Journal of Brachial Plexus and Peripheral Nerve Injury最新文献

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.

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.

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.

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.

Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

Level of evidence: 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).