Complete brachial plexus injuries are devastating injuries. A viable C5 spinal nerve can offer additional sources of axons and alter surgical treatment. We aimed to determine factors that portend C5 ...nerve root avulsion.
A retrospective study of 200 consecutive patients with complete brachial plexus injuries at two international centers (Mayo Clinic in the United States and Chang Gung Memorial Hospital in Taiwan) was performed. Demographic information, concomitant injuries, mechanism, and details of the injury were determined, and kinetic energy (KE) and Injury Severity Score were calculated. C5 nerve root was evaluated by preoperative imaging, intraoperative exploration, and/or intraoperative neuromonitoring. A spinal nerve was considered viable if it was grafted during surgery.
Complete five-nerve root avulsions of the brachial plexus were present in 62% of US and 43% of Taiwanese patients, which was significantly different. Increasing age, the time from injury to surgery, weight, body mass index of patient, motor vehicle accident, KE, Injury Severity Score, and presence of vascular injury significantly increased the risk of C5 avulsion. Motorcycle (≤150cc) or bicycle accident decreased the risk of avulsion. Significant differences were found between demographic variables between the two institutions: age of injury, body mass index, time to surgery, vehicle type, speed of injury, KE, Injury Severity Score, and presence of vascular injury.
The rate of complete avulsion injury was high in both centers. Although there are a number of demographic differences between the United States and Taiwan, overall the KE of the accident increased the risk of C5 avulsion.
Free flap monitoring is essential for postmicrosurgical management and outcomes but traditionally relies on human observers; the process is subjective and qualitative and imposes a heavy burden on ...staffing. To scientifically monitor and quantify the condition of free flaps in a clinical scenario, we developed and validated a successful clinical transitional deep learning (DL) model integrated application.
Patients from a single microsurgical intensive care unit between 1 April 2021 and 31 March 2022, were retrospectively analyzed for DL model development, validation, clinical transition, and quantification of free flap monitoring. An iOS application that predicted the probability of flap congestion based on computer vision was developed. The application calculated probability distribution that indicates the flap congestion risks. Accuracy, discrimination, and calibration tests were assessed for model performance evaluations.
From a total of 1761 photographs of 642 patients, 122 patients were included during the clinical application period. Development (photographs =328), external validation (photographs =512), and clinical application (photographs =921) cohorts were assigned to corresponding time periods. The performance measurements of the DL model indicate a 92.2% training and a 92.3% validation accuracy. The discrimination (area under the receiver operating characteristic curve) was 0.99 (95% CI: 0.98-1.0) during internal validation and 0.98 (95% CI: 0.97-0.99) under external validation. Among clinical application periods, the application demonstrates 95.3% accuracy, 95.2% sensitivity, and 95.3% specificity. The probabilities of flap congestion were significantly higher in the congested group than in the normal group (78.3 (17.1)% versus 13.2 (18.1)%; 0.8%; 95% CI, P <0.001).
The DL integrated smartphone application can accurately reflect and quantify flap condition; it is a convenient, accurate, and economical device that can improve patient safety and management and assist in monitoring flap physiology.
Background
Distal nerve transfer has proven efficacy. The purpose of this study was to investigate if an injured nerve can be used as a donor nerve for transfer, and to determine the threshold of ...injury.
Materials and Methods
Rat's left ulnar‐nerves in the axilla with different degrees of injury were selected as the donor nerves for transfer, and the musculocutaneous‐nerves the target nerves for being re‐innervated. Six rats each served as positive and negative controls: Group A, intact ulnar‐nerve transfer; and Group E, the ulnar‐nerve was cut but no transfer. Ten rats each were assigned to Group B to Group D with 25%, 50%, and 75% transected ulnar‐nerve, respectively and all were transferred to the musculocutaneous‐nerve. After a 12‐week recovery period, outcomes were evaluated.
Results
Biceps muscle weight measurements showed all experimental groups—D 0.28 ± 0.02 g/72%, C 0.28 ± 0.03 g/73%, B 0.29 ± 0.04 g/74%, and A 0.29 ± 0.04 g/80%—were lighter than group H 0.36 ± 0.04 g, which were all statistically significant (P < 0.001). Muscle tetanus contraction force measurements were the lowest in group D35 ± 8.6 g/69%. Groups C and B measured 41 ± 8.5 g/75% and 40 ± 2.2 g/77% and group A 41 ± 9.4 g/95%, respectively. Group H showed muscle contraction force of 52 ± 7.2 g, which was statistically significant when compared to experimental groups (P < 0.05–0.001). EMG measurements of the biceps muscles showed: group D was 3.6 ± 0.7 mV/69%, group C was 3.6 ± 0.6 mV/75%, and group B was 4.2 mV ± 0.7/81%. Group H was5.1 ± 0.7 mV and statistically significant different when compared with experimental groups (P < 0.05–0.001).Axon counts of healthy ulnar‐nerve (Group H) were 1849 ± 362. Axon counts of the injured ulnar‐nerve were in group B 1447 ± 579/78%, group C 1051 ± 367/57% and group D 567 ± 230/31%.
