RESUMO
BACKGROUND: The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. METHODS: A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. RESULTS: In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function. CONCLUSIONS: Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.
Assuntos
Neuropatias do Plexo Braquial/etiologia , Plexo Braquial/anormalidades , Descompressão Cirúrgica/efeitos adversos , Traumatismos dos Nervos Periféricos/etiologia , Nervo Frênico/anormalidades , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto , Plexo Braquial/lesões , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Feminino , Humanos , Masculino , Maryland , Traumatismos dos Nervos Periféricos/fisiopatologia , Philadelphia , Nervo Frênico/lesões , Nervo Frênico/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/fisiopatologia , Resultado do TratamentoRESUMO
Peripheral nerve and brachial plexus injuries typically cause severe impairment in the affected limb. The incidence of neuropathic pain is high, reaching up to 95% of cases, especially if cervical root avulsion has occurred. Neuropathic pain results from damage to the somatosensory system, and its progression towards chronicity depends upon disruptions affecting both the peripheral and central nervous system. Managing these painful conditions is complex and must be accomplished by a multidisciplinary team, starting with first-line pharmacological therapies like tricyclic antidepressants and calcium channel ligands, combined physical and occupational therapy, transcutaneous electrical stimulation and psychological support. For patients refractory to the initial measures, several neurosurgical options are available, including nerve decompression or reconstruction and ablative/modulatory procedures.
Assuntos
Plexo Braquial/lesões , Neuralgia/terapia , Traumatismos dos Nervos Periféricos/complicações , Plexo Braquial/fisiopatologia , Gânglios Espinais/lesões , Gânglios Espinais/fisiopatologia , Humanos , Neuralgia/etiologia , Neuralgia/fisiopatologia , Traumatismos dos Nervos Periféricos/fisiopatologia , Resultado do TratamentoRESUMO
BACKGROUND: Among other factors, like the time from trauma to surgery or the number of axons that reach the muscle target, a patient's age might also impact the final results of brachial plexus surgery. OBJECTIVE: To identify (1) any correlations between age and the 2 outcomes: elbow flexion strength and shoulder abduction range; (2) whether childhood vs adulthood influences outcomes; and (3) other baseline variables associated with surgical outcomes. METHODS: Twenty pediatric patients (under age 20 yr) who had sustained a traumatic brachial plexus injury were compared against 20 patients, 20 to 29 yr old, and 20 patients, 30 yr old or older. Univariate, univariate trend, and correlation analyses were conducted with patient age, time to surgery, type of injury, and number of injured roots included as independent variables. RESULTS: A statistically significant trend toward decreasing mean strength in elbow flexion, progressing from the youngest to oldest age group, was observed. This linear trend persisted when subjects were subdivided into 4 age groups (<20, 20-29, 30-39, ≥40). There were no differences by age group in final shoulder abduction range or the percentage achieving a good shoulder outcome. CONCLUSION: Our data suggest that age is somehow linked to the outcomes of brachial plexus surgery with respect to elbow flexion, but not shoulder abduction strength. Increasing age is associated with steadily worsening elbow flexion outcomes, perhaps indicating the need for earlier surgery and/or more aggressive repairs in older patients.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Plexo Braquial/lesões , Amplitude de Movimento Articular/fisiologia , Recuperação de Função Fisiológica/fisiologia , Adolescente , Adulto , Fatores Etários , Plexo Braquial/fisiopatologia , Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/fisiopatologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transferência de Nervo/métodos , Prognóstico , Procedimentos de Cirurgia Plástica/métodos , Resultado do Tratamento , Adulto JovemRESUMO
