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Crowe CS, Pulos N, Spinner RJ, Bishop AT, Wigle DA, Shin AY. The diagnostic utility of inspiratory-expiratory radiography for the assessment of phrenic nerve palsy associated with brachial plexus injury. Acta Neurochir (Wien) 2023; 165:2589-2596. [PMID: 37198276 DOI: 10.1007/s00701-023-05622-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/06/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND The phrenic nerve is commonly injured with trauma to the brachial plexus. Hemi-diaphragmatic paralysis may be well-compensated in healthy individuals at rest but can be associated with persistent exercise intolerance in some patients. This study aims to determine the diagnostic value of inspiratory-expiratory chest radiography compared to intraoperative stimulation of the phrenic nerve for assessing phrenic nerve injury associated with brachial plexus injury. METHODS Over a 21-year period, the diagnostic utility of three-view inspiratory-expiratory chest radiography for identification of phrenic nerve injury was determined by comparison to intraoperative phrenic nerve stimulation. Multivariate regression analysis was used to identify independent predictors of phrenic nerve injury and having an incorrect radiographic diagnosis. RESULTS A total of 237 patients with inspiratory-expiratory chest radiography underwent intraoperative testing of phrenic nerve function. Phrenic nerve injury was present in approximately one-fourth of cases. Preoperative chest radiography had a sensitivity of 56%, specificity of 93%, positive predictive negative of 75%, and negative predictive value of 86% for identification of a phrenic nerve palsy. Only C5 avulsion was found to be a predictor of having an incorrect diagnosis of phrenic nerve injury on radiography. CONCLUSION While inspiratory-expiratory chest radiography has good specificity for detecting phrenic nerve injuries, a high number of false negatives suggest that it should not be relied upon for routine screening of dysfunction after traumatic brachial plexus injury. This is likely multifactorial and relates to variation in diaphragm shape and position, as well as limitations regarding static image interpretation of a dynamic process.
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Affiliation(s)
- Christopher S Crowe
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA
| | - Nicholas Pulos
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA
| | | | - Allen T Bishop
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA
| | - Dennis A Wigle
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, USA
| | - Alexander Y Shin
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, 200 1st St., Southwest Rochester, MN, 55905, USA.
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Yajima W, Yoshida T, Kondo T, Uzura M. Respiratory failure due to diaphragm paralysis after brachial plexus injury diagnosed by point-of-care ultrasound. BMJ Case Rep 2022; 15:15/2/e246923. [PMID: 35228232 PMCID: PMC8886360 DOI: 10.1136/bcr-2021-246923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A man in his fifties was injured in a traffic accident and diagnosed with traumatic subarachnoid haemorrhage, liver injury, and fractures of the rib, right clavicle, right scapula and right femur. He also presented with motor and sensory disturbances of the right upper extremity and was suspected of having a brachial plexus injury. After undergoing mechanical ventilation due to multiple traumas, he was extubated. However, he developed acute respiratory failure and required reintubation. Respiratory symptoms were not clear until just before reintubation. The diagnosis of right diaphragm paralysis was made using point-of-care ultrasound with no other findings that could cause respiratory failure. MRI led to the diagnosis of brachial plexus injury, which likely caused diaphragm paralysis. Point-of-care ultrasound provided a clear visualisation and rapid bedside diagnosis of diaphragm paralysis, which can be challenging to diagnose while ruling out other causes of respiratory failure.
