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Journal of Anatomy Dec 2020Diffusion tensor magnetic resonance imaging (DTI) can be used to reconstruct the brachial plexus in 3D via tracts connecting contiguous diffusion tensors with similar...
Diffusion tensor magnetic resonance imaging (DTI) can be used to reconstruct the brachial plexus in 3D via tracts connecting contiguous diffusion tensors with similar primary eigenvector orientations. When creating DTI tractograms, the turning angle of connecting lines (step angle) must be prescribed by the user; however, the literature is lacking detailed geometry of brachial plexus to inform such decisions. Therefore, the spinal cord and brachial plexus of 10 embalmed adult cadavers were exposed bilaterally by posterior dissection. Photographs were taken under standardised conditions and spatially calibrated in MATLAB. The roots of the brachial plexus were traced from the dorsal root entry zone for 5 cm laterally using a 2.5-mm Cartesian grid overlay. The trace was composed of points connected by lines, and the turning angle between line segments (the step angle) was resolved. Our data show that the geometry of the roots increased in tortuosity from C5 to T1, with no significant differences between sides. The 1 thoracic root had the most tortuous course, turning through a maximum angle of 56° per 2.5 mm (99% CI 44° to 70°). Significantly higher step angles and greater variability were observed in the medial 2 cm of the roots of the brachial plexus, where the dorsal and ventral rootlets coalesce to form the spinal root. Throughout the brachial plexus, the majority of step angles (>50%) were smaller than 20° and <1% of step angles exceeded 70°. The geometry of the brachial plexus increases in tortuosity from C5 to T1. To reconstruct 99% of tracts representing the roots of the brachial plexus by DTI tractography, users can either customise the step angle per root based on our findings or select a universal threshold of 70°.
Topics: Aged, 80 and over; Brachial Plexus; Cadaver; Diffusion Tensor Imaging; Dissection; Humans; Spinal Nerve Roots
PubMed: 32628794
DOI: 10.1111/joa.13270 -
Journal of Neurology Apr 2022Axonal polyneuropathy is the main feature of hereditary transthyretin amyloidosis (ATTRv). Nerve morphological abnormalities have been reported, but longitudinal changes...
Axonal polyneuropathy is the main feature of hereditary transthyretin amyloidosis (ATTRv). Nerve morphological abnormalities have been reported, but longitudinal changes have never been assessed. We performed a prospective widespread nerve ultrasound evaluation and nerve cross-sectional area (CSA) was compared with baseline data in both ATTRv patients and pre-symptomatic carriers. Thirty-eight subjects were evaluated (mean follow-up 17.1 months), among them 21 had polyneuropathy while 17 were pre-symptomatic carriers. CSA significantly increased at brachial plexus in both groups (p = 0.008 and p = 0.012) pointing to progressive brachial plexus enlargement as a longitudinal biomarker of both disease progression and disease occurrence in pre-symptomatic carriers.
Topics: Amyloid Neuropathies, Familial; Biomarkers; Brachial Plexus; Disease Progression; Humans; Neurons; Polyneuropathies; Prospective Studies
PubMed: 34410494
DOI: 10.1007/s00415-021-10754-9 -
Hand (New York, N.Y.) Jan 2023There is variability in treatment strategies for patients with brachial plexus injury (BPI). We used qualitative research methods to better understand surgeons'...
BACKGROUND
There is variability in treatment strategies for patients with brachial plexus injury (BPI). We used qualitative research methods to better understand surgeons' rationale for treatment approaches. We hypothesized that distal nerve transfers would be preferred over exploration and nerve grafting of the brachial plexus.
METHODS
We conducted semi-structured interviews with BPI surgeons to discuss 3 case vignettes: pan-plexus injury, upper trunk injury, and lower trunk injury. The interview guide included questions regarding overall treatment strategy, indications and utility of brachial plexus exploration, and the role of nerve grafting and/or nerve transfers. Interview transcripts were coded by 2 researchers. We performed inductive thematic analysis to collate these codes into themes, focusing on the role of brachial plexus exploration in the treatment of BPI.
RESULTS
Most surgeons routinely explore the supraclavicular brachial plexus in situations of pan-plexus and upper trunk injuries. Reasons to explore included the importance of obtaining a definitive root level diagnosis, perceived availability of donor nerve roots, timing of anticipated recovery, plans for distal reconstruction, and the potential for neurolysis. Very few explore lower trunk injuries, citing concern with technical difficulty and unfavorable risk-benefit profile.
CONCLUSIONS
Our analysis suggests that supraclavicular exploration remains a foundational component of surgical management of BPI, despite increasing utilization of distal nerve transfers. Availability of abundant donor axons and establishing an accurate diagnosis were cited as primary reasons in support of exploration. This analysis of surgeon interviews characterizes contemporary practices regarding the role of brachial plexus exploration in the treatment of BPI.
