RESUMEN
SUMMARY: The teres minor is one of the rotator cuff muscles that comprise the superior margin of the quadrangular space. Quadrangular space syndrome (QSS) refers to the entrapment or compression of the axillary nerve and the posterior humeral circumflex artery in the quadrangular space, often caused by injuries, dislocation of the shoulder joint, etc. Patients who fail the primary conservative treatments and have persistent symptoms and no pain relief for at least six months would be considered for surgical interventions for QSS. This cadaveric study of 17 cadavers (males: 9 and females: 8) was conducted in the Gross Anatomy Laboratory at the Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University. The cadavers were preserved in a 10 % formaldehyde solution and obtained ethical approval by the ethical commission of the Siriraj Institutional Review Board. The morphology of the teres minor muscle-tendon junction, the bifurcation type of the axillary nerve, and the length and number of the terminal branches of the nerve to the teres minor were documented. Specimens with quadrangular space contents and surrounding muscles that had been destroyed were excluded from the study. The results showed that 47.06 % of the specimens had type A bifurcation, 47.06 % had type B bifurcation, and the remaining 5.88 % had type C bifurcation. It was observed that 58.82 % had nonclassic muscle-tendon morphology, while 41.18 % were classic. The average length of the terminal branches of the nerve to the teres minor in males was 1.13 cm, with the majority having two branches. For females, many showed one terminal branch with an average length of 0.97 cm. Understanding the differences in anatomical variations can allow for a personalized treatment plan prior to quadrangular space syndrome surgical procedures and improve the recovery of postsurgical interventions for patients.
El músculo redondo menor es uno de los músculos del manguito rotador que comprende el margen superior del espacio cuadrangular. El síndrome del espacio cuadrangular (QSS) se refiere al atrapamiento o compresión del nervio axilar y la arteria circunfleja humeral posterior en el espacio cuadrangular, a menudo causado por lesiones, dislocación de la articulación humeral, entre otros. En los pacientes en los que fracasan los tratamientos conservadores primarios y presentan síntomas persistentes y ningún alivio del dolor durante al menos seis meses se considerarían para intervenciones quirúrgicas para QSS. Este estudio cadavérico de 17 cadáveres (hombres: 9 y mujeres: 8) se llevó a cabo en el Laboratorio de Anatomía Macroscópica del Departamento de Anatomía de la Facultad de Medicina del Hospital Siriraj de la Universidad Mahidol. Los cadáveres se conservaron en una solución de formaldehído al 10 % y obtuvieron la aprobación ética de la comisión ética de la Junta de Revisión Institucional de Siriraj. Se documentó la morfología de la unión músculo-tendón del músculo redondo menor, el tipo de bifurcación del nervio axilar y la longitud y el número de las ramas terminales del nervio para el músculo redondo menor. Se excluyeron del estudio los especímenes con contenido de espacios cuadrangulares y músculos circundantes que habían sido destruidos. Los resultados mostraron que el 47,06 % de los especímenes presentó bifurcación tipo A, el 47,06 % una bifurcación tipo B y el 5,88 % restante una bifurcación tipo C. Se observó que el 58,82 % presentaba una morfología músculo-tendinosa no clásica, mientras que el 41,18 % era clásica. La longitud pmedia de los ramos terminales del nervio hasta el músculo redondo menor en los hombres era de 1,13 cm, y la mayoría tenía dos ramos. En el caso de las mujeres, mostraron un ramo terminal con una longitud promedio de 0,97 cm. Comprender las diferencias en las variaciones anatómicas puede permitir un plan de tratamiento personalizado antes de los procedimientos quirúrgicos del síndrome del espacio cuadrangular y mejorar la recupe- ración de las intervenciones posquirúrgicas de los pacientes.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Axila/inervación , Manguito de los Rotadores/inervación , Músculo Esquelético/inervación , Cadáver , Disección , Variación AnatómicaRESUMEN
SUMMARY: The axilla is the main communication channel connecting the upper limbs, the neck and chest. Stabilization of the internal structure is essential for upper limb and shoulder mobility. In this case, we observed and recorded the characteristics of the variation of the radial nerve as well as the intercalated ectopic muscle from latissimus dorsi muscle. The position relationship between both, was also particularly noted by us. In view of the presence of the variation we reported, related clinical research, surgery and disease diagnosis are expected to take this case into account.
La axila es el principal canal de comunicación que conecta los miembros superiores, el cuello y el tórax. La estabilización de la estructura interna es fundamental para la movilidad del miembro superior y del hombro. En este caso observamos y registramos las características de la variación del nervio radial así como del músculo ectópico intercalado del músculo latísimo del dorso. La relación de posición entre ambas también fue significativa en este estudio. En vista de la presencia de la variación que informamos, se espera que la investigación clínica relacionada con la cirugía y el diagnóstico de la enfermedad tengan en cuenta este caso.
