procedures involved exploration, neurolysis, and nerve grafting, or their combination, depending on intraoperative findings. The surgical results were analyzed in 46 patients (85.1%) with 119 (80.1%) of the 148 nerve elements, with follow-up periods of more than 24 months. Standard grading scores for motor and sensory function were used and ranged according to functional priorities in the surgery of brachial plexus and individual nerves. MEASUREMENTS AND MAIN RESULTS: Neurolysis and nerve grafting generally gave similar rates of functional recovery, 90.2 and 87.8%, respectively. They were successful in all cases with injuries to the upper spinal nerves, the upper trunk, the lateral and posterior cord, and the musculocutaneous and axillary nerves. The failures were related to neurolysis or grafting of the ulnar and radial nerve lesions. CONCLUSION: Compared with previous studies, the number of lesions with complete functional loss and complete anatomic loss of continuity is larger. In cases that were prognostically favorable according to the location of injury, the results are similar regardless of the type of nerve repair.

Adolescent↗

PubMedDate not supplied

Entrapment neuropathy contributing to dysfunction after birth brachial plexus injuries.

Although surgical treatment of brachial plexus birth palsy has yielded encouraging results, persistent inability to abduct and elevate the shoulder is common even in children with excellent return of arm and hand function. The reason for deltoid weakness in the afflicted children is not completely understood and may be multifactorial. Clinical observations, including a pattern of position-dependent weakness, suggest that primary nerve damage may not be the sole cause. The authors performed a retrospective chart study to investigate the outcome of surgical treatment to augment shoulder function in a series of 10 children (ages 9 months to 8 years) with inadequate external rotation of the shoulder and inability to actively raise the arm beyond 90 degrees from a birth brachial plexus injury. At follow-up 6 months after surgery, increased shoulder range of motion was noticed in all, with significantly increased abduction/elevation in 8 of the 10 children. Analysis of data, including pre- and postoperative functional testing and intraoperative electrophysiologic monitoring, led to the conclusion that secondary compression of the axillary nerve in the quadrangular space is a separate and common reason for impairment in children with brachial plexus birth palsy and persistent weakness of the deltoid muscle and may provide an important reason for early intervention.

Brachial Plexus↗

PubMed2004

Changes in spinal cord architecture after brachial plexus injury in the newborn.

Obstetric brachial plexus palsy is a devastating birth injury. While many children recover spontaneously, 20-25% are left with a permanent impairment of the affected limb. So far, concepts of pathology and recovery have focused on the injury of the peripheral nerve. Proximal nerve injury at birth, however, leads to massive injury-induced motoneuron loss in corresponding motoneuron pools and therefore limits the extent of functional recovery. In the present study, the role of spinal cord plasticity after injury and recovery from obstetric brachial plexus lesions was investigated. A selective injury to spinal roots C5 and C6 was induced in newborn Sprague-Dawley rats, leading to motoneuron loss in corresponding motoneuron pools. Recovery of extremity function was evaluated with different behavioural paradigms. Permanent changes of adjacent motoneuron pools were quantitatively evaluated by retrograde tracing and functional muscle testing. We report that the adjacent C7 motoneuron contribution to biceps muscle innervation increased four-fold after upper trunk lesions in newborns, thus compensating for the injury-induced motoneuron loss. These results indicate that, in obstetric brachial plexus palsy, changes in spinal cord architecture are an integral part not only of primary pathology but also of the subsequent recovery process. While present treatment is directed towards the restoration of neural continuity, future treatment strategies must recognize and take advantage of CNS participation in the injury and recovery process.

Animals↗

PubMed1999

Restoration of wrist extension by tendon transfer in cases of obstetrical brachial plexus palsy.

Sequelae from obstetrical brachial plexus palsy are sometimes severe even after early microsurgical repair. Tendon transfer may improve hand function but to date, there is no large series that has been published on the results. Fifty-six children with obstetrical brachial plexus palsies were operated on for lack of wrist extension. A functional assessment scale was developed. Postoperatively, 42.5% of patients achieved an active wrist extension, 32.5% a static wrist extension. The extent of paralysis seems to influence the results. Some tendon transfert seems to give better results. The age at the time of transfert has no influence on the out come.

