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Fulltext Quantitative and qualitative evaluation of sural nerve graft donor site

Ng SS, Kwan MK, Ahmad TS

Med J Malaysia, 2006 Dec;61 Suppl B:13-7.
PMID: 17600987

This study is designed to evaluate twenty patients after sural nerve harvest using the single longitudinal incision method. The area of sensory loss to pin prick was assessed by the authors at different intervals. Donor site factors, scar cosmesis, functional status and complications were assessed using a questionnaire. The mean area of anaesthesia at one month was 65 cm2 and it had reduced by 77% to 15 cm2 at one and a half years. The mean area of reduced sensation was 49 cm2 at one month and it increased by 18% to 58 cm2 over the same period. Therefore, the total area of sensory deficit was reduced by 36% from 114 cm2 at one month to 73 cm2 at one and a half years. Subjective patient evaluation indicated moderate level of pain during immediate post surgical period, which reduced significantly at one month. A low level of neuroma symptoms was recorded throughout the study period. At a mean follow-up period of two years, there was no area of anaesthesia in 50% of the patients. Mean area of anaesthesia for all patients was 12 cm2 and mean area of reduced sensation was 55 cm2. Subjective patient evaluation indicated a low level of pain, neuroma symptoms and numbness over the sural nerve sensory distribution. Twenty five percent of the patients were not satisfied with the scar appearance. Function and daily activities were not affected significantly. No surgical complications were observed.

Matched MeSH terms: Brachial Plexus/injuries; Brachial Plexus/surgery
Fulltext Pearls and Pitfalls of Phrenic Nerve Transfer for Shoulder Reconstruction in Brachial Plexus Injury

Doi K, Sem SH, Ghanghurde B, Hattori Y, Sakamoto S

J Brachial Plex Peripher Nerve Inj, 2021 Jan;16(1):e1-e9.
PMID: 33584849 DOI: 10.1055/s-0041-1722979

Objectives The purpose of this study was to report the functional outcomes of phrenic nerve transfer (PNT) to suprascapular nerve (SSN) for shoulder reconstruction in brachial plexus injury (BPI) patients with total and C5-8 palsies, and its pulmonary complications. Methods Forty-four out of 127 BPI patients with total and C5-8 palsies who underwent PNT to SSN for shoulder reconstruction were evaluated for functional outcomes in comparison with other types of nerve transfers. Their pulmonary function was analyzed using vital capacity in the percentage of predicted value and Hugh-Jones (HJ) breathless classification. The predisposing factors to develop pulmonary complications in those patients were examined as well. Results PNT to SSN provided a better shoulder range of motion significantly as compared with nerve transfer from C5 root and contralateral C7. The results between PNT and spinal accessory nerve transfer to SSN were comparable in all directions of shoulder motions. There were no significant respiratory symptoms in majority of the patients including six patients who were classified into grade 2 HJ breathlessness grading. Two predisposing factors for poorer pulmonary performance were identified, which were age and body mass index, with cut-off values of younger than 32 years old and less than 23, respectively. Conclusions PNT to SSN can be a reliable reconstructive procedure in restoration of shoulder function in BPI patients with total or C5-8 palsy. The postoperative pulmonary complications can be prevented with vigilant patient selection.

Matched MeSH terms: Brachial Plexus
Fulltext Huge brachial plexus schwannoma, masking as a cystic neck mass

Kho JPY, Prepageran N

AME Case Rep, 2018;2:41.
PMID: 30363802 DOI: 10.21037/acr.2018.08.01

Schwannomas are solitary, benign tumors arising from the nerve sheaths. They are frequently reported in the thorax predominantly in the posterior mediastinum, but are rarely seen to arise from the brachial plexus. Schwannomas are well demarcated lesions with a slow insidious growth. Presented is a case of a large brachial plexus schwannoma, masking as a cystic lesion in the lateral neck. The patient presented with concerns of a cystic mass progressively increasing in size over a period of four years, initially symptomless, but later caused numbness and tingling sensation over his right forearm, tip of right thumb and index finger. Following histological confirmation via fine needle aspiration and magnetic resonance imaging, the patient underwent surgical excision where by the tumor was dissected from its attachment to the nerve sheath. The patient recovered well, and by the third day post operatively, his neurological symptoms resolved completely. Upon follow up in clinic 1-week post-surgery, the scar had healed well, and his numbness or tingling sensation remained in abeyance. This case illustrates that a schwannoma may present insidiously as a cystic lesion and its possible origin may arise from the brachial plexus.

