Surgical Neuromodulation of Traumatic Brachial Plexus Injuries a Systematic Review and Meta-analysis

Background

Traumatic brachial plexus injuries are common among young adults, with a majority of patients succumbing to chronic pain syndromes. Conservative management is usually not satisfactory in these cases and surgical interventions are often required. We have conducted a systematic review and meta-analysis examining one of the neurosurgical techniques, spinal cord stimulation (SCS), in chronic pain neuromodulation in cases of chronic pain syndrome after traumatic brachial plexus injuries.

Objective

This systematic review aims to explore the reported use of cervical spinal cord stimulation as a neuromodulator in patients with chronic pain syndromes following traumatic brachial plexus injury.

Methods

A systematic literature search was conducted using MEDLINE through the OVID interface, ProQuest, Web of Science, The Cochrane Library, and Scopus. Our own files and reference lists of identified key articles were also searched.

Results

A total of 13 studies (8 case reports and 5 case series), comprising 29 patients were included. Most brachial plexus injuries were sustained in motor vehicle accidents. 86% (25/29) of patients showed a good initial response to SCS, however, the response decreased over time, and 69% (20/29) of the patients reported a good response at the end of follow-up. Lead migration was the only complication reported in two studies.

Conclusion

SCS is a less invasive procedure with significantly fewer neurological side effects. A trial period of SCS is suggested in patients who have failed conservative treatment modalities before other neurosurgical interventions are considered.

Parsonage-Turner syndrome associated with hepatitis E infection in immunocompetent patients

Introduction The hepatitis E virus (HEV) is the leading cause of acute hepatitis around the world. In recent years, knowledge has increased concerning extrahepatic manifestations caused by HEV, including neurological manifestations such as Parsonage-Turner syndrome (PTS). PTS is characterized by severe shoulder or arm pain and patchy paresis with muscle weakness. The aim of the present study was to assess the association between HEV and PTS. Materials and Methods We reported two cases of PTS associated with HEV, which were diagnosed in a short period of time in the same village. PTS was diagnosed by physical examination and electrophysiological studies, and serology testing for IgM, low-avidity IgG, and RNA of HEV established the diagnosis of acute HEV infection. Results A 44-year-old man who presented cervicobrachial pain accompanied by paresthesia, dyspnea, and isolated derangement of liver enzymes and 57-year-old women with cervical pain radiated to upper limbs, paresthesia, and liver cytolysis, although, this patient was initially diagnosed as having drug-induced hepatitis. Finally, the diagnosis was Parsonage- Turner syndrome associated with hepatitis e virus. In both patients, symptoms were bilateral and they required hospital admission. Both consumed vegetables are grown in a local patch and the phylogenetic analysis showed genotype 3f. Then, we reviewed the literature on PTS and HEV and we found 62 previously described cases that were more likely to be men (86.20 %) with more frequent bilateral symptoms (85.71 %). Genotype 3 is the most commonly associated. Three of those cases were diagnosed in Spain. Conclusions According to our findings, HEV should be considered in patients with neuralgic amyotrophy, including those with the absence of liver cytolysis.

Birth palsy in congenital varicella syndrome: A lesson in anatomy

While brachial plexus palsy sustained due to birth trauma is well known, congenital palsies are decidedly rare. We report such a case caused by congenital varicella syndrome, with associated congenital Horner's syndrome and heterochromia iridis. The surprising juxtaposition of a classic upper plexus palsy and a Horner's syndrome raises points of interest. Similar reports in literature are reviewed, and the genesis of a very characteristic group of findings is discussed.

Analysis According to Characteristics of 18 Cases of Brachial Plexus Tumors : A Review of Surgical Treatment Experience

Objective

Because the anatomical structure of the brachial plexus is very complex, surgical treatment of tumors in this region is challenging. Therefore, a lot of clinical and surgical experience is required for successful treatment; however, many neurosurgeons have difficulty accumulating this experience owing to the rarity of brachial plexus tumors. The purpose of this report is to share our surgical experience with brachial plexus tumor with other neurosurgeons.

Methods

The records of 18 consecutive patients with brachial plexus tumors who underwent surgical treatment between January 2010 and December 2017 in a single institution were retrospectively reviewed. The surgical approach was determined according to the tumor location and size, and intraoperative neurophysiological monitoring (IONM) was used in most of cases to prevent iatrogenic nerve injury during surgery. In addition, to evaluate the differences in tumor characteristics according to pathologic diagnosis, the tumors were divided twice into two groups, based on two separate classifications, and statistical analysis was performed.

Results

The 18 brachial plexus tumors comprised 15 (83.3%) benign peripheral nerve sheath tumors including schwannoma and neurofibroma, one (5.6%) malignant peripheral nerve sheath tumor, one (5.6%) benign tumor of non-neural sheath origin (neurogenic cyst), and one (5.6%) metastatic tumor (papillary carcinoma). The authors analyzed relationship between tumor size/location and tumor characteristic parameters such as age, size, right-left, and pathology. There were no statistically significant differences except a tendency of bigger tumor size in young age.

