Biomedical subjects
Publications and source records attributed to C B Parry.
This article concerns traction lesions of the brachial plexus in adults, focusing on management and recovery. Open wounds of the plexus are now treated surgically as soon as possible. The subsequent rehabilitation is the same as that for closed traction lesions of the brachial plexus in which significant recovery is expected.
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The author reviews the progress that has been made in the development of orthotics and rehabilitation techniques for patients with extensive paralysis of the upper limb after injury and disease. Splint components and their variations are described with regard to patients with less extensive or recovering lesions.
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The author reviews the diagnosis and treatment of avulsion injuries of the brachial plexus. He discusses the nature of the pain and the use of transcutaneous nerve stimulation for its relief.
The increase in the knowledge of pain mechanisms has contributed to a wide variety of modalities available to treat this sensory disability. More recent experience has shown that an intensive multidisciplinary approach gives better success rates. Further involvement of physicians, surgeons and basic scientists in the study of pain can only lead to mutual benefit.
The operation of transfer of the extensor digitorum brevis muscle to the face in the treatment of unilateral facial palsy (Thompson and Gustavson, 1976) has been further modified by immediate anastomosis of its vascular pedicle to the superficial temporal vessels. Six of our ten patients showed some new movement but in only three did this approach symmetry with the other side. Long term follow-up showed that improvement can be expected for up to two years after transfer. Our technique is assessed critically and suggestions are made for further improvement.
Forty-two patients with unilateral brachial plexus traction lesions were investigated by recording sensory nerve action potentials (SNAPs) from the lower arm and somatosensory evoked potentials (SEPs) from the clavicle, the cervical spine and the scalp overlying the contralateral somatosensory cortex, in response to electrical stimulation of peripheral nerves. The median and radial nerves were assumed to derive principally from the C6 and C7 roots, and the ulnar nerve from the C8 and T1 roots. Combination of SEP and SNAP findings suggested a location for the lesion (preganglionic, postganglionic or combining pre-and postganglionic elements) which was found to be accurate in 10 out of 16 operated cases, and substantially accurate in another 3. There was a poor correlation, however, between the presence of absence of SNAPs in the musculocutaneous nerve and the location of the lesion to the C5 root.
A series of 100 patients with pain in the leg was studied and the accuracy of electrical studies in the diagnosis of nerve root lesions was investigated before operation. The electrical studies which were performed on all the patients, included recordings of fibrillation potentials, H-reflex and ankle reflex latencies. This diagnosis technique was found to be more accurate than radiculography or clinical examination and did not give false evidence. Seventy patients were classed as having a lesion of the nerve root. Fifty of these patients were treated surgically. The operation revealed compression of the nerve root by osteophytes arising from degenerative and incompletely dislocated posterior facet joints in 43 patients.
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The experience of our institution is presented to support the proposition that formal sensory retraining procedures are well worthwhile in adult patients after median nerve lesions. The retraining programme is described and the results achieved in our series of patients are discussed, with particular emphasis on the roles of the patients' relatives, occupational therapists and physiotherapists.
A plea is made for the early recognition of the possible development of painful conditions affecting peripheral nerves, since it is believed that the experience of our institution, which is detailed here, confirms that while rehabilitation programmes are of benefit to the patient, successful therapy depends upon prompt institution of prophylactic measures to prevent sensitization to sympathetic outflow. Patients are encouraged to use their hands, and it is considered important that they would understand that their complaints arise from a genuine organic condition.
In 15 patients who underwent open exploration of the brachial plexus, the somatosensory evoked potentials and nerve action potentials recorded at the time of operation were useful as guides to the most appropriate surgical procedure, and also in predicting the outcome in certain lesions. In three patients the apparent normality of the upper trunk of the plexus was concealing a more proximal lesion which was irrecoverable. The presence of a somatosensory evoked potential showed functional continuity in three patients in whom the C7 root was clinically involved and who recovered after operation. In five patients proximal stumps of ruptured C5 roots showed functional central continuity; this indicated their suitability for grafting. These patients recovered except one who suffered from co-existing disease. The electrophysiological studies also confirmed the clinical diagnosis of avulsion of the C8 and T1 roots and therefore prevented unnecessary dissection.
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