Matched MeSH terms: Brachial Plexus
Fulltext Comparison of 0.5% ropivacaine and 0.5% levobupivacaine for infraclavicular brachial plexus block

Mageswaran R, Choy YC

Med J Malaysia, 2010 Dec;65(4):300-3.
PMID: 21901950

A prospective randomized double-blind study was conducted which involved, 60 ASA 1-2, aged 18-65 years patients, who had elective or emergency orthopaedic surgeries of the upper limbs. They were randomly divided into two groups: Group I received 30 mls of 0.5% ropivacaine; and Group II received 0.5% levobupivacaine for infraclavicular brachial plexus block based on the coracoid approach. The onset time required for sensory block of all required dermatomes (C5-T1) and the onset time of motor block were documented. Based on the Visual Analogue Score, pain scores were recorded every 30 minutes during surgery and at the 6th hour. The mean onset time (SD) for sensory block with ropivacaine was 13.5 +/- 2.9 minutes compared to levobupivacaine at 11.1 +/- 2.6 minutes (p = 0.003). The onset time for motor block was 19.0 +/- 2.7 minutes in Group I compared to 17.1 +/- 2.6 minutes (p = 0.013) in Group II. Patients in both groups experienced both mild to moderate pain at the 6th hour. In conclusion, there were statistically significant differences in the onset-time for sensory and motor block. However, there was no statistically significant difference in terms of effectiveness of analgesia at the 6th hour. Although the clinical advantage of levobupivacine is not substantial, its safety profile becomes a major consideration in the choice of local anaesthetic for brachial plexus block where a large volume is required for an effective result.

Matched MeSH terms: Brachial Plexus*
Fulltext Faster onset time of supraclavicular brachial plexus block using local anesthetic diluted with dextrose

Lim HJ, Hasan MS, Chinna K

Braz J Anesthesiol, 2016 Jul-Aug;66(4):341-5.
PMID: 27343781 DOI: 10.1016/j.bjane.2014.11.012

BACKGROUND AND OBJECTIVES: A high sodium concentration is known to antagonize local anesthetics when infiltrated around neural tissue. Thus, we hypothesized that the onset time for sensory and motor blockade, in supraclavicular brachial plexus block using ropivacaine diluted with dextrose would be shorter than with saline.

METHODS: Patients scheduled for upper limb surgery were randomized to receive ultrasound guided supraclavicular brachial plexus block with 0.5% ropivacaine. Evaluation of sensory and motor blockade was performed every 5min for 60min. Patients were followed-up on postoperative day 1, and between days 7 and 10 for the presence of any complications. Twenty-five patients in each group were analyzed.

RESULTS: Mean time for onset of analgesia for the dextrose group was 37.6±12.9min while the mean time for the saline group was 45.2±13.9min with a p-value of 0.05. The effect size was 0.567, which was moderate to large. No major complications were observed.

CONCLUSION: We conclude that there was a decrease in onset time of analgesia when dextrose was used as a diluent instead of saline for ultrasound guided supraclavicular block.

