Traumatic Brachial Plexus Injury in Indonesia: An Experience from a Developing Country

Background Brachial plexus injuries (BPI) cause severe physical disability and major psycho-socioeconomic burden. Although various countries have reported BPI incidence, the data from Indonesia as the fourth most populated country in the world remains unknown. We aim to assess the distribution of traumatic BPI, patients' characteristics, and treatment modalities in Indonesia. Methods A retrospective investigation was performed comprising 491 BPI patients at a tertiary referral hospital in Indonesia from January 2003 to October 2019. Demographic and outcomes data were retrieved from medical records. Results The average BPI patients' age was 27.3 ± 11.6 years old, with a male/female ratio of 4.6:1. Motorcycle accidents caused the majority (76.1%) of all BPI cases. Concomitant injuries were present in 62.3% of patients, dominated by fractures (57.1%) and brain injuries (25.4%). BPI lesion type was classified into complete (C5-T1, observed in 70% patients), upper (C5-C6, in 15% patients), extended upper (C5-C7, in 14% patients), and lower type (C8-T1, in 1% patients). The average time to surgery was 16.8 months (range 1–120 months), with the majority (76.6%) of the patients was operated on six months after the trauma. Free functional muscle transfer (FFMT) was the most common procedure performed (37%). We also analyzed the functional outcomes (active range of motion (AROM) and muscle power), DASH (Disabilities of the Arm, Shoulder, and Hand) score, and VAS (Visual Analogue Scale) across four most frequent procedures involving nerve reconstruction (FFMT, nerve transfer, external neurolysis, and nerve grafting). We found that FFMT was significantly better than nerve transfer in terms of DASH score and VAS (p = 0.000 and p = 0.016, respectively) in complete BPI (C5-T1). Moreover, we also found that nerve grafting resulted in a significantly better shoulder abduction AROM than nerve transfer and external neurolysis in extended upper BPI (C5-C7) (p = 0.033 and p = 0.033, respectively). Interestingly, no significant differences were observed in other measurements. Conclusion This study provides an overview of traumatic BPI patients in a single tertiary trauma center in Indonesia, expressing the profile of their characteristics and functional outcomes after surgical procedures.

Analysis of the Long-Term Outcome in Open Carpal Tunnel Release Surgeries with and without External Neurolysis of Median Nerve, Using Boston Carpal Tunnel Questionnaire (BCTQ)–Hindi Version

Background The effectiveness of open carpal tunnel release (OCTR) in treating carpal tunnel syndrome (CTS) is well known. However, the role of ancillary external neurolysis of the median nerve is not well-documented. The Boston carpal tunnel questionnaire (BCTQ) is a commonly used disease-specific outcome instrument for CTS, which is validated across major languages of the world. No such validated Hindi version of BCTQ exists. Objectives To analyze and compare the long-term outcome in patients who underwent OCTR alone and OCTR with external neurolysis of the median nerve, using BCTQ–Hindi version, while checking its validity. Materials and Methods A retrospective, cross-sectional study was conducted at a tertiary care institute. The BCTQ was translated into Hindi language by a language expert. Eighty-four consecutive patients who underwent either unilateral/bilateral OCTR, with or without external neurolysis of the median nerve, between 2009 and 2019 were included in the study. Outcome analysis was done using BCTQ–Hindi version and patient satisfaction scoring. BCTQ–Hindi version was examined for statistical validity. Subgroup analysis of the outcome based on surgical technique (OCTR vs. OCTR with external neurolysis) used was carried out. Results Response rate was 80.9%. Total hands evaluated were 108. BCTQ–Hindi version showed statistical validity. Overall symptom severity score (SSS) and functional severity score (FSS) were 1.14 ± 0.4 and 1.12 ± 0.35, respectively. Subgroup analysis of outcome revealed statistically significant results in favor of OCTR with external neurolysis of the median nerve. Conclusions BCTQ–Hindi version is statistically validated. OCTR with external neurolysis of the median nerve is a promising avenue in surgical management of CTS. Further prospective studies are warranted.

