Block of the Pericapsular Nerve Group of the Hip with and without Ultrasound Guidance: Comparative Cadaveric Study / Bloqueio do grupo de nervos pericapsulares do quadril com e sem auxílio de ultrassonografia: Estudo cadavérico comparativo

Abstract Objective To evaluate the technical reproducibility of a block of the pericapsular nerve group (PENG) of the hip aided or not by ultrasound in cadavers. Materials and Methods The present is a randomized, descriptive, and comparative anatomical study on 40 hips from 2 cadaver groups. We compared the PENG block technique with the method with no ultrasound guidance. After injecting a methylene blue dye, we verified the dispersion and topographical staining of the anterior hip capsule through dissection. In addition, we evaluated the injection orifice in both techniques. Results In the comparative analysis of the techniques, there were no puncture failures, damage to noble structures in the orifice path, or differences in the results. Only 1 hip from each group (5%) presented inadequate dye dispersion within the anterior capsule, and in 95% of the cases submitted to either technique, there was adequate dye dispersion at the target region. Conclusion Hip PENG block with no ultrasound guidance is feasible, safe, effective, and highly reliable compared to its conventional counterpart. The present is a pioneer study that can help patients with hip pain from various causes in need of relief.

Resumo Objetivo Propor e avaliar a reprodutibilidade técnica do bloqueio do grupo de nervos pericapsulares (pericapsular nerve group, PENG, em inglês) do quadril sem o auxílio da ultrassonografia, em cadáveres, de forma comparativa à realização do bloqueio guiado pela ultrassonografia em outro grupo de cadáveres. Materiais e Métodos Estudo anatômico randomizado, descritivo e comparativo, realizado em 40 quadris divididos em 2 grupos amostrais de cadáveres. Fez-se uma comparação da técnica do bloqueio do PENG à técnica não guiada por ultrassonografia injetando-se corante azul de metileno, seguida de dissecção para verificação da dispersão e da coloração topográfica da cápsula anterior do quadril, além de avaliação do pertuito das injeções entre as técnicas. Resultados Na análise comparativa das técnicas, não houve falha na punção, lesão de estruturas nobres no pertuito, ou diferença nos resultados. Não houve adequada dispersão do corante pela cápsula anterior somente em 1 quadril de cada grupo (5%), e em 95% dos casos submetidos a qualquer uma das técnicas observou-se dispersão adequada do corante pela região alvo. Conclusão O bloqueio do PENG do quadril sem auxílio de ultrassonografia é factível, seguro, eficaz, e com alta confiabilidade quando comparado à sua realização guiada pelo aparelho de imagem. Este estudo é pioneiro, e pode ajudar muito os pacientes que têm dor no quadril por diversas causas e necessitam alívio.

Magnetic Resonance as a Method for Diagnosis for Traumatic Lesions by Brachial Plexus Avulsion / Ressonância magnética como método para diagnóstico das lesões traumáticas por avulsão do plexo braquial

Abstract Objective The incidence of traumatic brachial plexus injuries has been increasing considerably in Brazil, mainly due to the increase in the number of motorcycle accidents. The aim of the present study is to evaluate the sensitivity and specificity of magnetic resonance imaging (MRI) in the diagnosis of brachial plexus avulsion lesions, comparing it with the findings of physical and intraoperative examination. Methods A total of 16 patients with brachial plexus injury were prospectively evaluated and treated at the hand surgery outpatient clinic from our service. All patients underwent MRI of the brachial plexus, and the findings were inserted on a table, as well as the physical examination data, and part of the patients had the plexus evaluated intraoperatively. Results In the present study, the accuracy of MRI in the identification of root avulsion was 100%, with 100% sensitivity and specificity when comparing imaging with surgical findings. Conclusion Magnetic resonance imaging showed high sensitivity and specificity, confirmed by intraoperative findings, which allows considering this test as the gold standard in the diagnosis of avulsion in traumatic brachial plexus injuries.

Resumo Objetivo A incidência de lesões traumáticas do plexo braquial vem aumentando consideravelmente no Brasil, principalmente devido ao aumento do número de acidentes de motocicleta. O objetivo do presente estudo é avaliar a sensibilidade e a especificidade da ressonância magnética (RM) no diagnóstico das lesões por avulsão do plexo braquial, comparando com os achados do exame físico e do intraoperatório. Métodos Foram avaliados prospectivamente 16 pacientes com lesão do plexo braquial atendidos no ambulatório de cirurgia da mão de nosso serviço. Todos os pacientes foram submetidos ao exame de RM do plexo braquial e os achados foram inseridos em uma tabela, assim como os dados do exame físico, e parte dos pacientes teve o plexo avaliado intraoperatoriamente. Resultados No presente estudo, a acurácia da RM na identificação de avulsão de raízes foi de 100%, com 100% de sensibilidade e especificidade comparando-se achados da imagem e cirúrgicos. Conclusão A RM mostrou alta sensibilidade e especificidade, confirmadas por achados intraoperatórios, o que permite considerar este exame como padrão outro no diagnóstico de avulsão nas lesões traumáticas do plexo braquial.