Conclusion

For a successful surgical outcome, an appropriate surgical approach is essential, and the appropriate surgical approach is determined by the location and size of the tumor. Furthermore, applying IONM may prevent postoperative complications and it is favorable option for brachial plexus tumors surgery.

Hand-Use-at-Home Questionnaire: validity and reliability in children with neonatal brachial plexus palsy or unilateral cerebral palsy

OBJECTIVE

To investigate construct validity and test-retest reliability of the parent-rated Hand-Use-at-Home questionnaire (HUH) in children with neonatal brachial plexus palsy or unilateral cerebral palsy.

DESIGN AND SUBJECTS

For this cross-sectional study, children with neonatal brachial plexus palsy or unilateral cerebral palsy, aged 3-10 years, were eligible.

MAIN MEASURES

The HUH, Pediatric Outcome Data Collection Instrument Upper Extremity Scale (neonatal brachial plexus palsy only), and Children's Hand-Use Experience Questionnaire (unilateral cerebral palsy only) were completed. The HUH was completed twice in subgroups of both diagnoses. Lesion-extent (indication of involved nerve rootlets in neonatal brachial plexus palsy as confirmed during clinical observation and/or nerve surgery) and Manual Ability Classification System levels (unilateral cerebral palsy) were obtained from the medical records. Spearman correlation coefficients between the HUH and all clinical variables, agreement, standard error of measurement, smallest detectable change and intra-class correlation were calculated.

RESULTS

A total of 260 patients participated (neonatal brachial plexus palsy: 181), of which 56 completed the second HUH (neonatal brachial plexus palsy: 16). Median age was 6.9 years for children with neonatal brachial plexus palsy, 116 had C5-C6 lesions. Median age for children with unilateral cerebral palsy was 6.4 years, 33 had Manual Ability Classification System Level II. The HUH correlated moderately with lesion-extent ( r_s =-0.5), Pediatric Outcome Data Collection Instrument Upper Extremity Scale ( r_s = 0.6) and Children's Hand-Use Experience Questionnaire ( r_s = 0.5) but weakly with Manual Ability Classification System levels ( r_s = -0.4). Test-retest reliability was excellent (intra-class correlation_2,1 = 0.89, standard error of measurement = 0.599 and smallest detectable change = 1.66 logits) and agreement was good (mean difference HUH1 - HUH2 = 0.06 logits).

CONCLUSION

The HUH showed good construct validity and test-retest reliability in children with neonatal brachial plexus palsy or unilateral cerebral palsy.

Unilateral brachial plexopathy, a rare complication of Mycoplasma pneumoniae infection

Few reports in the literature describe isolated peripheral neuropathies in relation to Mycoplasma pneumoniae infection without concurrent damage to the central nervous system. To our knowledge only a single case of mononeuritis multiplex with brachial plexus neuropathy coincident with M. pneumoniae has been documented until now. Here we present the first clinical case of lobar M. pneumoniae pneumonia in a 19-year-old female patient, where coincident neurological complications manifested as unilateral brachial plexus neuropathy, affecting axillar and suprascapular nerves. Isolated M. pneumoniae from sputum belonged to P1 type 2 and to MLVA type 3-6-6-2. No mutation associated with macrolide resistance in domain V of the 23S rRNA gene was detected. Serological testing of a GM1 antibody showed positive results, which might support the role of immunologic mechanisms in the pathogenesis of peripheral neuropathies related to M. pneumoniae infection.

Participation restrictions among adolescents and adults with neonatal brachial plexus palsy: the patient perspective

PURPOSE

To examine the impact of neonatal brachial plexus palsy (NBPP) on societal participation of adolescents and adults.

METHODS

This cross-sectional study was conducted among patients with NBPP, aged ≥16 years, who had visited our NBPP clinic. Patients completed questions on the influence of NBPP on their choices regarding education/work and their work-performance, the Impact on Participation/Autonomy questionnaire and the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). In addition, health-related quality of life (HRQoL) was assessed.

RESULTS

Seventy-five patients participated (median age 20, inter quartile range 17-27). Twenty were full-time students, 28 students with a job, 21 employed, two unemployed, and four work-disabled. Sixty-six patients had had a job at some stage. Patients' overall HRQoL was comparable to the general population. 27/75 patients reported that NBPP had affected their choices regarding education and 26/75 those regarding work. 33/66 reported impact on their work performance. On the Impact on Participation/Autonomy questionnaire, 80% (49/61) reported restrictions in the work-and-education domain, 74% in social-relations and 67% in autonomy-outdoors. 37/61 reported participation restrictions on the USER-P.