Midarch Foot Pain: Entrapment Neuropathy of the Distal Medial Plantar Nerve and Its Branches

Medial forefoot pain, or midarch pain, is usually attributed to plantar fasciitis. The authors present their findings of a previously unreported nerve entrapment of the medial proper plantar digital nerve (MPPDN). Ten fresh-frozen cadaveric specimens were analyzed for anatomical variance in the nerve distribution of the MPPDN. In addition, clinical results from a retrospective review of nine patients who underwent surgical nerve decompression of the MPPDN are presented. Significant anatomical variance was found for the MPPDN in the cadaveric dissection of 10 fresh-frozen specimens. Nine patients with a clinical diagnosis of entrapment of the MPPDN all obtained excellent pain relief with surgical external neurolysis. Only one complication occurred: a hypertrophic scar formation that was successfully treated with intralesional steroid injections. The authors believe that this MPPDN entrapment is often overlooked or misdiagnosed as plantar fasciitis. Surgical peripheral nerve decompression of this nerve can provide positive outcomes for patients suffering from midarch foot pain caused by this pain generator.

Occipital Neuralgia following Acoustic Neuroma Resection

Background While postoperative outcomes of acoustic neuroma (AN) resection commonly consider hearing preservation and facial function, headache is a critical quality of life factor. Postoperative headache is described in the literature; however, there is limited discussion specific to occipital neuralgia (ON) following AN resection. Objective The aim of this study is to investigate the effectiveness of conservative management and surgery. Methods We conducted a retrospective review of 872 AN patients who underwent resection at our institution between 1988 and 2017 and identified 15 patients (1.9%) that met International Classification of Headache Disorders criteria for ON. Results Of the 15 ON patients, surgical approaches included 13 (87%) retrosigmoid (RS), one (7%) translabyrinthine (TL), and one (7%) combined RS + TL. Mean clinical follow-up was 119 months (11–263). Six (40%) patients obtained pain relief through conservative management, while the remaining nine (60%) underwent surgery or ablative procedure. Three (38%) patients received an external neurolysis, four (50%) received a neurectomy, one (13%) had both procedures, and one (13%) received two C2 to 3 radio frequency ablations. Of the nine patients who underwent procedural ON treatment, seven (78%) patients achieved pain relief, one patient (11%) continued to have pain, and one patient (11%) was lost to follow-up. Of the six patients whose pain was controlled with conservative management and nerve blocks, five (83%) found relief by using neuropathic pain medication and one (17%) found relief on nonsteroidal anti-inflammatory drug. Conclusion Our series demonstrates success with conservative management in some, but overall a minority (40%) of patients, reserving decompression only for refractory cases.

An intraneural ganglion cyst of the ulnar nerve at the wrist: a case report and literature review

Background Intraneural ganglion cysts of the ulnar nerve at the wrist are rare and poorly understood. We report a case of an intraneural ganglion cyst at the level of the wrist. Case presentation: A 48-year-old man presented with the complaints of weakness for 6 months and serious aggravation for 1 month in his right hand. After examinations, including ultrasound, the patient was diagnosed with an intraneural ganglion cyst. Intraoperatively, with exposure of the ulnar nerve, we found that the intraneural ganglion cyst was at the level of Guyon’s canal and extended approximately 6 cm proximally. Postoperatively, sensation of the fingers was normal, but atrophy of his muscles and limited straightening of his ring and little fingers were similar to those preoperatively. Conclusions Diagnosis of an intraneural cyst before surgery is mostly based on ultrasound and magnetic resonance imaging. Transection of the articular branch is an important measure to prevent recurrence of this cyst. If the ulnar nerve is compressed and causes symptoms, nerve decompression, including removal/aspiration of the cyst, and sometimes external neurolysis of the nerve, are necessary to relieve the symptoms and allow regeneration of the nerve. However, these should be performed without damaging the nerve fascicles.

