scholarly journals Nerves Transfer Procedure in Patients with Left Upper Extremities Weakness Following Gunshot Wounds: A Case Report

2021 ◽  
Vol 9 (C) ◽  
pp. 140-145
Author(s):  
Indra Rukmana Tri Pratistha ◽  
Nyoman Gede Bimantara ◽  
I. Gede Mahardika Putra ◽  
Made Bramantya Karna ◽  
Anak Agung Gde Yuda Asmara ◽  
...  
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Gunshot Wound ◽  
Nerve Transfer ◽  
Gunshot Wounds ◽  
Clinical Findings ◽  
Upper Extremities ◽  
Left Shoulder ◽  
Early Exploration ◽  
Peripheral Nerve Trauma

BACKGROUND: Gunshot wounds (GSWs) to the extremities can result in damage to the neurovascular structure which results in high morbidity and loss of function. According to the Centers for Disease Control report, the incidence of non-fatal GSWs has increased in the past decade. Trauma to the brachial plexus is a type of peripheral nerve trauma that is most difficult to treat due to its complex surgical procedures. Early exploration and reconstruction of peripheral nerve trauma are still being debated to this day. However, most recommend surgical exploration when the suspicion of neurovascular trauma is very high based on clinical findings. Nerve transfer is one of the recommended methods of nerve reconstruction even in pre-ganglionic lesions. We report a case of a patient with weakness of the upper limb after a gunshot wound to his left shoulder. Based on clinical considerations and investigations, nerve transfer procedure is carried out to restore patient’s shoulder function. CASE REPORT: Male, 32 years old, working as a policeman, complained difficulty on moving his shoulder for 3 months. Patients had a history of GSWs to the left shoulder which also results in a left clavicular fracture. First aid, debridement, and fracture management were performed at Bhayangkara Hospital, Palu. Physical examination revealed winging scapula positive on his left shoulder, shoulder abduction 5/1, and hypoesthesia at left C5 level. Electromyographic examination revealed lesions on the left posterior chord and left brachial plexus. Based on clinical findings and supporting examination, we performed nerve transfers procedure from the accessory nerve to suprascapular notch. In the previous study, 63% of cases GSWs associated with nerve dysfunction. About 75% of patients with nerve palsy are associated with nerve lacerations during surgical exploration. However, many surgeons continue to recommend early exploration after GSWs to the upper extremities, especially in patients who will undergo surgical treatment for other indications. Based on this, we suggest the probable cause of brachial plexus lesions in this case resulted from gunshot wound which injures the brachial plexus or as a complication from previous procedures. Surgery that is too early can interfere with the spontaneous reinnervation process, but late surgical procedures can result in failure of reinnervation. In general, optimal time is set between 3 and 6 months after trauma. Nerve transfer is one method of reconstructing peripheral nerve lesions that can be applied to pre-ganglionic or post-ganglionic lesions. CONCLUSION: This procedure has several benefits, namely, the proximity of the donor and the recipient nerve anatomy, shorter operating time and does not require grafts. Brachial plexus trauma due to trauma or non-trauma together has an impact on the patient’s quality of life. However, advances in surgical techniques and further understanding of nerve physiology have led clinicians and patients to better outcomes. The current trend of treatment strategies for brachial plexus trauma is surgical reconstruction with the nerve transfer procedure.

Peripheral Nerve and Brachial Plexus Impairment, AMA Guides, Sixth Edition

2017 ◽  
Vol 22 (2) ◽  
pp. 3-5
Author(s):  
James B. Talmage ◽  
Jay Blaisdell
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Complex Regional Pain Syndrome ◽  
Lower Extremities ◽  
Pain Syndrome ◽  
Upper Extremities ◽  
Motor Deficits ◽  
Type I ◽  
Sixth Edition ◽  
Nerve Entrapments

Abstract Physicians use a variety of methodologies within the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, to rate nerve injuries depending on the type of injury and location of the nerve. Traumatic injuries that cause impairment to the peripheral or brachial plexus nerves are rated using Section 15.4e, Peripheral Nerve and Brachial Plexus Impairment, for upper extremities and Section 16.4c, Peripheral Nerve Rating Process, for lower extremities. Verifiable nerve lesions that incite the symptoms of complex regional pain syndrome, type II (similar to the former concept of causalgia), also are rated in these sections. Nerve entrapments, which are not isolated traumatic events, are rated using the methodology in Section 15.4f, Entrapment Neuropathy. Type I complex regional pain syndrome is rated using Section 15.5, Complex Regional Pain Syndrome for upper extremities or Section 16.5, Complex Regional Pain Syndrome for lower extremities. The method for grading the sensory and motor deficits is analogous to the method described in previous editions of AMA Guides. Rating the permanent impairment of the peripheral nerves or brachial plexus is similar to the methodology used in the diagnosis-based impairment scheme with the exceptions that the physical examination grade modifier is never used to adjust the default rating and the names of individual nerves or plexus trunks, as opposed to the names of diagnoses, appear in the far left column of the rating grids.