The clinical value analysis of MRN on diagnosis and treatment of lumbosacral nerve injury associated with sacral fractures / 中华骨科杂志

Objective:To discuss the clinical value of magnetic resonance neurography (MRN) on diagnosis and treatment of lumbosacral nerve injury associated with sacral fractures and analyze the characters of nerve injury which was caused by sacral fractures.Methods:The clinical data of 40 patients who had lumbosacral nerve injury associated with sacral fractures and accepted treatment in Tianjin hospital from August 2018 to December 2020 were collected based on inclusion and exclusion criteria. Twenty-four patients had unilateral sacral fractures (Tile C1) which included 16 Denis II type fractures and 8 Denis III type fractures. Sixteen patients had bilateral sacral fractures which were all Tile C3, U shaped and Denis II type sacral fractures. All patients had symptoms or signs of lumbosacral nerve injury, and accepted contrast-enhanced three-dimensional magnetic resonance neurography (CE-3D MRN) to diagnose the injury part and severity degree. The L 5-S 4 nerves were separated to three parts based on injured side and intraspinal type (IS), intraforaminal type (IF) and extraforaminal type (EF) location, and were judged the mild, medium or severe degree of nerve injury severity. Overall and pairwise Chi-square test was performed on the number of nerve injuries. Eleven patients accepted the operation of nerve dissection and exploration. The nerve injury part and severity were recorded under direct vision, and were statistically analyzed with CE-3D MRN outcome. Results:The outcome of 239 lumbosacral nerve injuries which had different part and severity were found by MRN, and all combined with sacral fractures of the same side. The nerves which ranked from largest to fewest according to injured numbers were L 5, S 1, S 2, S 3 and S 4. The statistical analysis showed that there were significant differences of injured nerve numbers except between S 1 and S 2, S 3 and S 4, and there were no significant difference of nerve injury part and severity degree between the direct visual judgement intraoperatively and preoperative CE-3D MRN examination. Conclusion:MRN can reveal the part and severity degree of lumbosacral nerve injury associated with sacral fracture clearly and accurately, which has important clinical value and should become the preferred examination of such injuries. The lumbosacral nerve injury has the most frequent features of S 1 and S 2, followed by L 5, and the least in S 3 and S 4.

Fluorescence imaging in intraoperative visualization of neurovascular bundles (NVBs) surrounding the prostate: a literature review / 中华泌尿外科杂志

Preservation of erectile function is an important goal of radical prostatectomy. The neurovascular bundles (NVBs), which is closely related to erectile function, are quite susceptible to intraoperative injury because it is difficult to be identified and localized during surgical process. As a result, long-term postoperative potency rate is not satisfying. Techniques of monitoring pro-erectile neurovascular bundles, such as electrical stimulation, ultrasound and MRI have significant limitations in the context of real-time identification during operation. Advances of fluorescence imaging in the surgical navigation field has made it possible to achieve real-time visualization of NVBs in vivo. At present, there have already been many fluorescent agents worldwide targeting different structures within nerves, such as the axon, myelin, perineurium and vaso nervorum, and they varied in their affinity to nerves and imaging efficacies. Some lipophilic molecules, oxazine dyes and peptide-dye conjugates have successfully visualized in periprostatic autonomic nerves in rodents or in human prostate specimen. Indocyanine Green (ICG), a non-specific neurovascular dye, has already been used in clinical setting to guide during nerve-sparing radical prostatectomy. This review focused on fluorescent nerve imaging technique and its application in research on real-time imaging of NVBs in radical prostatectomy.

Experimental research progress of acupuncture regulating apoptosis in the treatment of peripheral nerve injury / 国际中医中药杂志

Recently, acupuncture is the main treatment for peripheral nerve injury in animal experiments. The main diseases involved sciatic nerve injury, denervated skeletal muscle atrophy and diabetic peripheral neuropathy. Acupuncture can promote the regeneration and repair of peripheral nerve injury by regulating apoptosis, so as to improve the function of peripheral nerve. The mechanism is to regulate the apoptosis, Bcl-2 family, Caspase-3, Caspase-8, apoptotic factor-1 and the ligand expression, and regulate MAPK signal pathway and PI3K-Akt signaling pathway and endoplasmic reticulum stress pathway forinhibiting apoptosis.

