Background:High-velocity projectile injuries to the regio deltoidea (RD) can result in persistent pain and motor shoulder dysfunction (MSD). The underlying mechanisms may involve direct axillary nerve (Ax) trauma or remote nociceptor irritation caused by cavitation effects. Objective:To characterize the anatomical basis of MSD and to establish a reliable diagnostic and surgical strategy for its management. Methods:Twenty-seven patients presenting with painful MSD following projectile trauma to the RD were included. Eight patients exhibited deltoid palsy associated with Ax injury, of whom three underwent Ax reconstruction. After positive diagnostic nerve blocks, 25 patients proceeded to denervation of the glenohumeral joint (GHJ): anterior ( n = 15) or posterior ( n = 3). Surgical procedures included neurotomy of the lateral pectoral nerve ( n = 18), suprascapular nerve ( n = 3), and Ax ( n = 4). In patients with persistent CRPS-like symptoms, neurotomy of the intercostal nerves (ICN) was performed. Results:Pain relief following Ax surgery was achieved in 25%. Anterior GHJ denervation resulted in 60% pain improvement, whereas posterior showed no significant benefit. RD injuries in 45% cases exhibited CRPS type I-like manifestations. Subsequent ICN neurotomy in 12 patients effectively resolved these symptoms. Conclusion:High-velocity projectile injuries to the RD may provoke nociceptor irritation at a distance from the entry site through a cavitation mechanism. Direct Ax injury accounted for only 25% of MSD cases. Irritated nociceptors generate CRPS-like symptoms at painful MSD without overt nerve disruption. Targeted neurotomy of the involved nociceptors represents a reasonable therapeutic option for pain alleviation in selected patients.
Background:Considerable between-center variability exists in the upper limit of normal (ULN) for the cross-sectional area (CSA) of the median nerve (MN) used to support the diagnosis of carpal tunnel syndrome (CTS). Objective:To evaluate whether a Dutch wrist circumference-dependent (WCD) equation for the ULN of MN CSA provides comparable classification of abnormal CSA in Italian and Dutch CTS populations. Methods:Wrist circumference (WC) and MN CSA were measured in 55 Italian (85 wrists) and 175 Dutch (175 wrists) patients with CTS. Abnormal wrists were identified using three thresholds: ULN9 (9 mm 2 ), ULN11 (11 mm 2 ), and a WCD equation ( y = 0.88 * x - 4, with y as ULN in mm 2 x as WC in cm). Findings were compared with electrodiagnostic results. Results:No significant differences in WC or MN CSA were observed between groups. The proportion of abnormal wrists in the Italian and Dutch populations, respectively, was 83.5 and 78.3% (ULN9, p = 0.321), 49.4 and 50.3% (ULN11, p = 0.895), and 61.1 and 55.4% (WCD, p = 0.379). Among 12 Italian patients with small wrists, abnormal results were found in 75.0% (ULN9), 25.0% (ULN11), and 66.7% (WCD). All Italian patients had abnormal electrodiagnostic testing results, compared with 66.3% of Dutch patients ( p < 0.0001). Conclusion:The WCD ULN for MN CSA yielded similar results in Italian and Dutch patients with CTS, and may be particularly useful in individuals with smaller wrists.
Background:Restoration of elbow extension in obstetric brachial plexus injury (OBPI) with triceps paralysis is essential for optimizing upper limb function, although often considered a secondary objective. Objective:To assess long-term functional outcomes of triceps reinnervation via nerve transfers in pediatric OBPI patients with persistent triceps paralysis. Methods:This retrospective cohort included 16 patients who underwent triceps reanimation between 2007 and 2018. Inclusion criteria were the absence of active elbow extension and a minimum 4-year follow-up. Depending on the lesion level, nerve transfers involved motor branches of the ulnar nerve to the flexor carpi ulnaris (FCUm) and intercostal nerves. Descriptive notes of these procedures are provided in the text. Outcomes were evaluated using the Medical Research Council (MRC) scale for strength and Gilbert's Elbow Scale (GES) for function. Results:Mean age at surgery was 48.9 months (range: 8-96), with a minimum follow-up of 4 years. At final evaluation, triceps strength improved significantly (mean MRC: 3.75, median: 4) as did elbow function (mean: GES 3.75, median: 4) compared with preoperative values ( p < 0.01). Triceps recovery contributed to a mean 35-degree reduction in elbow flexion contracture, suggesting a preventive role against progressive deformity. No complications or donor site morbidity were observed. Conclusion:Delayed nerve transfers for triceps reinnervation-performed up to 8 years of age-yielded satisfactory long-term results without compromising recovery. These findings support including elbow extension restoration among surgical priorities in OBPI management, even for complete brachial plexus palsies when suitable donor nerves remain available after primary reconstructions.
