RESUMO
We report the study of the anatomical feasibility of transferring the nerve to the brachialis muscle to the upper medial head motor branch that innervate the triceps, and outcomes of such transfers in restoring elbow extension in five patients with posterior cord lesion of the brachial plexus. The length of the branches to the brachialis muscle measured 7.6 cm and the triceps upper medial head motor branch was 5 cm in 10 adult cadavers. Five male patients were treated with this transfer 5 months after the injury (range 4 to 6 months) after posterior cord injury of the brachial plexus with a mean follow-up of 31 months (range 28 to 36 months). Elbow extension scored M4 in all cases. No complications occurred. These preliminary results suggest that transferring the nerve to the brachialis muscle is an effective technique for the reconstruction of elbow extension after posterior cord brachial plexus injuries. LEVEL OF EVIDENCE: IV.
Assuntos
Braço/inervação , Plexo Braquial/lesões , Articulação do Cotovelo/fisiologia , Músculo Esquelético/inervação , Nervo Musculocutâneo/transplante , Adulto , Braço/anatomia & histologia , Plexo Braquial/cirurgia , Humanos , Masculino , Amplitude de Movimento Articular , Adulto JovemRESUMO
BACKGROUND: Extranodal lymphoma are rare, in particular, breast non-Hodgkin's lymphoma has an impact of lower 0.5%. It is difficult to diagnose during the pre-operative period, since it can be confused with breast carcinoma. CASE REPORT: A 52 years old female patient was sent due to a lump in her left breast identified in a mammogram. A study was conducted with supplementary tests, being eventually diagnosed as low-grade B-cell follicular lymphoma. She was subjected to a mammary and axillary radioguided occult lesion localisation (ROLL). After, radiation therapy was delivered. CONCLUSIONS: It is a very rare pathology, therefore, there is not relevant research to show effective treatment or diagnosis.
Assuntos
Neoplasias da Mama , Linfoma Folicular , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/cirurgia , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
The rat models currently employed for studies of nerve regeneration present distinct disadvantages. We propose a new technique of stretch-induced nerve injury, used here to evaluate the influence of gabapentin (GBP) on nerve regeneration. Male Wistar rats (300 g; n=36) underwent surgery and exposure of the median nerve in the right forelimbs, either with or without nerve injury. The technique was performed using distal and proximal clamps separated by a distance of 2 cm and a sliding distance of 3 mm. The nerve was compressed and stretched for 5 s until the bands of Fontana disappeared. The animals were evaluated in relation to functional, biochemical and histological parameters. Stretching of the median nerve led to complete loss of motor function up to 12 days after the lesion (P<0.001), compared to non-injured nerves, as assessed in the grasping test. Grasping force in the nerve-injured animals did not return to control values up to 30 days after surgery (P<0.05). Nerve injury also caused an increase in the time of sensory recovery, as well as in the electrical and mechanical stimulation tests. Treatment of the animals with GBP promoted an improvement in the morphometric analysis of median nerve cross-sections compared with the operated vehicle group, as observed in the area of myelinated fibers or connective tissue (P<0.001), in the density of myelinated fibers/mm2 (P<0.05) and in the degeneration fragments (P<0.01). Stretch-induced nerve injury seems to be a simple and relevant model for evaluating nerve regeneration.
RESUMO
The rat models currently employed for studies of nerve regeneration present distinct disadvantages. We propose a new technique of stretch-induced nerve injury, used here to evaluate the influence of gabapentin (GBP) on nerve regeneration. Male Wistar rats (300 g; n=36) underwent surgery and exposure of the median nerve in the right forelimbs, either with or without nerve injury. The technique was performed using distal and proximal clamps separated by a distance of 2 cm and a sliding distance of 3 mm. The nerve was compressed and stretched for 5 s until the bands of Fontana disappeared. The animals were evaluated in relation to functional, biochemical and histological parameters. Stretching of the median nerve led to complete loss of motor function up to 12 days after the lesion (P<0.001), compared to non-injured nerves, as assessed in the grasping test. Grasping force in the nerve-injured animals did not return to control values up to 30 days after surgery (P<0.05). Nerve injury also caused an increase in the time of sensory recovery, as well as in the electrical and mechanical stimulation tests. Treatment of the animals with GBP promoted an improvement in the morphometric analysis of median nerve cross-sections compared with the operated vehicle group, as observed in the area of myelinated fibers or connective tissue (P<0.001), in the density of myelinated fibers/mm2 (P<0.05) and in the degeneration fragments (P<0.01). Stretch-induced nerve injury seems to be a simple and relevant model for evaluating nerve regeneration.
