Review of brachial plexus anatomy as seen on diagnostic imaging: clinical correlation with computed tomography-guided brachial plexus block.
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Brachial Plexus↗
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Nerve transfer in brachial plexus traction injuries.
Brachial plexus palsy due to traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Nerve transfer is the only possibility for repair in cases of spinal nerve-root avulsion. This technique was analyzed in 37 patients with 64 reinnervation procedures of the musculocutaneous and/or axillary nerve using upper intercostal, spinal accessory, and regional nerves as donors. The most favorable results, with an 83.8% overall rate of useful functional recovery, were obtained in patients with upper brachial plexus palsy in which regional donor nerves, such as the medial pectoral, thoracodorsal, long thoracic, and subscapular nerves, had been used. The overall rates of recovery for the spinal accessory and upper intercostal nerves were 64.3% and 55.5%, respectively, which are significantly lower. The authors evaluate the results of nerve transfer and analyze different donor nerves as factors influencing the prognosis of surgical repair.
Accessory Nerve↗
Selective motor hyperreinnervation by using contralateral C-7 motor rootlets in the reconstruction of an avulsion injury of the brachial plexus. Case report.
Brachial plexus avulsion injuries are a clinical challenge. In recent experimental studies the authors have demonstrated the high degree of muscle reinnervation attained when a C-4 motor rootlet was directly connected to the musculocutaneous nerve. This degree of reinnervation was attributed to the good chance that a muscle fiber can be reinnervated by a motor fiber when the number of regenerating motor neurons is increased and when competitive sensory fibers are excluded from the process. The authors present the first clinical case in which this phenomenon has been observed. This 26-year-old man, who was involved in an automobile accident, presented with an upper brachial plexus avulsion, for which he underwent operation 4 months later. The axillary and suprascapular nerves were directly surgically connected to the motor rootlets of the C-7 contralateral root by using two cables of sural nerve graft. Two years postsurgery, the patient was able to perform shoulder abduction of 120 degrees and hold an 800-g weight at 90 degrees. These results are encouraging, and in selected patients motor rootlet transfer might prove to be a useful surgical strategy.
Adult↗
[Obstetric lesions of brachial plexus].
BACKGROUND: Obstetrical brachial plexus lesion (OBPL) (also known in its various forms as Erb's palsy, Klumpke's paralysis, Erb-Duchenne palsy) complicates a very small proportion of births. Furthermore, it seems that more likely many cases recover with little in the way of remaining deficit, but it is equally certain that some cases will not recover. Electro diagnostic examinations are used as following the physical examination and can provide data on both the severity and timing of the injury. The initial study usually is performed 2-3 weeks after injury, when signs of enervation are seen in children with moderate or serious injuries. The incidence of obstetric brachial plexus palsy varies from 0.4 to 1 case per 1000 new born children. This incidence has remained unchanged since the beginning of this century despite current technologic advances. The aim of this paper is to review the literature and authors experience with OBPL. PATIENTS AND METHODS: The study included 30 children examined in last 10 years at Electro myoneurography laboratory, Department of Neurology, University Clinical Center Tuzla, Bosnia and Herzegovina. RESULTS AND DISCUSSION: Total out of 20 children (66.67%) were male, and 10 (33.3%) female; in 11 (36.67%) palsy was on left, and in 19 (63.33%) on right side. Erb's palsy was seen in 27 (90%) and total palsy in the remaining 3 (10%) limbs. Electromyography was very useful test not only for diagnosis, but also for evaluation of recovery. Good recovery was observed in majority of these children, but some children has difficulty with active shoulder abduction, forward flexion, symmetric elbow flexion and forearm supination at age of one year and more, and mild shortening and atrophy of the limb are also observed.
Birth Injuries↗
[Brachial plexus block in children. Approach through the brachial canal].
This study included 35 children (average age: 8 years) undergoing surgery of the upper limb under brachial plexus block. The brachial plexus was approached by the brachial canal route, which is a simple, rapid and efficient way (34 were successful). The main advantage of this technique was the avoidance, in most children, of general anaesthesia as a complement. In addition, postoperative analgesia was satisfactory in all cases. In spite of large doses and volumes of lidocaine and bupivacaine used with this technique, no complication was observed.
Adolescent↗
Brachial plexus surgery (honorary lecture).
Brachial plexus injuries (B.p.i.) are lesions occurring more and more frequently due to high velocity road and sport traumas. They are severe lesions with disabling sequelae. Surgical procedures and results could greatly be improved in the last 2 decades. Although the anatomy of brachial plexus is well known, less known are the functional maps of the various brachial plexus elements. In this paper treatment modalities for obstetrical, traumatic (adult) and actinic B.p.i. are being described too.
Brachial Plexus↗
[Parascalene brachial plexus block].