Background Restoring elbow extension is an important objective to pursue when repairing the brachial plexus in patients with a flail arm. Based upon the good results obtained using the phrenic nerve to restore elbow flexion and shoulder stability, we hypothesized that this nerve could also be employed to reconstruct elbow extension in patients with severe brachial plexus injuries. Methods A retrospective study of 10 patients in which the phrenic nerve targeted the radial nerve (7 patients) or the branch to the long head of the triceps (3 patients) as a surgical strategy for reconstruction of the brachial plexus. Results The mean postoperative follow-up time was 34 months. At final follow-up, elbow extension graded as M4 was measured in three patients, Medical Research Council MRC M3 in five patients, and M2 in one patient, while one patient experienced no measurable recovery (M0). No patient complained or demonstrated any signs of respiratory insufficiency postoperatively. Conclusions The phrenic nerve is a reliable donor for reanimation of elbow extension in such cases, and the branch to the long head of the triceps should be considered as a better target for the nerve transfer.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Plexo Braquial/lesões , Articulação do Cotovelo/inervação , Articulação do Cotovelo/cirurgia , Transferência de Nervo , Nervo Frênico/transplante , Adolescente , Adulto , Plexo Braquial/fisiopatologia , Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Amplitude de Movimento Articular , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Muitas transferências musculares têm sido defendidas para restaurar os movimentos do membro superior após paralisia grave do plexo braquial. A paralisia dos músculos deltoide e supraespinal pode ser tratada por meio de transferência do músculo trapézio. A paralisia dos músculos extensores de punho, mão e dedos, quando o nervo mediano está preservado, pode ser corrigida com emprego dos músculos pronador redondo, flexor ulnar do carpo e palmar longo. Os autores descrevem um caso de reabilitação de paciente portador de lesão parcial antiga do plexo braquial à direita, de predomínio em tronco superior, principalmente da raiz de C6 e de fascículo posterior. Foi evidenciada fraqueza dos músculos deltoide e extensores do punho e dos dedos, sem antecedentes de reparo microcirúrgico do plexo braquial. Foi realizada, inicialmente, cirurgia de transferência tendínea para ganho de extensão de punho, mão e dedos e, após um ano, transferência do músculo trapézio, para estabilização do ombro. O sucesso na transferência para tratamento de paralisia do plexo braquial requereu especialização do cirurgião, motivação do paciente e programa de reabilitação.
A variety of muscle transfer techniques have been proposed to restore motion of the upper extremities following severe brachial plexus palsy. Paralysis of the deltoid and supraspinatus muscles can be treated with transfer of the trapezius muscle. Paralysis of the wrist, hand, and digital extensor muscles can be corrected using the pronator teres, flexor carpi ulnaris, and palmaris longus muscles if the median nerve is preserved. Here we describe the rehabilitation of a patient with an old partial injury to the right brachial plexus that primarily involved the upper trunk from the C6 root to the posterior cord. Weakness of the deltoid muscle, wrist, and digital extensor muscles was observed. Microsurgical repair of the brachial plexus had not been performed. Tendon transfer surgery was performed to improve wrist, hand, and digital extension. One year later, transfer of the trapezius muscle was performed to stabilize the shoulder. The success of muscle transfer in the treatment of the brachial plexus palsy required the surgeon's specialization, the patient's motivation, and a rehabilitation program.
Assuntos
Humanos , Masculino , Adulto , História do Século XXI , Reabilitação , Articulação do Ombro , Procedimentos Cirúrgicos Operatórios , Plexo Braquial , Hiperostose , Músculo Esquelético , Hipertrofia , Articulação do Ombro/cirurgia , Articulação do Ombro/fisiopatologia , Articulação do Ombro/lesões , Procedimentos Cirúrgicos Operatórios/métodos , Plexo Braquial/cirurgia , Plexo Braquial/fisiopatologia , Plexo Braquial/lesões , Hiperostose/cirurgia , Hiperostose/fisiopatologia , Músculo Esquelético/cirurgia , Músculo Esquelético/fisiopatologia , Músculo Esquelético/transplanteRESUMO
OBJECTIVE: To evaluate the prognostic value of absent thumb pain sensation in newborns and young infants with birth brachial plexopathy. METHODS: We evaluated 131 patients with birth brachial plexopathy with less than two months of age. Pain sensation was evoked by thumb nail bed compression to evaluate sensory fibers of the upper trunk (C6). The patients were followed-up monthly. Patients with less than antigravity elbow flexion at six months of age were considered to have a poor outcome. RESULTS: Thirty patients had absent thumb pain sensation, from which 26 showed a poor outcome. Sensitivity of the test was 65% and specificity was 96%. CONCLUSION: Evaluation of thumb pain sensation should be included in the clinical assessment of infants with birth brachial plexopathy.