RESUMO
Stretch injuries of the C5-C7 roots of the brachial plexus traditionally have been associated with palsies of shoulder abduction/external rotation, elbow flexion/extension, and wrist, thumb, and finger extension. Based on current myotome maps we hypothesized that, as far as motion is concerned, palsies involving C5-C6 and C5-C7 root injuries should be similar. In 38 patients with upper-type palsies of the brachial plexus, we examined for correlations between clinical findings and root injury level, as documented by CT tomomyeloscan. Contrary to commonly held beliefs, C5-C7 root injuries were not associated with loss of extension of the elbow, wrist, thumb, or fingers, but residual hand strength was much lower with C5-C7 vs C5-C6 lesions.
Assuntos
Braço/inervação , Neuropatias do Plexo Braquial/cirurgia , Paralisia/cirurgia , Raízes Nervosas Espinhais/lesões , Raízes Nervosas Espinhais/cirurgia , Adulto , Análise de Variância , Braço/diagnóstico por imagem , Braço/fisiopatologia , Braço/cirurgia , Neuropatias do Plexo Braquial/diagnóstico por imagem , Neuropatias do Plexo Braquial/fisiopatologia , Humanos , Masculino , Força Muscular/fisiologia , Músculo Esquelético/inervação , Paralisia/fisiopatologia , Estudos Prospectivos , Raízes Nervosas Espinhais/diagnóstico por imagem , Raízes Nervosas Espinhais/fisiopatologia , Tomografia Computadorizada EspiralRESUMO
An internal rotation contracture is a common complication of obstetric brachial plexus palsy. We describe the operative treatment of seven children with a recurrent internal rotation contracture of the shoulder following earlier corrective surgery which included subscapularis slide and latissimus dorsi transfer. We performed z-lengthening of the tendon of the subscapularis muscle and transferred the lower trapezius muscle to the infraspinatus tendon. Two years postoperatively the mean gain in active external rotation was 47.1 degrees, which increased to 54.3 degrees at four years. Lengthening of the tendon of subcapularis and lower trapezius transfer to infraspinatus improved the range of active external rotation in patients who had previously had surgery for an internal rotation contracture.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Contratura/cirurgia , Articulação do Ombro/cirurgia , Tendões/cirurgia , Neuropatias do Plexo Braquial/complicações , Neuropatias do Plexo Braquial/fisiopatologia , Criança , Pré-Escolar , Contratura/etiologia , Feminino , Humanos , Masculino , Procedimentos Ortopédicos/métodos , Amplitude de Movimento Articular/fisiologia , Recidiva , Articulação do Ombro/fisiopatologia , Tendões/fisiopatologia , Resultado do TratamentoRESUMO
Elbow extension is a prerequisite for adequate hand position. Muscle transfers are often employed in partial injuries of the brachial plexus, when neurological surgery is unlikely to achieve desired results. The posterior deltoid and latissimus dorsi are the two muscles most commonly used for transfer but there are few alternatives when these two muscles are paralysed. We now report on the successful transfer of the lower trapezius muscle to reconstruct triceps function in three patients with longstanding lesions of the brachial plexus that had not been previously treated surgically.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Plexo Braquial/lesões , Cotovelo/inervação , Músculo Esquelético/transplante , Amplitude de Movimento Articular/fisiologia , Adulto , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Humanos , Masculino , Contração Muscular/fisiologia , Complicações Pós-Operatórias/fisiopatologia , Ombro/fisiopatologia , Técnicas de Sutura , Tendões/cirurgia , Coleta de Tecidos e Órgãos/métodosRESUMO
Ten patients with scaphoid non-unions which had been present for longer than 2 years were treated using a vascularised bone graft harvested from the thumb and pedicled on the first dorsal metacarpal artery. Bone harvesting and grafting were performed by a single palmar approach. Concomitant cancellous bone graft was not used. Bone healing was confirmed by CT scans in nine of the ten patients. Persistence of the non-union was observed in one patient who was the oldest in this series, had the longest standing non-union and was a heavy smoker. Twelve months after surgery, nine of the ten patients had significant pain relief with an improved range of motion and grip strength.