Topics: Humans; Brachial Plexus; Nerve Transfer; Brachial Plexus Neuropathies; Neurosurgical Procedures
PubMed: 34018448
DOI: 10.1177/15589447211014613 -
Clinics in Orthopedic Surgery Feb 2023Brachial plexus injury (BPI) is a peripheral nerve injury that results in severe functional impairment and disability. Even after prompt treatment, predicting the...
BACKGROUND
Brachial plexus injury (BPI) is a peripheral nerve injury that results in severe functional impairment and disability. Even after prompt treatment, predicting the prognosis of BPI is not easy as it involves various factors. An objective and valid scoring system would aid clinicians in informing families and anticipating problems related to the recovery of BPI. Prognosis BPI (PRO-BPI) score, a new prognostic score to predict the outcome of traumatic BPI (TBPI), was developed in 2019 by Suroto and Rahman. This study aimed to evaluate its validity and reliability.
METHODS
Retrospective cohort analysis was conducted for 111 BPI patients. A serial assessment of Disabilities of the Arm, Shoulder and Hand (DASH) score and PRO-BPI score was done. Validity analysis was done by assessing Spearman correlations between PRO-BPI score and other scoring systems (DASH, Michigan hand outcomes, and 36-item short form survey score [SF-36]). Internal structure consistency using Cronbach's alpha and test-retest reliability were measured for reliability analyses. A -value was considered significant if < 0.05.
RESULTS
A total of 96 male and 15 female patients were included in our study with a mean age of 27.9 ± 10.6 years. Most of the patients (56.75%) had a poor prognosis based on the scoring system (average, 14.38 ± 3.98). Major contributors of this low score were the persistent pain (score 1 in 57.7% patients) and initial pain scale score (score 1 in 31.5% patients). Validity test showed that 6 parameters were all valid ( < 0.01). Reliability testing was done using Cronbach's alpha and found acceptable internal consistency (α = 0.767). Test-retest reliability was high. Moderate correlations were observed between the measures.
CONCLUSIONS
PRO-BPI score is a valid and reliable scoring system in predicting the prognosis of TBPI.
Topics: Humans; Male; Female; Adolescent; Young Adult; Adult; Reproducibility of Results; Retrospective Studies; Disability Evaluation; Brachial Plexus; Prognosis; Surveys and Questionnaires; Pain
PubMed: 36778991
DOI: 10.4055/cios22168 -
Journal of Anatomy May 2020In classic anatomy teaching, the brachial plexus generally features as an enigmatic rote-learned structure, leaving the student with a feeling of complexity. The notion...
In classic anatomy teaching, the brachial plexus generally features as an enigmatic rote-learned structure, leaving the student with a feeling of complexity. The notion of complexity may increase in dissections, where plexuses significantly differing from the standard plexus model are readily found. This raises questions: what determines the existence and prevalence of variants and to what degree should they be considered anomalous? A model linking brachial plexus morphology and its variability to causative morphological parameters which would also standardize plexus description and teaching would be beneficial. The present study aims to provide such a model by analyzing the context of plexus development and applying this model in the analysis of plexus variability in anatomical specimens. Based on a thorough literature review, a generic developmental model was formulated and different factors of variability defined. In 56 plexuses, the proposed generic principles of plexus variability were found consistent with the variations encountered. Summarized, the modeled generic principles are as follows. Brachial plexus axon bundles grow out into an environment of chemical tracer paths in which constraints and obstacles are present: the geometry of the arm bud, cartilaginous bone precursors and vessels. The overall constancy of these factors generates a gross plexus outline, while the variability in these factors gives rise to typical plexus variations. The usefulness of the model derives from the fact that the variability of the main morphologically determining factors is not random but is the expression of the possibilities of the embryological substrate. Within the model, the major plexus morphological determinant is the segmental position of the subclavian artery, which is determined by the segment level of the intersegmental artery from which it develops. Normally, the subclavian artery develops from intersegmental artery i7. However, the subclavian artery can develop from inferior or superior segmental levels, from intersegmental artery i8 or i6, and possibly also from i9 or i5. Each of these arterial variants creates a typical, morphologically distinct, predictable plexus configuration. Superimposed on these basic plexus configurations, the underlying embryological substrate may develop further variability by integrating remnants of other intersegmental arteries into the arterial network. The resulting plexus configurations are further modified by local factors, e.g. the splitting of outgrowing axon bundles around vessels. A large split in the lateral cord around a large vein or veins crossing from lateral to medial, tangentially cranially over the subclavian artery was found in 54% of the 56 investigated BP and therefore might be added to plexus teaching. The distinct plexus morphologies associated with the subclavian artery segmental levels were further found associated with, among others, typical variations in the pectoral nerves and their ansas; these associations were also modeled. The presented models could allow brachial plexus rote learning to be replaced by a more insightful narrative of formative principles suitable for teaching. Clinically, improved understanding of the relationship between plexus variability and the local anatomical environment should be relevant to brachial plexus surgery and reconstruction.