Asunto(s)
Humanos , Masculino , Persona de Mediana Edad , Nervio Radial/anatomía & histología , Plexo Braquial/anatomía & histología , Músculo Esquelético/anomalías , Variación Anatómica , Axila/inervación , Cadáver , CoristomaRESUMEN
Resumen: Objetivo: Determinar la eficacia del tratamiento quirúrgico mediante neurotización radial en pacientes con diagnóstico de lesión traumática aislada de nervio axilar. Material y métodos: Se presenta una serie de siete casos, seis hombres y una mujer, con promedio de edad de 51.6 años, con diagnóstico de lesión traumática aislada de nervio axilar tratados quirúrgicamente entre Enero 2013 y Diciembre 2016. Todos los pacientes fueron tratados mediante transferencia nerviosa de rama motora radial de la cabeza medial del tríceps, entre el sexto y decimoséptimo mes después del traumatismo, con un seguimiento mínimo de 12 meses. Se evaluó la eficacia del tratamiento mediante la Medical Research Council (MRC) y el cuestionario DASH. Resultados: En el análisis bivariado encontramos diferencias estadísticamente significativas con respecto al grado de mejoría de fuerza de rotación externa y de abducción medido por MRC preoperatoria y postoperatoria (p < 0.05). Los resultados también demostraron una significancia estadística en el rango de movimiento de abducción postoperatorio de hombro (p = 0.01). El cuestionario DASH demostró un porcentaje promedio de discapacidad de 20.29% después de 12 meses de seguimiento. Conclusión: La neurotización radial en pacientes con diagnóstico de lesión traumática aislada de nervio axilar proporciona un excelente grado de mejoría de fuerza de rotación externa y abducción, además de mejorar significativamente el rango de abducción del hombro; también se demostró, mediante cuestionario DASH, que el porcentaje de discapacidad es bajo.
Abstract: Purpose: To determine the efficacy of surgical treatment by radial nerve transfer in patients with a diagnosis of isolated axillary nerve traumatic injury. Material and methods: We present a series of seven cases, six men and one woman, with a mean age of 51.6 years, with a diagnosis of isolated traumatic axillary nerve injury between January 2013 and December 2016. All patients were treated by radial motor branch nerve transfer of the medial triceps head between the sixth and seventeenth months after trauma, with a minimum follow-up of 12 months. The efficacy of the treatment was evaluated by the Medical Research Council (MRC) and the DASH questionnaire. Results: In the bivariate analysis we found statistically significant differences regarding the degree of external rotation and abduction strength measured by preoperative and postoperative MRC (p < 0.05). The results also demonstrated a statistical significance in the range of postoperative shoulder abduction movement (p = 0.01). The DASH questionnaire showed an average percentage of disability of 20.29% after 12 months of follow-up. Conclusion: Radial nerve transfer in patients diagnosed with axillary nerve traumatic injury provides an excellent degree of improvement in external rotation and abduction strength, in addition to significantly improving the shoulder abduction range, it was also demonstrated by DASH questionnaire that the percentage disability is low.
Asunto(s)
Humanos , Masculino , Femenino , Plexo Braquial/lesiones , Transferencia de Nervios , Axila/inervación , Rango del Movimiento Articular , Resultado del Tratamiento , Persona de Mediana EdadRESUMEN
PURPOSE: To determine the efficacy of surgical treatment by radial nerve transfer in patients with a diagnosis of isolated axillary nerve traumatic injury. MATERIAL AND METHODS: We present a series of seven cases, six men and one woman, with a mean age of 51.6 years, with a diagnosis of isolated traumatic axillary nerve injury between January 2013 and December 2016. All patients were treated by radial motor branch nerve transfer of the medial triceps head between the sixth and seventeenth months after trauma, with a minimum follow-up of 12 months. The efficacy of the treatment was evaluated by the Medical Research Council (MRC) and the DASH questionnaire. RESULTS: In the bivariate analysis we found statistically significant differences regarding the degree of external rotation and abduction strength measured by preoperative and postoperative MRC (p 0.05). The results also demonstrated a statistical significance in the range of postoperative shoulder abduction movement (p = 0.01). The DASH questionnaire showed an average percentage of disability of 20.29% after 12 months of follow-up. CONCLUSION: Radial nerve transfer in patients diagnosed with axillary nerve traumatic injury provides an excellent degree of improvement in external rotation and abduction strength, in addition to significantly improving the shoulder abduction range, it was also demonstrated by DASH questionnaire that the percentage disability is low.