Assuntos
Fraturas não Consolidadas/cirurgia , Ossos Metacarpais/irrigação sanguínea , Ossos Metacarpais/transplante , Osso Escafoide/cirurgia , Polegar/cirurgia , Adulto , Transplante Ósseo/métodos , Estudos de Coortes , Consolidação da Fratura , Fraturas não Consolidadas/diagnóstico por imagem , Força da Mão , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Radiografia , Amplitude de Movimento Articular , Osso Escafoide/diagnóstico por imagem , Osso Escafoide/lesões , Polegar/irrigação sanguíneaRESUMO
Tendon transfers are frequently needed to improve hand function in obstetric brachial plexus injuries. The reconstruction cannot always be achieved using local donor transfers in the forearm as these are not always available. In such cases, we propose the use of the brachialis muscle as a useful donor for transfer. Five adolescents with obstetric brachial plexus palsy were operated on to reconstruct wrist extension and/or pronation using the brachialis muscle transfer to the pronator teres (n=1), extensor carpi radialis brevis (n=1) and extensor carpi radialis longus (n=3). Twelve months after surgery, average active motion recovery was 20 degrees for wrist extension and 14 degrees for pronation. Active and passive range of motion was similar.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Plexo Braquial/cirurgia , Músculo Esquelético/cirurgia , Adolescente , Plexo Braquial/lesões , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Criança , Articulação do Cotovelo/fisiopatologia , Feminino , Antebraço/cirurgia , Humanos , Masculino , Amplitude de Movimento Articular/fisiologia , Articulação do Punho/fisiopatologia , Articulação do Punho/cirurgiaRESUMO
OBJECTIVES: In the clinical set, autologus nerve grafts are the current option for reconstruction of nerve tissue losses. The length of the nerve graft has been suggested to affect outcomes. Experiments were performed in the rat in order to test this assumption and to detect a possible mechanism to explain differences in recovery. METHODS: The rat median nerve was repaired by ulnar nerve grafts of different lengths. Rats were evaluated for 12 months by behavioural assessment and histological studies, including ATPase myofibrillary histochemistry and retrograde neuronal labelling. RESULTS: It was demonstrated that graft length interferes in behavioural functional recovery that here correlates to muscle weight recovery. Short nerve grafts recovered faster and better. Reinnervation was not specific either at the trunk level or in the muscle itself. The normal mosaic pattern of Type I muscle fibres was never restored and their number remained largely augmented. An increment in the number of motor fibres was observed after the nerve grafting in a predominantly sensory branch in all groups. This increment was more pronounced in the long graft group. In the postoperative period, about a 20% reduction in the number of misdirected motor fibres occurred in the short nerve graft group only. CONCLUSION: Variation in the length of nerve grafts interferes in behavioural recovery and increases motor fibres misdirection. Early recovery onset was related to a better outcome, which occurs in the short graft group.
Assuntos
Nervo Mediano/cirurgia , Músculo Esquelético/fisiologia , Transferência de Nervo/métodos , Recuperação de Função Fisiológica/fisiologia , Transplante Autólogo/métodos , Nervo Ulnar/transplante , Adenosina Trifosfatases/metabolismo , Análise de Variância , Animais , Células do Corno Anterior/metabolismo , Comportamento Animal , Benzofuranos/metabolismo , Feminino , Força da Mão/fisiologia , Histocitoquímica/métodos , Nervo Mediano/fisiopatologia , Modelos Animais , Músculo Esquelético/anatomia & histologia , Músculo Esquelético/inervação , Tamanho do Órgão/fisiologia , Desempenho Psicomotor/fisiologia , Ratos , Ratos Sprague-Dawley , Fatores de TempoRESUMO
The towel test consists of covering an infant's face with a towel and seeing if he/she can remove it with either arm. In this study it has been used to aid the clinical and electromyographic assessment of 21 infants with obstetric brachial plexus palsy. At 2 to 3 months, none of the 21 infants succeeded in removing the towel, either with their normal or affected arm. At 6 months, all the infants succeeded in removing the towel with their normal arm, but 11 could not with their affected arm, and the same was observed at a further assessment at 9 months. The towel test is a reliable technique for evaluating children with obstetric brachial plexus injuries.
Assuntos
Plexo Braquial/lesões , Paralisia Obstétrica/diagnóstico , Plexo Braquial/fisiopatologia , Eletromiografia , Face , Feminino , Humanos , Lactente , Masculino , Paralisia Obstétrica/fisiopatologia , Postura/fisiologiaRESUMO
Macrodactyly is a rare congenital anomaly of the hand that is difficult to treat. We describe a new technique consisting of hemidigital, longitudinal, and transverse en bloc resection with collateral ligament transplantation to the proximal interphalangeal joint that we used in a case of macrodactyly. Four years after the procedure the digit's appearance was largely improved with preservation of complete motion at the proximal interphalangeal joint. Transplantation of the collateral ligament ensured a stable joint. Fingertip sensibility was maintained.