Assuntos
Traumatismos do Nascimento/fisiopatologia , Neuropatias do Plexo Braquial/diagnóstico , Plexo Braquial/lesões , Hipestesia/diagnóstico , Limiar da Dor/fisiologia , Polegar/fisiopatologia , Traumatismos do Nascimento/complicações , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Articulação do Cotovelo/fisiologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Prognóstico , Amplitude de Movimento Articular , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: To evaluate the prognostic value of absent thumb pain sensation in newborns and young infants with birth brachial plexopathy. METHODS: We evaluated 131 patients with birth brachial plexopathy with less than two months of age. Pain sensation was evoked by thumb nail bed compression to evaluate sensory fibers of the upper trunk (C6). The patients were followed-up monthly. Patients with less than antigravity elbow flexion at six months of age were considered to have a poor outcome. RESULTS: Thirty patients had absent thumb pain sensation, from which 26 showed a poor outcome. Sensitivity of the test was 65% and specificity was 96%. CONCLUSION: Evaluation of thumb pain sensation should be included in the clinical assessment of infants with birth brachial plexopathy.
OBJETIVO: Avaliar o valor prognóstico da hipoestesia dolorosa no polegar em recém-nascidos e lactentes jovens com plexopatia braquial obstétrica. MÉTODOS: Avaliamos 131 pacientes com plexopatia braquial obstétrica com menos de dois meses de idade. A sensação dolorosa foi provocada pela compressão do leito ungueal do polegar para avaliar fibras sensitivas do tronco superior (C6). Os pacientes foram seguidos mensalmente. Prognóstico desfavorável foi atribuído aos pacientes sem força antigravitacional para flexão do cotovelo aos seis meses de idade. RESULTADOS: Trinta pacientes apresentaram hipoestesia dolorosa do polegar, dos quais 26 tiveram prognóstico desfavorável. A sensibilidade do teste foi de 65% e a especificidade 96%. CONCLUSÃO: A avaliação da sensibilidade dolorosa do polegar deve ser incluída na avaliação clínica de pacientes com plexopatia braquial obstétrica.
Assuntos
Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Traumatismos do Nascimento/fisiopatologia , Neuropatias do Plexo Braquial/diagnóstico , Plexo Braquial/lesões , Hipestesia/diagnóstico , Limiar da Dor/fisiologia , Polegar/fisiopatologia , Traumatismos do Nascimento/complicações , Neuropatias do Plexo Braquial/fisiopatologia , Plexo Braquial/fisiopatologia , Articulação do Cotovelo/fisiologia , Prognóstico , Amplitude de Movimento Articular , Sensibilidade e EspecificidadeRESUMO
OBJECT: Classically, C5-7 root injuries of the brachial plexus have been associated with palsies of shoulder abduction/external rotation, elbow flexion/extension, and wrist, thumb, and finger extension. However, current myotome maps generally indicate that C-8 participates in the innervation of thumb and finger extensors. Therefore, the authors have hypothesized that, for palsies of the thumb and finger extensors, the injury should affect the C-5 through C-8 roots. METHODS: The authors tested their hypothesis in 30 patients with upper-type palsies of the brachial plexus. They traced a correlation between clinical findings and root injury, as documented by CT myelography, direct visualization during surgery, and electrophysiological studies. RESULTS: In C5-8 root injuries, shoulder abduction and external rotation were paralyzed, and in all patients, wrist extensors were paralyzed. However, in 22 of the 30 patients, wrist extension was possible, because of contraction of the extensor digitorum communis and extensor pollicis longus. Wrist flexion and pronation also were preserved. The T-1 root contributed significantly to innervation of the thumb and finger flexors, ensuring 34% grasping and 40% pinch strength relative to the normal side. Hand sensation was largely preserved. CONCLUSIONS: Based on the authors' observations, they suspect that the clinical scenario previously attributed to a C5-7 root injury is, in fact, a C5-8 root injury. The authors propose referring to this partial palsy of the brachial plexus as a "T-1 hand."