Clinical analysis and literature review of 6 cases of burning mouth syndrome-like symptoms caused by the long-term oral administration of omeprazole / 口腔疾病防治

Objective @#To analyze the oral adverse drug reactions induced by omeprazole and provide a reference for rational clinical drug use.@*Methods@#From January 2019 to June 2020, the clinical data of patients with burning mouth syndrome caused by omeprazole were collected and analyzed. Additionally, the related literature was reviewed. @*Results@#Among the six patients, omeprazole was taken orally for as little as 6 months and as long as more than 5 years. The symptoms of burning mouth syndrome were mainly burning sensation in the mouth and paresthesia on the tongue that might be accompanied by extremity numbness. Vitamin and trace element supplementation was administered. The patient discontinued omeprazole, and symptoms disappeared after symptomatic treatment for 1 month to half a year. Literature review suggests that the reason may be associated with peripheral or central nervous system injury, altered saliva composition, and impaired vitamin and micronutrient intake caused by omeprazole.@*Conclusion @# The cause of burning mouth syndrome-like symptoms may be related to peripheral nerve injury caused by omeprazole and saliva changes. The main treatment is withdrawal and symptomatic treatment.

Innervation of the median nerve motor branches in the forearm and its clinical significance / Inervação dos ramos do nervo mediano no antebraço e sua significancia clínica

ABSTRACT Objective: To analyse the anatomical variations of the median nerve motor branches in the elbow region. Methods: Twenty upper limbs of 10 adult male cadavers were prepared by intra-arterial injection of a solution of 10% glycerol and formaldehyde. All cadavers belonged to the institution anatomy laboratory. Results: We found a great variability within the distribution of median nerve branches leading to forearm muscles. Only three limbs (14%) presented the normal standard of innervation described in anatomy treatises. The pronator teres muscle (PTM), flexor carpi radialis (FCR), palmaris longus (PL), and the flexor digitorum superficialis (FDS) received exclusive innervation from the median nerve in all forearms. The anterior interosseous nerve (AIN) also originated from the median nerve in all dissected limbs. Conclusion: A thorough understanding of the anatomy of the median nerve branches is important for performing surgeries such as: approach to the proximal third of the forearm, alleviation of pronator teres and anterior interosseous nerve compression syndromes, and distal nerve transfers. It also enables a better understanding the recovery of muscle function after a nerve injury. Level of Evidence IV, Case series.

RESUMO Objetivo: Analisar as variações anatômicas dos ramos motores do nervo mediano na região do cotovelo. Avaliamos origem, curso, comprimento, terminações nervosas dos ramos e suas relações com estruturas vizinhas. Métodos: Selecionamos 20 membros de 10 cadáveres adultos dissecados, preparados por injeção intra-arterial com solução de glicerina e formol a 10%. Todos do sexo masculino, pertencentes ao laboratório de anatomia da instituição. Resultados: O primeiro ramo do nervo mediano no antebraço foi o músculo pronador redondo. A distribuição dos ramos do nervo mediano para os músculos do antebraço mostrou grande variabilidade. Apenas 3 membros (14%) apresentaram padrão normal de inervação descrito nos tratados de anatomia. Os músculos pronador redondo, flexor radial do carpo, palmar longo e flexor superficial dos dedos receberam inervação exclusiva do nervo mediano em todos os antebraços. O nervo interósseo anterior originou-se do nervo mediano nos membros dissecados. Conclusão: Conhecer a anatomia dos ramos motores do nervo mediano é importante para realizar procedimentos cirúrgicos na região como a abordagem do terço proximal do antebraço, por exemplo a liberação das síndromes compressivas do pronador redondo e do nervo interósseo anterior; as transferências nervosas distais; também entender a ordem de recuperação da função muscular após uma lesão nervosa. Nível de Evidência IV, Série de casos.

Assessment of the Effects of Swimming as a Postoperative Rehabilitation on Nerve Regeneration of Wistar Rats Submitted to Grafting of Autologous Nerves after Injury to the Sciatic Nerve / Avaliação dos efeitos da natação como reabilitação pós-operatória na regeneração nervosa de ratos da linhagem Wistar submetidos a enxerto de nervos autólogos após lesão do nervo ciático

