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Biomedical subjects

R Birch

Publications and source records attributed to R Birch.

At least 19 recordsLinked to original sources
PubMed2007

Motor recovery and the breathing arm after brachial plexus surgical repairs, including re-implantation of avulsed spinal roots into the spinal cord.

Forty-four patients with severe traction brachial plexus avulsion injuries were studied following surgical repairs. In eight patients, re-implanting avulsed spinal roots directly to the spinal cord was performed with other repairs and motor recovery in the proximal limb was similar to that achieved by conventional nerve grafts and transfers when assessed using the MRC clinical grades, Narakas scores, EMG and Transcranial Magnetic Stimulation (TMS). Thirty-four of the 37 patients had co-contractions of agonist and antagonist muscle groups. Spontaneous contractions of limb muscles in synchrony with respiration, the "breathing arm", were noted in 26 of 37 patients: in three patients, the source of the breathing arm was from spinal cord re-connection, providing evidence of regeneration from the CNS to the periphery. Our study shows that re-connection of avulsed spinal roots can produce good motor recovery and provides a clinical model for developing new treatments which may enhance nerve regeneration.

Adolescent↗
PubMed2006

Pain phenomena and sensory recovery following brachial plexus avulsion injury and surgical repairs.

Seventy-six patients with severe brachial plexus avulsion injuries were studied using pain questionnaires and quantitative sensory testing. There was significant correlation between pain intensity and the number of roots avulsed prior to surgery (P=0.0004) and surgical repairs were associated with pain relief. Sensory recovery to thermal stimuli was observed, mainly in the C5 dermatome. Allodynia to mechanical and thermal stimuli was observed in the border zone of affected and unaffected dermatomes in 18% of patients assessed early (<6 months) and 37% patients at later stages. Pain and sensations referred to the original source of afferents occurred at a later stage (>6 months) in 12% of patients and were related to nerve regeneration. By contrast, "wrong-way" referred sensations (e.g. down the affected arm while shaving or drinking cold fluids) were reported by 44% of patients and often occurred early, suggesting CNS plasticity. Understanding sensory mechanisms will help develop new treatments for severe brachial plexus injuries.

Afferent Pathways↗
PubMed2006

The effect of neurotrophic factors on morphology, TRPV1 expression and capsaicin responses of cultured human DRG sensory neurons.

We have studied the effect of key neurotrophic factors (NTFs) on morphology, levels of the vanilloid receptor-1 (TRPV1) and responses to capsaicin in adult human sensory neurons in vitro. Avulsed dorsal root ganglia (DRG, n = 5) were cultured with or without a combination of nerve growth factor (NGF), glial cell (line)-derived growth factor (GDNF) and neurotrophin3 (NT3) for 5 days. In the absence of NTFs, the diameter of neurons ranged from 20 to 100 microm (mean 42 +/- 4 microm). Adding NTFs caused a significant increase in neuronal sizes, up to 120 microm (mean diameter 62 +/- 5 microm, P < 0.01, t-test), an overall 35% increase of TRPV1-positive neurons (P < 0.003), and notably of large TRPV1-positive neurons > 80 microm (P < 0.05). Responses to capsaicin were significantly enhanced with calcium ratiometry (P < 0.0001). Short duration (1h) exposure of dissociated sensory neurons to NTFs increased numbers of TRPV1-positive neurons, but not of TRPV3, Nav 1.8 and IK1 and the morphological size-distribution remained similar to intact post-mortem DRG neurons. NTFs thus increase size, elevate TRPV1 levels and enhance capsaicin responses in cultured human DRG neurons; these changes may relate to pathophysiology in disease states, and provide an in vitro model to study novel analgesics.

Adult↗
PubMed2006

Primary sciatic nerve lymphoma: a case report and review of the literature.