Assuntos
Neuropatias do Plexo Braquial/fisiopatologia , Plexo Braquial/lesões , Plexo Braquial/fisiopatologia , Paralisia/fisiopatologia , Raízes Nervosas Espinhais/lesões , Raízes Nervosas Espinhais/fisiopatologia , Adolescente , Adulto , Neuropatias do Plexo Braquial/etiologia , Neuropatias do Plexo Braquial/cirurgia , Vértebras Cervicais , Articulação do Cotovelo/inervação , Articulação do Cotovelo/fisiologia , Feminino , Dedos/inervação , Dedos/fisiologia , Força da Mão/fisiologia , Humanos , Masculino , Paralisia/etiologia , Paralisia/cirurgia , Articulação do Ombro/inervação , Articulação do Ombro/fisiologia , Polegar/inervação , Polegar/fisiologia , Articulação do Punho/inervação , Articulação do Punho/fisiologia , Adulto JovemRESUMO
After injury of the brachial plexus, sensory disturbance in the affected limb varies according to the extent of root involvement. The goal of this study was to match sensory assessments and pain complaints with findings on CT myelo scans and surgical observations. One hundred fifty patients with supraclavicular stretch injury of the brachial plexus were operated upon within an average of 5.4 months of trauma. Preoperatively, upper limb sensation was evaluated using Semmes-Weinstein monofilaments. Pain complaints were recorded for each patient. With lesions affecting the upper roots of the brachial plexus, hand sensation was largerly preserved. Sensory disturbances were identified over a longitudinal bundle on the lateral arm and forearm. In C8-T1 root injuries, diminished protective sensation was observed on the ulnar aspect of the hand. If the C7 root also was injured, sensation in the long finger was impaired. Eighty-four percent of our 64 patients with total palsy reported pain, versus just 47% of our 72 patients with upper type palsies. This rate dropped to 29% in the 14 patients with a lower-type palsy. C8 and T1, when injured, always were avulsed from the cord; when avulsion of these roots was the only nerve injury, pain was absent. Hand sensation was largely preserved in patients with partial injuries of the brachial plexus, particularly on the radial side. Even when T1 was the only preserved root, hand sensation was mostly spared. This indicates that overlapping of the dermatomal zones seems much more widespread than previously reported.