Background:Peripheral nerve injuries may accompany traumatic extremity injuries and are associated with significant morbidity. Diagnostic options are limited in young children since compliance might be restricted. High-resolution ultrasound (HRUS) is a promising technique to close the diagnostic gap, but clear recommendations are lacking. This study evaluates clinical outcomes after conservative versus surgical management, considering HRUS findings in pediatric patients with upper extremity peripheral nerve injuries. Methods:We retrospectively analyzed our pediatric neurosurgery database from August 2008 to December 2022 including patients < 18 years with traumatic upper extremity nerve injury and excluding obstetrical brachial plexus injury. Systematic HRUS examinations were implemented from 2016 onwards. Clinical, intraoperative, sonographic and electrophysiological findings were assessed. Results:A total of 73 nerve injuries in 67 patients (median age = 7.0 years) were analyzed. The most frequently affected nerves were the ulnar (49.3%), radial (21.9%), and median nerve (19.2%). At initial presentation, 47.9% underwent electrophysiology and 67.1% received HRUS. Surgery was performed in 49.3% at a median of 4 months posttrauma, whereas 50.7% were managed conservatively. Patients undergoing surgery initially had more severe sensory and motor deficits (χ 2 = 3.98, p = 0.046), but final outcomes showed no significant difference in nerve function (median follow-up = 6.0 months). Binary logistic regression identified age (odds ratio [OR] = 1.3, p = 0.028), HRUS (OR = 10.6, p = 0.035), and injured nerve (OR = 3.1, p = 0.022) as independent outcome predictors. Interpretation:Good functional recovery in pediatric patients with peripheral nerve injury was demonstrated. HRUS-guided treatment and age < 9 years were independent predictors of favorable outcome. These findings support HRUS as a valuable, noninvasive tool for guiding pediatric nerve injury management.
True neurogenic thoracic outlet syndrome (nTOS) is a rare condition resulting from brachial plexus compression, frequently associated with congenital anomalies such as cervical ribs or fibrous bands. We report a unique case of nTOS involving both a cervical rib and fibrous band, complicated by an incidental intraoperative finding of a fascicular rupture in the lower part of lower trunk. Notably, the patient had no history of trauma but had undergone multiple sessions of manual therapy and a single extracorporeal shockwave therapy to the cervical region, raising concerns about a potential iatrogenic contribution.
Background:Iatrogenic nerve injuries of the upper limb have profound impacts on patients their pain, functionality, and quality of life. Objectives:This study aims to identify and analyze the most cited publications on those iatrogenic injuries to elicit trends, thematic analysis, and reduce risk. Methodology:A bibliometric analysis was performed using the Web of Science database. Search terms included "Iatrogenic," "Upper Limb," "Nerve," and "Injury." The top 50 cited peer-reviewed publications were ranked by citation count and analyzed for publication year, journal, country of origin, institutional affiliations, authorship, and research focus. Trends in diagnostic and management practices were also evaluated. Results:The most cited articles, published between 1995 and 2022, peaked in publication frequency in 2010 and 2017 ( n = 4 each). Citation counts ranged from 7 to 260, with a median of 26.5 (± 15.0, 95% confidence interval: 16-75). These articles were featured in 44 journals. The United States emerged as the leading contributor in both volume and impact ( n = 16). Prominent themes included supracondylar humerus fractures ( n = 21) and humeral shaft fractures ( n = 10), alongside mentions of diaphyseal humeral fractures and shoulder surgery ( n = 4 each). Ulnar nerve injuries were the most frequently discussed ( n = 23), followed by injuries involving multiple nerves ( n = 18) and the radial nerve ( n = 14). Conclusions:This bibliometric analysis highlights key studies on iatrogenic upper limb nerve injuries, identifies trends and gaps, and lays a foundation for evidence-based protocols. It also serves as a guide for future research and collaborative efforts to improve prevention and treatment.
