us exist including GSW laceration and stretchcontusionwith the TOS - PDF document

us exist including GSW, laceration, and stretch/contusion,with the TOS. Birth palsy, or obstetrical BPI, is yet anoth- Neurosurg Focus 16 (5): OBERT Neurosurg. Focus / Volume 16 / May, 2004 Abbreviations used in this paper:BPI = brachial plexus injury;CT = computerized tomography; GSW = gunshot wound; LSUH-SC = Louisiana State University Health Sciences Center; MR =magnetic resonance; NAP = nerve action potential; TOS = thoracicoutlet syndrome. 8QDXWKHQWLFDWHG_'RZQORDGHG$087& and angiography, were performed in cases of suspectedTOS and tumors. ty of cases; however, a posterior subscapular approachpatients with TOS, 17% of patients with tumors, and 10%in a nonregenerating nerve. A large amplitude NAP withactual NAP was due to sensory fiber sparing distal to thefunction distal to the lesion. With severe postganglionicerative NAP indicated a regenerative NAP. External neu-rolysis was performed using a No. 15 scalpel blade orrecordings were flat the spinal nerve or extradural rootlar approach was used for infraclavicular plexus lesions inthere was a large interneural gap, an end-to-end repair waslevel to enable a gr

ouped interfascicular repair. Graftsmitted across the lesion but a portion of the element’ssplit away, it was resected and repaired by grafting.Excess scar tissue was removed from the segment to becases: 1) if the fascicular structure from which to lead outRESULTScontusion injury, which was the most frequent lesionwounds resulted in 118 injuries (12%), and there were 71lesions, and TOS was associated with 160 injuries or 16%laceration groups. Birth palsy, or obstetrical injury, isanother category of injury, but it was not included in thelast LSUHSC brachial plexus study. arm, (total upper-extremity paralysis [Fig. 2]); 2) 75 C5–7tion weakness of the C-7 muscles, which are the elbow, D. H. Kim, et al. 2Neurosurg. Focus / Volume 16 / May, 2004 8QDXWKHQWLFDWHG_'RZQORDGHG$087& C8–T1 or C7–T1 nerves (8%) (Table 1).11 were associated with suprascapular nerve injuries, 13were associated with the posterior cord, and 16 were asso-delineations are included in Table 2.in the LSUHSC series (Table 3). Most of the 293 plexusnuity when surgically exposed. Conversely, only 8% ofduring surgical exploration. There were 202 elementslesions in continuity recovered spontaneously, but others Neurosurg. Focus / Volume 1

6 / May, 2004 3 Fig. 1.Pie chart illustrating five main mechanisms of injury Fig. 2.Photograph showing a patient with left shoulder sublux- Fig. 3.Photograph of a patient with an upper trunk brachial 8QDXWKHQWLFDWHG_'RZQORDGHG$087& ements (Table 4). One third of patients with laceratinginjuries to the brachial plexus underwent acute surgicalcontinuity, despite the laceration injury as a mechanism.proach was used in 98 and 62 patients with TOS, respec-tively. Unilateral symptoms were present in 142 patients,lateral surgery. Female patients were slightly more preva-lent. The patients ranged in age from 11 to 70 years andSeventy-eight patients had undergone a total of 127operations before undergoing TOS surgery at LSUHSC.undergone cervical rib removal and 27 had undergoneneurofibromas and 32 (20%) underwent removal of neu-mas, and three sarcomas of different origins, which were1,11is due to a C5–6 innervated upper trunk injury. As a resultof this injury, the shoulder is adducted and internally rotat-called “waiter’s tip” posture. The muscles involved in- up to 90biceps and brachioradialis or elbow flexors, the supinator

,which include the pectoralis major, which also adductsKlumpke palsy results in atrophic paralysis of the fore-cal sympathetic system can also occur. Klumpke paralysisibly abducted over the head. The timing of surgery is con-brachial plexus surgery is that of absence of elbow flexionagainst gravity. There are few large series of BPIs and their mecha-mechanism included 111 traction injuries (51%), 38 stabreview, there were 16 birth injuries (7%) and 11 “other D. H. Kim, et al. 4Neurosurg. Focus / Volume 16 / May, 2004 8QDXWKHQWLFDWHG_'RZQORDGHG$087& injuries” (5%). In a review by Terzis, et al.,mented 119 patients with BPIs due to “high-velocitymotor-vehicle accidents,” which were further subdividedinto 73 motorcycle accidents and 46 auto accidents. Tenpedestrians sustained injury after being hit by a car. In theTerzis series GSWs caused 20 brachial plexus palsieswork or other type of injury. One hundred twelve patientslar postganglionic injury, and 43 had their trauma local-ized to the infraclavicular region. The difficulty of com-paring the mechanisms found in the Terzis series with“High-velocity motor-vehicle accidents” likely causedincidence of 10%, however, is in accordance with theder and arm