Assuntos
Neuropatias do Plexo Braquial/etiologia , Plexo Braquial/lesões , Plexo Braquial/fisiopatologia , Dor/etiologia , Polirradiculopatia/fisiopatologia , Distúrbios Somatossensoriais/etiologia , Extremidade Superior/lesões , Extremidade Superior/fisiopatologia , Adulto , Plexo Braquial/diagnóstico por imagem , Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/diagnóstico , Feminino , Humanos , Masculino , Mielografia , Dor/diagnóstico , Paralisia/diagnóstico , Paralisia/etiologia , Paralisia/fisiopatologia , Polirradiculopatia/diagnóstico , Polirradiculopatia/diagnóstico por imagem , Polirradiculopatia/etiologia , Estudos Prospectivos , Distúrbios Somatossensoriais/diagnóstico , Distúrbios Somatossensoriais/fisiopatologia , Tomografia Computadorizada por Raios X , Extremidade Superior/diagnóstico por imagem , Extremidade Superior/cirurgiaRESUMO
OBJECTIVE: Phrenic nerve transfer has been used for treating lesions of the brachial plexus since 1970. Although, today, surgeons are more experienced with the technique, there are still widespread concerns about its effects on pulmonary function. This study was undertaken to evaluate the effectiveness and safety of this procedure. METHODS: Fourteen patients with complete palsy of the upper limb were submitted to phrenic nerve transfer as part of a strategy for surgical reconstruction of their plexuses. Two patients were lost to follow-up, and 2 patients were followed for less than 2 years. Of the remaining 10 patients, 9 (90%) were male. The lesions affected both sides equally. The mean age of the patients was 24.8 years (range, 14-43 years), and the mean interval from injury to surgery was 6 months (range, 3-9 months). The phrenic nerve was always transferred to the musculocutaneous nerve, and a nerve graft (mean length, 8 cm; range, 4.5-12 cm) was necessary in all cases. RESULTS: There was no major complication related to the surgery. Seven patients (70%) recovered functional level biceps strength (Medical Research Council grade >or=3). All of the patients exhibited a transient decrease in pulmonary function tests, but without clinical respiratory problems. CONCLUSION: On the basis of our small series and data from the literature, we conclude that phrenic nerve transfer in well-selected patients is a safe and effective procedure for recovering biceps function.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Transferência de Nervo/métodos , Paralisia/cirurgia , Nervo Frênico/transplante , Adolescente , Adulto , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/patologia , Neuropatias do Plexo Braquial/fisiopatologia , Cotovelo/anatomia & histologia , Cotovelo/fisiologia , Feminino , Humanos , Masculino , Paralisia/patologia , Paralisia/fisiopatologia , Nervo Frênico/anatomia & histologia , Nervo Frênico/fisiologia , Amplitude de Movimento Articular/fisiologia , Recuperação de Função Fisiológica/fisiologia , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The criteria and timing for nerve surgery in infants with obstetric brachial plexopathy remain controversial. Our aim was to develop a new method for early prognostic assessment to assist this decision process. METHODS: Fifty-four patients with unilateral obstetric brachial plexopathy who were ten to sixty days old underwent bilateral motor-nerve-conduction studies of the axillary, musculocutaneous, proximal radial, distal radial, median, and ulnar nerves. The ratio between the amplitude of the compound muscle action potential of the affected limb and that of the healthy side was called the axonal viability index. The patients were followed and classified in three groups according to the clinical outcome. We analyzed the receiver operating characteristic curve of each index to define the best cutoff point to detect patients with a poor recovery. RESULTS: The best cutoff points on the axonal viability index for each nerve (and its sensitivity and specificity) were <10% (88% and 89%, respectively) for the axillary nerve, 0% (88% and 73%) for the musculocutaneous nerve, <20% (82% and 97%) for the proximal radial nerve, <50% (82% and 97%) for the distal radial nerve, and <50% (59% and 97%) for the ulnar nerve. The indices from the proximal radial, distal radial, and ulnar nerves had better specificities compared with the most frequently used clinical criterion: absence of biceps function at three months of age. CONCLUSIONS: The axonal viability index yields an earlier and more specific prognostic estimation of obstetric brachial plexopathy than does the clinical criterion of biceps function, and we believe it may be useful in determining surgical indications in these patients.