OBJETIVO: Determinar la eficacia del tratamiento quirúrgico mediante neurotización radial en pacientes con diagnóstico de lesión traumática aislada de nervio axilar. MATERIAL Y MÉTODOS: Se presenta una serie de siete casos, seis hombres y una mujer, con promedio de edad de 51.6 años, con diagnóstico de lesión traumática aislada de nervio axilar tratados quirúrgicamente entre Enero 2013 y Diciembre 2016. Todos los pacientes fueron tratados mediante transferencia nerviosa de rama motora radial de la cabeza medial del tríceps, entre el sexto y decimoséptimo mes después del traumatismo, con un seguimiento mínimo de 12 meses. Se evaluó la eficacia del tratamiento mediante la Medical Research Council (MRC) y el cuestionario DASH. RESULTADOS: En el análisis bivariado encontramos diferencias estadísticamente significativas con respecto al grado de mejoría de fuerza de rotación externa y de abducción medido por MRC preoperatoria y postoperatoria (p 0.05). Los resultados también demostraron una significancia estadística en el rango de movimiento de abducción postoperatorio de hombro (p = 0.01). El cuestionario DASH demostró un porcentaje promedio de discapacidad de 20.29% después de 12 meses de seguimiento. CONCLUSIÓN: La neurotización radial en pacientes con diagnóstico de lesión traumática aislada de nervio axilar proporciona un excelente grado de mejoría de fuerza de rotación externa y abducción, además de mejorar significativamente el rango de abducción del hombro; también se demostró, mediante cuestionario DASH, que el porcentaje de discapacidad es bajo.
Asunto(s)
Plexo Braquial , Transferencia de Nervios , Axila/inervación , Plexo Braquial/lesiones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Rango del Movimiento Articular , Resultado del TratamientoRESUMEN
BACKGROUND: This study investigated whether axillary nerve (AN) distance to the inferior border of the humeral head and inferior glenoid would change while placing the glenohumeral joint in different degrees of external rotation and abduction. METHODS: A standard deltopectoral approach was performed on 10 fresh-frozen cadaveric specimens. The distance between AN and the inferior border of the humeral head and inferior glenoid while placing the shoulder in 0°, 45°, and 90° of external rotation or abduction was measured. Continuous variables for changes in AN position were compared with paired 2-tailed Student t test. RESULTS: The mean distance between the AN and the humeral head with the shoulder in 0°, 45°, and 90° of external rotation and 0° of abduction was 13.77 mm (SD 4.31), 13.99 mm (SD 4.12), and 16.28 mm (SD 5.40), respectively. The mean distance between the AN and glenoid with the shoulder in 0°, 45°, and 90° of external rotation was 16.33 mm (SD 3.60), 15.60 mm (SD 4.19), and 16.43 (SD 5.35), respectively. The mean distance between the AN and the humeral head with the shoulder in 0°, 45°, and 90° of abduction and 0° of external rotation was 13.76 mm (SD 4.31), 10.68 mm (SD 4.19), and 3.81 mm (SD 3.08), respectively. The mean distance between the AN and glenoid with the shoulder in 0°, 45°, and 90° of abduction was 16.33 mm (SD 3.60), 17.66 mm (SD 5.80), and 12.44 mm (SD 5.57), respectively. CONCLUSIONS: The AN position relative to the inferior aspect of the glenohumeral joint does not significantly change despite position of external rotation. Increasing shoulder abduction over 45° decreases the distance from the glenohumeral joint to the AN and should be avoided.
Asunto(s)
Axila/inervación , Plexo Braquial/anatomía & histología , Rotación , Articulación del Hombro/anatomía & histología , Articulación del Hombro/fisiología , Anciano , Anciano de 80 o más Años , Cadáver , Femenino , Humanos , Húmero/anatomía & histología , Masculino , Persona de Mediana EdadRESUMEN
Clásicamente, la inervación del músculo tríceps braquial se atribuye al nervio radial. Sin embargo, reportes clínicos han observado parálisis de la cabeza larga del músculo tríceps braquial posterior a lesiones del nervio axilar, ocurridas luego de una luxación de la articulación glenohumeral, poniendo en duda la inervación de la cabeza larga del músculo tríceps braquial. El objetivo del presente estudio es verificar la inervación de la cabeza larga del músculo tríceps braquial por parte del nervio axilar. Se disecaron 12 regiones posteriores de hombro y brazo, previamente fijadas en solución fijadora conservadora, identificando ramos de inervación del nervio axilar hacia la cabeza larga del músculo tríceps braquial, luego se obtuvieron muestras para estudio histológico con Hematoxilina-Eosina. Fue posible identificar en todos los casos ramos del nervio axilar, penetrando en la mitad superior de la cabeza larga del músculo tríceps braquial. El estudio histológico mostró una imagen compatible con tejido nervioso en todas las muestras analizadas. Estos resultados contrastan con las descripciones realizadas en textos clásicos respecto a la inervación del músculo tríceps braquial, el cual podría presentar una doble inervación proveniente de los nervios radial y axilar, o una inervación diferente para cada cabeza. Los hallazgos presentados aportan información a la hora de analizar las lesiones del nervio axilar post luxaciones de hombro, al realizar procedimientos quirúrgicos en esta región o en la planificación de la rehabilitación de estos pacientes.