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Reynaud V, Prigent H, Mulliez A, Durand MC, Lofaso F. Phrenic nerve conduction study to diagnose unilateral diaphragmatic paralysis. Muscle Nerve 2020; 63:327-335. [PMID: 33314195 DOI: 10.1002/mus.27144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Unilateral diaphragmatic paralysis (UDP) has major clinical and etiological implications and, therefore, is important to diagnose. Lung function tests and invasive transdiaphragmatic pressure (Pdi) measurements are widely used to this end but, contrary to phrenic nerve conduction study (NCS), they require volitional maneuvers and/or may be poorly tolerated by patients. The purpose of this study was to compare the diagnostic accuracy of Pdi and phrenic NCS for UDP. METHODS We retrospectively reviewed 28 patients with suspected UDP. The diagnosis established during a multidisciplinary meeting was the reference standard. RESULTS Phrenic NCS correlated well with Pdi (r = 0.82, P < .005), and the two tests showed good agreement (κ = 0.82, P < .005). Phrenic NCS and Pdi measurements both had 95% sensitivity, 87.5% specificity, 95% positive predictive, and 87.5% negative predictive values. CONCLUSIONS Both tests were highly sensitive and specific. Phrenic NCS measurement is a simple, reproducible, noninvasive method whose results correlate well with Pdi and provide insight into the UDP mechanism. In the most difficult cases, combining lung function tests, respiratory muscle assessments, and phrenic NCS can help to establish the diagnosis.
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Affiliation(s)
- Vivien Reynaud
- Centre Médical Germaine Revel, Chabanière, France.,Service de Physiologie et Explorations Fonctionnelles, GH Paris Ile de France Ouest - Site Raymond Poincaré - APHP, Garches, France
| | - Hélène Prigent
- Service de Physiologie et Explorations Fonctionnelles, GH Paris Ile de France Ouest - Site Raymond Poincaré - APHP, Garches, France
| | - Aurélien Mulliez
- Direction recherche clinique et Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Marie-Christine Durand
- Service de Physiologie et Explorations Fonctionnelles, GH Paris Ile de France Ouest - Site Raymond Poincaré - APHP, Garches, France
| | - Frédéric Lofaso
- Service de Physiologie et Explorations Fonctionnelles, GH Paris Ile de France Ouest - Site Raymond Poincaré - APHP, Garches, France
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Examining the Comparison of the Outcome Comparison of Nerve Transfer with Different Donor Nerves in a Rat Model. Can J Neurol Sci 2016. [DOI: 10.1017/cjn.2016.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Boudarham J, Pradon D, Prigent H, Falaize L, Durand MC, Meric H, Petitjean M, Lofaso F. Optoelectronic Plethysmography as an Alternative Method for the Diagnosis of Unilateral Diaphragmatic Weakness. Chest 2013; 144:887-895. [DOI: 10.1378/chest.12-2317] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Zheng MX, Qiu YQ, Xu WD, Xu JG. Long-term observation of respiratory function after unilateral phrenic nerve and multiple intercostal nerve transfer for avulsed brachial plexus injury. Neurosurgery 2012; 70:796-801; discussion 801. [PMID: 22426043 DOI: 10.1227/neu.0b013e3181f74139] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Phrenic nerve transfer (PNT) or multiple intercostal nerve transfer (MIT) alone are reported to have no significant impact on pulmonary function in the short or medium term, but it has rarely been reported whether the combination of PNT-MIT could influence respiratory function in the long term. OBJECTIVE Respiratory function was evaluated after PNT and PNT-MIT 7 to 19 years (mean, 10 years) postoperatively. METHODS Twenty-three adult patients with brachial plexus avulsion injuries who underwent PNT-MIT were compared with 19 corresponding patients who underwent PNT. Pulmonary function testings, phrenic nerve conduction study, and chest fluoroscopy were performed. In the PNT-MIT group, further investigation was performed on the effect of the number of transferred intercostal nerves and the timing of MIT. RESULTS In the PNT-MIT group, forced vital capacity, forced expiratory volume in one second, and total lung capacity were 73.69%, 72.04%, and 74.81% of predicted values without significant differences from the PNT group. Diaphragmatic paralysis permanently existed with 1 to 1.5 intercostal spaces (ICSs) elevation and near 1 ICS reduced excursion. There was no statistical difference between the PNT and PNT-MIT groups. Furthermore, 3 and 4 intercostal nerves transferred resulted in no further decrease in pulmonary function test results than 2 intercostal nerves. No significant difference was found when PNT and MIT were performed at the same stage or with an interval. CONCLUSION PNT-MIT did not result in additional impairment in respiratory function in adult patients compared with PNT alone. It is safe to transfer 2 to 4 intercostal nerves at 1 to 2 months delay after PNT.