Restoring elbow flexion is a priority in adults with complete brachial plexus palsy. If the nerve root is not avulsed, a graft can be placed between the existing root and the musculocutaneous nerve. The aim of this study was to evaluate the outcomes of using vascularized ulnar nerve grafts in this context. Our case series consisted of 17 male and 3 female patients (mean age of 31 years) presenting complete brachial plexus palsy after a motorcycle accident. A graft at the C5 or C6 root on the musculocutaneous nerve was done in all patients using a pedicled vascularized ulnar nerve to restore elbow flexion at a mean of 5 months after the accident. At a mean follow-up of more than 3 years, elbow flexion was graded as M4 in six patients and between M0 and M2 in the other 14 patients on the Medical Research Council scale. None of the patients had M3 strength. While the results of long grafts using a vascularized ulnar nerve are disappointing in this case series, they are consistent with previous publications. Encouraging results have only been reported with short grafts (<10 cm), which can rarely be used with supraclavicular lesions. For this reason, we currently prefer using a sural nerve graft or nerve transfer, when possible, to restore elbow flexion in adult patients with brachial plexus injuries.
Background:Peripheral brachial plexus injuries, particularly Radial nerve palsy (RNP), are a common complication of humeral shaft fractures. Despite previous research, the specific fracture patterns associated with RNP remain unclear. Objectives:This study aims to assess the frequency and patterns of humeral shaft fractures, determine the incidence of peripheral brachial plexus injuries such as radial and ulnar nerve palsies, and investigate the association between specific fracture patterns and these nerve injuries. We also explored other factors influencing RNP development and identified potential risk factors or predictors. Methods:This retrospective cohort study analyzed 144 patients with humeral shaft fractures at King Saud Medical City from 2015 to 2022. Patient data, such as age, gender, and neurovascular status, were extracted and analyzed using SPSS. RNP was diagnosed clinically. Statistical analyses included chi-square and student t -tests, with a p -value of <0.05 for significance. Results:This study found a 37.5% incidence of RNP in humeral shaft fractures. Significant differences were observed in age ( p = 0.032) and mechanism of injury ( p < 0.0001), with most fractures due to road traffic accidents (72.22%) and closed (93.75%). Common fracture patterns were AO 12A (37.5%) and AO 12B (39.58%), with a higher prevalence of comminuted fractures (71 cases). Significant differences in fracture patterns ( p < 0.0001) and anteromedial comminution ( p = 0.002) were noted between patients with and without RNP. Interestingly, four cases of concomitant ulnar nerve palsy were observed in patients with radial nerve palsy. However, no significant differences were found in gender ( p = 0.343), open fractures ( p = 0.214), or associated fractures ( p = 0.106). Conclusion:This study suggests that the severity of trauma, rather than specific fracture patterns, is a more significant factor in RNP development in humeral shaft fractures. Further research is needed to understand the underlying biomechanics.
Peripheral nerve masses have a wide differential diagnosis; however, there is no established diagnostic framework for evaluating non-neoplastic etiologies, such as inflammatory or infectious lesions. Here, we present a rare case of an ulnar nerve granuloma that initially mimicked a peripheral nerve sheath tumor (PNST) on imaging and clinical presentation to elucidate the relevant medical history, imaging, and histology that aid in distinguishing inflammatory, infectious, and neoplastic peripheral nerve lesions. An 85-year-old man with melanoma and multiple prior right elbow surgeries presented with right-hand weakness and a rapidly enlarging gadolinium-enhancing ulnar nerve mass suggestive of a PNST that warranted surgical resection. Surgical histology showed a necrotizing granulomatous lesion that then became most concerning for a parasitic infection. However, broad serum and histologic testing by the Centers for Disease Control and Prevention were all ultimately negative. The final diagnosis was an inflammatory reaction to a retained foreign body from his prior elbow surgeries. In summary, surgery and comprehensive histologic workup are required for diagnosing granulomatous peripheral nerve lesions that mimic PNSTs on imaging and infection on histology.