Cortical Reorganization in Dual Innervation by Single Peripheral Nerve

Neurosurgery ◽  
2017 ◽  
Vol 83 (4) ◽  
pp. 819-826
Author(s):  
Mou-Xiong Zheng ◽  
Yun-Dong Shen ◽  
Xu-Yun Hua ◽  
Ao-Lin Hou ◽  
Yi Zhu ◽  
...  
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Phrenic Nerve ◽  
Nerve Transfer ◽  
Behavioral Observation ◽  
Cortical Reorganization ◽  
Side Group ◽  
Motor Representation ◽  
End To End ◽  
End Group

Abstract BACKGROUND Functional recovery after peripheral nerve injury and repair is related with cortical reorganization. However, the mechanism of innervating dual targets by 1 donor nerve is largely unknown. OBJECTIVE To investigate the cortical reorganization when the phrenic nerve simultaneously innervates the diaphragm and biceps. METHODS Total brachial plexus (C5-T1) injury rats were repaired by phrenic nerve–musculocutaneous nerve transfer with end-to-side (n = 15) or end-to-end (n = 15) neurorrhaphy. Brachial plexus avulsion (n = 5) and sham surgery (n = 5) rats were included for control. Behavioral observation, electromyography, and histologic studies were used for confirming peripheral nerve reinnervation. Cortical representations of the diaphragm and reinnervated biceps were studied by intracortical microstimulation techniques before and at months 0.5, 3, 5, 7, and 10 after surgery. RESULTS At month 0.5 after complete brachial plexus injury, the motor representation of the injured forelimb disappeared. The diaphragm representation was preserved in the “end-to-side” group but absent in the “end-to-end” group. Rhythmic contraction of biceps appeared in “end-to-end” and “end-to-side” groups, and the biceps representation reappeared in the original biceps and diaphragm areas at months 3 and 5. At month 10, it was completely located in the original biceps area in the “end-to-end” group. Part of the biceps representation remained in the original diaphragm area in the “end-to-side” group. Destroying the contralateral motor cortex did not eliminate respiration-related contraction of biceps. CONCLUSION The brain tends to resume biceps representation from the original diaphragm area to the original biceps area following phrenic nerve transfer. The original diaphragm area partly preserves reinnervated biceps representation after end-to-side transfer.

Computer-Aided Localisation of Peripheral Nerve Lesions

1991 ◽  
Vol 16 (1) ◽  
pp. 19-24 ◽  
Author(s):  
P. BURGE ◽  
B. TODD
Keyword(s):  
Retrospective Study ◽  
Peripheral Nerve ◽  
Computer Program ◽  
Simulation Model ◽  
Brachial Plexus ◽  
Upper Limb ◽  
Clinical Findings ◽  
Nerve Lesions ◽  
Peripheral Nerve Lesions ◽  
Computer Aided

The clinical localisation of peripheral nerve lesions can sometimes be difficult, particularly following injury to the brachial plexus when multiple lesions are often present. In this situation, computers may be of assistance in interpreting the complicated patterns of clinical findings. This paper describes the evaluation of a computer program that uses a simulation model of the consequences of nerve injury, based on a representation of the relevant anatomy. A retrospective study of 26 patients with upper limb nerve lesions was carried out. The computer program compared favourably with three clinicians in interpreting the findings correctly. It is suggested that this approach may be transferable to other applications.

Peripheral Nerve

2020 ◽  
pp. 63-96
Keyword(s):  
Carpal Tunnel Syndrome ◽  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Carpal Tunnel ◽  
Nerve Transfer ◽  
International Consensus ◽  
Magnetic Resonance Neurography ◽  
Louisiana State University ◽  
Tunnel Syndrome ◽  
Birth Palsy

This chapter addresses the peripheral nerve. The first set of studies discusses the management of carpal tunnel syndrome as well as the treatment for ulnar neuropathy at the elbow, which is the second most common entrapment neuropathy after carpal tunnel syndrome, and it describes lower extremity entrapment neuropathies. The second set of studies examines solitary benign neurofibromas or neurilemomas, which are relatively rare, and considers the international consensus on malignant peripheral nerve sheath tumors in neurofibromatosis 1. The third set of studies assesses the ulnar nerve as an alternative for nerve transfer after complete avulsion of the C5–C6 brachial plexus roots in order to restore elbow function, looks at outcomes of surgery in 1,019 brachial plexus lesions treated at Louisiana State University Health Sciences Center, and evaluates the surgical treatment of brachial plexus birth palsy. The last two studies introduce the application of magnetic resonance neurography in the evaluation of patients with peripheral nerve pathology and propose a five-tiered classification of peripheral nerve injuries.

Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons

2004 ◽  
Vol 101 (3) ◽  
pp. 365-376 ◽  
Author(s):  
Allan J. Belzberg ◽  
Michael J. Dorsi ◽  
Phillip B. Storm ◽  
John L. Moriarity
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Surgical Intervention ◽  
Nerve Repair ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Medical Community ◽  
Shoulder Abduction ◽  
Content Type ◽  
Fine Print

Object. Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering the limb a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear. The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons as to the management of BPIs. Methods. The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians and 49 (39%) participated in the study. The respondents represent 22 different countries and multiple surgical subspecialties. They performed a mean of 33 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, treatment of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal or proximal coaptation during nerve transfer. Conclusions. Experienced peripheral nerve surgeons disagree in important ways as to the management of BPI. The decisions made by the various treating physicians underscore the many areas of disagreement regarding the treatment of BPI, including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, the treatment of neuroma-in-continuity, the choice of nerve transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.

Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons

2004 ◽  
Vol 16 (5) ◽  
pp. 1-11 ◽  
Author(s):  
Allan J. Belzberg ◽  
Michael J. Dorsi ◽  
Phillip B. Storm ◽  
John L. Moriarity
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Surgical Intervention ◽  
Nerve Repair ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Medical Community ◽  
Shoulder Abduction ◽  
Nerve Transfers ◽  
The Many

Background Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering it a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear. Object The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons regarding the management of BPIs. Methods The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians of whom 49 (39%) participated in the study. The respondents represented 22 countries and multiple surgical subspecialties. They performed a mean of 34 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal compared with proximal coaptation during nerve transfer. Conclusions Experienced peripheral nerve surgeons disagreed in important respects as to the management of BPI. The decisions made by the various treating physicians underscored the many areas of disagreement regarding the treatment of BPI including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, choice of nerve transfers to achieve elbow flexion and shoulder abduction, use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.

scholarly journals Near-complete resolution of Nerve Constriction in Neuralgic Amyotrophy on Magnetic Resonance Neurography

2020 ◽  
Author(s):  
DO Robin Warner ◽  
Esther Zusstone ◽  
Joseph Feinberg ◽  
Ogonna Nwawka ◽  
Darryl Sneag
Keyword(s):  
Brachial Plexus ◽  
Nerve Root ◽  
Sudden Onset ◽  
Clinical Findings ◽  
Left Shoulder ◽  
Initial Examination ◽  
Mr Neurography ◽  
Magnetic Resonance Neurography ◽  
Diagnosis And Prognosis ◽  
History Of

Abstract INTRODUCTION/BACKGROUND: The diagnosis of brachial plexitis is based on history and clinical findings, supported by needle EMG and MRI. MR neurography can detect focal and multifocal inflammation within nerve.OBJECTIVE: To determine if MR neurography allows objective data mirroring clinical improvement in brachial plexitis.CASE REPORT: A 39-year-old man developed sudden onset pain in his left shoulder after a mild infection, which intensified over 3-4 days. Weakness followed, being unable to lift his left arm above the level of his shoulder. There were no sensory symptoms. There was a remote history of Bell’s palsy, but no relevant family history. Initial examination showed weakness of the left deltoid and infraspinatus (2/4). Reflexes were present. Needle EMG/NCSs showed left C5 radiculopathy, primarily involving the anterior ramus division with severe denervation of C5-innervated muscles, then progressive reinnervation of the C5 muscles through axonal regeneration. A left brachial plexus MR neurography with gadolinium showed an enlarged hyperintensity in the C5 nerve root at the level of the interscalene triangle with a denervation pattern edema of regional muscles. The patient was treated with IVIg. Ten months after onset, strength of all muscles is normal, although there is decreased muscle bulk in his deltoid and pectoral muscles. Serial MRIs show progressively decreasing nerve root hyperintensity and size in the post foraminal nerve root. The last MRI and needle EMG/NCSs were normal, correlating with the clinical syndrome.SUMMARY/CONCLUSION: MR neurography of the brachial plexus may be important in diagnosis and prognosis in patients with brachial plexitis.

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