Epidemiological characteristics of surgically treated civilian traumatic brachial plexus injuries in Serbia

Factors Affecting C5 Viability and Demographic Variability in Two Brachial Plexus Centers

Complete brachial plexus injuries are devastating injuries. A viable C5 spinal nerve can offer additional sources of axons and alter surgical treatment. We aimed to determine factors that portend C5 nerve root avulsion.

Methods

A retrospective study of 200 consecutive patients with complete brachial plexus injuries at two international centers (Mayo Clinic in the United States and Chang Gung Memorial Hospital in Taiwan) was performed. Demographic information, concomitant injuries, mechanism, and details of the injury were determined, and kinetic energy (KE) and Injury Severity Score were calculated. C5 nerve root was evaluated by preoperative imaging, intraoperative exploration, and/or intraoperative neuromonitoring. A spinal nerve was considered viable if it was grafted during surgery.

Results

Complete five-nerve root avulsions of the brachial plexus were present in 62% of US and 43% of Taiwanese patients, which was significantly different. Increasing age, the time from injury to surgery, weight, body mass index of patient, motor vehicle accident, KE, Injury Severity Score, and presence of vascular injury significantly increased the risk of C5 avulsion. Motorcycle (≤150cc) or bicycle accident decreased the risk of avulsion. Significant differences were found between demographic variables between the two institutions: age of injury, body mass index, time to surgery, vehicle type, speed of injury, KE, Injury Severity Score, and presence of vascular injury.

Conclusions

The rate of complete avulsion injury was high in both centers. Although there are a number of demographic differences between the United States and Taiwan, overall the KE of the accident increased the risk of C5 avulsion.

Peripheral nerve surgery in Serbia: "Think global, act local" and the privilege of service

Introduction

The phrase "think globally, act locally", which has often been used to refer to conservation of the environment, highlights the importance of maintaining a holistic perspective and stipulates that each individual has a role to play in their community and larger world. Although peripheral nerve surgery has been largely unemphasized in global neurosurgical efforts, a wide disparity in peripheral nerve surgery is presumed to exist between high-income and low- and middle-income countries. Serbia is an upper middle-income country with a long history of peripheral nerve surgery.

Research question

How can understanding the development of peripheral nerve surgery in Serbia advance global education and improve peripheral nerve surgery worldwide?

Material and methods

An anecdotal and narrative review of recent advances in peripheral nerve surgery in Serbia was conducted. The World Federation of Neurosurgical Society (WFNS) Peripheral Nerve Surgery Committee discussions on improving peripheral nerve surgery education were summarized.

Results

In this manuscript, we describe the application of "think globally, act locally" to peripheral nerve surgery by providing an account of the development of peripheral nerve surgery in Serbia. Then, we report measures taken by the WFNS Peripheral Nerve Surgery Committee to improve education on peripheral nerve surgery in LMICs.

Discussion and conclusion

Viewing the development of peripheral nerve surgery in Serbia through the lens of "think globally, act locally" may guide the development of peripheral nerve surgery in LMICs.

Etiological and epidemiological characteristics of surgically treated radial nerve lesions: A 20-year single-center experience

Introduction

Radial nerve lesions present a clinical entity that may lead to disability, psychological distress, and job loss, and thus requires great attention. Knowledge of the etiology and exact mechanism of the nerve impairment is of great importance for appropriate management of these patients, and there are only a few papers that focused on these features in patients with surgically treated radial nerve lesions. The lack of studies presenting the etiology and injury mechanisms of surgically treated radial nerve lesions may be due to a relatively small number of specialized referral centers, dispersion to low-flow centers, and a greater focus on the surgical treatment outcomes.

Aim

The aim of this study was to describe the etiological and epidemiological characteristics of patients with surgically treated radial nerve lesions of various origins.

Methods

This retrospective study evaluated 147 consecutive patients with radial nerve lesion, treated in the department during the last 20 years, from January 1, 2001, until December 31, 2020.

Results

The majority of patients belonged to the working population, and 70.1% of them were male. Most commonly, the etiology of nerve lesion was trauma (63.3%) or iatrogenic injury (28.6%), while the less common origin was idiopathic (4.1%) or neoplastic (4.1%). The most frequent location of the lesion was in the upper arm, followed by the elbow and forearm. Fracture-related contusion was the most common mechanism (29.9%), followed by postoperative fibrosis (17.7%), lacerations (17.7%), and compression (15.6%).

Conclusion

Based on the fact that traumatic or iatrogenic injuries constitute the majority of cases, with their relevant mechanisms and upper arm predomination, it is crucial to raise awareness and understanding of the radial nerve injuries among orthopedic surgeons to decrease the numbers of these patients and properly preserve or treat them within the initial surgery.

Traumatic Brachial Plexus Injury in Indonesia: An Experience from a Developing Country

Background  Brachial plexus injuries (BPI) cause severe physical disability and major psycho-socioeconomic burden. Although various countries have reported BPI incidence, the data from Indonesia as the fourth most populated country in the world remains unknown. We aim to assess the distribution of traumatic BPI, patients' characteristics, and treatment modalities in Indonesia.

Methods  A retrospective investigation was performed comprising 491 BPI patients at a tertiary referral hospital in Indonesia from January 2003 to October 2019. Demographic and outcomes data were retrieved from medical records.