The supraclavicular brachial plexus block originated by Kulenkampff is useful but accompanies the danger of injury to the lung, i.e. pneumothorax, because the needle is directed caudad. Reviewing the anatomy of the brachial plexus in cadavers, we have found that the parascalene brachial plexus block originated by Vongvises is safer than Kulenkampff's method. We modified this block as follows: (1) An assistant pulls lightly the affected upper extremity caudad. (2) A 23-gauge 35 mm needle is inserted at right angles to the clavicle and directed cephalad at an angle of 0-30 degrees. One hundred and eighty four ASA I and II patients were operated under this block. Their ages ranged from 11 to 77, and there were 31 patients whose cervical spinal cord had been injured. Our success rate was 92%. The only complication we encountered was Horner's syndrome which occurred in 20% of our cases. None of our patients showed clinical symptoms of pneumothorax, hematoma, epidural as well as subarachnoideal block, recurrent nerve paralysis or phrenic nerve paralysis.
Brachial Plexus↗
[Constitutional anomalies of the terminal branches of the brachial plexus in the axial and brachial regions. Results of 42 cases and review of the literature].
The authors report anatomical variations of the terminal brachial plexus branches in 42 cadaveric dissections. The results are compared with results reported in literature which revealed a new variation: ulnar nerve originating in posterior beam. This study demonstrates that there exist not one but several brachial plexes which could have potential clinical implications.
Arm↗
[Pain syndromes and post-traumatic lesions of the brachial plexus. Study of the effect of surgical repair on the pain syndrome in 211 operated patients with post-traumatic lesions caused by avulsion or rupture of the brachial plexus].
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Brachial Plexus↗
Continuous shoulder analgesia via an indwelling axillary brachial plexus catheter.
Continuous interscalene brachial plexus blockade can provide anesthesia and analgesia in the shoulder region. Difficulty accessing the interscalene space and premature displacement of interscalene catheters may preclude their use in certain situations. We present two case reports in which a catheter was advanced from the axilla along the brachial plexus sheath to the interscalene space to provide continuous cervicobrachial plexus analgesia. In the first case report, previous neck surgery made the anatomic landmarks for performing an interscalene block very difficult. An epidural catheter was advanced from the axillary brachial plexus sheath to the interscalene space under fluoroscopic guidance. This technique provided both intraoperative analgesia for shoulder surgery as well as 24-hour postoperative analgesia by an infusion of 0.125% bupivacaine. In the second case report, a catheter was inserted in a similar fashion from the axillary to the interscalene space to provide 14 days of continuous analgesia in the management of complex regional pain syndrome. We have found that this technique allows us to secure the catheter more easily than with the traditional interscalene approach and thus prevents premature dislodgment. This approach may be a suitable alternative when either an interscalene or an infraclavicular catheter may not be inserted.
Aged↗
Adult traumatic brachial plexus injury.
Injury to the brachial plexus in the adult is usually a closed injury and the result of considerable traction to the shoulder. Brachial plexus injury in the adult is an increasingly common clinical problem. Recent advances in neurosurgical techniques have improved the outlook for patients with brachial plexus injuries. The choice of surgical procedure depends on the level of the injury and the radiologist has an important role in guiding the surgeon to the site of injury. This article will describe the anatomy and pathophysiology of traction brachial plexus injury in the adult. The neurosurgical options available will be described with emphasis on the information that the surgeon wants from imaging studies of the brachial plexus. The relative merits of MRI and CT myelography are discussed.
Adult↗
Management of infant brachial plexus injuries.
Management of brachial plexus injuries is geared toward normalization of limb function, primarily through optimization of nerve regeneration and mechanical increase in elbow flexion and shoulder stabilization. Changes in the skeletal muscles and the osteous structures of the upper extremity are ongoing throughout the course of treatment, mandating continual assessment and aggressive rehabilitation. In patients who present too late for microsurgical intervention, irreversible changes take place in skeletal muscles, highlighting the importance of early referral. However, secondary procedures have been shown to be beneficial in older patients and in those whose primary procedures failed. Further advances in bionics and stem cell therapy may help replace the dynamic functional deficits of obstetric brachial plexus palsy.
Birth Injuries↗
Brachial plexus injury following median sternotomy.
Brachial plexus injuries are annoyingly common after median sternotomies and vary from those causing minor symptoms to those producing major disability. We compared two groups of patients operated upon with the arms either abducted to a 90 degree angle or at the sides and found no difference in the incidence of brachial plexus injury. However, the finding of Horner's syndrome in one patient and the finding in another (at autopsy) of brachial plexus penetration by a fractured first rib caused us to question traction on the brachial plexus as the correct pathogenesis of the injury. A concomitant autopsy study demonstrated fractured first ribs penetrating the brachial plexus in 11 of 15 patients whose sternum was opened with the sternal retractor placed in the usual location, but in none in 15 patients whose sternum was opened with the retractor displaced two intercostal spaces caudally. The injury can be minimized by opening the sternal retractor as little as is necessary and by placing it as caudally as possible commensurate with adequate exposure.