A patient with primary B cell non-Hodgkin's lymphoma of the sciatic nerve is described. He presented with neuropathic symptoms in the left leg, initially diagnosed as tarsal tunnel syndrome. Magnetic resonance imaging (MRI) identified the abnormality in the sciatic nerve. A fascicular biopsy of the sciatic nerve showed a diffuse large B cell non-Hodgkin's lymphoma. The patient was treated with chemotherapy and rituximab (anti-CD20 monoclonal antibody). Four months later he was in remission, and remains so 48 months from presentation. Primary lymphoma of single peripheral nerves may be a unique subtype of extranodal lymphoma, which usually follows an aggressive course and has a variable response to current therapeutic strategies. MRI is useful, alongside electrophysiological studies, in patients with atypical peripheral nerve symptoms.

Antibodies, Monoclonal↗
PubMed2006

Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children: the experience of a specialist referral centre.

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome.

Brachial Plexus↗
PubMed2006

Posterior subluxation and dislocation of the shoulder in obstetric brachial plexus palsy.

We describe the results of surgical treatment in a prospective study of 183 consecutive cases of subluxation (101) and dislocation (82) of the shoulder secondary to obstetric brachial plexus palsy between 1995 and 2000. Neurological recovery was rated 'good' or 'useful' in all children, whose lesions fell into groups 1, 2 or 3 of the Narakas classification. The mean age at operation was 47 months (3 to 204). The mean follow-up was 40 months (24 to 124). The mean gain in function was 3.6 levels (9.4 to 13) using the Mallet score and 2 (2.1 to 4.1) on the Gilbert score. The mean active global range of shoulder movement was increased by 73 degrees ; the mean range of active lateral rotation by 58 degrees and that of supination of the forearm by 51 degrees . Active medial rotation was decreased by a mean of 10 degrees . There were 20 failures. The functional outcome is related to the severity of the neurological lesion, the duration of the dislocation and onset of deformity.

Bone Remodeling↗
PubMed2006

The effects of operative delay on the relief of neuropathic pain after injury to the brachial plexus: a review of 148 cases.

We investigated the effect of delay before nerve repair on neuropathic pain after injury to the brachial plexus. We studied 148 patients, 85 prospectively and 63 retrospectively. The mean number of avulsed spinal nerves was 3.2 (1 to 5). Pain was measured by a linear visual analogue scale and by the peripheral nerve injury scale. Early repair was more effective than delayed repair in the relief from pain and there was a strong correlation between functional recovery and relief from pain.

Adolescent↗
PubMed2005

Entrapment of a displaced common peroneal nerve following knee ligament reconstruction.

We present a case of disruption of the posterolateral corner of the knee with avulsion of the tendon of biceps femoris. Repair and reconstruction included an allogenic tendon graft to replace the posterior cruciate ligament. Surgery was followed by a complete common peroneal nerve palsy. Revision surgery revealed that the nerve had been displaced anteriorly by avulsion of the biceps tendon and the tendon graft encircled it. Release of the nerve restored normal function at five months.

Adult↗
PubMed2005

Repair of obstetric brachial plexus palsy: results in 100 children.

This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations. Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired. The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer. Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert score and 1.6 on the Mallett score. Pre-operative electrodiagnosis is a reliable indicator of the depth of the lesion and of the outcome after repair. Intra-operative somatosensory evoked potentials were helpful in the detection of occult intradural (pre-ganglionic) injury.

Age Factors↗
PubMed2005

Low-energy arterial injury at the shoulder with progressive or delayed nerve palsy.

We describe 20 patients, aged between 43 and 88 years, with delayed nerve palsy or deepening of an initial palsy caused by arterial injury from low-energy injuries to the shoulder. The onset of palsy ranged from immediately after the injury to four months later. There was progression in all the patients with an initial partial nerve palsy. Pain was severe in 18 patients, in 16 of whom it presented as neurostenalgia and in two as causalgia. Dislocation of the shoulder or fracture of the proximal humerus occurred in 16 patients. There was soft-tissue crushing in two and prolonged unconsciousness from alcoholic intoxication in another two. Decompression of the plexus and repair of the arterial injury brought swift relief from pain in all the patients. Nerve recovery was generally good, but less so in neglected cases. The interval from injury to the repair of the vessels ranged from immediately afterwards to 120 days. Delayed onset of nerve palsy or deepening of a nerve lesion is caused by bleeding and/or impending critical ischaemia and is an overwhelming indication for urgent surgery. There is almost always severe neuropathic pain.