in another, resulting in severe stretching ofsoft tissues including nerves and, less frequently, vessels.Arm traction in a caudal direction affects the upper rootsAvulsion of one or more nerve roots, which changes thelesion from a post- to a preganglionic injury, is common,Avulsion results in thedural cavity, and spinal cord injury. Avulsion may also beroot injury. It is thought that nerve root pseudomeningo-root injury, do not of themselves contribute to neurologi-cal dysfunction. Rarely, meningoceles may enlarge,lesions in continuity, but can also transect elements. Themissile caliber, velocity, and angle of incidence. Missilethan shock wave and cavitation effects, which compressto recover spontaneously. Associated vascular injuries warrant emergency repair,duce pseudoaneurysms or arteriovenous fistulas, both ofthat required emergency repair. ments. Secondary repair, however, is reserved for bluntlytransected injuries or those suspected to be in continuity.let. Trauma in the area of the thoracic outlet may also pre-dispose to TOS, which can present with pain, paresthesias,and often weakness of the affected upper extremity. Trans-axillary first-rib resection as well as resection of the ante-Tumors in the brachial plexusextremity. Thus, these tumors are uncommon l

esions in-sected off the tumor capsule. An interfascicular dissectionNeurofibromas were removed in a similar fashion to thefrom the tumor. Neurofibromas had more than one fasci- Neurosurg. Focus / Volume 16 / May, 2004 5 8QDXWKHQWLFDWHG_'RZQORDGHG$087& larger than those in the schwannomas. It was important to 6Neurosurg. Focus / Volume 16 / May, 2004 Fig. 4.A: A myelogram revealing two right C6–7 pseudomeningoceles represented by extravasation of contrast dyeas shown.B: An axial postmyelogram CT scan revealing a pseudomeningocele extending into the intervertebral fora- Fig. 5.A: An axial Tnot be associated with nerve root avulsions.B: A coronal T 8QDXWKHQWLFDWHG_'RZQORDGHG$087& large on initial presentation. Such tumors were firm andschwannomas and neurofibromas. Treatment must be in-neurosarcomas in which as thorough a resection as possi-ble was performed. Radiation therapy, chemotherapy, orfound in 2399 neonates (0.18%). Variables associatedfetal macrosomia, shoulder dystocia, breech delivery, op-erative vaginal delivery, maternal diabetes mellitus

, sec-delivery.increased incidence of Erb palsy. Gherman, et al.,ever, reviewed the obstetrical literature and suggested thatin which a review of several of theirfactors for injury.all infants who re-secondary surgery. If recovery of the biceps muscle hadwas considered poor, and surgical repair of the plexus wasThe determinant used to establish the need for surgerybeen managed without surgery.SC, but have performed surgery in only 21.TOSs (16%). Other lesions of the brachial plexus include1.Al-Qattan M: The outcome of Erb’s palsy when the decision to2.Birch R, Bonney G, Wynn Parry CB: 3.Ganju A, Roosen N, Kline DG, et al: Outcomes in a consecu-4.Gherman RB, Ouzounian JG, Goodwin TM: Brachial plexus5.Giddins GEB, Birch R, Singh D, et al: Risk factors for obstetric162, 2000 (Abstract)6.Goff CD, Parent FN, Sato DT, et al: A comparison of surgery7.Hader WJ, Fairholm D: Giant intraspinal pseudomeningocelesthree cases. 8.Huang JH, Samadani U, Zager EL: Brachial plexus region9.Kim DH, Cho YJ, Tiel RL, et al: Outcomes of surgery in 101910.Kline DG, Hudson AR: 11.Kline DG, Judice DJ: Operative management of selected bra-12.Ladfors L, Mollberg M, Hagberg H: 272: A population basedanalysis of risk factors for BPI in neonates: an analysis based13.Mackinnon SE, Dellon AL: 14.Mi

chelow BJ, Clarke HM, Curtis CG, et al: The natural history Neurosurg. Focus / Volume 16 / May, 2004 7 8QDXWKHQWLFDWHG_'RZQORDGHG$087& 15.Midha R: Epidemiology of BPIs in a multitrauma population.16.Ouzounian JG, Korst LM, Phelan JP: Permanent Erb palsy: a17.Peach SA, Ackerman C, Visser JH: Results of treatment18.Samardzic MM, Rasulic LG, Grujicic DM: Gunshot injuries to19.Soni AL, Mir NA, Kishan J, et al: Brachial plexus injuries in20.Terzis JK, Papakonstantinou KC: The surgical treatment of21.Terzis JK, Vekris MD, Soucacos PN: Outcomes of brachial22.Uetani M, Hayashi K, Hashmi R, et al: Traction injuries of the23.Zhao S, Pang Y, Beuerman RW, et al: Expression of c-Fos24.Zorub DS, Nashold BS Jr, Cook WA Jr: Avulsion of the bra- Accepted in final form April 2, 2004.Address reprint requests to:Daniel H. Kim, M.D., Department ofNeurosurgery, Stanford University Medical Center, Room R-2001,Edwards Building, 300 Pasteur Drive, Stanford, California 94305-5327. email: neurokim@stanford.edu. 8Neurosurg. Focus / Volume 16 / May, 2004 8QDXWKHQWLFDWHG_'RZQORDGHG$0