Assuntos
Traumatismos do Nascimento/diagnóstico , Neuropatias do Plexo Braquial/diagnóstico , Plexo Braquial/fisiopatologia , Condução Nervosa , Potenciais de Ação , Traumatismos do Nascimento/cirurgia , Neuropatias do Plexo Braquial/cirurgia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Força Muscular , Seleção de Pacientes , Prognóstico , Curva ROC , Sensibilidade e Especificidade , Extremidade Superior/inervaçãoRESUMO
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
BACKGROUND: Tumours of the brachial plexus region are rare and most publications are case reports or studies with a small series of patients. The aim of this study is to present our experience in managing these lesions. METHODS: We review 18 patients with tumours in the brachial plexus region submitted to surgical treatment in a 6 year period, including their clinical presentation, neuro-imaging data, surgical findings and outcome. FINDINGS: The tumours comprised a heterogeneous group of lesions, including schwannomas, neurofibromas, malignant peripheral nerve sheath tumour (MPNST), sarcomas, metastases, desmoids and an aneurysmal bone cyst. The most common presentation was an expanding lump (83.33%). Eleven tumours were benign and 7 were malignant. Neurofibromatosis was present in only 2 patients (11.11%). Gross total resection was achieved in 14 patients and sub-total resection in the others. Only 3 patients presented with new post-operative motor deficits. The incidence of complications was low (16.5 %). CONCLUSIONS: The majority of tumours were benign and most of them could be excised with a low incidence of additional deficits. Some of the malignant tumours could be controlled by surgery plus adjuvant therapy, but this category is still associated with high morbidity and mortality rates.
Assuntos
Neuropatias do Plexo Braquial/diagnóstico , Neuropatias do Plexo Braquial/cirurgia , Plexo Braquial/patologia , Plexo Braquial/cirurgia , Neoplasias do Sistema Nervoso Periférico/diagnóstico , Neoplasias do Sistema Nervoso Periférico/cirurgia , Adolescente , Adulto , Cistos Ósseos Aneurismáticos/diagnóstico , Cistos Ósseos Aneurismáticos/patologia , Cistos Ósseos Aneurismáticos/cirurgia , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Criança , Feminino , Fibromatose Agressiva/diagnóstico , Fibromatose Agressiva/fisiopatologia , Fibromatose Agressiva/cirurgia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica/diagnóstico , Metástase Neoplásica/fisiopatologia , Recidiva Local de Neoplasia/epidemiologia , Neoplasias de Bainha Neural/diagnóstico , Neoplasias de Bainha Neural/fisiopatologia , Neoplasias de Bainha Neural/cirurgia , Neurilemoma/diagnóstico , Neurilemoma/fisiopatologia , Neurilemoma/cirurgia , Neurofibroma/diagnóstico , Neurofibroma/fisiopatologia , Neurofibroma/cirurgia , Procedimentos Neurocirúrgicos , Dor/etiologia , Parestesia/etiologia , Neoplasias do Sistema Nervoso Periférico/fisiopatologia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Sarcoma/diagnóstico , Sarcoma/fisiopatologia , Sarcoma/cirurgia , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto JovemRESUMO
O autor apresenta 20 casos de paralisia alta do plexo braquial, acometendo as raízes C5, C6 ± C7, tratadas pela neurotização dos fascículos do nervo musculocutâneo que inervam o músculo bíceps braquial por fascículos do nervo ulnar para recuperação da flexão do cotovelo (Técnica de Oberlin).A neurorrafia pode ser executada sem enxertos nervosos de interposição. Em todos os paciente aferiu-se resultado positivo, com início da recuperação funcional aos 5,5 ± 1,7 meses pós- operatórios e flexão do cotovelo contra resistência aos 14,7 ± 5,5 meses depois da cirurgia.A seqüela provocada pela secção dos fascículos doadores do nervo ulnar foram clinicamente desprezíveis quando comparadas ao beneficio proporcionado. O sucesso alcançado pelo procedimento cirúrgico se deu, principalmente, pelo curto espaço de tempo entre o acidente e a cirurgia. Os resultados descritos estão de acordo com os da literatura e reafirmam que a neurotização "Ulnar-Biceps" e o procedimento de escolha para o tratamento cirúrgico das paralisias altas do plexo braquial.