Assuntos
Ligamentos Colaterais/transplante , Dedos/cirurgia , Deformidades Congênitas da Mão/cirurgia , Procedimentos Ortopédicos , Adulto , Feminino , Dedos/diagnóstico por imagem , Deformidades Congênitas da Mão/diagnóstico por imagem , Humanos , RadiografiaRESUMO
OBJECT: This study was conducted to evaluate the effects of dorsal rhizotomy on upper-limb spasticity, functional improvement, coordination, and hand sensibility. METHODS: Fifteen spastic upper limbs in 13 patients were selected and prospectively studied. Brachial plexus dorsal rhizotomy was performed in which two, three, or four dorsal roots were completely sectioned. Patients were followed up for at least 12 months after surgery; the mean follow-up period was 15.6 months and the maximum period was 30 months. A remarkable relief of spasticity was observed in all cases. Recurrence was observed in only one patient and was caused by insufficient dorsal root section. Functional improvement was observed in all cases, and functional improvement in the hand was found to be related to the presence of active finger extension in the preoperative period. Even when extended dorsal root section was performed, no hand anesthesia, either total or partial, was observed. No patient lost movement ability in the postoperative period, and no ataxic limbs were observed. CONCLUSIONS: Brachial plexus dorsal rhizotomy is very effective as a treatment for upper-limb spasticity and results in functional improvement without loss of sensation in the hand.
Assuntos
Braço/inervação , Plexo Braquial/cirurgia , Espasticidade Muscular/cirurgia , Rizotomia , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Mãos/inervação , Força da Mão/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Espasticidade Muscular/diagnóstico , Exame Neurológico , Complicações Pós-Operatórias/diagnóstico , Estudos Prospectivos , Resultado do TratamentoRESUMO
Sensory reconstruction has recently been stressed in breast reconstruction. However, there are no reports concerning the reconstruction of a sensitive areola. The bilateral reconstruction of a sensitive areola using a neurocutaneous flap based on the medial antebrachial cutaneous nerve is reported. The flap was harvested from the distal third of the forearm as an island flap and tunneled to reach the apex of the new breast, which was previously reconstructed using a 135-cc, gel-filled, silicone prosthesis covered by a latissimus dorsi myocutaneous flap. Six months later, fine sensibility in the reconstructed areola was demonstrated. The patient could perceive light touch, pain, and 14 mm two-point discrimination. At 2 months after surgery, 50 percent of cutaneous faulty stimulus location was observed. However, at 4 and 6 months after surgery, faulty location disappeared. Six months after harvesting the medial antebrachial cutaneous nerve, the sensory deficit was minimal; it included a hypoesthesic zone of 4 to 7 cm and an anesthesic zone of 2.5 to 5 cm on the middle third of the forearm. Fifteen months after the procedure, no hypoesthesic zone was observed; only a 2 to 3 cm anesthesic zone on the proximal medial side of the forearm existed. This sensory deficit passed unnoticed by the patient. The technique developed here is a refinement in breast reconstruction, and we think it should be used in selected patients.
Assuntos
Mamoplastia/métodos , Microcirurgia/métodos , Mamilos/cirurgia , Retalhos Cirúrgicos/inervação , Adulto , Feminino , Humanos , Mastectomia Radical Modificada , Reoperação , Pele/inervação , Técnicas de SuturaRESUMO
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.
Assuntos
Plexo Braquial/lesões , Músculo Esquelético/inervação , Transferência de Nervo , Raízes Nervosas Espinhais/cirurgia , Ferimentos Penetrantes/cirurgia , Adulto , Humanos , Masculino , Pescoço , Ombro/fisiopatologiaRESUMO
Brachial plexus avulsion injuries are devastating injuries to the upper limb, and nerve transfer remains the only option in reconstruction. Despite the encouraging results concerning recovery of shoulder and elbow function, no option is available for treatment of the paralytic hand. In rats, we sectioned the radial nerve in the elbow region and transferred it across the chest to reinnervate the lesioned contralateral medial cord of the brachial plexus. Rats were then evaluated for motor and sensory recovery, electrophysiologically, behaviorally and morphologically. Forepaw functional recovery was estimated to be 90%. In cadavers, the radial nerve and profunda brachii artery were dissected. It was observed that the radial nerve vascularized by the profunda brachii artery was able to reach the contralateral brachial plexus distal to the shoulder region without nerve grafts. After sectioning the radial nerve, sensory loss is minimal and motor palsy can be easily restored by tendon transfers. The results of tendon transfer for radial nerve palsy are better than for any other nerve. Cross-chest radial nerve transfer might be of clinical interest in the reconstruction of hand function in entire injury to the brachial plexus.