Adult↗
PubMed2005

Displacement of the common peroneal nerve in posterolateral corner injuries of the knee.

We reviewed the relationship between the pattern of damage to the posterolateral corner of the knee and the position of the common peroneal nerve in 54 consecutive patients with posterolateral corner disruption requiring surgery. We found that 16 of the 18 patients with biceps avulsions or avulsion-fracture of the fibular head had a displaced common peroneal nerve. The nerve was pulled anteriorly with the biceps tendon. None of the 34 proximal injuries resulted in an abnormal nerve position. Whenever bone or soft-tissue avulsion from the fibular head is suspected, the surgeon should expect an abnormal position of the common peroneal nerve and appreciate the increased risk of iatrogenic damage.

Fibula↗
PubMed2003

Late complications following clavicular fractures and their operative management.

We describe our experience of the operative treatment of sequelae from high-energy injuries of the clavicle. Surgery was performed on 17 patients who often had more than one indication. This included the following: painful non-union (nine patients), neurogenic thoracic outlet syndrome (TOS), hypertrophic non-union three patients, hypertrophic malunion five patients, bony spike two patients), vascular TOS (two patients) and brachial plexus neuroma (one patient). At clinical review, functional outcome was assessed by using a Constant score, a visual analogue pain score, return to work status and by patient subjective satisfaction rating. We performed 11 decompressions with callus excision, three simple neurolysis, eight fixations for non-union, one osteotomy and three excisions of bone spikes. Two patients required a further decompression procedure; one patient developed deep sepsis requiring sequestrectomy and two patients required removal of metalwork. At mean follow-up of 49 months the average Constant score was 64 (range 27-93). The mean pain score was 4. Ten patients returned to work at an average of 8 months. Five patients were completely asymptomatic, eight reported occasional paraesthesiae and three had significant cold intolerance. Patient satisfaction scores were 14% very satisfied, 50% satisfied, 14% unsatisfied and 22% very unsatisfied. High-energy clavicle injuries can cause significant morbidity due to non-union and TOS. Refractory symptoms can be improved by operative intervention with satisfactory functional outcome. However, the majority of patients experience some degree of residual symptoms.

Adult↗
PubMed2003

Neurophysiological prediction of outcome in obstetric lesions of the brachial plexus.

Seventy-three children with slow recovery after obstetric lesion of the brachial plexus (biceps function returning after 3 months of age) and with relatively favourable neurophysiological investigation were followed until a mean age of 4.3 years. Predictions for C6 and C7 were confirmed in 92% and 96% of the cases, respectively. Predictions for C5 were confirmed in a smaller proportion of cases (78%). The inability to record nerve action potentials for C5, and the high frequency of secondary shoulder pathology are reasons for this. In all, 33 of the 73 children came to operation for medial rotation contracture (11) or posterior subluxation/dislocation (21); there was one case operated for inferior contracture.

Action Potentials↗
PubMed2003

Obstetric brachial plexus lesions: a study of 74 children registered with the British Paediatric Surveillance Unit (March 1998-March 1999).

Seventy-four children with obstetric brachial plexus palsy registered with the British Paediatric Surveillance Unit were prospectively followed for a minimum of 2 years. Thirty-nine (52.7%) spontaneously recovered to normal or nearly normal levels and a further 29 (39.3%) regained good function in the upper limb. The most important secondary deformity involved the gleno-humeral joint and 20 patients (27%) needed surgical correction. Two more children await operation for shoulder deformity. The brachial plexus was explored in nine patients (12.2%) and repaired in seven.

Brachial Plexus Neuropathies↗
PubMed2002

The prevalence of spinal trauma associated with brachial plexus injuries.

Severe closed traction lesions to the adult brachial plexus are caused by high energy transfer injuries, in which injuries to other systems are common. Of the 149 patients urgently operated on for lesions of the brachial plexus between 1 June 1997 and 1999, 18 (12%) suffered significant injury to the spinal column. Accurate diagnosis of the spinal injury was made in 13 cases of these before transfer to our unit.The injury to the spine was not necessarily a contraindication to urgent exploration of the brachial plexus.

Adolescent↗