Permanent upper trunk plexopathy after interscalene brachial plexus block

Interscalene brachial plexus block (IBPB) has been widely used in shoulder surgical procedures. The incidence of postoperative neural injury has been estimated to be as high as 3 %. We report a long-term neurologic deficit after a nerve stimulator assisted brachial plexus block. A 55 year-old male, with right shoulder impingement syndrome was scheduled for elective surgery. The patient was given an oral dose of 10 mg of diazepam prior to the nerve stimulator assisted brachial plexus block. The patient immediately complained, as soon as the needle was placed in the interscalene area, of a sharp pain in his right arm and he was sedated further. Twenty-four hours later, the patient complained of severe shoulder and arm pain that required an increased dose of analgesics. Severe peri-scapular atrophy developed over the following days. Electromyography studies revealed an upper trunk plexus injury with severe denervation of the supraspinatus, infraspinatus and deltoid muscles together with a moderate denervation of the biceps brachii muscle. Chest X-rays showed a diaphragmatic palsy which was not present post operatively. Pulmonary function tests were also affected. Phrenic nerve paralysis was still present 18 months after the block as was dysfunction of the brachial plexus resulting in an inability to perform flexion, abduction and external rotation of the right shoulder. Severe brachial plexopathy was probably due to a local anesthetic having been administrated through the perineurium and into the nerve fascicles. Severe brachial plexopathy is an uncommon but catastrophic complication of IBPB. We propose a clinical algorithm using ultrasound guidance during nerve blocks as a safer technique of regional anesthesia.     

气性坏疽伴下肢截肢患者的护理

总结分析8例严重外伤导致气性坏疽伴下肢截肢患者的护理经验,包括入院后的急救处理、消毒和隔离、心理护理、截肢残端护理、氧疗护理等。认为全面系统规范的护理能促进患者的康复,改善临床救治疗效。     

Ultrasound-guided supraclavicular brachial plexus nerve block vs procedural sedation for the treatment of upper extremity emergencies

Background

Emergency physicians often treat patients who require procedural sedation for the management of upper extremity fractures, dislocations, and abscesses (upper extremity emergencies). Unfortunately, procedural sedation is associated with several rare but potentially serious adverse effects and requires continuous hemodynamic monitoring and several dedicated staff members. The purpose of this study was to determine the role of ultrasound-guided supraclavicular brachial plexus nerve blocks in the emergency department (ED) as an alternative to procedural sedation for the management of upper extremity emergencies.

Methods

In a prospective trial, a convenience sample of ED patients with upper extremity emergencies that would normally require procedural sedation were assigned to receive either procedural sedation or an ultrasound-guided supraclavicular brachial plexus nerve block. Emergency department length of stay (ED LOS) was the primary outcome measure and was analyzed using a paired 2-tailed Student t test.

Results

A total of 12 subjects were enrolled. Average ED LOS for subjects receiving the brachial plexus nerve block was 106 minutes (95% confidence interval, 57-155 minutes). Average ED LOS for subjects receiving procedural sedation was 285 minutes (95% confidence interval, 228-343 minutes). The ED LOS was significantly shorter in the nerve block group (P < .0005). Patient satisfaction was high in both groups, and no significant complications occurred in either group.

Conclusions

In our population, ultrasound-guided brachial plexus nerve blocks resulted in shorter ED LOS compared to procedural sedation for patients with upper extremity fractures, dislocations, or abscesses.     

Comparison of two approaches to brachial plexus anesthesia for proximal upper extremity surgery: interscalene and intersternocleidomastoid

We conducted a prospective, randomized study to compare differences between groups of patients given a brachial plexus block using an interscalene (IS) or an intersternocleidomastoid (ISCM) approach. Specific variables analyzed included overall success rates, time to achieve sensory and motor anesthesia, time to place block, and incidence of side effects. For the study, 81 patients were randomized to receive a brachial plexus blockade using the IS or ISCM approach followed by general anesthesia for their surgical procedure. Intraoperative analgesics were controlled for in both groups. No differences in demographics, block success rate, pain scale scores, and analgesia duration were noted between groups. The ISCM group required less time to complete the block (7.08 +/- 2.9 min) compared with the IS group (9.62 +/- 5.31 min) (P = .039), achieved a significantly higher rate of complete motor and sensory block at 30 minutes (P = .032), and had fewer side effects (P = .049). Based on our results, we found that using the ISCM approach to the brachial plexus resulted in a faster onset of anesthesia and a higher ratio of complete block at 30 minutes compared with the IS approach.     