Primarily, innervation of the triceps brachii muscle has been attributed to the axillary nerve. However, clinical reports have observed paralysis from the long head of the triceps brachii muscle following axillary nerve lesions which occurred after dislocation of the glenohumeral joint. This has raised questions about the innervation of the long head of triceps brachii muscle. The objective of this study was to verify the innervation of the long head of the triceps brachii muscle by the axillary nerve. Twelve previously fixed posterior areas of shoulder and arm were dissected and branches of innervation of the axillary nerve towards the long head of triceps brachii muscle were identified. Subsequently, samples were taken for histological hematoxylin-eosin study. In all cases, we observed branches of the axillary nerve penetrating the upper half of the long head of the triceps brachii muscle. The histological study showed an image compatible with nerve tissue in each sample analyzed. The results contrast with the description in classic texts regarding innervation of the triceps brachii muscle, which could present with double innervation from the radial and axillary nerves, or a separate innervation for each head. These results provide information for axillary nerve lesion analysis following shoulder dislocation, at the time of performing surgical procedures in the area, or when planning rehabilitation for these patients.
Asunto(s)
Humanos , Axila/inervación , Músculo Esquelético/inervación , Articulación del Hombro/anatomía & histologíaRESUMEN
PURPOSE: To update the gross and sonographic anatomy and propose landmarks to perform ultrasound-guided (US-guided) axillary brachial plexus block (BPB) in rabbits. METHODS: Forty New Zeeland's rabbit (NZR) cadavers were dissected and the nerves were trimmed, identified, measured, and photographed. Additionally, in twenty NZRs, sonographic images of brachial plexus (BP) were performed through a simple-resolution ultrasound device. The US-guided block was achieved through a minimum volume of lidocaine necessary to surround the BP roots. The effectiveness of the brachial plexus block was assessed on sensitivity and motor functions. RESULTS: The BP resulted from connections between the ventral branches of the last four cervical spinal nerves and the first thoracic spinal nerve. In the axillary sonoanatomy, the BP appeared as an agglomerate of small, round hypoechoic structures surrounded by a thin hyperechoic ring. The amount of time and the minimum volume required to perform was 4.3 ± 2.3 min and 0.8 ± 0.3ml, respectively. CONCLUSIONS: The gross and sonographic anatomy of the BP showed uncommon morphological variations. Moreover, from sonographic landmarks, we showed complete reproducibility of the axillary US-guided brachial plexus block with simple resolution equipment and small volume of anesthetics required.
Asunto(s)
Bloqueo del Plexo Braquial/métodos , Plexo Braquial/anatomía & histología , Plexo Braquial/diagnóstico por imagen , Modelos Animales , Puntos Anatómicos de Referencia , Anestésicos Locales/administración & dosificación , Animales , Axila/irrigación sanguínea , Axila/inervación , Arteria Axilar/anatomía & histología , Bloqueo del Plexo Braquial/veterinaria , Femenino , Miembro Anterior/inervación , Masculino , Conejos , Reproducibilidad de los Resultados , Ultrasonografía/métodosRESUMEN
PURPOSE: To update the gross and sonographic anatomy and propose landmarks to perform ultrasound-guided (US-guided) axillary brachial plexus block (BPB) in rabbits. METHODS: Forty New Zeeland's rabbit (NZR) cadavers were dissected and the nerves were trimmed, identified, measured, and photographed. Additionally, in twenty NZRs, sonographic images of brachial plexus (BP) were performed through a simple-resolution ultrasound device. The US-guided block was achieved through a minimum volume of lidocaine necessary to surround the BP roots. The effectiveness of the brachial plexus block was assessed on sensitivity and motor functions. RESULTS: The BP resulted from connections between the ventral branches of the last four cervical spinal nerves and the first thoracic spinal nerve. In the axillary sonoanatomy, the BP appeared as an agglomerate of small, round hypoechoic structures surrounded by a thin hyperechoic ring. The amount of time and the minimum volume required to perform was 4.3 ± 2.3 min and 0.8 ± 0.3ml, respectively. CONCLUSIONS: The gross and sonographic anatomy of the BP showed uncommon morphological variations. Moreover, from sonographic landmarks, we showed complete reproducibility of the axillary US-guided brachial plexus block with simple resolution equipment and small volume of anesthetics required.