Introduction:To investigate a high-sensitivity electrodiagnostic (EDX) combination for diagnosing mild carpal tunnel syndrome (CTS). Methods:A total of 68 healthy controls (HCs, 136 hands) and 91 adult patients (CTSs, 162 hands) clinically diagnosed with CTS were enrolled. All patients accepted EDXs, including the sensory ganglia segment method of the median and ulnar nerves, and motor nerve conduction of the median and ulnar nerves. We examined the electrophysiological results and compared the sensitivity and specificity of various sensory nerve detection methods for the median nerve between the two groups. Results:The electrophysiological results of the CTSs were significantly different from those of HCs. All EDX techniques selected showed high specificity (>96.3%), positive predictive value (>95.2%), and large area under the curve (0.922 as the smallest) for the diagnosis of CTSs. A comparison of the median distal sensory latencies with the ulnar distal sensory latencies in fingers 2 and 4 showed a high sensitivity of 98.1%. Comparison of the nerve conduction study between the median and ulnar nerves in the same hand is the most reliable EDX technique for diagnosing very mild CTS because of its high sensitivity and specificity. Conclusion:If clinical CTS patients exhibit normal median motor distal latency or sensory nerve conduction velocity across the wrist, a comparison of median and ulnar nerve conduction through the wrist, including M-U and M-U ringdiff, is recommended.
The latissimus dorsi tendon transfer (LDTT) to the supraspinatus tendon is a common procedure for restoring shoulder abduction and external rotation in upper root brachial plexus lesions. However, its association with scapular retraction often limits shoulder abduction. This retrospective study compared the functional outcomes of teres major tendon transfer (TMTT) combined with anterior coracohumeral ligament release (CHLR) versus LDTT. Patients who underwent surgery at our center between January 2012 and December 2022 were included, with a mean follow-up of 38 months. Outcomes were assessed using a range of motion and the Mallet scale. A total of 40 patients were included, with 20 undergoing TMTT with CHLR and 20 undergoing LDTT. The overall mean age was 3.9 years (range: 2.7–4.8), with mean ages of 3.4 years (range: 2.2–5.2) in the LDTT group and 4.1 years (range: 2.8–5.2) in the TMTT with the CHLR group. The TMTT with CHLR group achieved mean gains of +77 degrees in active abduction, +44 degrees in active external rotation, and +46 degrees in passive external rotation. In comparison, the LDTT group demonstrated gains of +46, +27, and +24 degrees, respectively, for the same parameters. TMTT combined with anterior CHLR significantly improves shoulder abduction and external rotation in patients with Brachial plexus birth injury, particularly those with internal rotation contractures. This technique offers superior functional outcomes compared to LDTT, suggesting a more effective therapeutic alternative. IV, retrospective comparative study.
Brachial plexus injury (BPI) occurs when the brachial plexus (BP) is compressed, stretched, or avulsed. A mild BPI results in acute arm pain, tingling, or numbness, while more severe injuries can lead to permanent muscle weakness or loss of function of the extremity if left untreated. Many BPI treatments developed in small animal models fail to translate effectively to human clinical trials. Furthermore, there is a lack of comparative studies exploring the anatomical differences between BPs in different species. The objective of this study is to compare the BP anatomy between humans and Sprague–Dawley (SD) rats to determine if the SD rat is a suitable model for studying BPI mechanisms and treatments. Four human BPs were compared to five SD rat BPs. Gross anatomical analysis revealed mild similarities in the branching patterns of SD rat and human BP. Histological results indicated that SD rats had significantly smaller musculocutaneous (p = 0.0095), median (p < 0.0001), and ulnar (p < 0.0001) nerves compared to humans. Additionally, SD rats had significantly fewer axons than humans in the musculocutaneous (p = 0.0190), median (p < 0.0001), and ulnar nerves (p < 0.0001). Due to the anatomical and histological differences between the two species, therapeutic interventions for BPIs developed in rats should be further tested in a larger animal model, such as the Wisconsin Miniature Swine, before progressing to human clinical trials.