Topics: Brachial Plexus; Dissection; Humans; Models, Anatomic; Subclavian Artery
PubMed: 31814126
DOI: 10.1111/joa.13123 -
Medicine Oct 2023Intraoperative positioning-related nerve injuries, particularly those affecting the brachial plexus, are concerning complications believed to arise from stretching...
Intraoperative positioning-related nerve injuries, particularly those affecting the brachial plexus, are concerning complications believed to arise from stretching and/or compression of peripheral nerves. Although sonoelastography, a new ultrasound technology, is emerging as a valuable tool in the musculoskeletal system, its utility in evaluating peripheral nerves remains unclear. This study aimed to utilize sonoelastography to assess the brachial plexus during surgery, specifically investigating changes in its stiffness values in relation to different head and arm positions. In this prospective cohort study, bilateral brachial plexuses of 8 volunteers in 3 different positions were enrolled. Using a high-frequency linear probe, the stiffness of the brachial plexus was quantitatively measured in kilopascals (kPa) under 3 different positions: neutral, head rotated, and head rotated with arm hyperabducted. Intra-class agreement was evaluated. The stiffness of the brachial plexus was 7.39 kPa in the neutral position (NP), 10.28 kPa with head rotation, and 17.24 kPa when the head was turned, and the ipsilateral arm was hyperabducted. Significant increases were observed in stiffness values when the head was turned, whether ipsilaterally or contralaterally, and during hyperabduction of the arm while the head was turned (for all P < .001). Strong intra-class correlations were found for the measurements of stiffness values (ICC = 0.988-0.989; P < .001; Cronbach Alpha = 0.987-0.989). Sonoelastography revealed significant increases in the stiffness of the brachial plexus with various head rotations and arm positions compared to the neutral state. These findings suggest that sonoelastography could potentially serve as a valuable tool for assessing the risk of brachial plexus injury during surgery and for guiding optimal patient positioning. Further research with larger sample sizes is needed to establish definitive clinical applications.
Topics: Humans; Elasticity Imaging Techniques; Arm; Prospective Studies; Brachial Plexus; Ultrasonography
PubMed: 37832128
DOI: 10.1097/MD.0000000000035559 -
Injury Apr 2020Brachial plexus injuries will cause a significantly decreased quality of life. Patients with upper arm type brachial plexus injuries, which means C5 and C6 roots injury,... (Review)
Review
Brachial plexus injuries will cause a significantly decreased quality of life. Patients with upper arm type brachial plexus injuries, which means C5 and C6 roots injury, will lose their shoulder elevation/abduction/external rotation, and elbow flexion function. Additional elbow, wrist, and hand extension function deficit will occur in patients with C7 root injury. With the advances of reconstructive procedures, the upper arm brachial plexus injuries can be successfully restored through nerve repair, nerve grafting, nerve transfer, muscle / tendon transfer and free functioning muscle transfer. In this review article, we summarized the various reconstructive procedures to restore the function of shoulder and elbow. Nowadays, the upper arm type BPI can be treat with satisfied outcomes (80-90% successful rate).
Topics: Accessory Nerve; Adult; Axilla; Brachial Plexus; Elbow Joint; Humans; Muscle Strength; Muscle, Skeletal; Nerve Transfer; Range of Motion, Articular; Shoulder Joint; Spinal Nerve Roots; Ulnar Nerve
PubMed: 32156416
DOI: 10.1016/j.injury.2020.02.076 -
Journal of Reconstructive Microsurgery Sep 2022Brachial plexus injuries (BPI) cause severe physical disability and major psycho-socioeconomic burden. Although various countries have reported BPI incidence, the...
BACKGROUND
Brachial plexus injuries (BPI) cause severe physical disability and major psycho-socioeconomic burden. Although various countries have reported BPI incidence, the data from Indonesia as the fourth most populated country in the world remains unknown. We aim to assess the distribution of traumatic BPI, patients' characteristics, and treatment modalities in Indonesia.
METHODS
A retrospective investigation was performed comprising 491 BPI patients at a tertiary referral hospital in Indonesia from January 2003 to October 2019. Demographic and outcomes data were retrieved from medical records.