The author presents 20 cases of upper brachial plexus palsies, concerning C5, C6 ± C7 roots, treated by neurotization of the musculocutaneus nerve fascicles innervating the biceps brachial muscle with ulnar nerve fascicles to recover elbow flexion (Oberlin's Technique). The neurorraphy could be executed without interposition of nerve grafts. All the patients had positive result, with beginning of the functional recovery at 5.5 ± 1.7 of postoperative month sandel bow flexi on again stresistance at 14.7 ± 5.5 months after the surgery. The sequel provoked by the sectioned donor fascicles of the ulnar nerve is clinically worthless when compared with the benefit produced. The success reached by the surgical procedure can be mainly given by short gap of time between accident and surgery. The described results are in accordance with the literature and reaffirm that the Ulnar-Biceps neurotization is the first choice procedure for the surgical treatment of the upper brachial plexus palsies.
Assuntos
Humanos , Plexo Braquial , Paralisia , Nervo Ulnar , Nervo Ulnar/anormalidades , Nervo Ulnar/cirurgia , Nervo Ulnar/patologia , Paralisia/cirurgia , Plexo Braquial/anatomia & histologia , Plexo Braquial/anormalidades , Plexo Braquial/cirurgia , Plexo Braquial/fisiopatologia , Plexo Braquial/lesõesRESUMO
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
OBJECT: The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. METHODS: Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90 degrees and 92 degrees in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70 degrees. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3 + and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. CONCLUSIONS: Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.
Assuntos
Plexo Braquial/lesões , Plexo Braquial/cirurgia , Transferência de Nervo , Escápula/inervação , Raízes Nervosas Espinhais/cirurgia , Nervo Acessório/fisiopatologia , Nervo Acessório/cirurgia , Adolescente , Adulto , Plexo Braquial/fisiopatologia , Articulação do Cotovelo/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Nervo Musculocutâneo/fisiopatologia , Nervo Musculocutâneo/cirurgia , Nervo Frênico/fisiopatologia , Nervo Frênico/cirurgia , Amplitude de Movimento Articular/fisiologia , Recuperação de Função Fisiológica/fisiologia , Articulação do Ombro/fisiopatologia , Resultado do Tratamento , Nervo Ulnar/fisiopatologia , Nervo Ulnar/cirurgiaRESUMO
PURPOSE: To describe the clinical features of patients with a neurophysiologic diagnosis of carpal tunnel syndrome (CTS) in the state of Rio Grande do Sul, Brazil. METHODS: We prospectively studied 1039 patients with a neurophysiologic diagnosis of CTS in southern Brazil. All patients completed a clinicoepidemiological questionnaire which included a drawing of the arm and hand, in which they were asked to paint the areas in which paresthesia and pain occurred. In part of the sample, we also investigated the presence of clinical signs such as Tinel's, Phalen, and tenar atrophy. The diagnosis of CTS was performed using a predetermined neurophysiological protocol. RESULTS: A total of 1528 hands were diagnosed with CTS. The severity of CTS was mild in 42% of cases, moderate in 18% and severe in 40%. Patients had a mean age of 48.3 +/- 12.4 years old, and a ratio of 5.6 females to 1 male was observed. Symptoms restricted to the hand and wrist was observed in 51.8% of cases with paresthesia and in 18.5% of cases with pain. In 92.5% of the partially affected hands, paresthesia was present in at least one of the first three fingers, while pain affected the three first fingers in 78.8% of these hands. Pain with a distribution which did not involve the hand occurred in 18.5% of cases, while paresthesia without involvement of the hand occurred in only 1.9%. Distribution of symptoms, according to Katz's hand diagram, showed a classic pattern in 12.6% of affected hands, a pattern classified as probable CTS in 66.3%, and an unlikely CTS pattern in 4.1%. Tinel's and Phalen's sign were observed in 34.2 and 56.3% of the hands, respectively. CONCLUSION: The clinical presentation of CTS is pleomorphic, ranging from the absence of symptoms to very severe cases. This variation probably is dependent on coexistent diseases, such as tendinitis and fibromyalgia, as well as on subjective aspects of the patients.