Asunto(s)
Animales , Masculino , Femenino , Conejos , Plexo Braquial/anatomía & histología , Plexo Braquial/diagnóstico por imagen , Modelos Animales , Bloqueo del Plexo Braquial/métodos , Axila/inervación , Axila/irrigación sanguínea , Arteria Axilar/anatomía & histología , Reproducibilidad de los Resultados , Ultrasonografía/métodos , Puntos Anatómicos de Referencia , Bloqueo del Plexo Braquial/veterinaria , Miembro Anterior/inervación , Anestésicos Locales/administración & dosificaciónRESUMEN
OBJECT: The objective of this study was to report the results of elbow, thumb, and finger extension reconstruction via nerve transfer in midcervical spinal cord injuries. METHODS: Thirteen upper limbs from 7 patients with tetraplegia, with an average age of 26 years, were operated on an average of 7 months after a spinal cord injury. The posterior division of the axillary nerve was used to reinnervate the triceps long and upper medial head motor branches in 9 upper limbs. Both the posterior division and the branch to the middle deltoid were used in 2 upper limbs, and the anterior division of the axillary nerve in the final 2 limbs. For thumb and finger extension reconstruction, the nerve to the supinator was transferred to the posterior interosseous nerve. RESULTS: In 22 of the 27 recipient nerves, a peripheral type of palsy with muscle denervation was identified. At an average of 19 months follow-up, elbow strength scored M4 in 11 upper limbs and M3 in 2, according to the British Medical Research Council scale. Thumb extension scored M4 in 8 upper limbs and scored M3 in 4. Finger extension scored M4 in 12 hands. No donor-site deficits were reported or observed. CONCLUSIONS: Nerve transfers are effective at restoring elbow, thumb, and finger extension in patients with a midcervical spinal cord injury, which occurs in the majority of patients with a peripheral type of palsy with muscle denervation in their upper limbs. Efforts should be made to perform operations in these patients within 12 months of injury.
Asunto(s)
Vértebras Cervicales/lesiones , Codo/cirugía , Dedos/cirugía , Tejido Nervioso/trasplante , Procedimientos de Cirugía Plástica/métodos , Traumatismos de la Médula Espinal/cirugía , Adulto , Axila/inervación , Axila/cirugía , Músculo Deltoides/inervación , Músculo Deltoides/cirugía , Codo/inervación , Femenino , Dedos/inervación , Humanos , Masculino , Cuadriplejía/etiología , Cuadriplejía/cirugía , Recuperación de la Función , Pulgar/inervación , Pulgar/cirugía , Resultado del Tratamiento , Adulto JovenRESUMEN
Surgery to transfer the axillary nerve and the nerve of the long head of the triceps presents two obstacles: 1) the access portals are not standardized and 2) the nerves are for their larger part approached through large incisions. The goal of this study was to explore the feasibility of an endoscopic microsurgical approach. The posterior aspect of a cadaver shoulder was approached through three communicating mini-incisions. The Da Vinci robot camera was installed on a central trocart, and the instrument arms on the adjacent trocarts. A gas insufflation distended the soft tissues up to the lateral axillary space. The branches of the axillary nerve and the nerve to the long head of the triceps brachii muscle were identified. The dissection of the axillary nerve trunk and its branches was easy. The posterior humeral circumflex veins and artery were dissected as well without any difficulty. Finding the nerve to the long head of the triceps brachii was found to be more challenging because of its deeper location. Robots properties allow performing conventional microsurgery: elimination of the physiologic tremor and multiplication of the movements. They also facilitate the endoscopic approach of the peripheral nerves, as seen in our results on the terminal branches of the axillary nerve and the nerve to the long head of the triceps brachii.
Asunto(s)
Axila/inervación , Plexo Braquial/cirugía , Microcirugia/métodos , Robótica , Axila/cirugía , Cadáver , Estudios de Factibilidad , HumanosRESUMEN
BACKGROUND AND OBJECTIVE: Shoulder arthroscopic surgeries evolve with intense postoperative pain. Several analgesic techniques have been advocated. The aim of this study was to compare suprascapular and axillary nerve blocks in shoulder arthroscopy using the interscalene approach to brachial plexus blockade. METHODS: According to the technique used, sixty-eight patients were allocated into two groups: interscalene group (IG, n=34) and selective group (SG, n=34), with neurostimulation approach used for both techniques. After appropriate motor response, IG received 30 mL of 0.33% levobupivacaine in 50% enantiomeric excess with adrenalin 1:200,000. After motor response of suprascapular and axillary nerves, SG received 15 mL of the same substance on each nerve. General anesthesia was then administered. Variables assessed were time to perform the blocks, analgesia, opioid consumption, motor block, cardiovascular stability, patient satisfaction and acceptability. RESULTS: Time for interscalene blockade was significantly shorter than for selective blockade. Analgesia was significantly higher in the immediate postoperative period in IG and in the late postoperative period in SG. Morphine consumption was significantly higher in the first hour in SG. Motor block was significantly lower in SG. There was no difference between groups regarding cardiocirculatory stability and patient satisfaction and acceptability. Failure occurred in IG (1) and SG (2). CONCLUSIONS: Both techniques are safe, effective, and with the same degree of satisfaction and acceptability. The selective blockade of both nerves showed satisfactory analgesia, with the advantage of providing motor block restricted to the shoulder.
