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Han Y, An M, Zilundu PLM, Zhuang Z, Chen J, Jiang Z, Gu L, Yang J, Wang D, Xu D, Zhou LH. Anatomical variations of the brachial plexus in adult cadavers: A descriptive study and clinical significance. Microsurgery 2024; 44:e31182. [PMID: 38798147 DOI: 10.1002/micr.31182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/24/2024] [Accepted: 04/18/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Brachial plexus injury is recognized as one of the most severe clinical challenges due to the complex anatomical configuration of the brachial plexus and its propensity for variation, which complicates safe clinical interventions. This study aimed to ascertain the prevalence and characterize the types of brachial plexus variations, and to elucidate their clinical implications. MATERIALS AND METHODS We conducted meticulous dissections of 60 formalin-fixed cadavers' upper arm, axilla and lower neck to reveal and assess the roots, trunks, divisions, cords, and branches of the brachial plexus. The pattern of branching was noted by groups of dissecting medical students and confirmed by the senior anatomists. The variations discovered were record and photographed using a digital camera for further analysis. RESULTS Variations in the brachial plexus were identified in 40 of the 60 cadavers, yielding a prevalence rate of 66.7%. These variations were classified into root anomalies (2.1%), trunk anomalies (8.5%), division anomalies (2.1%), and cord anomalies (4.3%). Notably, anomalies in communicating branches were observed in 39 cadavers (83.0%): 14 with bilateral anomalies, 14 with anomalies on the left side, and 11 on the right side. These communicating branches formed connections between the roots and other segments, including trunks, cords, and terminal nerves, and involved the median, musculocutaneous, and ulnar nerves. CONCLUSION The frequency and diversity of brachial plexus variations, particularly in communicating branches, are significant in cadavers. It is imperative that these variations are carefully considered during the diagnostic process, treatment planning, and prior to procedures such as supraclavicular brachial plexus blocks and nerve transfers, to mitigate the risk of iatrogenic complications.
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Affiliation(s)
- Yueyin Han
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Mingjie An
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Prince L M Zilundu
- Basic Medical and Dental Sciences Department Center of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
| | - Zhuokai Zhuang
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Junyu Chen
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Zhen Jiang
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Liqiang Gu
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jiantao Yang
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Dong Wang
- Department of Orthopedics, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Dazheng Xu
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Li-Hua Zhou
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
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Makeľ M, Němcová V, Hora A, Whitley A, Kulvajtová M, Sukop A, Kaiser R. Anterior transposition of the radial nerve to achieve primary suture for its reconstruction: Anatomical feasibility study. J Plast Reconstr Aesthet Surg 2024; 89:1-6. [PMID: 38118360 DOI: 10.1016/j.bjps.2023.11.045] [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: 05/05/2023] [Revised: 11/23/2023] [Accepted: 11/26/2023] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Radial nerve palsy after humeral shaft fractures is often associated with formation of a neuroma in continuity. The current standard of treatment is neuroma resection and nerve grafting with contentious results. Anterior transposition of the radial nerve may reduce the length of its path, allowing reconstruction by primary suture. The aim of this study was to determine the maximum length of radial nerve defect that can be treated by the anterior transposition to allow primary suture to be performed. METHODS We use 10 arms from five fresh cadavers. The radial nerve was dissected in the lateral inter-muscular septum and along the anterior aspect of the forearm. The radial nerve was transected at the level of the spiral groove and both stumps were than transposed anterior to the medial inter-muscular septum. The length of tension-free overlap that could be achieved was measured. RESULTS The average length of the overlap at zero degrees of elbow flexion was 10.00 ± 1.84 mm. Theoretically, this will allow a defect of 20 ± 3.69 mm SD to be treated by primary suture. CONCLUSION Our results suggest that anterior transposition can be used for radial nerve defects up to 2 cm; however, dissection of both stumps proved to be challenging.
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Affiliation(s)
- Michal Makeľ
- Department of Plastic Surgery, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic; Department of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Veronika Němcová
- Department of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Adam Hora
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Adam Whitley
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of General Surgery, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Markéta Kulvajtová
- Department of Forensic Medicine, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Andrej Sukop
- Department of Plastic Surgery, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
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Khadanovich A, Herma T, Al-Redouan A, Kaiser R, Kachlik D. The communication patterns between the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve. Ann Anat 2023:152110. [PMID: 37207848 DOI: 10.1016/j.aanat.2023.152110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION The superficial branch of the radial nerve (SBRN) and the lateral antebrachial cutaneous nerve (LACN) are sensory nerves coursing within the forearm in a close relationship. This high degree of overlap and eventual communication between the nerves is of great surgical importance. The aim of our study is to identify the communication pattern and overlap of the nerves, to localize the position of this communication in relation to a bony landmark, and to specify the most common communication patterns. MATERIALS and methods: One hundred and two adult formalin-fixed cadaveric forearms from 51 cadavers of Central European origin were meticulously dissected. The SBRN, as well as the LACN, were identified. The morphometric parameters concerning these nerves, as well as their branches and connections, were measured with a digital caliper. RESULTS We have described the primary (PCB) and secondary communications (SCB) between the SBRN and the LACN and their overlap patterns. One hundred and nine PCBs were found in 75 (73.53%) forearms of 44 (86.27%) cadavers and fourteen SCBs in eleven hands (10.78%) of eight cadavers (15.69%). Anatomical and surgical classifications were created. Anatomically, the PCBs were classified in three different ways concerning: (1) the role of the branch of the SBRN within the connection; (2) the position of the communicating branch to the SBRN; and (3) the position of the LACN branch involved in the communication to the cephalic vein (CV). The mean length and width of the PCBs were 17.12mm (ranged from 2.33-82.96mm) and 0.73mm (ranged from 0.14-2.01mm), respectively. The PCB was located proximally to the styloid process of the radius at an average distance of 29.91mm (ranged from 4.15-97.61mm). Surgical classification is based on the localization of the PCBs to a triangular zone of the SBRN branching. The most frequent branch of the SBRN involved in the communication was the third (66.97%). Due to the frequency and position of the PCB with the third branch of the SBRN, the danger zone was predicted. According to the overlap between the SBRN and the LACN, we have divided 102 forearms into four types: (1) no overlap; (2) present overlap; (3) pseudo-overlap; and (4) both present and pseudo-overlap. Type 4 was the most common. CONCLUSION The patterns of communicating branch arrangements appeared to be not just a rare phenomenon or variation, but rather a common situation highlighting clinical importance. Due to the close relationship and connection of these nerves, there is a high probability of simultaneous lesion.