Assuntos
Plexo Braquial/lesões , Transferência de Nervo , Nervo Radial/cirurgia , Análise de Variância , Animais , Axônios/fisiologia , Comportamento Animal , Artéria Braquial/patologia , Artéria Braquial/cirurgia , Plexo Braquial/patologia , Plexo Braquial/cirurgia , Estimulação Elétrica , Eletrofisiologia , Potenciais Evocados/fisiologia , Feminino , Membro Anterior/inervação , Membro Anterior/fisiologia , Contração Isométrica/fisiologia , Movimento/fisiologia , Músculo Esquelético/inervação , Regeneração Nervosa/fisiologia , Limiar da Dor/fisiologia , Paralisia/cirurgia , Nervo Radial/irrigação sanguínea , Nervo Radial/patologia , Ratos , Ratos Sprague-Dawley , Sensação/fisiologia , Transferência TendinosaRESUMO
Soft-tissue repair in the hand often requires skin flaps due to exposure of bone, tendons, nerves, and arteries. However, alternatives for flap surgery are very limited, especially in dealing with palmar hand reconstruction. In the present report, the dorsal branch of the ulnar nerve and its accompanying artery were studied anatomically, and a neurocutaneous flap distally based on these structures was developed. The flap was raised on the medial aspect of the hand and distal half of the forearm, and its rotation point was located dorsally near the metacarpalphalangeal joints. The clinical use of this flap for the repair of skin defects in the hand is reported. All the clinical flaps survived completely, including a 3.5 x 13-cm large flap. Donor site morbidity was minimal. This flap represents a new alternative in hand reconstruction.
Assuntos
Contratura/cirurgia , Traumatismos da Mão/cirurgia , Mãos/cirurgia , Retalhos Cirúrgicos , Adolescente , Queimaduras/complicações , Cadáver , Criança , Contratura/etiologia , Feminino , Traumatismos da Mão/etiologia , Humanos , Masculino , Retalhos Cirúrgicos/irrigação sanguínea , Retalhos Cirúrgicos/inervação , Artéria Ulnar/anatomia & histologia , Nervo Ulnar/anatomia & histologiaRESUMO
In closed injuries, nerves may be damaged by compression, stretch, or friction; the lesion may be circumscribed or extensive. Indications for exploratory surgery are very difficult to establish. However, in a number of cases, no lesions are observed during surgery and only neurolysis is performed. Neurolysis, nevertheless, may devascularize the nerves, compromising the final outcome of nerve regeneration. The goal of this reported work was to study the effects of neurolysis during the process of regeneration. Experiments were performed in the rat median nerve, and assessment was made by behavioral and electrophysiologic studies 2, 3, 6 and 12 weeks after surgery. The experiments demonstrated that exploratory microneurolysis had no deleterious effect on nerve recovery when performed during the process of nerve regeneration. Indeed, microneurolysis accelerated the rate of nerve recovery. Early exploratory surgery thus had no deleterious effects on nerve regeneration, and not only offered a better prognosis in reparable lesions, but also a potential beneficial effect of neurolysis in accelerating recovery.
Assuntos
Regeneração Nervosa , Nervos Periféricos/cirurgia , Animais , Eletrofisiologia , Feminino , Microcirurgia , Ratos , Ratos WistarRESUMO
OBJECTIVE: In brachial plexus injuries, when the dorsal root ganglion (DRG) is avulsed from the spinal cord there is no possibility of direct repair. Therefore, in the present report the median nerve was connected directly to the contralateral C7 DRG, to restore forepaw sensation. METHODS: The ulnar nerve was sectioned, and a 15-mm segment of nerve was removed. The median nerve was sectioned, transposed dorsally, and repaired using a sural nerve graft directly implanted into the C7 contralateral DRG. Rats were then assessed 6 and 12 months later by behavioral, histological, and plasma extravasion techniques. RESULTS: All animals recovered sensation in the forepaw. Retrogradely labeled sensory neurons were demonstrated in the C7 DRG, and the whole forepaw was labeled after plasma extravasion induction by median nerve antidromic stimulation. Several myelinated and positively neurofilament-stained fibers were demonstrated in the grafted median nerve. CONCLUSION: The surgical strategy proposed might be a useful alternative to selective sensory repair in the emerging field of brachial plexus reconstruction by direct spinal cord surgery.