Arm↗
External rotation as a result of suprascapular nerve neurotization in obstetric brachial plexus lesions.
OBJECTIVE: Obstetric brachial plexus lesions may cause lifelong limitations of upper limb function. Nerve repair is widely advocated in infants who do not show spontaneous recovery. Typically, the suprascapular nerve (SSN) is involved in the lesion. Neurotization of the SSN routinely is performed, aiming at reinnervation of the infraspinatus muscle to restore external rotation. The results after SSN neurotization have not, as yet, been studied in detail; therefore, this study was undertaken. Of special interest was the comparison of two commonly applied SSN neurotization procedures: nerve grafting from C5 versus nerve transfer of the accessory nerve. METHODS: Infants with obstetric brachial plexus lesions after nerve grafting of C5 to the SSN (n = 65) or nerve transfer of the accessory nerve to the SSN (n = 21) were selected for retrospective analysis after a mean follow-up period of 3 years. Outcome was expressed in degrees of true glenohumeral external rotation. This was defined as the angle between the position of the 90 degrees (actively or passively) flexed elbow resting against the abdomen and the position of the flexed elbow after external rotation with the upper arm held in adduction by the investigator. This movement can be executed only by infraspinatus muscle contraction. In addition, functional external rotation was evaluated by testing the ability to reach the mouth and the back of the head. RESULTS: Only 17 (20%) of the 86 patients reached more than 20 degrees of external rotation, whereas 35 (41%) were unable to perform true external rotation. There was no statistically significant difference between nerve grafting from C5 and extraplexal nerve transfer using the accessory nerve. Functional scores showed that 88% can reach the mouth and that 75% can reach the head. CONCLUSION: The restoration of a fair range of true glenohumeral external rotation after neurotization of the SSN in infants with obstetric brachial plexus lesions, whether by grafting from C5 or by nerve transfer of the accessory nerve, is disappointingly low. However, it seems that compensatory techniques contribute to effectuate a considerable range of movement.
Birth Injuries↗
An attempt to prevent spread of local anaesthetic to the phrenic nerve by compression above the injection site during the interscalene brachial plexus block.
The brachial plexus was identified by electrical stimulation before interscalene block with 30 mL 0.5% bupivacaine and adrenaline 1:200,000. During injection, compression was applied with a finger proximal to the injection site. Spirometric measurements were made before the block, and then at 5 min, 10 min, 20 min and 4 h after the injection. Diaphragmatic excursion was measured radiographically before the block, and at 15 min and 4 h afterwards. In 25 patients studied, spirometric measurements decreased. Twenty minutes after the injection, the forced vital capacity was 27% less, forced expiratory volume at 1 s 34% less and peak expiratory flow rate 15% less (all P < 0.05). Right diaphragmatic excursion decreased from 4.5 cm (SD 1.2 cm) to 1.8 cm (0.6 cm) at 15 mins and to 1.1 cm (0.6 cm) at 4 h (P < 0.05). Identification of the plexus by electric stimulation combined with finger compression above the injection site did not prevent diaphragmatic paresis.
Adrenergic Agonists↗
Brachial plexus traction injuries.
Brachial plexus traction injuries most frequently occur following acute flexion or extension of the neck. The symptomatology following this injury may be defined clearly into the anatomic patterns of upper trunk, lower trunk, posterior cord, medial cord, and lateral cord radiations. This injury is the most common cause of the neurogenic form of thoracic outlet syndrome and is frequently seen in conjunction with cervical spine disease as well as peripheral entrapment syndromes of the ulnar, radial, and medial nerves.
Brachial Plexus↗
Surgical treatment of brachial plexus birth palsy.
Brachial plexus birth palsy remains a challenging condition. In the 1000 infants followed from 1977 to 1988, functional results were much improved over those obtained by observation only, if surgical exploration and repair were performed when no clinical recuperation of biceps function occurred by three months of age. Recovery is slow, and comprehensive follow-up study of reconstructed and conservatively managed children is required to prevent joint contractures. Children who will benefit from palliative procedures such as tendon transfers must also be identified.
Brachial Plexus↗
Orthopaedic considerations in obstetric brachial plexus palsy.
Obstetric brachial plexus palsies are seen in orthopaedic practice today despite improved obstetric care. The incidence is believed to be 0.35 to 0.87 cases per 1,000 live births. The pathomechanics of these injuries are not fully understood, although numerous risk factors have been identified. Large birth weight, breech presentation, shoulder dystocia, and forceps-assisted deliveries have all been implicated. No one standard treatment modality exists. Therefore, the treating orthopaedist must be familiar with this entity and with the various accepted treatment approaches in order to formulate the appropriate therapy for a particular patient.
Brachial Plexus↗