连续臂丛神经阻滞治疗上肢带状疱疹后遗神经痛的临床分析

目的探讨连续臂丛神经阻滞治疗上肢带状疱疹后遗神经痛的临床效果。方法回顾性分析自2008～2011年68例进行连续臂丛神经阻滞治疗上肢带状疱疹后遗神经痛患者的临床资料,对比同期行口服药物、外用药物及针灸理疗(保守治疗)的患者。结果治疗后重新进行疼痛视觉模拟评分并综合评估,连续臂丛治疗组的治疗优良率为92.4%,对比的保守治疗组的治疗优良率为79.0%,两组优良率差异具有统计学差异(P<0.05)。臂丛组治疗后共出现不良反应例数22例,其主要不良反应为患区后遗症状,如痒感,蚁行感和牵拉或紧束感仍然存在,19例患者均能够耐受,并在治疗后1个月内缓解。3例患者在天气骤变后出现暂时性疼痛加重,气温升高后缓解。保守治疗组治疗后共出现不良反应例数9例,其中恶心、呕吐4例,复视、视物模糊3例,晕针现象2例,均于停药及停止针炙治疗后好转。结论连续臂丛阻滞在治疗带状疱疹后遗神经痛较传统的药物和理疗具有治疗效果确切,镇痛完全的特点,可成为治疗带状疱疹后遗神经痛的重要临床治疗手段。     

Rehabilitation of the patient with a lower extremity amputation.

Preservation of life is an incomplete and inadequate objective for the lower extremity amputee. A comprehensive rehabilitation program must be designed to meet his individual needs. This is the responsibility of the professional community that purports to treat disease and maintain the health of the population. The multidisciplinary team functions in a coordinated effort to identify and resolve the amputee's problems, and to establish realistic goals during each phase of his rehabilitation program. The rehabilitation process begins when the prospective LE amputee is identified and continues until he has achieved optimal independence; that is, he has learned to cope with his disability within the boundaries of his normal environment.     

Brachial plexus anesthesia for outpatient surgical procedures on an upper extremity

We retrospectively reviewed 543 brachial plexus blocks performed on 526 outpatients. Most (98%) of the blocks were performed by means of the axillary approach. Various techniques were used, including paresthesia, transarterial fixation, nerve stimulation, or a combination of techniques; a high success rate was achieved with each of them. Only 7% of the blocks were incomplete and thus necessitated either general anesthesia or block supplementation with thiopental sodium and nitrous oxide. No persistent neurologic deficit was ascribed to the anesthetic technique. This review indicates that brachial plexus block, especially with use of the axillary approach, is a safe and effective option for outpatient surgical procedures on an upper extremity.     

Rehabilitation of patients with end-stage renal failure after lower extremity amputation

Four patients with end-stage renal failure on maintenance hemodialysis and one patient with near end-stage renal failure received inpatient rehabilitation following lower extremity amputation. All were prosthetically restored. Three of the patients had bilateral below-knee amputations and were ambulatory at the time of discharge, including the patient with near end-stage renal failure who was on maintenance hemodialysis at follow-up. One unilateral below-knee amputee was also ambulatory at discharge. The other unilateral below-knee amputee had an ulcer on the other foot and used a pylon for transfers only. To assess the prevalence of patients on maintenance hemodialysis with lower extremity amputations, a survey of 310 patients at four dialysis units was performed. Of the 310 patients 2.9 percent had at least one amputated lower extremity and 1.0 percent had bilateral lower extremity amputations. Preliminary data and the potential for functional results following prosthetic restoration suggest the need for further research concerning prosthetic restoration in the lower extremity amputee with end-stage renal failure.     

1例乳腺癌化疗后截肢患者的危机干预

报告对1例接受左乳腺癌保乳根治术和化疗后合并手足坏疽致截肢而引发心理危机和自杀意念的患者实施危机干预的过程。 根据危机干预6步法：确定问题、保证安全、提供心理支持、提出并验证变通的应对方式、制订计划并承诺实施,在住院、转院到出院期间的12个月内共实施了13次危机干预,取得了良好的干预效果。 患者最终完成截肢手术,度过心理危机,获得成长,重新适应生活。     

Helping hands: caring for the upper extremity transplant patient

Caring for upper extremity transplant recipients can offer challenges and opportunities to nursing staff in combining new patient procedures, new technologies, and complex patient care needs including unique physical care, monitoring and observation, rehabilitation expectations, and psychiatric/psychosocial support. Medical professionals continue to be apprehensive about the risks of immunosuppressive therapy and the possibility of acute and chronic rejection. The sustained development and research into reliable, reduced-dose immunosuppression or immunomodulatory strategies could expand the life-enhancing benefits of reconstructive transplantation.     