Abstract Objective To evaluate the effects of swimming on nerve regeneration after sciatic nerve injury in Wistar rats. Methods A total of 30 Wistar rats was divided into 3 groups: Sham + Nat group animals that were not submitted to graft surgery and were submitted to swimming (n = 10); Graft group: animals submitted to autologous sciatic nerve graft (n = 10); and Graft + Nat group: animals submitted to autologous sciatic nerve graft surgery and to swimming (n = 10). The results were analyzed on the software (GraphPad Software, San Diego, CA, USA). Results In the first evaluation, all sciatic functional index (SFI) values were similar (p = 0.609). Thirty days after the surgical procedure, we observed differences between all the comparisons: Sham + Nat (−34.64 ± 13.89) versus Graft (−145.9 ± 26.06); Sham + Nat versus Graft + Nat (−89.40 ± 7.501); Graft (−145.9 ± 26.06) versus Graft + Nat (−89.40 ± 7.501). In the measurements (60 and 90 days), there was no statistical difference between the Graft and Graft + Nat groups, with significantly lower values in relation to the control group (p < 0.001). The number of motor neurons presented differences in the comparisons between the Sham + Nat and Graft groups (647.1 ± 16.42 versus 563.4 ± 8.07; p < 0.05), and between the Sham + Nat and Graft + Nat groups (647.1 ± 16.42 versus 558.8 ± 14.79; p < 0.05). There was no difference between the Graft and Graft + Nat groups. Conclusion Animals submitted to the swimming protocol after the sciatic nerve grafting procedure did not present differences in the SFI values and motor neuron numbers when compared to the control group. Therefore, this type of protocol is not efficient for the rehabilitation of peripheral nerve lesions that require grafting. Therefore, further studies are needed.

Resumo Objetivo Avaliar os efeitos da natação na regeneração nervosa após a lesão do nervo ciático em ratos Wistar. Métodos Um total de 30 ratos Wistar foram divididos em 3 grupos: grupo Sham + Nat: animais que não foram submetidos à cirurgia de enxerto e foram submetidos à natação (n = 10); grupo Enxerto: animais que foram submetidos à cirurgia de enxerto autólogo de nervo ciático (n = 10); e grupo Enx + Nat: animais submetidos à cirurgia de enxerto autólogo de nervo ciático e à natação (n = 10). Os resultados foram analisados pelo software GraphPad Prism 5.0 (GraphPad Software, San Diego, CA, EUA). Resultados Na primeira avaliação, todos os valores do índice funcional do ciático (IFC) foram semelhantes (p = 0.609). Após 30 dias do procedimento cirúrgico, foram observadas diferenças entre todas as comparações: Sham + Nat (−34,64 ± 13,89) versus Enxerto (−145,9 ± 26,06), grupos Sham + Nat versus Enx + Nat (−89,40 ± 7,501), grupos Enxerto (−145,9 ± 26,06) versus Enx + Nat (−89,40 ± 7,501). Nas medidas (60 e 90 dias), não houve diferença estatística entre os grupos Enxerto e Enx + Nat, com valores significativamente menores em relação ao grupo controle (p < 0,001). O número de motoneurônios apresentou diferenças nas comparações entre os grupos Sham + Nat e Enxerto (647,1 ± 16,42 versus 563,4 ± 8,07; p < 0,05) e Sham + Nat e Enx + Nat (647,1 ± 16,42 versus 558,8 ± 14,79; p < 0,05), não havendo diferença entre os grupos Enxerto e Enx + Nat. Conclusão Os animais submetidos ao protocolo de natação após o procedimento de enxerto do nervo ciático não apresentaram diferenças nos valores de IFC e nos números de motoneurônios quando comparados com grupo controle. Portanto, este tipo de protocolo não é eficiente para reabilitação de lesões nervosas periféricas que necessitam de enxerto, sendo necessários novos estudos.

Criteria for assessing peripheral nerve injury. Behavioral and functional assessment in non-operated Wistar rats

Abstract Purpose To evaluate the normality pattern in functional tests of peripheral nerves. Methods Sixty female and sixty male Wistar rats were submitted to vibrissae movement and nictitating reflex for facial nerve; grooming test and grasping test for brachial plexus; and walking tracking test and horizontal ladder test for lumbar plexus. The tests were performed separately, with an interval of seven days between each. Results All animals showed the best score in vibrissae movement, nictitating reflex, grooming test, and horizontal ladder test. The best score was acquired for the first time in more than 90% of animals. The mean of strength on the grasping test was 133.46±12.08g for the right and 121.74±8.73g for the left anterior paw. There was a difference between the right and left sides. There was no difference between the groups according to sex. There is no statistical difference comparing all functional indexes between sex, independent of the side analyzed. The peroneal functional index showed higher levels than the sciatic and tibial functional index on both sides and sex. Conclusions The behavioral and functional assessment of peripheral nerve regeneration are low-cost, easy to perform, and reliable tests. However, they need to be performed by experienced researchers to avoid misinterpretation.