Matched MeSH terms: Brachial Plexus Block/methods*
Fulltext The Flail and Pulseless Upper Limb: an Extreme Case of Traumatic Scapulo-thoracic Dissociation

Maria SW, Sapuan J, Abdullah S

Malays Orthop J, 2015 Jul;9(2):54-56.
PMID: 28435612 MyJurnal DOI: 10.5704/MOJ.1507.002

Scapulo-thoracic dissociation is an infrequent injury resulting from high energy trauma which is often associated with severe neurological and vascular injuries which may be unrecognised at the time of presentation. A 24 year-old female presented with bilateral rib fractures, pneumothorax, liver and kidney injuries following a road traffic accident. She also sustained fractures of her right scapula, odontoid, right transverse processes of the thoracic and lumbar vertebrae and a closed fracture of her right femur. Her right upper limb was later noted to be flail and pulseless, due to complete right brachial plexus injury, scapula-thoracic dissociation and subclavian artery avulsion. We managed the upper limb injuries non-operatively, and focused on resuscitation of the patient. Early exploration of the complete brachial plexus injury was not undertaken in spite of the possible associated poor functional outcome as there was no life-threatening indication.

Matched MeSH terms: Brachial Plexus
Fulltext Neonatal clavicle fracture: a review of fourteen cases in east coast Peninsular Malaysia

Awang, M.S., Abdul Razak, A.H., Che Ahmad, A., Mohd Rus, R.

International Medical Journal Malaysia, 2017;16(2):79-83.
MyJurnal

Introduction: The purpose of this study is to identify the incidence of clavicle fractures in newborn
associated with fetal, maternal and process of deliveries in Kuantan General Hospital from June 2012 until
January 2014. This study is to determine epidemiological data of clavicle fractures, maternal and baby risk
factors associated with clavicle fractures of newborn and its’ outcome.

Methods: This is a prospective
study. 13 patients were identified to fulfill the inclusion criteria of the study. The data of
sociodemographic, associated fetal and maternal risk factors and the outcomes were recorded using
proforma. The statistical data analysis was done using SPSS 12.0.

Results: Out of 20,257 live births at our
centre during the study period, 13 infants were diagnosed to have clavicle fractures, giving an incidence of
0.64 per 1000 live births. There were 5 (38.5%) left, 7 (53.8%) right and one (7.7%) bilateral fracture. All
fractures located at the mid shaft of the clavicle and none have associated brachial plexus injuries. All
infants were delivered through vaginal delivery (61.5%); five through assisted delivery (instrumental); 2
(15.4%) forcep and 3 (23.1%) vacuum. Two of the babies developed shoulder dystocia. The average birth
weight was 3371 grams (SD 0.269) and mean gestational age was 38.7 weeks (SD 1.16). Five of the mothers
(38.5%) were primigravida and eight (61.5%) were multigravida in which,7 (53.8%)were healthy without
other co-morbidty, 5 (38.5%) having gestational diabetis and one (7.7%) hypertension. The average maternal
weight was 62.0 kg and height 1.58 metres with average BMI of 24.16 (3.29SD). All eventually had a
complete recovery at 6 weeks with clinical and radiological evident of fracture union.

Conclusions: In
conclusion, all patients with clavicle fractures were found following vaginal delivery. There were no
associations between neonatal clavicle fractures with maternal or baby risk factors. All fractures healed
without any complications.

Matched MeSH terms: Brachial Plexus
Histological analysis of motoneuron survival and microglia inhibition after nerve root avulsion treated with nerve graft implantation and minocycline: an experimental study

Wu W, Jafri M Abdullah, Faizul H Ghazali

Sains Malaysiana, 2016;45:1641-1648.