Validation of the orthotics and prosthetics user survey upper extremity functional status module in people with unilateral upper limb amputation.

OBJECTIVE: To evaluate the measurement properties of the Upper Extremity Functional Status module of the Orthotics and Prosthetics User Survey (OPUS). DESIGN: Methodological research on an outcome measure administered by clinical interview. PATIENTS: A convenience sample of 61 adults who had unilateral upper limb amputations and completed rehabilitation at the Institute for Rehabilitation in Ljubljana, Slovenia, at least one year prior to interview. Thirty-four patients had undergone amputation of the dominant hand. Four patients did not use a prosthesis. METHODS: Rating scale analysis (Rasch model) was used to evaluate functioning of the rating scale categories, the validity of the measure by examining fit of items to the latent trait, and the hierarchy of item difficulties compared with expectations of the construct. RESULTS: Rasch analysis allowed us to improve the Upper Extremity Functional Status by rescoring to reduce the response categories from 5 to 4, and identifying 19 of 23 items that are useful to measure upper extremity function. The results allow us to have high confidence in the consistency of both person-ability and item-difficulty estimates. CONCLUSION: This revised Upper Extremity Functional Status is a promising instrument to measure the degree of manual functioning after a unilateral upper limb amputation.     

Participation restrictions among adolescents and adults with neonatal brachial plexus palsy: the patient perspective

Abstract

Purpose: To examine the impact of neonatal brachial plexus palsy (NBPP) on societal participation of adolescents and adults.

Methods: This cross-sectional study was conducted among patients with NBPP, aged ≥16 years, who had visited our NBPP clinic. Patients completed questions on the influence of NBPP on their choices regarding education/work and their work-performance, the Impact on Participation/Autonomy questionnaire and the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). In addition, health-related quality of life (HRQoL) was assessed.

Results: Seventy-five patients participated (median age 20, inter quartile range 17–27). Twenty were full-time students, 28 students with a job, 21 employed, two unemployed, and four work-disabled. Sixty-six patients had had a job at some stage. Patients’ overall HRQoL was comparable to the general population. 27/75 patients reported that NBPP had affected their choices regarding education and 26/75 those regarding work. 33/66 reported impact on their work performance. On the Impact on Participation/Autonomy questionnaire, 80% (49/61) reported restrictions in the work-and-education domain, 74% in social-relations and 67% in autonomy-outdoors. 37/61 reported participation restrictions on the USER-P.

Conclusions: Although their overall HRQoL was not impaired, a substantial proportion of adolescent/adult patients reported that NBPP had an impact on choices regarding education and profession, as well as on work-performance. Restrictions in participation, especially in work and education were also reported. Guiding patients in making choices on education and work at an early stage and providing tailored physical as well as psychosocial care may prevent or address restrictions, which may improve participation.

• Implications for Rehabilitation

• Adolescent and adult patients with neonatal brachial plexus palsy perceive restrictions in societal participation, especially regarding the work-and-education domain.

• All patients with neonatal brachial plexus palsy may perceive restrictions in societal participation regardless of lesion severity, treatment history and side of the lesion.

• Adolescents and adults with neonatal brachial plexus palsy report that their choices regarding education and work, as well as their work-performance are influenced by their neonatal brachial plexus palsy.

• Patients with neonatal brachial plexus palsy should be followed throughout their life in order to provide them with appropriate information and treatment when health- or participation-related issues arise.

• Rehabilitation treatment is the best option to address all of the aforementioned issues, as surgical options in adolescents and adults are limited.

     

Tick paralysis with atypical presentation: isolated, reversible involvement of the upper trunk of brachial plexus

Tick paralysis is a disease that occurs worldwide. It is a relatively rare but potentially fatal condition. The only way to establish the diagnosis is to carefully search for the tick paralysis. It is caused by a neurotoxin secreted by engorged female ticks. Tick paralysis generally begins in the lower extremities and ascends symmetrically to involve the trunk, upper extremities and head within a few hours. Although early‐onset prominent bulbar palsy and isolated facial weakness without generalised paralysis are rare, there is no report in the English literature concerning isolated, reversible involvement of the upper trunk of brachial plexus caused by tick bite. We report a case of isolated, reversible involvement of the upper trunk of brachial plexus as a variant of tick paralysis. Diagnosis was confirmed with needle electromyography and nerve conduction examination. Within 2 weeks, the patient was fully recovered. The purpose of presenting this case is to remind clinicians that tick paralysis should be considered even in cases with atypical neurological findings admitted to the emergency department.     