Daño neurológico perioperatorio. Identificación de factores de riesgo, prevención y estudios relacionados / Perioperative nerve injury. Risk factor identification, prevention and work-up

BACKGROUND: Regional anesthesia techniques can have adverse effects, like peripheral nerve injuries. This can affect the practitioner on the choice of techniques when offering multimodal analgesia. CASE REPORT: We present the case of an arthroscopic rotator cuff repair on a patient with no comorbidities who presented peripheral nerve injury during post-op. Initially thought to have occurred as a consequence of the anesthetic technique, further study of the patient revealed the injuries to have been produced by the arthroscopic surgery. CONCLUSION: There are multiple factors that influence the possibility of peripheral nerve injury associated with nerve blocks. They can be grouped as related to the patient, the anesthetic technique or the surgical technique, the latter being the most relevant. If a patient manifests signs of peripheral nerve injury high-resolution magnetic resonance of the neural tissue must be performed immediately. Sensory nerve conduction study and electromyography must be performed 4 weeks after by an expert neurologist.

INTRODUCCIÓN: La anestesia regional puede producir como efecto adverso lesiones de nervios periféricos, lo que puede hacer desistir al anestesiólogo de realizar técnicas que mejoran la analgesia multimodal. CASO CLÍNICO: Se presenta el caso de un paciente sin comorbilidades que se operó de reparación artroscópica del manguito rotador y presentó daño neurológico postoperatorio. Inicialmente se sospechó que el daño había sido producido durante la técnica anestésica, sin embargo, el estudio adecuado demostró que el daño se relacionaba con la técnica quirúrgica. CONCLUSIÓN: Existen factores que influyen en la posibilidad de daño neurológico asociado a bloqueos de nervios periféricos que pueden ser propios del paciente, de la técnica anestésica o quirúrgicos, siendo estos últimos los más relevantes. En un paciente con clínica compatible debe realizarse resonancia magnética del tejido neural de alta resolución de forma inmediata; estudio de conducción neural sensitiva y electromiografía a las 4 semanas de evolución por un neurólogo experto.

Association between postpartum neurological complications and epidural analgesia in labor / 中华围产医学杂志

As one of the most effective and commonly used analgesic methods during labor and delivery,epidural analgesia has been widely accepted in terms of its safety.Neurological complications following childbirth,which are most related to pregnancy and childbirth factors rather than labor analgesia,has not been well studied or recognized in China.Therefore,there are some confusions and misunderstandings of reasons for these neurological complications,and,to a certain extent,have affected the clinical implementation of epidural labor analgesia.This review analyzed the etiology and prognosis of this problem in order to help the clinicians in identifying the risk factors and causes and also to improve clinical awareness,prevention,and management for these conditions.

Transfer of nerve branches of the flexor carpi radialis to the posterior interosseous nerve / Transferência de ramos nervosos do músculo flexor radial do carpo para o nervo interósseo posterior

ABSTRACT Objective: The objective of this paper was to study the anatomical variations of the flexor carpi radialis muscle (FCR) and determine in cadaver limbs whether the FCR nervous branch can be connected to the posterior interosseous nerve (PIN) without tension and how close to the target muscles the transfer can be performed. Method: Thirty cadaveric upper limbs were dissected. Results: The FCR received exclusive innervation of the median nerve, distally to the intercondylar line of the humerus. In 5 limbs, an isolated branch was found and in 25, a common trunk with other nervous branches occurred. We investigated whether the branch for the FCR was long enough to be transferred to the PIN. The diameter of the nerve branch for the FCR corresponded on average to 50% of the PIN. Conclusion: In 12 limbs, the branch destined to the FCR could be connected to the PIN, distally to the nerve branches to the supinator muscle even during the movements of the forearm and the elbow. In 18 specimens, it was necessary to mobilize the PIN for this innervation. Level of Evidence IV, Case Series.

RESUMO Objetivo: O objetivo do trabalho foi estudar as variações anatômicas do músculo flexor radial do carpo (FRC) e determinar, em membros de cadáveres, se o ramo nervoso do músculo FRC pode ser conectado ao nervo interósseo posterior (NIP) sem tensão e quão próximo dos músculos alvos a transferência pode ser realizada. Método: Trinta membros superiores cadavéricos foram dissecados. Resultados: O FRC recebeu inervação exclusiva do nervo mediano, distalmente à linha intercondilar do úmero. Em 5 membros encontrou-se um ramo isolado e em 25 ocorreu um tronco comum com outros ramos nervosos. Investigamos se o ramo para o FRC tinha comprimento suficiente para ser transferido para o NIP. O diâmetro do ramo nervoso para o músculo FRC correspondia, em média, a 50% do NIP. Conclusão: Em 12 membros, o ramo destinado ao FRC poderia ser conectado ao NIP, distalmente aos ramos nervosos para o músculo supinador mesmo durante os movimentos do antebraço e do cotovelo. Em 18 peças foi necessária a mobilização do NIP para essa inervação. Nível de Evidência IV, Série de Casos.