Birth Injuries↗

PubMed1999

Management of traumatic brachial plexus injuries in adults.

Adult brachial plexus injury (BPI) is a closed injury. It usually involves a plexus of nerves formed by a number of roots, spinal nerves, trunks, cords, and numerous terminal branches, in a complicated fashion. Successful results in the management of adult BPI are based on the knowledge of anatomic arrangement, pathophysiology considerations, preoperative evaluation and diagnosis, surgical technique, postoperative management, rehabilitation and regular patient follow-up, surgical treatment of sequelae deformities, and factors influencing its results. This article deals with traumatic lesions of the brachial plexus in adults, and focuses on controversial questions and philosophy of treatment of adult BPI.

Adult↗

PubMed2006

Fetal deformations: a risk factor for obstetrical brachial plexus palsy?

The purpose of this report is to discuss the association of brachial plexus palsy and congenital deformations. We reviewed all charts of patients less than 1 year of age with obstetrical brachial plexus palsy evaluated by one of the authors (IA) between January 1998 and October 2005 at Miami Children's Hospital Brachial Plexus Center. Of 158 patients with obstetrical brachial plexus palsy, 7 had deformations (4.4%). Deformations were present in 32% of patients delivered by cesarean section, but in only 2% of patients delivered vaginally. The deformations were ipsilateral, involving the chest in two patients, distal arms in two patients, proximal arm in one patient, ear in one patient, and the leg in one patient. All patients with deformations had unilateral Erb's palsies. None had a history of maternal uterine malformation. Two presumptive mechanisms of injury, one causing the deformation (compressive forces) and one causing brachial plexus palsy at the time of delivery (traction forces), were present in all cases. The higher incidence of deformation in patients with obstetrical brachial plexus palsy born by cesarean sections and the presence of two presumptive mechanisms in all of the cases presented here raises the possibility that fetal deformations are a risk factor for obstetrical brachial plexus palsy.

Birth Injuries↗

PubMed1982

Brachial plexus block for pain relief after modified radical mastectomy.

Brachial plexus block using an intraclavicular approach was performed at the completion of surgery in 47 patients having modified radical mastectomies. In 48 control patients having similar operations, brachial plexus block was not performed. Of the 47 patients in whom brachial plexus block was performed, 26 (55%) required analgesia during the first 24 hours after the operation, whereas 44 (91%) of the 48 control patients required analgesics (p less than 0.0005). The time elapsed between the end of anesthesia and requirement of the first analgesic was significantly longer when the brachial plexus was blocked (p less than 0.001). The efficacy, simplicity, and safety of blocking the brachial plexus at the completion of surgery following modified mastectomy demonstrate that this technique could be routinely used for the relief of postoperative pain in patients having modified radical mastectomies.

Analgesics↗

PubMed2003

Neurogenic motor evoked potentials: role in brachial plexus surgery. Case report.

Peripheral nerve graft repair after severe brachial plexus injury is futile if there is degeneration of motor fibers in the proximal nerve stump to which the graft must be attached. Traditional intraoperative neurophysiological assessment methods like nerve action potential (NAP) and somatosensory evoked potential (SSEP) monitoring have been used to evaluate proximal nerve stump integrity, but these methods do not allow evaluation of the integrity of motor fibers back to the anterior horn cell. Consequently, the authors used transcranial electrical stimulation and recorded neurogenic motor evoked potentials (MEPs) directly from the brachial plexus in a patient undergoing surgical repair of a complete upper brachial plexus injury (Erb palsy) to assess the functional continuity of motor fibers. In addition, selected elements of the brachial plexus were directly stimulated, and NAPs were recorded. Finally, SSEPs were recorded from the scalp after stimulation of selected elements of the brachial plexus. Neurogenic MEPs were present from the medial cord of the brachial plexus, but not the middle or upper trunk; NAPs were present from the lateral and posterior cords after middle trunk stimulation, but absent after upper trunk stimulation; and SSEPs were present after medial cord stimulation but absent after stimulation of the upper and middle trunks. For the first time, neurogenic MEPs were coupled with NAPs and SSEPs to evaluate successfully the functional status of motor fibers back to the anterior horn cell for accurate localization of the lesion sites.

Action Potentials↗