Pain Relief after Surgical Decompression of the Distal Brachial Plexus

Background Brachial plexopathy causes pain and loss of function in the affected extremity. Entrapment of the brachial plexus terminal branches within the surrounding connective tissue, or medial brachial fascial compartment, may manifest in debilitating symptoms. Open fasciotomy and external neurolysis of the neurovascular bundle in the medial brachial fascial compartment were performed as a surgical treatment for pain and functional decline in the upper extremity. The aim of this study was to evaluate pain outcomes after surgery in patients diagnosed with brachial plexopathy. Methods We identified 21 patients who met inclusion criteria. Documents dated between 2005 and 2019 were reviewed from electronic medical records. Chart review was conducted to collect data on visual analog scale (VAS) for pain, Semmes-Weinstein monofilament test (SWMT), and Medical Research Council (MRC) scale for muscle strength. Pre- and postoperative data was obtained. A paired sample t-test was used to determine statistical significance of pain outcomes. Results Pain severity in the affected arm was significantly reduced after surgery (pre: 6.4 ± 2.5; post: 2.0 ± 2.5; p < 0.01). Additionally, there was an increased response to SWMT after the procedure. More patients achieved an MRC rating score ≥3 and ≥4 in elbow flexion after surgery. This may be indicative of improved sensory and motor function. Conclusion Open fasciotomy and external neurolysis at the medial brachial fascial compartment is an effective treatment for pain when nerve continuity is preserved. These benefits were evident in patients with a prolonged duration elapsed since injury onset.

Brachial Plexus Surgery

The magnitude problems of brachial plexus lesions are not only about the surgical approaches but also the basic problems. Its vague clinical symptoms, the complexity of anatomy structure, the use of advanced imaging followed by electrophysiology to address the lesions, and the challenging of surgical timing and options make those lesions management more challenging. These challenges in Indonesia are more difficult because not so many neurosurgeons are familiar with brachial plexus surgery.Brachial plexus surgery is in evolution. For brachial plexus nerve sheath tumours, a fascicular level resection of tumours and preservation of uninvolved fascicles is now possible. Neuropathic pain may be improved by a dorsal root entry zone lesion procedure. The timing of surgery is different in each pathology, especially in traumatic injury. In traumatic injury, it depends on several factors, e.g. the mechanism of injury, type of injury, the speed of the vehicle, and the mode of fall while victim lands on the ground.The common surgical options in traumatic injury are direct repair by means of an end-to-end suture, external neurolysis, nerve grafting, and nerve transfers. Secondary reconstruction to improve function has been widely introduced such as soft-tissue reconstruction (tendon/muscle transfer or free muscle transfer) and bone procedures (arthrodesis or osteotomy). Brachial plexus surgery demands a broad multidisciplinary approach to a common problem, targeting not only the peripheral nerve, but also the brain, spinal cord, muscle, end-organ, bone and joints, and their complex interactions.

Brachial Plexus Surgery

The magnitude problems of brachial plexus lesions are not only about the surgical approaches but also the basic problems. Its vague clinical symptoms, the complexity of anatomy structure, the use of advanced imaging followed by electrophysiology to address the lesions, and the challenging of surgical timing and options make those lesions management more challenging. These challenges in Indonesia are more difficult because not so many neurosurgeons are familiar with brachial plexus surgery.Brachial plexus surgery is in evolution. For brachial plexus nerve sheath tumours, a fascicular level resection of tumours and preservation of uninvolved fascicles is now possible. Neuropathic pain may be improved by a dorsal root entry zone lesion procedure. The timing of surgery is different in each pathology, especially in traumatic injury. In traumatic injury, it depends on several factors, e.g. the mechanism of injury, type of injury, the speed of the vehicle, and the mode of fall while victim lands on the ground.The common surgical options in traumatic injury are direct repair by means of an end-to-end suture, external neurolysis, nerve grafting, and nerve transfers. Secondary reconstruction to improve function has been widely introduced such as soft-tissue reconstruction (tendon/muscle transfer or free muscle transfer) and bone procedures (arthrodesis or osteotomy). Brachial plexus surgery demands a broad multidisciplinary approach to a common problem, targeting not only the peripheral nerve, but also the brain, spinal cord, muscle, end-organ, bone and joints, and their complex interactions.