Action of vanillin (Vanilla planifolia) on the morphology of tibialis anterior and soleus muscles after nerve injury / Ação da vanilina (Vanilla planifolia) sobre a morfologia dos músculos tibial anterior e sóleo após lesão nervosa

ABSTRACT Objective To evaluate the action of vanillin (Vanilla planifolia) on the morphology of tibialis anterior and soleus muscles after peripheral nerve injury. Methods Wistar rats were divided into four groups, with seven animals each: Control Group, Vanillin Group, Injury Group, and Injury + Vanillin Group. The Injury Group and the Injury + Vanillin Group animals were submitted to nerve injury by compression of the sciatic nerve; the Vanillin Group and Injury + Vanillin Group, were treated daily with oral doses of vanillin (150mg/kg) from the 3rd to the 21st day after induction of nerve injury. At the end of the experiment, the tibialis anterior and soleus muscles were dissected and processed for light microscopy and submitted to morphological analysis. Results The nerve compression promoted morphological changes, typical of denervation, and the treatment with vanillin was responsible for different responses in the studied muscles. For the tibialis anterior, there was an increase in the number of satellite cells, central nuclei and fiber atrophy, as well as fascicular disorganization. In the soleus, only increased vascularization was observed, with no exacerbation of the morphological alterations in the fibers. Conclusion The treatment with vanillin promoted increase in intramuscular vascularization for the muscles studied, with pro-inflammatory potential for tibialis anterior, but not for soleus muscle.

RESUMO Objetivo Avaliar a ação da vanilina (Vanilla planifolia) sobre a morfologia dos músculos tibial anterior e sóleo após lesão nervosa periférica. Métodos Ratos Wistar foram divididos em quatro grupos, com sete animais cada, sendo Grupo Controle, Grupo Vanilina, Grupo Lesão e Grupo Lesão + Vanilina. Os animais dos Grupos Lesão e Grupo Lesão + Vanilina foram submetidos à lesão nervosa por meio da compressão do nervo isquiático, e os Grupos Vanilina e Grupo Lesão + Vanilina foram tratados diariamente com doses orais de vanilina (150mg/kg) do 3o ao 21o dia após a indução da lesão nervosa. Ao término do experimento, os músculos tibial anterior e sóleo foram dissecados e seguiram o processamento de rotina em microscopia de luz, para posterior análise morfológica. Resultados A compressão nervosa promoveu alterações morfológicas características de denervação, sendo que o tratamento com vanilina foi responsável por respostas distintas nos músculos estudados. Para o tibial anterior, houve aumento do número de células satélites, núcleos centrais e atrofia das fibras, bem como desorganização fascicular. Já no sóleo, houve apenas aumento da vascularização, sem exacerbação das alterações morfológicas nas fibras. Conclusão O tratamento com vanilina promoveu o aumento da vascularização intramuscular para os músculos estudados, com potencial pró-inflamatório para o tibial anterior, o que não ocorreu no músculo sóleo.

Upper limb nerve injuries caused by intramuscular injection or routine venipuncture

The reported cases of upper limb nerve injury followed by needle procedure such as intramuscular injection or routine venipuncture are rare. However, it should not be overlooked, because neurological injury may cause not only minor transient pain but also severe sensory disturbance, hand deformity and motor dysfunction with poor recovery. Recognizing competent level of anatomy and adept skill of needle placement are crucial in order to prevent this complication. If a patient notices any experience of abnormal pain or paresthesia during the needle procedures, an administrator should be alert to the possibility of nerve injury and should withdraw the needle immediately. Careful monitoring of the injection site for hours is required for early detection of nerve injury.

High prevalence of neuropathic pain in the hand of patients with traumatic brachial plexus injury: a cross-sectional study / Alta prevalência de dor neuropática em sujeitos com lesão traumática do plexo braquial: um estudo de corte transversal

ABSTRACT Objective To describe the pain profile of patients with traumatic brachial plexus injury. Methods We enrolled 65 patients with traumatic brachial plexus injury. The Douleur Neuropathique 4 questionnaire was used to classify pain and the SF-36 was used to evaluate quality of life. Results The patients with traumatic brachial plexus injury were predominantly young male victims of motorcycle accidents. Pain was present in 75.4% of the individuals and 79% presented with neuropathic pain, mostly located in the hands (30.41%). The use of auxiliary devices (p = 0.05) and marital status (p = 0.03) were both independent predictors of pain. Pain also impacted negatively on the quality of life (p = 0.001). Conclusions Pain is frequent in patients with traumatic brachial plexus injury. Despite the peripheral nervous system injury, nociceptive pain is not unusual. Pain evaluation, including validated instruments, is essential to guide optimal clinical management of patients with the condition.