Assuntos
Síndrome do Túnel Carpal/complicações , Dor/etiologia , Parestesia/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Plexo Braquial/fisiopatologia , Brasil , Síndrome do Túnel Carpal/diagnóstico , Síndrome do Túnel Carpal/fisiopatologia , Criança , Eletromiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Condução Nervosa/fisiologia , Estudos Prospectivos , Tempo de Reação/fisiologia , Índice de Gravidade de DoençaRESUMO
Recently, our laboratory has proposed the avulsion of rat brachial plexus as a new and reliable model for the study of neuropathic pain. In this model, the neuropathy can be detected even at distant sites from the injury, both in ipsilateral and contralateral hindpaws. The purpose of this study was to pharmacologically characterise this behavioural model of persistent peripheral neuropathic pain by assessing the effects of several analgesic drugs currently used in clinical practice. For this purpose, the effects of these drugs on the mechanical and cold allodynia were analysed 20-40 days after rat brachial plexus avulsion. Injection of saline, administered by the same route as the other drugs, did not significantly affect the nociceptive threshold either in sham-operated or in neuropathic rats. However, administration of the opioid analgesic morphine (5 mg/kg, s.c.), the alpha2 adrenoceptor agonist clonidine (300 microg/kg, i.p.), the NMDA receptor antagonist ketamine (25 mg/kg, i.p.) or the anticonvulsant drug gabapentin (70 mg/kg, p.o.) consistently reduced both mechanical and cold allodynia following avulsion of rat brachial plexus. The administration of the selective COX-2 inhibitor celecoxib (10 mg/kg, p.o.) blocked mechanical allodynia, but not cold allodynia, whereas the sodium channel blocker lidocaine (40 mg/kg, i.p.) attenuated only cold allodynia. The non-steroidal anti-inflammatory drug diclofenac (100 mg/kg, i.p.), the steroidal anti-inflammatory dexamethasone (1.5 mg/kg, i.p.) and the antidepressant imipramine (10 mg/kg, i.p.) all failed to significantly attenuate both mechanical and cold allodynia in the rats following avulsion of brachial plexus. These findings suggest that avulsion-associated mechanical and cold allodynia, two classic signs of persistent neuropathic pain, were consistently prevented by several analgesics currently available in clinical practice, namely morphine, clonidine, ketamine and gabapentin, and to a lesser extent by celecoxib and lidocaine. Therefore, this new proposed model of persistent nociception seems to be suitable for the study of the underlying mechanisms involved in neuropathic pain and for the identification of potential clinically relevant drugs to treat this aspect of peripheral neuropathy.
Assuntos
Aminas , Analgésicos/uso terapêutico , Neuropatias do Plexo Braquial/tratamento farmacológico , Plexo Braquial/fisiopatologia , Ácidos Cicloexanocarboxílicos , Neuralgia/tratamento farmacológico , Nociceptores/efeitos dos fármacos , Limiar da Dor/efeitos dos fármacos , Ácido gama-Aminobutírico , Acetatos/uso terapêutico , Análise de Variância , Animais , Plexo Braquial/efeitos dos fármacos , Plexo Braquial/lesões , Neuropatias do Plexo Braquial/etiologia , Neuropatias do Plexo Braquial/fisiopatologia , Celecoxib , Clonidina/uso terapêutico , Modelos Animais de Doenças , Gabapentina , Ketamina/uso terapêutico , Lidocaína/uso terapêutico , Masculino , Morfina/uso terapêutico , Neuralgia/etiologia , Neuralgia/fisiopatologia , Medição da Dor , Pirazóis , Radiculopatia/complicações , Radiculopatia/tratamento farmacológico , Radiculopatia/fisiopatologia , Ratos , Ratos Wistar , Sulfonamidas/uso terapêuticoRESUMO
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.