Brachial plexus injury mimicking a spinal-cord injury.

Objective High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis.Clinical presentation A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department.Intervention Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion.Conclusion Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury

Critical Upper Limb Ischemia Due to Brachial Tourniquet in Misdiagnosed Thoracic Outlet Syndrome after Carpal Tunnel Decompression: A Case Report

We present the case of a 68-year-old woman, referred to our department for critical upper limb ischemia, which had occurred a few days after homolateral surgical ligamentotomy for carpal tunnel syndrome, diagnosed and confirmed by electromyography, and performed with a brachial tourniquet. The patient was later admitted for subsequent progressive necrosis of the first three fingers of the left hand, accompanied by signs of upper limb ischemia. An accessory cervical rib was identified, completely obliterating the subclavian artery distally at the origin of the suprascapular artery. A complete humeral artery occlusion was also found at the middle third of the humerus. The accessory rib was resected and the subclavian artery recanalized. A few days later, necrosis of the distal third of the first two fingers appeared and surgical resection was performed. Despite this chronic condition, the acute occlusion of collateral circles was probably induced by the brachial tourniquet. This represents a rare event, never previously reported in the literature: a case of critical upper limb ischemia due to a brachial tourniquet in a patient with misdiagnosed thoracic outlet syndrome. Until specific electrophysiological criteria for this syndrome can be found, attention should focus on history and clinical examination in patients with suspected carpal tunnel syndrome

3D computerized model for measuring strain and displacement of the brachial plexus following placement of reverse shoulder prosthesis

The aim of the present study was to develop a method for three-dimensional (3D) reconstruction of the brachial plexus to study its morphology and to calculate strain and displacement in relation to changed nerve position. The brachial plexus was finely dissected and injected with contrast medium and leaden markers were implanted into the nerves at predefined places. A reverse shoulder prosthesis was inserted in a cadaveric specimen what induced positional change in the upper limb nerves. Computed tomography (CT) was performed before and after this surgical intervention. The computer assisted image processing package Mimics (R) was used to reconstruct the pre- and postoperative brachial plexus in 3D. The results show that the current interactive model is a realistic and detailed representation of the specimen used, which allows 3D study of the brachial plexus in different configurations. The model estimated strains up to 15.3% and 19.3% for the lateral and the medial root of the median nerve as a consequence of placing a reverse shoulder prosthesis. Furthermore, the model succeeded in calculating the displacement of the brachial plexus by tracking each implanted lead marker. The presented brachial plexus 3D model currently can be used in vitro for cadaver biomechanical analyses of nerve movement to improve diagnosis and treatment of peripheral neuropathies. The model can also be applied to study the exact location of the plexus in unusual upper limb positions like during axillary radiation therapy and it is a potential tool to optimize the approaches of brachial plexus anesthetic blocks

Detection of evolving injury to the brachial plexus during transaxillary robotic thyroidectomy.

OBJECTIVES/HYPOTHESIS: Continuous intraoperative neuromonitoring (IONM) of transcranial electric motor evoked potentials (tceMEPs) and somatosensory evoked potentials (SSEPs) has gained universal acceptance as an efficacious method for detecting emerging positional brachial plexopathy or peripheral nerve compression during spinal and shoulder surgery. This has implications for transaxillary thyroid surgery. STUDY DESIGN: Case report with literature review. METHODS: The patient underwent robotic transaxillary thyroid surgery with continuous tceMEP and SSEP monitoring of brachial plexus function. We present detailed IONM data depicting the emergence of positional brachial plexopathy. RESULTS: Significant amplitude loss of both IONM modalities were identified during an evolving positional plexopathy, which resolved upon upper extremity repositioning and conversion to an open procedure. No permanent nerve injury or deficit was noted following surgery. CONCLUSIONS: Given the potential for brachial plexus injury during robotic transaxillary thyroid surgery secondary to arm positioning, we recommend that continuous tceMEP and SSEP monitoring be considered during such procedures

Abduction extension cervical nerve root stress test: anatomical basis and clinical relevance