RESUMO Objetivo Descrever o perfil de dor de sujeitos com lesão traumática do plexo braquial. Métodos Nós incluímos 65 indivíduos com lesão traumática do plexo braquial. O Douleur Neuropathique 4 foi usado para classificar a dor e o SF-36 foi usado para avaliar a qualidade de vida. Resultados Sujeitos com lesão traumática do plexo braquial eram em sua maioria homens jovens, vítimas de acidentes motociclísticos. A dor esteve presete em 75.4% dos indivíduos e 79% deles apresentaram dor neuropática, mais frequentemente localizada nas mãos (30.41%). O uso de dispositivos auxiliares (p = 0.05) e o estado civil foram, ambos, preditores independentes de dor. A dor ainda impactou negativamente da qualidade de vida (p = 0.001). Conclusões A dor é frequente em sujeitos com lesão traumática do plexo braquial. Apesar de envolver uma lesão do sistema nervoso a dor nociceptiva não é infrequente. A avaliação da dor, incluindo instrumentos validados, é essencial para direcionar as condutas clínicas de sujeitos com esta condição.

Infraclavicular topography of the brachial plexus fascicles in different upper limb positions / Topografía infraclavicular de los fascículos del plexo braquial en diferentes posiciones del miembro superior

Brachial plexus neuropathies are common complaints among patients seen at orthopedic clinics. The causes range from traumatic to occupational factors and symptoms include paresthesia, paresis, and functional disability of the upper limb. Treatment can be surgical or conservative, but detailed knowledge of the brachial plexus is required in both cases to avoid iatrogenic injuries and to facilitate anesthetic block, preventing possible vascular punctures. Therefore, the objective of this study was to evaluate the topography of the infraclavicular brachial plexus fascicles in different upper limb positions adopted during some clinical procedures. A formalin-preserved, adult, male cadaver was used. The infraclavicular and axillary regions were dissected and the distance of the brachial plexus fascicles from adjacent bone structures was measured. No anatomical variation in the formation of the brachial plexus was observed. The metric relationships between the brachial plexus and adjacent bone prominences differed depending on the degree of shoulder abduction. Detailed knowledge of the infraclavicular topography of neurovascular structures helps with the diagnosis and especially with the choice of conservative or surgical treatment of brachial plexus neuropathies.

Las neuropatías del plexo braquial son quejas comunes entre los pacientes atendidos en las clínicas ortopédicas. Las causas van desde traumas a factores ocupacionales y los síntomas incluyen parestesias, paresia e incapacidad funcional del miembro superior. El tratamiento puede ser quirúrgico o conservador, pero se requiere un conocimiento detallado del plexo braquial en ambos casos para evitar lesiones iatrogénicas y para facilitar el bloqueo anestésico, evitando posibles lesiones vasculares. Por lo tanto, el objetivo de este estudio fue evaluar la topografía de los fascículos del plexo braquial infraclavicular en diferentes posiciones de los miembros superiores adoptadas durante algunos procedimientos clínicos. Se llevó a cabo la disección de las regiones infraclavicular y axilar de un cadáver adulto, de sexo masculino, conservado en formaldehído. Se midió la distancia de los fascículos del plexo braquial en relación a las estructuras óseas adyacentes. No se observó variación anatómica en la formación del plexo braquial. Las relaciones métricas entre el plexo braquial y las prominencias óseas adyacentes difieren en función del grado de abducción del hombro. El conocimiento detallado de la topografía infraclavicular de las estructuras neurovasculares ayuda con el diagnóstico y sobre todo con la elección del tratamiento conservador o quirúrgico de las neuropatías del plexo braquial.

Ulnar nerve paralysis after forearm bone fracture / Paralisia do nervo ulnar seguida de fratura dos ossos do antebraço

ABSTRACT Paralysis or nerve injury associated with fractures of forearm bones fracture is rare and is more common in exposed fractures with large soft-tissue injuries. Ulnar nerve paralysis is a rare condition associated with closed fractures of the forearm. In most cases, the cause of paralysis is nerve contusion, which evolves with neuropraxia. However, nerve lacerations and entrapment at the fracture site always need to be borne in mind. This becomes more important when neuropraxia appears or worsens after reduction of a closed fracture of the forearm has been completed. The importance of diagnosing this injury and differentiating its features lies in the fact that, depending on the type of lesion, different types of management will be chosen.

RESUMO A paralisia ou lesão nervosa associada à fratura dos ossos do antebraço é rara, é mais comum nas fraturas expostas com grande lesão de partes moles. A paralisia do nervo ulnar é uma condição incomum associada a fraturas fechadas do antebraço. Na grande maioria dos casos, a causa da paralisia é a contusão do nervo, que evolui com neuropraxia. No entanto, devemos sempre estar atentos às lacerações do nervo e ao encarceramento do nervo no foco de fratura. Isso se torna mais importante quando ocorre o surgimento da neuropraxia ou pioria após a feitura da redução da fratura fechada do antebraço. A importância do diagnóstico da lesão e diferenciar suas características estão no fato de que, conforme o tipo de lesão, diferentes tipos de manejo serão escolhidos.