Asunto(s)
Analgesia , Bloqueo Nervioso/métodos , Manejo del Dolor , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Axila/inervación , Plexo Braquial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Hombro/inervación , Adulto JovenRESUMEN
JUSTIFICATIVA E OBJETIVO: Cirurgias artroscópicas do ombro cursam com intensa dor pós-operatória. Diversas técnicas analgésicas têm sido preconizadas. O objetivo deste estudo foi comparar o bloqueio dos nervos supraescapular e axilar nas cirurgias artroscópicas de ombro com a abordagem interescalênica do plexo braquial. MÉTODO: Sessenta e oito pacientes foram alocados em dois grupos de 34, de acordo com a técnica utilizada: grupo interescalênico (GI) e grupo seletivo (GS), sendo ambas as abordagens realizadas com neuroestimulador. No GI, após resposta motora adequada foram injetados 30 mL de levopubivacaína em excesso enantiomérico de 50% a 0,33% com adrenalina 1:200.000. No GS, após resposta motora do nervo supraescapular e axilar, foram injetados 15 mL da mesma substância em cada nervo. Em seguida, realizada anestesia geral. Variáveis avaliadas: tempo para realização dos bloqueios, analgesia, consumo de opioide, bloqueio motor, estabilidade cardiocirculatória, satisfação e aceitabilidade pelo paciente. RESULTADOS: Tempo para execução do bloqueio interescalênico foi significativamente menor que para realização do bloqueio seletivo. Analgesia foi significativamente maior no pós-operatório imediato no GI e no pós-operatório tardio no GS. Consumo de morfina foi significativamente maior na primeira hora no GS. Bloqueio motor foi significativamente menor no GS. Estabilidade cardiocirculatória, satisfação e aceitabilidade da técnica pelo paciente não diferiram entre os grupos. Ocorreu uma falha no GI e duas no GS. CONCLUSÕES: Ambas as técnicas são seguras, eficazes com mesmo grau de satisfação e aceitabilidade. O bloqueio seletivo de ambos os nervos apresentou analgesia satisfatória, com a vantagem de proporcionar bloqueio motor restrito ao ombro.
BACKGROUND AND OBJECTIVE: Shoulder arthroscopic surgeries evolve with intense postoperative pain. Several analgesic techniques have been advocated. The aim of this study was to compare suprascapular and axillary nerve blocks in shoulder arthroscopy using the interscalene approach to brachial plexus blockade. METHODS: According to the technique used, sixty-eight patients were allocated into two groups: interscalene group (IG, n = 34) and selective group (SG, n = 34), with neurostimulation approach used for both techniques. After appropriate motor response, IG received 30 mL of 0.33% levobupivacaine in 50% enantiomeric excess with adrenalin 1:200,000. After motor response of suprascapular and axillary nerves, SG received 15 mL of the same substance on each nerve. General anesthesia was then administered. Variables assessed were time to perform the blocks, analgesia, opioid consumption, motor block, cardiovascular stability, patient satisfaction and acceptability. RESULTS: Time for interscalene blockade was significantly shorter than for selective blockade. Analgesia was significantly higher in the immediate postoperative period in IG and in the late postoperative period in SG. Morphine consumption was significantly higher in the first hour in SG. Motor block was significantly lower in SG. There was no difference between groups regarding cardiocirculatory stability and patient satisfaction and acceptability. Failure occurred in IG (1) and SG (2). CONCLUSIONS: Both techniques are safe, effective, and with the same degree of satisfaction and acceptability. The selective blockade of both nerves showed satisfactory analgesia, with the advantage of providing motor block restricted to the shoulder.
JUSTIFICATIVA Y OBJETIVOS: Las cirugías artroscópicas del hombro cursan con un intenso dolor postoperatorio. Diversas técnicas analgésicas han sido preconizadas. El objetivo de este estudio fue comparar el bloqueo de los nervios supraescapular y axilar en las cirugías artroscópicas de hombro con el abordaje interescalénico del plexo braquial. MÉTODO: Sesenta y ocho pacientes fueron ubicados en dos grupos de 34, de acuerdo con la técnica utilizada: grupo Interescalénico (GI) y grupo selectivo (GS), siendo ambos abordajes realizados con neuroestimulador. En el GI, y después de la respuesta motora adecuada, se inyectaron 30 mL de levopubivacaina en exceso enantiomérico de un 50% al 0,33% con adrenalina 1:200.000. En el GS, y después de la respuesta motora del nervio supraescapular y axilar, se inyectaron 15 mL de la misma sustancia en cada nervio. Enseguida se realizó la anestesia general. Las variables que se evaluaron fueron: tiempo para la realización de los bloqueos, analgesia, consumo de opioide, bloqueo motor, estabilidad cardiocirculatoria, satisfacción y aceptabilidad por parte del paciente. RESULTADOS: El tiempo para la ejecución del bloqueo interescalénico fue significativamente menor que para la realización del bloqueo selectivo. La analgesia fue significativamente mayor en el postoperatorio inmediato en el GI y en el postoperatorio tardío en el GS. El consumo de morfina fue significativamente mayor en la primera hora en el GS. El bloqueo motor fue significativamente menor en el GS. La estabilidad cardiocirculatoria, satisfacción y aceptabilidad de la técnica por el paciente no fueron diferentes entre los grupos. Ocurrió un fallo en el GI y dos en el GS. CONCLUSIONES: Ambas técnicas son seguras y eficaces con el mismo grado de satisfacción y de aceptabilidad. El bloqueo selectivo de ambos nervios presentó una analgesia satisfactoria, con la ventaja de proporcionar un bloqueo motor restringido al hombro.