Results  The average BPI patients' age was 27.3 ± 11.6 years old, with a male/female ratio of 4.6:1. Motorcycle accidents caused the majority (76.1%) of all BPI cases. Concomitant injuries were present in 62.3% of patients, dominated by fractures (57.1%) and brain injuries (25.4%). BPI lesion type was classified into complete (C5-T1, observed in 70% patients), upper (C5-C6, in 15% patients), extended upper (C5-C7, in 14% patients), and lower type (C8-T1, in 1% patients). The average time to surgery was 16.8 months (range 1–120 months), with the majority (76.6%) of the patients was operated on six months after the trauma. Free functional muscle transfer (FFMT) was the most common procedure performed (37%). We also analyzed the functional outcomes (active range of motion (AROM) and muscle power), DASH (Disabilities of the Arm, Shoulder, and Hand) score, and VAS (Visual Analogue Scale) across four most frequent procedures involving nerve reconstruction (FFMT, nerve transfer, external neurolysis, and nerve grafting). We found that FFMT was significantly better than nerve transfer in terms of DASH score and VAS ( p  = 0.000 and p  = 0.016, respectively) in complete BPI (C5-T1). Moreover, we also found that nerve grafting resulted in a significantly better shoulder abduction AROM than nerve transfer and external neurolysis in extended upper BPI (C5-C7) ( p  = 0.033 and p  = 0.033, respectively). Interestingly, no significant differences were observed in other measurements.

Conclusion  This study provides an overview of traumatic BPI patients in a single tertiary trauma center in Indonesia, expressing the profile of their characteristics and functional outcomes after surgical procedures.

The role of arm volumes evaluation in the functional outcome and patient satisfaction following surgical repair of the brachial plexus traumatic injuries

OBJECTIVE

Brachial plexus injuries are among the most complex injuries of the peripheral nervous system and among the most devastating injuries overall. In complete lesions, functional priorities include the reinnervation of the musculocutaneous and axillary nerves for proximal functions restoration. Three major nerves - radial, median, and ulnar - and the corresponding muscles remain denervated, which results in subsequent muscle atrophy. This study was aimed at the evaluation of arm volumes in surgically treated patients with brachial plexus injuries, in correlation with the type of palsy, recovery and associated factors.

METHODS

The study included 36 patients with brachial plexus injuries who were surgically treated in our institution over a 15-year-long period. The evaluation of arm and arm segments volumes was carried out using water displacement testing, based on the Archimedes principle.

RESULTS

Statistically significant differences were noted between the operated arm and the healthy arm in all of the measured segments (hands, forearms and upper arms), as well as between the patients with complete and upper palsy, and in correlation with the shoulder abduction recovery.

CONCLUSIONS

Previous studies were mainly focused on the functional outcome and quality of life; although related to both, arm volumes in patients with brachial plexus injuries were not analyzed before. Significant differences between the operated arm and the healthy arm volumes, as well as between the various types of palsy, found in the present study should trigger further prospective research in relation to neurophysiology, useful functional recovery and quality of life.

Traumatic brachial plexus injury: a study of 510 surgical cases from multicenter services in Guangxi, China

BACKGROUND

Traumatic brachial plexus injuries are severe lesions, and the incidence of these injuries has been increasing in recent years.

METHODS

The clinical data of 510 operated patients with brachial plexus injury recruited from 74 hospitals in Guangxi from 2004 to 2016 were retrospectively studied.

RESULTS

Our study included 447 males and 63 females, with an average age of 29.04 years. Traffic accidents were the most common cause of injury (64.71%), especially motorcycle accidents. Closed injuries accounted for 88.24% of cases, and 83.53% of patients had associated injuries, the most common of which were fractures (76.27%). The preoperative predictive value of root injury of MRI and CT was 74.71% and 71.28%, respectively. 44.71% of patients underwent an initial operation within 6 months after the trauma. Regarding the surgery, neurolysis alone, brachial plexus reconstruction, and free functioning gracilis graft accounted for 16.67%, 75.50%, and 4.51%, respectively. A total of 415 patients were followed up with an average time of 47.95 (25-68) months, and anxiety or depression were found among 81.20% of them. Two hundred seventy-six patients suffered from nerve pain, with mild pain present in 67.03% of patients. Additionally, 347 patients were followed up for more than 3 years, 76.81% of patients with C5-C6 injury recovery to useful function, and the procedure of neurolysis alone demonstrated the best efficacy (79.45%).

CONCLUSIONS

Brachial plexus injury is still a challenging trauma for surgeons, and traffic accidents are the dominant cause. Timely and effective surgery is important for functional limb recovery.

MANAGEMENT OF BRACHIAL PLEXUS MISSILE INJURIES

SUMMARY – Missile injuries are among the most devastating injuries in general traumatology. Traumatic brachial plexus injuries are the most difficult injuries in peripheral nerve surgery, and most complicated to be surgically treated. Nevertheless, missile wounding is the second most common mechanism of brachial plexus injury. The aim was to evaluate functional recovery after surgical treatment of these injuries. Our series included 68 patients with 202 nerve lesions treated with 207 surgical procedures. Decision on the treatment modality (exploration, neurolysis, graft repair, or combination) was made upon intraoperative finding. Results were analyzed in 60 (88.2%) patients with 173 (85.6%) nerve lesions followed-up for two years. Functional recovery was evaluated according to functional priorities. Satisfactory functional recovery was achieved in 90.4% of cases with neurolysis and 85.7% of cases with nerve grafting. Insufficient functional recovery was verified in ulnar and radial nerve lesions after neurolysis, and in median and radial nerve lesions when graft repair was done. We conclude that the best time for surgery is between two and four months after injury, except for the gunshot wound associated with injury to the surrounding structures, which requires immediate surgical treatment. The results of neurolysis and nerve grafting were similar.