Conclusion
The donor nerve should be healthy in order to provide optimal result. A big nerve (e.g., ulnar nerve) but injured with at least 75% axon spared is still potentially effective for transfer. In contrast, a small nerve (e.g., intercostal nerve) once injured with 75%axon spared would be considered a suboptimal donor nerve.
Background Free vascularized ulnar nerve flaps (VUNF) are effective method for long nerve defects reconstruction. However, the monitorization of its microvascular circulation and the nerve regrowth ...can be challenging since it is usually designed as a buried flap. We designed a skin paddle based on a septocutaneous perforator from the ulnar artery that can be dissected and raised in conjunction with the vascularized ulnar nerve flap, which aims to improve postoperative monitorization to optimizing the clinical results.
Methods We retrospectively reviewed 10 cases with long nerve defects who underwent reconstruction using VUNF between June 2018 and June 2019, including eight acute brachial plexus injuries, 1 multiple nerve injury due to a rolling machine accident, and 1 sequalae of nerve injury after arm replantation. All the demographic data, surgical details, outcomes, and perioperative complications were recorded.
Results We evaluated 10 male patients, with a mean age of 34 ± 16 years. Cases included 5 antegrade, 4 retrograde, and 1 U-shaped VUNF. All chimeric skin paddles survived, and all of the underlying nerves presented with adequate circulation and functional improvement. There were no intraoperative or microvascular complications. One skin paddle had a transitory postoperative circulation compromise due to external compression (bandage) which resolved spontaneously after pressure release.
Conclusion VUNF chimerization of a septocutaneous perforator skin flap is a relatively easy and efficient method for postoperative monitorization of the nerve's microvascular circulation as well as beneficial for postoperative Tinel's sign checkup to confirm the success of the nerve coaptation. The outcome is potentially improved.
Thoracic outlet syndrome (TOS) has many controversies that include nomenclature, etiology, diagnosis, treatment and surgical approach. The aim of this article is to give a comprehensive review of our ...experience of treatment of TOS for more than 35 years.
From 1985 to 2021, a total of 100 TOS patients were treated and 114 surgeries were performed. They all had decompression surgeries for their compression neuropathy in the thoracic outlet with at least one year postoperative follow-up. Fourteen patients were bilateral TOS, undergoing bilateral TOS surgeries. Preoperative evaluation covered “TOS Examination Sheet” and imaging studies MRI and CT. Diagnosis was confirmed by intraoperative findings. All had near-total resection of the anterior scalene muscle and the first rib. Additional structual abnormalities were treated at the same time. The operative time was typically 2–3 h.
Major postoperative complications were rare. Nearly all patients (96%) experienced significant symptoms and signs relief after a period of clinical follow-up and rehabilitation.
TOS is a real clinical entity. Once the preoperative diagnosis is made, conservative treatment is followed but failed, decompression surgery with extensive resection of anterior scalene muscle and the 1st rib, and any other structural abnormalities is recommended to resolve the problems. Long-term postoperative follow-up is crucial and important to resolve the residual problems. Our result carries a 96% success rate with a favorable benefit:risk ratio.
•A total of 100 thoracic outlet syndrome (TOS) patients were treated and 114 surgeries were performed.•Preoperative evaluation, intraoperative findings and procedure, and postoperative follow-up were included.•Decompression surgery included resection of anterior scalene muscle, the 1st rib, and any other structural abnormalities.•Our result carries a 96% success rate with a favorable benefit:risk ratio.
Möbius syndrome (MS) can present with unilateral or bilateral facial paralysis. In performing 1-stage bilateral MS facial reanimation, we used bilateral spinal accessory (XI) nerves to innervate 2 ...free functional muscle transfers (FFMTs).
Of 12 MS patients, 6 had bilateral facial paralysis. Bilateral gracilis were transferred and innervated using bilateral XI nerves. Results were evaluated using smile excursion score, cortical adaptation stage, and patient satisfaction questionnaire.
In all, 13 FFMTs were performed (with 1 gracilis failure). Mean smile excursion score improved from 0.7 to 3.4 (out of 5) postoperatively. Four patients achieved spontaneous smile, 1 achieved independent smile, and 1 achieved dependent smile. Mean satisfaction score was 2.8 (out of 5).
One-stage bilateral FFMTs neurotized by bilateral XI nerves are effective in treating bilateral MS patients. Careful patient selection, adequate neurologic and psychologic examination, and postoperative smile training are all important factors in achieving optimal outcomes.
BACKGROUND:Postparalysis facial synkinesis (PPFS) can occur after any cause of facial palsy. Current treatments are still inadequate. Surgical intervention, instead of Botox and rehabilitation only, ...for different degrees of PPFS was proposed.