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Affiliation(s)
- Mou-Xiong Zheng
- Department of Hand Surgery, Hua-Shan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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Pornrattanamaneewong C, Limthongthang R, Vathana T, Kaewpornsawan K, Songcharoen P, Wongtrakul S. Diaphragmatic height index: new diagnostic test for phrenic nerve dysfunction. J Neurosurg 2012; 117:890-6. [PMID: 22957532 DOI: 10.3171/2012.8.jns111734] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The diaphragmatic height index (DHI) was developed to measure the difference in diaphragm levels. The purpose of this study was to set definite DHI values and test the accuracy of these values for use as a new diagnostic test for phrenic nerve dysfunction. METHODS All data for this study were obtained from medical charts and retrospectively reviewed. RESULTS One hundred sixty-five patients with brachial plexus injury who had undergone nerve transfers between 2005 and 2008 were divided into Groups A and B. Group A consisted of 40 patients (mean age 28.0 years) who had sustained concomitant injury of the brachial plexus and phrenic nerves. Patients in Group A1 had right phrenic nerve injury and those in Group A2 had left phrenic nerve injury. Intraoperative direct electrical stimulation of the phrenic nerve was considered the gold standard in assessing nerve function in all patients with brachial plexus injury. Group B consisted of 125 patients (mean age 28.7 years) with brachial plexus injury and normal phrenic nerve function. Group C, the control group, consisted of 80 patients with nonbrachial plexus injury (mean age 34.0 years) who had undergone other kinds of orthopedic operations between April and June 2009. Standard posteroanterior chest radiographs were blindly interpreted using the Siriraj inhouse picture archiving and communication system in all 245 patients in the study. First, a reference line (R line) was drawn along the inferior endplate of T-10. Then, 2 lines (lines A and B) were drawn through the highest point of each diaphragm and parallel to the R line. The difference between these 2 lines divided by the height of T-10 was defined as the DHI. The cutoff points of the DHI for diagnosing right and left phrenic nerve dysfunction were analyzed with a receiver operating characteristic curve. The accuracy of these DHI values was then evaluated. The DHI in Group C was 0.64 ± 0.44, slightly higher than the DHI in Group B, with no significant difference. Diaphragmatic height indexes in Groups A1 and A2 were 2.0 ± 0.99 and -1.04 ± 0.83, respectively, which were significantly different from those in Groups B and C (p < 0.05). The cutoff point of the DHI for diagnosing right phrenic nerve dysfunction was > 1.1, and that for left phrenic nerve dysfunction was < 0.2. The sensitivity and specificity of right and left DHI values were 90.5% and 86.3%, and 94.7 and 88.3%, respectively. CONCLUSIONS Data in this study show that diaphragm paralysis can be simply and reliably predicted by the DHI. Diaphragmatic height index values > 1.1 and < 0.2 are proposed as the new diagnostic test for right and left phrenic nerve dysfunction with a high degree of accuracy. This index is applicable in diagnosing phrenic nerve dysfunction that occurs concomitantly with brachial plexus injury or from other etiologies.
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Kachramanoglou C, Li D, Andrews P, East C, Carlstedt T, Raisman G, Choi D. Novel strategies in brachial plexus repair after traumatic avulsion. Br J Neurosurg 2010; 25:16-27. [PMID: 20979435 DOI: 10.3109/02688697.2010.522744] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Clinical trials in spinal cord injury (SCI) can be affected by many confounding variables including spontaneous recovery, variation in the lesion type and extend. However, the clinical need and the paucity of effective therapies has spawned a large number of animal studies and clinical trials for SCI. In this review, we suggest that brachial plexus avulsion injury, a longitudinal spinal cord lesion, is a simpler model to test methods of spinal cord repair. We explore reconstructive techniques currently explored for the repair of brachial plexus avulsion and focus on the use of olfactory ensheathing cell transplantation as an adjunct treatment in brachial plexus repair.