We present an easy classification for nerve lesions observed in reconstructive surgery for obstetric brachial plexus palsy, performed through a supraclavicular approach and systematic exposure of nerve roots and trunks. A description of signs related to nerve traction injury (scarring, fascicular rupture, and dislocated ganglions) is combined with a grading system of microscopic tissue changes occurring in slices from traumatized nerve endings (fascicular structure, changes in perineurium and endoneurium). Both tools are proposed for any surgical brachial plexus exploration and later interaction with other professionals (pediatricians, physiotherapists, or obstetricians).
Introduction GABA (gamma-aminobutyric acid) is the major inhibitory neurotransmitter in the brain. In response to injury within the central nervous system, GABA promotes cortical plasticity and represents a potential pharmacological target to improve functional recovery. However, it is unclear how GABA changes in the brain after traumatic brachial plexus injuries (tBPIs) which represents the rationale for this pilot study. Methods We serially scanned seven males (mean age 42 years [SD 19] without head injury) up to 19 months after tBPIs. T1-weighted images (1-mm isotropic resolution) and J-edited spectra (MEscher-GArwood Point RESolved Spectroscopy [MEGA-PRESS], TE 68 ms, TR 2,000 ms, 2 cm isotropic voxels) were acquired using a MAGNETOM Prisma 3T (Siemens Healthcare, Erlangen, Germany). Data were analyzed in jMRUI blind to clinical information to quantify GABA, creatine plus phosphocreatine (Cr), and N-acetylaspartate (NAA) concentrations. Additionally, gray matter and white matter proportions were assessed using SPECTRIM software. Interhemispheric means were compared using linear methods. Confidence intervals (CIs) were generated to the 95% level. Results Within weeks of injury, the hemisphere representing the injured upper limb had a significantly lower GABA:NAA ratio (mean difference 0.23 [CI 0.06-0.40]) and GABA:Cr ratio (mean difference 0.75 [CI 0.24-1.25]) than the uninjured side. There were no interhemispheric differences in NAA:Cr. By 12 months post-injury, interhemispheric differences in metabolite concentrations equalized. There was no difference in the proportion of gray matter, white matter, or cerebrospinal fluid between the injured and uninjured hemispheres. Conclusion After brachial plexus injuries, there are interhemispheric differences in GABA concentrations within the sensory and motor cortex. This represents a potential pharmacological target that warrants further investigation.
Background To date, there are no uniform guidelines for the treatment of obstetric plexus lesions in German-speaking countries. An end-to-end direct suture after resection of trunk neuroma is recommended for surgical treatment if tension-free coaptation is possible, whereas the use of autologous nerve grafts bridging the gap between the adaptation margins is advised by consensus if tension-free coaptation is impossible. Objective The aim of the study was to investigate which reconstruction strategy may provide a better recovery of motor function for patients after obstetric brachial plexus lesion. Methods This study compared postoperative functional outcome after obstetric brachial plexus palsy from a patient collective including a total of 43 children. The surgical techniques of plexus reconstruction by end-to-end coaptation versus the use of sural nerve interposition graft have been analyzed. Therefore, the degrees of active motion of abduction and external rotation in the shoulder joint, and flexion in the elbow joint were assessed using the neutral zero method. Results For abduction in the shoulder joint, significantly better motor function was found in the group with direct sutures (p = 0.033). For external rotation in the shoulder joint and flexion in the elbow joint, there was no statistically significant difference between the groups (p = 0.284 and p = 0.270, respectively). Conclusions This study could not demonstrate absolute superiority of either reconstruction method. Slight evidence was found for a better functional outcome for plexus reconstruction by direct coaptation. Further arguments support a better suitability of plexus reconstruction by direct suture if its use is justifiable.