CONCLUSIONS

Although their overall HRQoL was not impaired, a substantial proportion of adolescent/adult patients reported that NBPP had an impact on choices regarding education and profession, as well as on work-performance. Restrictions in participation, especially in work and education were also reported. Guiding patients in making choices on education and work at an early stage and providing tailored physical as well as psychosocial care may prevent or address restrictions, which may improve participation. Implications for Rehabilitation Adolescent and adult patients with neonatal brachial plexus palsy perceive restrictions in societal participation, especially regarding the work-and-education domain. All patients with neonatal brachial plexus palsy may perceive restrictions in societal participation regardless of lesion severity, treatment history and side of the lesion. Adolescents and adults with neonatal brachial plexus palsy report that their choices regarding education and work, as well as their work-performance are influenced by their neonatal brachial plexus palsy. Patients with neonatal brachial plexus palsy should be followed throughout their life in order to provide them with appropriate information and treatment when health- or participation-related issues arise. Rehabilitation treatment is the best option to address all of the aforementioned issues, as surgical options in adolescents and adults are limited.

Obstetric paralysis: anterior arthroscopic release of the shoulder and transfer of the latissimus dorsi using a homologous graft

OBJECTIVE

Description of a new surgical technique for treating the shoulders of patients with sequelae of obstetric paralysis. Preliminary analysis on the results obtained from this technique.

METHODS

Five consecutive patients underwent the proposed surgical procedure, consisting of arthroscopic anterior joint release followed by transfer of the latissimus dorsi tendon (elongated and reinforced with a homologous tendon graft) to the posterosuperior portion of the greater tubercle, using a single deltopectoral approach. All the patients were reevaluated after a minimum postoperative period of twelve months. The functional assessment was based on the range of motion and the modified Mallet classification system. Statistical analyses were not possible because of the small sample.

RESULTS

Overall, passive and active lateral rotations increased, while medial rotation decreased. The other movements (elevation, capacity to place a hand in the mouth and capacity to place a hand behind the neck) had less consistent evolution. The mean modified Mallet score improved by 4.2 points (from 11.4 to 15.6).

CONCLUSION

The latissimus dorsi tendon can be transferred to the posterosuperior portion of the greater tubercle through a single deltopectoral approach when elongated and reinforced with a homologous tendinous graft.

Translation and adaptation of the Pediatric Outcome Data Collecting Instrument (PODCI) into the Dutch language and preliminary validation in children with Neonatal Brachial Plexus Palsy

PURPOSE

This study aimed to translate and cross-culturally adapt the Pediatric Outcome Data Collecting Instrument (PODCI) into the Dutch language and evaluate its measurement properties among children (age 3-10) with Neonatal Brachial Plexus Palsy (NBPP).

METHODS

The PODCI was translated and adapted according to international guidelines and administered to 10 children with NBPP before and after surgery and thereafter twice again. Subsequently, the Mallet-score, Assisting Hand Assessment and active Range of Motion (aROM) were recorded. Cronbach's-α and correlations between the PODCI and other outcome measures were determined, as well as Intraclass Correlation Coefficients (ICC). In addition, effect sizes (ES), Standard Response Means (SRM) and change scores with the 95% Confidence Interval (95% CI) were calculated.

RESULTS

The final Dutch PODCI `Upper Extremity and Physical Function' subscale and total score `Global Functioning' showed good internal consistency (Cronbach's-α 0.695/0.781) and reliability (ICC 0.97/0.80) and were significantly associated with aROM and the Mallet-score. After surgery a significant change of the total score (ES 0.57, SRM 1.23, change 4.22 points, 95% CI 1.04-7.4) was seen.

CONCLUSION

The final Dutch PODCI had good measurement properties and appears useful in evaluating quality of life and functioning in children with NBPP.

Evaluation of shoulder function after secondary surgery in children with Neonatal Brachial Plexus Palsy

PURPOSE

Shoulder function in children with Neonatal Brachial Plexus Palsy (NBPP) can be impaired. Functional gain is possible by an internal contracture release and muscle tendon transfer (ICL+MTT) for external rotation. This study evaluates the functional results of this intervention.

METHODS

Assessments were done pre-operatively and 3, 6 and 12 months thereafter and included joint-mobility (ROM), muscle strength, arm function (Assisting Hand Assessment (AHA) and Mallet-score), Quality of Life (QoL) (Pediatric Outcome Data Collecting Instrument (PODCI)) and parental satisfaction. Changes were examined using Wilcoxon's Signed-Rank test and Cohen's effect size.

RESULTS

Ten children (5 boys) aged 3-10 years who underwent a combined ICL+MTT (mm. Latissimus Dorsi/Teres Major) were included.Active and passive external rotation ROM and muscle strength improved (p < 0.05). Arm function improved according to the Mallet-score (Hand-to-Head, Hand-to-Mouth, External-Rotation) (p < 0.05) and the arm use and pace scales of the AHA (p < 0.05). The PODCI Upper Extremity/Physical Functioning and Global Functioning subscales also showed improvements (p < 0.05). Parents were highly satisfied concerning daily life activities and sports.

CONCLUSION

ICL+MTT leads to improvement of ROM, strength, arm function, QoL and high parental satisfaction in this studies' patients and is therefore a good intervention to consider in children with NBPP with limited shoulder function.