Asunto(s)
Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Analgesia , Bloqueo Nervioso/métodos , Manejo del Dolor , Axila/inervación , Plexo Braquial , Estudios Prospectivos , Hombro/inervaciónRESUMEN
Las comunicaciones entre los ramos terminales de plexo braquial son frecuentes y tienen importancia en la evaluación de traumatismos y procedimientos quirúrgicos de las regiones axilar y braquial. En este artículo presentamos un caso en el que durante la disección de rutina del miembro superior, se observó la presencia de comunicaciones bilaterales entre los nervios musculocutáneo y mediano. Los ramos comunicantes fueron descritos en su trayecto, relaciones y morfometría y se discutió acerca de la prevalencia e importancia clínica de estas comunicaciones.
Communication of the musculocutaneous and median nerves of the brachial plexus is common and is important in the evaluation of trauma and surgical procedures in axillary and brachial regions. This paper presents a case in which during a routine dissection of upper limb the presence of bilateral communication between musculocutaneous and medium nerves was observed. Trajectory of communicating branches was described, relation and morphometry was discussed with regard to prevalence and clinical significance of these communications.
Asunto(s)
Persona de Mediana Edad , Axila/inervación , Nervio Mediano/anatomía & histología , Nervio Musculocutáneo/anatomía & histología , Cadáver , Nervio Mediano/anomalías , Nervio Musculocutáneo/anomalías , Plexo Braquial/anatomía & histologíaRESUMEN
PURPOSE: To describe and validate the use of a test of abduction in internal rotation for the assessment of axillary nerve injury. METHODS: A total of 14 male patients with a mean age of 29 years (SD ± 6 y), with axillary nerve lesions lasting an average of 6 months, participated. We measured their shoulder range of motion. In the upright position, with the trunk bending forward, we asked our patients to actively extend the shoulder (swallowtail test), and then we extended the shoulders and asked each patient to hold them in that position (deltoid extension lag test). For the abduction in internal rotation test, we asked patients to abduct the shoulder in internal rotation. If full abduction compared with the normal contralateral side was not possible, the examiner passively held the affected limb in maximal abduction and internal rotation. The patient was instructed to maintain the position when the examiner released the limb. In each test, any lag compared with the normal side accounted for deltoid palsy. RESULTS: All patients exhibited abduction beyond horizontal and full external rotation. The swallowtail test and the deltoid extension lag test identified the axillary nerve lesion in 10 of 14 patients. The abduction in internal rotation test recognized the axillary nerve injury in all 14. The average difference in the range of abduction in internal rotation between the normal and affected side was 37° (abduction lag). CONCLUSIONS: Compensatory abduction in axillary nerve palsy has been attributed to the action of the supraspinatus, biceps, coracobrachialis, and pectoralis major. During abduction in internal rotation, compensatory abduction is impaired, clearly indicating deltoid muscle dysfunction.
Asunto(s)
Axila/inervación , Evaluación de la Discapacidad , Músculo Esquelético/fisiopatología , Rango del Movimiento Articular/fisiología , Articulación del Hombro/fisiopatología , Adulto , Fenómenos Biomecánicos , Humanos , Masculino , RotaciónRESUMEN
In spinal cord injuries at the C6 level, elbow extension is lost and needs reconstruction. Traditionally, elbow extension has been reconstructed by muscle transfers, which improve function only moderately. We have hypothesized that outcomes could be ameliorated by nerve transfers rather than muscle transfers. We anatomically investigated nerve branches to the teres minor and posterior deltoid as donors for transfer to triceps motor branches. In eight formalin-fixed cadavers, the axillary nerve, the teres minor branch, the posterior deltoid branch, the triceps long and upper medial head motor branches, and the thoracodorsal nerve were dissected bilaterally, their diameters measured and their myelinated fibers counted. To simulate surgery, using an axillary approach in two fresh cadavers, we transferred the teres minor or the posterior deltoid branch to the triceps long head and to the thoracodorsal nerve. The posterior division of the axillary nerve gave off the teres minor motor branch and then the branch to the posterior deltoid, terminating as the superior lateral brachial cutaneous nerve. The diameters of the teres minor motor branch, posterior deltoid, triceps long and upper medial head branches, and the thoracodorsal nerve all were â¼2 mm, with minimal variation. The nerves varied little in their numbers of myelinated fibers, being consistently about 1,000. Via an axillary approach, either the teres minor or the posterior deltoid branch could be transferred directly to the thoracodorsal nerve or to triceps branches without any tension.