RESULTS
The average BPI patients' age was 27.3 ± 11.6 years old, with a male/female ratio of 4.6:1. Motorcycle accidents caused the majority (76.1%) of all BPI cases. Concomitant injuries were present in 62.3% of patients, dominated by fractures (57.1%) and brain injuries (25.4%). BPI lesion type was classified into complete (C5-T1, observed in 70% patients), upper (C5-C6, in 15% patients), extended upper (C5-C7, in 14% patients), and lower type (C8-T1, in 1% patients). The average time to surgery was 16.8 months (range 1-120 months), with the majority (76.6%) of the patients was operated on six months after the trauma. Free functional muscle transfer (FFMT) was the most common procedure performed (37%). We also analyzed the functional outcomes (active range of motion (AROM) and muscle power), DASH (Disabilities of the Arm, Shoulder, and Hand) score, and VAS (Visual Analogue Scale) across four most frequent procedures involving nerve reconstruction (FFMT, nerve transfer, external neurolysis, and nerve grafting). We found that FFMT was significantly better than nerve transfer in terms of DASH score and VAS ( = 0.000 and = 0.016, respectively) in complete BPI (C5-T1). Moreover, we also found that nerve grafting resulted in a significantly better shoulder abduction AROM than nerve transfer and external neurolysis in extended upper BPI (C5-C7) ( = 0.033 and = 0.033, respectively). Interestingly, no significant differences were observed in other measurements.
CONCLUSION
This study provides an overview of traumatic BPI patients in a single tertiary trauma center in Indonesia, expressing the profile of their characteristics and functional outcomes after surgical procedures.
Topics: Adolescent; Adult; Brachial Plexus; Brachial Plexus Neuropathies; Developing Countries; Female; Humans; Indonesia; Male; Nerve Transfer; Range of Motion, Articular; Retrospective Studies; Treatment Outcome; Young Adult
PubMed: 34470060
DOI: 10.1055/s-0041-1735507 -
The Journal of Hand Surgery, European... Mar 2021The majority of children with obstetric brachial plexus injury show some degree of spontaneous recovery. This review explores the available evidence for the use surgical... (Review)
Review
The majority of children with obstetric brachial plexus injury show some degree of spontaneous recovery. This review explores the available evidence for the use surgical brachial plexus repair to improve outcome. So far, no randomized trial has been performed to evaluate the usefulness of nerve repair. The evidence level of studies comparing surgical treatment with non-surgical treatment is Level IV at best. The studies on natural history that are used for comparison with surgical series are also, unfortunately, of too low quality. Among experts, however, the general agreement is that nerve reconstruction is indicated when spontaneous recovery is absent or severely delayed at specific time points. A major obstacle in comparing or pooling obstetric brachial plexus injury patient series, either surgical or non-surgical, is the use of many different outcome measures. A requirement for multicentre studies is consensus on how to assess and report outcome, both concerning motor performance and functional evaluation.
Topics: Birth Injuries; Brachial Plexus; Brachial Plexus Neuropathies; Child; Female; Humans; Neurosurgical Procedures; Paralysis, Obstetric; Pregnancy; Plastic Surgery Procedures; Treatment Outcome
PubMed: 32588706
DOI: 10.1177/1753193420934676 -
Anales de Pediatria Dec 2022Shoulder dystocia is a nonpreventable obstetric emergency that causes severe complications, such as obstetric brachial plexus palsy. The objective of the study was to... (Observational Study)
Observational Study
INTRODUCTION
Shoulder dystocia is a nonpreventable obstetric emergency that causes severe complications, such as obstetric brachial plexus palsy. The objective of the study was to determine the incidence of obstetric brachial plexus palsy and other neonatal complications associated with shoulder dystocia in deliveries managed in a university hospital after the implementation of a simulation-based training that was offered to all the labour and delivery staff on a voluntary basis.
MATERIAL AND METHODS
Retrospective observational study including all cases of shoulder dystocia and associated complications (mainly obstetric brachial plexus palsy) documented between January 2017 and December 2020, after the implementation of the training. In addition, we collected retrospective data on cases of obstetric brachial plexus palsy that developed in the hospital before the training (2008-2016).
RESULTS
In the 2017-2020 period, in the total of 125 cases of shoulder dystocia (amounting to 1.38% of vaginal deliveries), there were 14 cases of obstetric brachial plexus palsy (11.2% of the cases of shoulder dystocia), 7 clavicle fractures and 1 humerus fracture; none of the cases of obstetric brachial plexus palsy was permanent or required treatment or rehabilitation past six months. In the years preceding the training, there were 7 cases of obstetric brachial plexus palsy, 2 permanent and 5 temporary (3 of which required rehabilitation).
CONCLUSION
These results reflect the importance of knowing the morbidity present in the labour and delivery ward and the potential benefit of simulation-based training programmes in the resolution of these obstetric complications.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Shoulder Dystocia; Dystocia; Retrospective Studies; Brachial Plexus Neuropathies; Brachial Plexus; Paralysis
PubMed: 36266188
DOI: 10.1016/j.anpede.2022.06.011