Purpose: While the Lasègue straight leg raising test is an established test for lumbar nerve root compression, an established equivalent for cervical nerve root compression is missing. The aim of this bi-modal study was to find the most effective way to stretch the cervical nerve roots anatomically in cadavers and to assess its value in the clinical setting. Methods: Three positional maneuvers of the upper limb were tested on three cadavers to determine the displacement by stretch of the nerve roots C5, C6 and C7. The maneuver which was most efficient in nerve root displacement was applied in 24 patients with confirmed symptomatic cervical nerve root compression (cases) and 65 controls to assess the clinical value of the test. Results: The most efficient way to displace the cervical nerve roots by stretch was to apply dorsal pressure on the humeral head with the shoulder in 80° of abduction and 30° of extension, with slight elbow flexion while the head is facing the contralateral side. This maneuver produced 4-5mm of nerve root displacement in cadavers. This test aggravated radicular symptoms in 79% of the patients with cervical nerve root compression and was negative in 98% of the controls. Conclusion: The described abduction extension test with posterior push on the humeral head creates a fulcrum over which the brachial plexus can be displaced to create stress on cervical nerve roots. This simple test is easy to perform clinically and aggravates radicular symptoms in most of the patients with cervical nerve root compression while it is negative in nearly all of the control

Variant Musculo-tendinous Slip between Teres major and Triceps brachii

A variation of the muscles of the scapular region is a very rare finding. During the routine dissection for the undergraduates, a variant short musculo-tendinous slip in between the teres major and the long head of triceps brachii muscles was seen. This slip could cause compression of the underlying brachial vessels and the cords of brachial plexus. Therefore this type of variation is worthy of being noted by the surgeons

Lack of uniform diagnostic criteria for cervical radiculopathy in conservative intervention studies: A systematic review

Purpose: Cervical radiculopathy (CR) is a common diagnosis. It is unclear if intervention studies use uniform definitions and criteria for patient selection. Our objective was to assess the uniformity of diagnostic criteria and definitions used in intervention studies to select patients with CR. Methods: We electronically searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL. Studies were included when evaluating conservative interventions in randomised clinical trials (RCTs) in patients with CR. Selection criteria and definitions for patients with CR were extracted and evaluated on their uniformity. Results: Thirteen RCTs were included. Pain was used as an inclusion criterion in 11 studies. Inclusion based on the duration and location of pain varied between studies. Five studies used sensory symptoms in the arm as inclusion crite

Penatalaksanaan Fisioterapi Pada Kasus Brachial Plexus Injury Dextra Dengan Modalitas Electrical Stimulation Dan Terapi Latihan Di RS Orthopedi Prof. Dr. R. Soeharso Surakarta

Background: The brachial plexus is a group of nerves that come from the spinal cord in the neck and travel down the arm, these nerves control the muscles of the shoulder of the shoulder, elbow, wrist, and hand, as wll as provide feeling in the arm. While, brachial plexus injury is the hard traumatic of upper extremity and neck which are caused by there traction or compression on brachial plexus. Objectives: To know what management of phisycal therapy used electrical stimulation and teraputic exercise on the case brachial plexus injury can maintaining motor sensory ability, prevent atropy muscle and maintaining the ability of daily functional activities. Results: After 6 week therapy, the result of flexor shoulder strength T1-T4: 1, T5-T6: 2, extensor shoulder T1-T4: 1, T5-T6: 2, abduktor shoulder T1: 1, T2: 2, tetap T3: 2, T4: 3, tetap T5: 3, tetap T6: 3, adduktor shoulder T1: 1, T2: 2, tetap T3: 2, T4-T6: 3, flexor elbow T1-T6: 4, extensor elbow T1-T6: 4, pronator elbow T1-T6: 3, supinator elbow T1-T6: 3, flexor wrist T1-T6: 4, extensor wrist T1-T6: 4, ulnar deviator T1-T6: 4, radial deviator T1-T6: 4, flexor finger T1-T6: 5. ROM shoulder rating T1-T4: S: 0o-0o-0o, T5-T6: S: 5o-0o-5o, T1-T3: F: 20o-0o-30o, T4-T6: F: 40o-0o-90o, ROM elbow T1-T6: S: 0o-145o, F: 80o-0o-90o, ROM wrist T1-T6: S: 50o-0o-60o, F: 20o-0o-30o, ROM MCP I T1-T6: S: 0o-60o, ROM MCP II-V T1-T6: S: 0o-90o, ROM DIP II-V T1-T6: S: 0o-45o, ROM PIP I T1-T6: S: 0o-65o, ROM PIP II-V T1-T6: S: 0o-100o. Assessment of muscle volume T1-T6 no increase in muscle volume. Conclusion: Electrical stimulation can maintain the physiological properties of upper limb muscle, and teraputic exercise can maintain the motor’s sensory ability of upper limb muscles, may prevent increased muscle atrophy and maintain the ability of daily functional activity