Motor vehicle accidents are the most common cause of injuries involving avulsion of the brachial plexus in humans,
resulting in debilitating motor dysfunction. Lack of an established animal model to test drug treatments hinders
the introduction of new pharmacological agents. Avulsion injury of cervical ventral roots can be replicated in rats,
resulting in a progressive loss of the motoneurons and increase in neurotoxic expression of microglia. This is a report
on the effect of prompt nerve implantation and minocycline treatment on the suppression of microglia activation and
survival of motoneurons. 20 adult female Sprague-Dawley rats were used for this study, which was approved by the
Animal Ethical Committee, USM (approval number /2011/(73)(346)). The animals underwent surgical avulsion of the
C6 nerve root, followed by reimplantation with peripheral nerve graft and treatment with intraperitoneal minocycline.
At 6 weeks postoperatively, immunohistochemistry using primary antibody Iba1 (microglia) and nicotinamide adenine
dinucleotide phosphate diaphorase (NADPh) with neutral-red staining (motoneuron) under flourescence microscopy
was performed at the C6 spinal cord segment and then quantified. This study showed significant reduction of microglia
expression in the study group; mean ranks of control and study group were 15.2 and 11.6, respectively; U=9.5, Z=3.02,
p<0.05. However, this did not translate into a significant increase of motoneuron survival in the combined group;
the mean ranks of control and study group were 40.6 and 41.6, respectively; U=44.5, Z=-.0378, p>0.05. This may
be due to the effect of the surgery; the surgery has the potential to cause additional trauma to the cord parenchyma,
leading to further motoneuron loss and an increase in scarring around the avulsed region, thus impeding regeneration
of the motoneuron.

Matched MeSH terms: Brachial Plexus
Fulltext The Effects of Minocycline on Spinal Root Avulsion Injury in Rat Model

Chin TY, Kiat SS, Faizul HG, Wu W, Abdullah JM

Malays J Med Sci, 2017 Mar;24(1):31-39.
PMID: 28381927 MyJurnal DOI: 10.21315/mjms2017.24.1.4

BACKGROUND: The neuroprotective role of minocycline in the treatment of brachial plexus injury is controversial.
OBJECTIVE: To study the neuroprotective effect of minocycline via different routes in adult Sprague Dawley rats with brachial plexus injury.
METHODS: The C7 nerve roots of the animals were avulsed via an anterior extravertebral approach. Traction force was used to transect the ventral motor nerve roots at the preganglionic level. Intraperitoneal and intrathecal minocycline (50 mg/kg for the first week and 25 mg/kg for the second week) were administered to promote motor healing. The spinal cord was harvested six weeks after the injury, and structural changes following the avulsion injury and pharmacological intervention were analysed.
RESULTS: Motor neuron death and microglial proliferation were observed after the administration of minocycline via two different routes (intraperitoneal and intrathecal) following traumatic avulsion injury of the ventral nerve root. The administration of intraperitoneal minocycline reduced the microglia count but increased the motor neuron count. Intrathecal minocycline also reduced the microglial count, with a greater reduction than in the intraperitoneal group, but it decreased the motor neuron count.
CONCLUSIONS: Intraperitoneal minocycline increased motor neuron survival by inhibiting microglial proliferation following traumatic avulsion injury of the nerve root. The inhibitory effect was augmented by the use of intrathecal minocycline, in which the targeted drug delivery method increased the bioavailability of the therapeutic agent. However, motor neuron survival was impaired at a higher concentration of minocycline via the intrathecal route due to the more efficient method of drug delivery. Microglial suppression via minocycline can have both beneficial and damaging effects, with a moderate dose being beneficial as regards motor neuron survival but a higher dose proving neurotoxic due to impairment of the glial response and Wallerian degeneration, which is a pre-requisite for regeneration.

Matched MeSH terms: Brachial Plexus
Fulltext Paclitaxel Inhibits Expression of Neuronal Nitric Oxide Synthase and Prevents Mitochondrial Dysfunction in Spinal Ventral Horn in Rats After C7 Spinal Root Avulsion

Sim SK, Tan YC, Tee JH, Yusoff AA, Abdullah JM

Turk Neurosurg, 2015;25(4):617-24.
PMID: 26242340 DOI: 10.5137/1019-5149.JTN.14035-15.1

This study evaluated the neuroprotective effect of intrathecally infused paclitaxel in the prevention of motoneuron death and mitochondrial dysfunction following brachial plexus avulsion injury.

Matched MeSH terms: Brachial Plexus/injuries

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