Bilateral brachial plexus injury after liver transplantation

We report a case of bilateral brachial plexus injury following living-donor liver transplantation. A 35-year-old man with hepatitis C cirrhosis underwent liver transplantation under general anesthesia, performed in the supine position with 90 degrees arm abduction. The surgery lasted for 14 h, and the anesthesia for 16 h. On postoperative day 1, it was noticed that he had brachial plexus injuries. We investigated the cause of the nerve injuries, in particular, the possible involvement of stretching, compression, or nerve ischemia, which can often result from excessive abduction, the use of shoulder braces, compression by the poles used in the operating theater or compression caused by surgeons leaning on the patient, or serious general status (e.g., hypotension or hypoxemia). Our findings were inconclusive, but we postulated that 90 degrees abduction of the arms per se may have resulted in excessive stretching of the brachial nerves, causing his injuries.     

Bilateral brachial plexus block

Bilateral regional anesthesia techniques in general and bilateral brachial plexus blocks in particular are rarely performed because they have few clinical indications. We present the case of a patient who presented to the operating room for bilateral upper extremity procedures where we thought regional anesthesia was appropriate. The anesthesia management is discussed as well as potential problems and complications. IMPLICATIONS: Reports on bilateral regional blocks are extremely rare in the literature. Whereas they have the potential for more complications than a single technique, they can be very useful in specific clinical situations.     

Obstetric brachial plexus injury

Obstetric brachial plexus injury (OBPI), also known as birth brachial plexus injury (BBPI), is unfortunately a rather common injury in newborn children. Incidence varies between 0.15 and 3 per 1000 live births in various series and countries. Although spontaneous recovery is known, there is a large subset which does not recover and needs primary or secondary surgical intervention. An extensive review of peer-reviewed publications has been done in this study, including clinical papers, review articles and systematic review of the subject. In addition, the authors’ experience of several hundred cases over the last 15 years has been added and has influenced the ultimate text. Causes of OBPI, indications of primary nerve surgery and secondary reconstruction of shoulder, etc. are discussed in detail. Although all affected children do not require surgery in infancy, a substantial proportion of them, however, require it and are better off for it. Secondary surgery is needed for shoulder elbow and hand problems. Results of nerve surgery are very encouraging. Children with OBPI should be seen early by a hand surgeon dealing with brachial plexus injuries. Good results are possible with early and appropriate intervention even in severe cases.KEY WORDS: Birth brachial plexus injury, obstetric palsy, primary surgery     

Brachial plexus injury following brachial plexus block

A patient developed paralysis over the left upper limb 2 days after an otherwise uneventful supraclavicular brachial plexus block. Symptoms continued for 8 weeks after the block. The various possible causes for this complication are discussed. Although brachial plexus injury following the block is rare, some recommendations are made to reduce the incidence of this complication.     

Treatment of brachial plexus injury

A brachial plexus injury is the most severe nerve injury of the extremities. To achieve good results from treatment, correct diagnosis and early nerve repair are mandatory. The brachial plexus should be explored as early as possible if there is an incised wound, if clinical findings or diagnostic imaging indicate that at least one root is avulsed, if there is damage to the subclavian artery, and if there is total-type injury. With an upper-type injury with no clinical signs of a preganglionic lesion, the patient should be treated conservatively for 3 months and if there are no signs of recovery, then the brachial plexus should be explored. During this exploration, recording of the spinal cord evoked potential (ESCP) or the somatosensory evoked potential (SEP) is mandatory to determine the site of injury. Nerve grafting is indicated for a rupture in the root demonstrating a positive ESCP or SEP potential, in the trunk or in the cord. Exploration of the brachial plexus should be extended distally as far as possible to achieve good results after nerve grafting; when this was done more than M3 (MRC grading) power of the infraspinatus, deltoid, and biceps was achieved in more than 70% of our 32, 30, 33 patients, respectively. Results of nerve grafting for the forearm muscles have been very poor. Intercostal nerve transfer is recommended to restore elbow flexion in root avulsion type of injury, with elbow flexion to more than M3 being regained in 70% of our 221 patients. The best results of intercostal nerve transfer were achieved in patients younger than 30 years who received the operation within 6 months after injury. Motor recovery of hand function after intercostal nerve transfer was poor but protective sensation was restored in fingers innervated by the median nerve. The recommended treatment for each type of injury is described according to the results achieved. Received for publication on March 18, 1997; accepted on Aug. 7, 1997     

Imaging of posttraumatic brachial plexus injury

After reviewing a series of 220 patients operated upon between 1975 and 1985 for traumatic brachial plexus injuries, the authors present the results of 103 myelographies, 48 computed tomographies (CT scans) combined with standard myelography, and 25 series of images obtained by magnetic resonance imaging (MRI). To evaluate precisely the type and level of injury, the accuracy of these three techniques was compared with clinical and operative findings. The accuracy of myelography was considered good in 84% of the cases, but 4% were evaluated as false positive results and 12% as false negative or doubtful results. The combined CT scan and myelography reduced the number of doubtful results and accuracy reached 94.25%, but they did not visualize the roots distal to the spinal foramina. MRI correlated well with CT scan images and, in addition, offered visualization of distal radicular injuries. MRI seems a promising diagnostic procedure and should also help to situate nerve grafts and check their viability.     

Tendon transfers for brachial plexus injury

Brachial plexus injuries result in severe functional deficits in the upper limb. The authors review a group of 74 patients with brachial plexus injuries who underwent 160 tendon transfer operations, as well as 94 additional procedures, in an attempt to augment lost function. Following evaluation of functional recovery, 58 percent of the patients were rated Good, 34 percent Improved, and 8 percent Unimproved. The authors conclude that significant benefit can be obtained by peripheral reconstruction and tendon transfers in patients with brachial plexus injuries.     

Functioning free-muscle transfer for brachial plexus injury

Functioning free-muscle transfers are now an important, even essential, tool in the current management of patients with brachial plexus injury. They are indicated for the restoration of elbow flexion in patients who delay presentation(those seen after 6 to 9 mo). Double free-muscle transfers provide the possibility of simple grasp function when combined with nerve transfers or grafts for restoration of shoulder motion, hand sensation, and triceps function.     

MRM在臂丛神经节前损伤诊断中的运用

目的 探讨运用三维超快速稳态进动成像序列(3D fast imaging employing steady-stateacquisition,FIESTA)进行磁共振椎管造影(magnetic resonance myelography,MRM)在诊断臂丛神经节前损伤中的使用价值.方法 采用MRM技术对10例臂丛神经损伤的患者进行臂丛扫描,将影像学诊断与手术所见及术中肌电检测结果进行比较.结果 臂丛神经节前损伤的MRM影像直接征象有脊神经前、后根消失或连续性的中断,间接征象有椎管内脑脊液囊性聚集、脑脊膜膨出.MRM对臂丛神经节前损伤正确诊断的灵敏度为86.1%,特异度100%,准确率达90.0%.阳性预测值为100%,阴性预测值为73.7%.结论 采用3D-FIESTA序列进行MB椎管内显像可以提供较为满意的图像信息,MRM可以为早期诊断臂丛神经节前损伤提供参考.     

Cold intolerance after brachial plexus nerve injury

Background  

The purpose of this study was to evaluate cold intolerance symptoms in patients with brachial plexus nerve injury. We hypothesized that higher levels of cold intolerance would be associated with more pain, greater disability, and unemployment.