Upper limb kinematics after Latissimus Dorsi transfer in children with brachial plexus birth palsy

BackgroundBrachial plexus birth palsy remains a frequent condition and one of its treatments is to transfer the Latissimus Dorsi tendon to the infraspinatus muscle. The aim of this study was to analyse, for the first time, the three-dimensional kinematic effects of this operation on the upper limb joints during the five Mallet tasks and their correlation with clinical parameters.MethodsKinematic analysis was performed using an electromagnetic device. An Index of Improvement taking into account the angle in preop and postop, the reproducibility and the angle of a control group was developed. Three groups of patients were analysed: sixteen patients (mean: 10,5 years) for the reproducibility, thirty children (mean: 9,5 years) for the control group and ten patients (mean: 8 years 7 months) who were operated.FindingsThe humerothoracic and glenohumeral external rotations improved during the external rotation, the neck and the abduction tasks and worsened during the spine task. The glenohumeral external rotation worsened during the mouth task. The Humerothoracic abduction improved during the abduction and the neck tasks. The elbow flexion improved for the neck task. Differences were observed between patients and correlations were obtained between the Index of Improvement and clinical parameters.InterpretationUsing kinematics allows to better analyse the evolution of joint angles after the latissimus dorsi transfer. The Index of Improvement allows to quickly analyse the effect of the operation for each angle and each patient. This effect depends on clinical parameters.     

Patient experience after lower extremity amputation for sarcoma in England: a national survey

Purpose: After amputation, rehabilitation and limb fitting services are critically important to optimise outcomes. We investigated the reported patient experience and variation in limb fitting services after amputation for musculoskeletal tumours in England.

Methods: A postal survey instrument was developed following literature review, patient and clinician consultation and piloting. The survey was sent from each of the five bone tumour surgical centres in England.

Results: One hundred and five responses were received from 250 patients (42%). The number of limb fitting centres accessed by each surgical centre varied from 2 to 28. Many patients reported care falling short of national standards in areas including pre-amputation counselling, information provision, meeting someone with a similar amputation before surgery, psychological support and falls management. Patients were seen sooner where limb fitting services were on site. Many patients rely on being driven, ambulance and public transport to access services.

Conclusion: This study demonstrates variation in the reported experience of limb fitting services by sarcoma patients. Areas for improvement include information provision, pre-amputation counselling, psychological support and falls management. Clinicians should be aware services are highly variable, and this may impact on outcomes. Patients treated in sarcoma centres with limb fitting services on site may experience better care.

• Implications for Rehabilitation

• Rehabilitation services should strive to meet agreed national standards consistently.

• Where preamputation counselling involving meeting someone with a similar amputation is not possible, good information including video could be helpful.

• Services should support rehabilitation in the form of early walking aids and efficient prosthetic repair and maintenance.

• Psychological support, occupational therapy and physiotherapy support must be provided in the acute and chronic phases, including access to long-term rehabilitation care.

• Rehabilitation programmes must include training to patients and families on reporting, prevention and management of falls.

• On site services may support better care.

• Mechanisms for delivering expert specialist care close to home are needed.

     

Tumor-like disorder of the brachial plexus region in a patient with hemophilia: A case report

BACKGROUNDVarious tumors and tumor-like disorders, originating from the neural sheath, as well as other types, may affect the brachial plexus region. Due to the infrequent presentation, brachial plexus palsy caused by spontaneous hematoma in patients with hemophilia might miss the treatment by early surgical decompression and progress to permanent nerve damage.CASE SUMMARYThe case reported here was a 30-year-old man with hemophilia, as well as both sensory and motor dysfunction of the left upper extremity. A presumptive diagnosis of brachial plexus tumor was initially made, which was subsequently confirmed to be an organized chronic hematoma rather than a neoplasm. The hemophilia-induced expanding hematoma compressing the brachial plexus was considered to be the main reason for the patient’s complaints. The clinical symptoms were alleviated and the involved nerves partially recovered at a follow-up of 1 year.CONCLUSIONEarly surgical intervention is crucial and it seems to be an essential precondition for recovery of nerve function in brachial plexus lesions.