Asunto(s)
Axila/inervación , Codo/inervación , Codo/cirugía , Microcirugia/métodos , Nervios Periféricos/trasplante , Cuadriplejía/cirugía , Músculo Deltoides/inervación , Codo/fisiología , Estudios de Factibilidad , Humanos , Procedimientos de Cirugía Plástica/métodosRESUMEN
PURPOSE: To investigate the results of distal nerve transfer, with and without nerve root grafting, in C5-C6 palsy of the brachial plexus. METHODS: We prospectively studied 37 young adults with C5-C6 brachial plexus palsy who underwent surgical repair an average of 6.3 months after trauma. In 7 patients, no nerve roots were available for grafting, so reconstruction was achieved by transferring the accessory nerve to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps branches to the axillary nerve (a triple nerve transfer). In 24 patients, C5 nerve root grafting to the anterior division of the upper trunk was combined with triple nerve transfer. In 6 patients, the C5+C6 nerve roots were grafted to the anterior and posterior divisions of the upper trunk, the accessory nerve was transferred to the suprascapular nerve, and ulnar nerve fascicles were connected to the biceps motor branch. The range of shoulder abduction/external rotation recovery and elbow flexion strength were evaluated between 24 and 26 months after surgery. RESULTS: Both full abduction and full external rotation of the shoulder were restored in one of the 7 patients in the C5 and C6 nerve root avulsion group, in 14 of 21 patients who received C5 nerve root grafting, and in 2 of 6 patients in the C5+C6 nerve root graft group. The average percentages of elbow flexion strength recovery, relative to the normal, contralateral side, were 27%, 43%, and 59% for the C5-C6 nerve root avulsion, C5 nerve root graft, and C5+C6 nerve root graft groups, respectively. CONCLUSIONS: We repaired C5-C6 brachial plexus palsies using a combination of strategies depending on the site of root injury (ie, intradural vs extradural). Patients with injuries that were able to be reconstructed with both root grafting and nerve transfers had the best function. These results suggest that the combined use of nerve transfers and root grafting may enhance outcomes in the reconstruction of C5-C6 injuries of the brachial plexus.
Asunto(s)
Plexo Braquial/lesiones , Transferencia de Nervios , Raíces Nerviosas Espinales/cirugía , Nervio Accesorio/cirugía , Adulto , Axila/inervación , Plexo Braquial/cirugía , Articulación del Codo/fisiopatología , Femenino , Humanos , Masculino , Fuerza Muscular , Músculo Esquelético/inervación , Rango del Movimiento Articular , Recuperación de la Función , Articulación del Hombro/fisiopatología , Nervio Cubital/cirugíaRESUMEN
OBJECT: Grafting or nerve transfers to the axillary nerve have been performed using a deltopectoral approach and/or a posterior arm approach. In this report, the surgical anatomy of the axillary nerve was studied with the goal of repairing the nerve through an axillary access. METHODS: The axillary nerve was bilaterally dissected in 10 embalmed cadavers to study its variations. Three patients with axillary nerve injuries then underwent surgical repair through an axillary access; the axillary nerve was repaired by transfer of the triceps long head motor branch. RESULTS: At the lateral margin of the subscapularis muscle, the axillary nerve was found in the center of a triangle bounded medially by the subscapular artery, laterally by the latissimus dorsi tendon, and cephalad by the posterior circumflex humeral artery. At the entrance of the quadrangular space, the axillary nerve divisions were loosely connected to each other, and could be clearly separated and correctly identified. Surgery for the axillary nerve repair through the axillary access was straightforward. Eighteen months after surgery, all three patients had recovered deltoid strength to a score of M4 on the Medical Research Council scale and had improved abduction strength by 50%. No deficit was evident in elbow extension. CONCLUSIONS: The axillary nerve and its branches can be safely dissected and repaired by triceps motor nerve transfer through an axillary access.
Asunto(s)
Brazo/inervación , Axila/inervación , Plexo Braquial/anatomía & histología , Plexo Braquial/cirugía , Músculo Esquelético/inervación , Transferencia de Nervios/métodos , Adulto , Axila/cirugía , Cadáver , Disección , Estudios de Factibilidad , Humanos , MasculinoRESUMEN
RESUMEN: La axila es un compartimiento piramidal relativamente pequeño, localizado entre la pared torácica y el brazo, que contiene músculos y estructuras neurovasculares. Estas estructuras son importantes desde los puntos de vista clínico y morfológico. En este artículo reportamos la presencia de una variación del músculo latisimocondíleo y de la arteria axilar, la cual se encuentra debajo del músculo mencionado. La variación es única en su tipo. La morfología y el significado clínico del músculo son discutidos.