METHODS:Seventy patients (43 females and 27 males) with PPFS were enrolled since 1986. They were divided into 4 patterns based on quality of smile and severity of synkinesis. Data collection for clinically various presentations was madepattern I (n = 14) with good smile but synkinesis, pattern II (n = 17) with acceptable smile but dominant synkinesis, pattern III (n = 34) unacceptable smile and dominant synkinesis, and pattern IV (n = 5) poor smile and synkinesis. Surgical interventions were based on patterns of PPFS. Selective myectomy and some cosmetic procedures were performed for pattern I and II patients. Extensive myectomy and neurectomy of the involved muscles and nerves followed by functioning free-muscle transplantation for facial reanimation in 1- or 2-stage procedure were performed for pattern III and many pattern II patients. A classic 2-stage procedure for facial reanimation was performed for pattern IV patients.
RESULTS:Minor aesthetic procedures provided some help to pattern I patients but did not cure the problem. They all had short follow-up. Most patients in patterns II (14/17, 82%) and III (34/34, 100%) showed a significant improvement of eye and smile appearance and significant decrease in synkinetic movements following the aggressively major surgical intervention. Nearly, all of the patients treated by the authors did not need repeated botulinum toxin A injection nor require a profound rehabilitation program in the follow-up period.
CONCLUSIONS:Treatment of PPFS remains a challenging problem. Major surgical reconstruction showed more promising and long-lasting results than botulinum toxin A and/or rehabilitation on pattern III and II patients.
Abstract
Background
Replantation of a single digit at the distal phalanx level is not routinely performed since it is technically challenging with questionable cost-effectiveness. The purpose of ...this study was to analyze international microsurgeons' clinical decisions when faced with this common scenario.
Methods
A survey of a right-middle finger distal phalanx transverse complete amputation case was conducted via online and paper questionnaires. Microsurgeons around the world were invited to provide their treatment recommendations. In total, 383 microsurgeons replied, and their responses were stratified and analyzed by geographical areas, specialties, microsurgery fellowship training, and clinical experiences.
Results
Among 383 microsurgeons, 170 (44.3%) chose replantation as their preferred management option, 137 (35.8%) chose revision amputation, 62 (16.2%) chose local flap coverage, 8 (2.1%) chose composite graft, and 6 (1.6%) favored other choices as their reconstruction method for the case study. Microsurgeons from the Asia-Pacific, Middle East/South Asia, and Central/South America regions tend to perform replantation (70.7, 68.8, and 67.4%, respectively) whereas surgeons from North America and Europe showed a lower preference toward replantation (20.5 and 26.8%, respectively
p
< 0.001). Having completed a microsurgery fellowship increased the attempt rate of replantation by 15.3% (
p
= 0.004). Clinical experience and the surgeons' specialties did not show statistical significance in clinical decision making.
Conclusion
From the present study, the geographic preferences and microsurgery fellowship experience influence the method of reconstruction for distal phalanx amputation. Multiple factors are taken into consideration in selecting the most suitable reconstructive method for each case scenario. In addition to the technical challenges of the proposed surgery, the cost of the procedure and the type of facility needed are important variables in the decision making process.
ABSTRACTLymphangiomas are rare malformations of the lymphatic system and can often be found in the neck region, where its proximity to the brachial plexus may cause compressive neuropathy and ...possible iatrogenic injuries during dissection. We report 4 cases of lymphangiomas with compression of the brachial plexus that were successfully removed without permanent nerve injuries and present a literature review of the preoperative approach and surgical techniques. A preoperative multidisciplinary approach can help surgeons predict what they may encounter during the surgery. A careful and stepwise dissection of the vital structures surrounding the tumor, especially the brachial plexus anatomy, is critical to avoiding severe complications. Incomplete resection or leakage of the lymph could result in higher rate of recurrence.
Background: Reconstruction of brachial plexus injuries (BPIs) at a delayed time point may prolong the denervation of target muscles and jeopardize the outcome. Sensory protection has been hailed as a ...promising technique that may help preserve muscle mass and restore functional outcome. We utilize the rat brachial plexus model to investigate the difference between early and delay repair, and evaluate if sensory protection of distal nerves can assist in delayed repair.
Materials and Methods: Forty-eight Lewis rats were randomly assigned to four groups (n = 12 in each group, including one positive control group). All the rats were transected at the upper, middle, and lower trunk levels with a 2-cm gap. Group I underwent immediate reconstruction from the upper trunk to the median; Group II underwent the same reconstruction but at 4 months after the initial transection; Group III was same as Group II and additional sensory protection to the median nerve via a nerve graft from the lower trunk. The final outcome was studied and analyzed 16 weeks postoperatively.
Results: Group I (immediate repair) showed the best functional results in muscle contraction force, muscle action potential, and muscle weight, in addition to higher axon counts. Groups II and III (delayed repair) both showed inferior results to Group I, and sensory protection did not show any significant improvements in outcome.
Conclusion: Delayed repair still shows inferior outcomes to acute repair in BPIs. There is no sufficient evidence to support the use of sensory protection in delayed repair.
PDF