Background Foot drop is a challenging condition that significantly impacts the affected patient's mobility and quality of life. Tendon transfer has emerged as a viable treatment option. We hereby present data of the tendon transfer procedures in patients with foot drop in our department. Besides a detailed description of our surgical technique, we also compare our results with those reported in the literature. Methods Data from 17 patients (11 males and 6 females) suffering from foot drop due to peripheral nerve or muscle lesions were retrospectively analyzed. All the patients underwent tendon transfer procedures between 2017 and 2022. Assessed outcomes encompassed parameters such as strength of foot dorsiflexion, the necessity for postoperative orthotic devices, and patient satisfaction. Demographic data, the time elapsed from injury/illness to surgery, and the underlying causes of foot drop were collected. Results Postsurgery, 14 patients regained robust dorsiflexion strength (M4), while 2 exhibited slightly lower strength (M3) and 1 attained equal strength as on the unaffected side (M5). Corrective procedures were undertaken in five patients to address problems with tendon tension. After an average follow-up period of 11.9 months (± 9.13), 82.4% of patients reported a high level of satisfaction, although three patients experienced persistent foot inversion. Most patients (94.1%) no longer required orthotic devices following the operative procedure. Conclusion A tendon transfer procedure for correction of foot drop has proven to be a safe and effective treatment option, resulting in a high level of patient satisfaction and restoration of quality of life.
Background Compression neuropathy, such as carpal tunnel syndrome (CTS), results in changed afferent nerve signaling, which may result in changes in somatosensory brain areas. The purpose of this study was to assess cerebral changes following unilateral CTS and to assess short-term and long-term cerebral effects of guided plasticity treatment using ipsilateral cutaneous forearm deafferentation. Methods Twenty-four patients with mild-to-moderate unilateral CTS were randomized to treatment with anesthetic cream (EMLA) or placebo. Patient-rated outcomes were assessed using Boston CTS questionnaire and disability of arm, shoulder, and hand questionnaire (QuickDASH). Patients were assessed for tactile discrimination and dexterity. Cortical activation during sensory stimulation was evaluated with functional magnetic resonance imaging at 3T. Assessments were performed at baseline, 90 minutes, and 8 weeks after treatment. Results Functional magnetic resonance imaging showed that sensory stimulation of the hand with CTS resulted in significantly less cortical activation in the primary somatosensory cortex (S1) than stimulation of the healthy hand. Treatment with cutaneous forearm deafferentation on the side with CTS resulted in increased cortical activation in S1 both after the initial treatment and following 8 weeks of treatment. In addition, QuickDASH and tactile discrimination showed improvement in the EMLA group over time. Conclusions Stimulation of median nerve-innervated fingers in patients with unilateral CTS results in smaller-than-normal activation in the contralateral S1. Cutaneous forearm anesthesia on the side with CTS results in larger activation in S1, suggesting recruitment of more neurons, and a slight improvement in sensory function.
► nerve transfer ► peripheral nerve surgery ► ulnar nerve ► median nerve ► plastic surgery ► ulnar nerve trauma ► anterior interosseous nerve ► deep motor branch ulnar nerve
Background With the advent of the coronavirus disease 2019 (COVID-19) pandemic, some doubts have been raised regarding the potential respiratory problems that patients who previously underwent a phrenic nerve transfer could have. Objectives To analyze the effects of the coronavirus infection on two populations, one from Argentina and another from Taiwan. Specific objectives were: (1) to identify the rate of COVID in patients with a history of phrenic nerve transfer for treatment of palsy; (2) to identify the overall symptom profile; (3) to compare Argentinian versus Taiwanese populations; and (4) to determine if any phrenic nerve transfer patients are at particular risk of more severe COVID. Methods A telephonic survey that included data regarding the number of episodes of acute COVID-19 infection, the symptoms it caused, the presence or absence of potential or life-threatening complications, and the status of COVID-19 vaccination were studied. Intergroup comparisons were conducted using the nonparametric Mann–Whitney U test, with categorical variables conducted using either the Pearson χ2 analysis or the Fisher's exact test, as appropriate. Results A total of 77 patients completed the survey, 40 from Taiwan and 37 from Argentina. Fifty-five (71.4%) developed a diagnosis of COVID. However, among these, only four had any level of dyspnea reported (4/55 = 7.3%), all mild. There were also no admissions to hospital or an intensive care unit, no intubations, and no deaths. All 55 patients isolated themselves at home. Conclusions It can be concluded that an acute COVID-19 infection was very well tolerated in our patients. (Level of evidence 3b, case reports).