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Affiliation(s)
- Anhelina Khadanovich
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Tomas Herma
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Azzat Al-Redouan
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Radek Kaiser
- Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Czech Republic.
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Health Care, College of Polytechnics Jihlava, Czech Republic.
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Al-Redouan A, Benes M, Abbaspour E, Kunc V, Kachlik D. Prevalence and anatomy of the anomalous subclavius posticus muscle and its clinical implications with emphasis in neurogenic thoracic outlet syndrome: Scoping review and meta-analysis. Ann Anat 2023; 247:152046. [PMID: 36690046 DOI: 10.1016/j.aanat.2023.152046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/30/2022] [Accepted: 01/01/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND The subclavius muscle runs underneath the clavicle. However, there have been a few reports of a duplicated subclavius muscle which is commonly referred to as subclavius posticus muscle due to its orientation being posterior to the proper subclavius muscle. Its occurrence seems to potentially create a narrowing interval at the superior thoracic aperture as it crosses over the brachial plexus. It might also have functional influence on the shoulder girdle. PURPOSE To provide comprehensive gross anatomy description of the variant "subclavius posticus muscle" and to investigate its reported clinical implications with emphasis on its involvement in causing brachial plexus compression. BASIC PROCEDURES A scoping review with meta-analysis of the gross anatomy of the subclavius posticus muscle was conducted along with investigating its correlation to the thoracic outlet syndrome. Forty-seven articles were pooled through two rounds of the selection process. The relevant information was extracted and meta-analyzed. MAIN FINDINGS The scoping review and meta-analysis of the 47 articles revealed a total prevalence of 11/2069 (4.9%); 10/1369 (5.1%) in cadaveric studies, and 1/700 (5.0%) in MRI studies. The subclavius posticus muscle is a short triangular muscle with an average length of 12 cm and an average width of 1 cm. It originates from the sternal end of the first rib in most cases with reported variants of one case originating from the costoclavicular ligament and one case where it was fused with the proper subclavius muscle. Its insertion is more variable: on the superior border of the scapula with variable length in 71.35%, on the coracoid process of the scapula in 25.42%, and on the clavicle in 0.90%. The subclavian nerve seems to be the dominant nerve supply with a 57.6% prevalence, while 25.8% are innervated by the suprascapular nerve. Other reported nerves were the nerve to the myolohyoid (4.5%), accessory phrenic nerve (4.5%), and a direct branch from the brachial plexus (2.0%). The blood supply was reported (only once) to be from the suprascapular artery. However, the venous drainage was not established at all. PRINCIPAL CONCLUSIONS The subclavius posticus muscle is a variant muscle occurring with a reported overall prevalence of 4.9%. It can compress the brachial plexus as it runs across at the space of the superior thoracic aperture with exquisite contact, and this can lead to a neurogenic thoracic outlet syndrome. It also can be involved in the vascular thoracic outlet syndrome. Lastly, it is important not to omit its potential influence in shoulder joint instability to some extent.
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Affiliation(s)
- Azzat Al-Redouan
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Michal Benes
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Ehsan Abbaspour
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Vojtech Kunc
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
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Patel NT, Smith HF. Clinically Relevant Anatomical Variations in the Brachial Plexus. Diagnostics (Basel) 2023; 13:diagnostics13050830. [PMID: 36899974 PMCID: PMC10001373 DOI: 10.3390/diagnostics13050830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023] Open
Abstract
Anatomical variation in the brachial plexus may result in a variety of clinically relevant patterns, including various neuralgias of the upper extremity and differing nerve territories. Some conditions can be debilitating in symptomatic patients, resulting in paresthesia, anesthesia, or weakness of the upper extremity. Others may simply result in cutaneous nerve territories that deviate from a traditional dermatome map. This study evaluated the frequency and anatomical presentations of a large number of clinically relevant brachial plexus nerve variations in a sample of human body donors. We identified a high frequency of various branching variants, of which clinicians, especially surgeons, should be aware. The medial pectoral nerves in 30% of the sample were found to originate from either the lateral cord, or both the medial and lateral cords of the brachial plexus rather than exclusively from the medial cord. The dual cord innervation pattern greatly increases the number of spinal cord levels traditionally believed to innervate the pectoralis minor muscle. The thoracodorsal nerve arose as a branch of the axillary nerve 17% of the time. The musculocutaneous nerve sent branches to the median nerve in 5% of specimens. The medial antebrachial cutaneous nerve shared a common trunk with the medial brachial cutaneous nerve in 5% of individuals and derived from the ulnar nerve in 3% of specimens.
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Affiliation(s)
- Niki T. Patel
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Heather F. Smith
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA
- Department of Anatomy, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
- School of Human Evolution and Social Change, Arizona State University, Tempe, AZ 85287, USA
- Correspondence: ; Tel.: +1-623-572-3726
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