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Abstract
Nerve transfers are becoming used increasingly for repair of severe nerve injures, especially brachial plexus injuries, where the proximal spinal nerve roots have been avulsed from the spinal cord. The procedure essentially involves the coaptation of a proximal foreign (donor) nerve to the distal denervated (recipient) nerve, so that the latter's end-organs will be reinnervated by the donated axons. Cortical plasticity appears to play an important physiologic role in the functional recovery of the reinnervated muscles. This article provides the indications for nerve transfer, principles for their use, and a comprehensive survey on various intraplexal and extraplexal nerves that have been used for transfer to repair clinical nerve injuries. Specific transfers to reanimate muscles denervated by the common patterns of brachial plexus are emphasized, including expected clinical outcomes based on the existing literature.
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Affiliation(s)
- Bassam M J Addas
- Division of Neurosurgery, Department of Surgery, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia
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Zhang CG, Terenghi G, Mantovani C, Wiberg M. Neuronal survival, regeneration and musclemorphology after posterior C7 nerve transfer:An experimental study. J Plast Reconstr Aesthet Surg 2006; 59:717-25. [PMID: 16782567 DOI: 10.1016/j.bjps.2005.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2005] [Accepted: 10/16/2005] [Indexed: 11/18/2022]
Abstract
C7 nerve transfer has been widely used in treating brachial plexus avulsion injuries. Little is known regarding the survival and regeneration of C7 motor and sensory neurons including their morphological changes after this procedure and also the possible change of muscle fibre phenotype. In this experimental study, the posterior division of C7 nerve was transferred to the musculocutaneous nerve ipsilaterally, and using fluorescent tracing techniques, the C7 spinal cord segment and dorsal root ganglion were found to contain 630.9 +/- 86.7 motor neurons and 3916.0 +/- 517.3 sensory neurons, respectively. Six months following transfer, 90% of the motor neurons and 78% of the sensory neurons survived and approximately 40% of them had regenerated and all displayed normal soma size. After posterior C7 transfer and reinnervation, the target muscles showed a percentage pattern of distribution and mean fibre diameters similar to those seen in normal biceps muscle. The present study suggests that the posterior C7 nerve transfer provides sufficient number of neurons and satisfactory results for regeneration to obtain an acceptable functional recovery.
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Affiliation(s)
- C-G Zhang
- Section for Hand and Plastic Surgery, Department of Surgical and Perioperative Science, University Hospital, Umeå, Sweden
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Jia L, Xu L, Jiang M, Gu Y, Zhang Z. Protein abnormality in denervated skeletal muscles from patients with brachial injury. Microsurgery 2005; 25:316-21. [PMID: 15880412 DOI: 10.1002/micr.20115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A proteomic analysis was performed to compare protein expression between normal sternocleidomastoid muscle and denervated muscle. Two-dimensional electrophoresis (2-DE) of muscle proteins showed that 26 proteins among about 800 spots in 2-DE gel displayed a decrease and 6 proteins an increase in expression in muscles with denervation atrophy compared to normal controls; the identified proteins that were abnormally expressed could be generally grouped together as metabolic proteins, chaperone proteins, and contractile-apparatus proteins. The significance of these altered proteins is discussed. In particular, the decrease in hD54 may reduce the activity of transmembrane signaling in atrophied muscle, while the disregulation of DnaJC 1 showed a possible role of molecular chaperones in the functional recovery of atrophied muscles.
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Affiliation(s)
- Linzhi Jia
- Department of Physiology and Biophysics, School of Life Sciences, Fudan University, Shanghai, People's Republic of China
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Electrodiagnostic assessment of respiratory dysfunction in motor neuron disease. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s1567-4231(04)04029-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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