Chordata method combined with electrotherapy in functional recovery after brachial plexus injury: report of three clinical cases / Método Chordata combinado com eletroterapia na recuperação funcional após lesão do plexo braquial: relato de três casos clínicos

AIMS: To report three clinical cases of complex brachial plexus injury treated with an innovative physical therapy program, the Chordata Method, combined with electrotherapy. CASE DESCRIPTION: Three patients suffered a complex brachial plexus injury. They were submitted to surgery and to long-term rehabilitation with the Chordata method (including suspension and tilting exercises) combined with electrotherapy. All patients exhibited significant signs of recovery in post-treatment electroneuromyography. Moreover, improvements in muscle strength and in the range of motion of the injured upper limb were also observed, leading to better posture and gains in activities of daily living (e.g., driving a modified car, holding objects, performing household chores, and doing leisure activities). CONSLUSIONS: There was great functional recovery after the physical therapy program with the Chordata Method combined with electrotherapy, with an impact on patients' daily lives as well as on electroneuromyography findings. Randomized clinical trials are needed to confirm or refute this new non-pharmacological strategy for the treatment of brachial plexus injuries.

OBJETIVOS: Descrever três casos clínicos em que os indivíduos tiveram lesão de plexo braquial complexa, tratada com um programa inovador de fisioterapia, o Método Chordata, associado à eletroterapia. DESCRIÇÃO DOS CASOS: Três pacientes sofreram lesões complexas do plexo braquial. Os três sujeitos foram submetidos à intervenção cirúrgica e a um longo período de reabilitação com o emprego do método Chordata (envolvendo exercícios de suspensão e pendulação corporal), combinada com a eletroterapia. Todos os pacientes apresentaram sinais significativos de recuperação na eletroneuromiografia pós-tratamento. Além disso, os três também apresentaram melhora na força muscular e nas amplitudes de movimento do membro superior acometido. Observou-se melhor postura e ganhos importantes nas atividades de vida diária (tais como dirigir um carro modificado, segurar objetos, realizar tarefas domésticas e atividades de lazer). CONCLUSÕES: Os resultados revelaram uma importante recuperação funcional após o programa de fisioterapia com o Método Chordata associado à eletroterapia, com impacto na vida diária dos pacientes, bem como nos achados eletroneuromiográficos. Ensaios clínicos randomizados são necessários para confirmar ou refutar esta nova estratégia terapêutica não farmacológica nas lesões de plexo braquial.

Early sensory re-education of the hand after peripheral nerve repair based on mirror therapy: a randomized controlled trial

BACKGROUND: Mirror therapy has been used as an alternative stimulus to feed the somatosensory cortex in an attempt to preserve hand cortical representation with better functional results. OBJECTIVE: To analyze the short-term functional outcome of an early re-education program using mirror therapy compared to a late classic sensory program for hand nerve repair. METHOD: This is a randomized controlled trial. We assessed 20 patients with median and ulnar nerve and flexor tendon repair using the Rosen Score combined with the DASH questionnaire. The early phase group using mirror therapy began on the first postoperative week and lasted 5 months. The control group received classic sensory re-education when the protective sensation threshold was restored. All participants received a patient education booklet and were submitted to the modified Duran protocol for flexor tendon repair. The assessments were performed by the same investigator blinded to the allocated treatment. Mann-Whitney Test and Effect Size using Cohen's d score were used for inter-group comparisons at 3 and 6 months after intervention. RESULTS: The primary outcome (Rosen score) values for the Mirror Therapy group and classic therapy control group after 3 and 6 months were 1.68 (SD=0.5); 1.96 (SD=0.56) and 1.65 (SD=0.52); 1.51 (SD=0.62), respectively. No between-group differences were observed. CONCLUSION: Although some clinical improvement was observed, mirror therapy was not shown to be more effective than late sensory re-education in an intermediate phase of nerve repair in the hand. Replication is needed to confirm these findings.

A case of malignant atrophic papulosis with cranial nerve and peripheral nerve impairment

Malignant atrophic papulosisis is a rare, multisystem obliterative vasculopathy of unknown etiology, occasionally involving the cranial nerve. We describe the first case of malignant atrophic papulosisis with cranial nerve and peripheral nerve involvement in China. A 47-year-old woman presented to our hospital with atrophic porcelain white papules over the trunk and extremities, numbness in the right calf, vision decrease and impaired movement of the right eye. She was diagnosed with malignant atrophic papulosisis, based on characteristic symptoms and histopathologic examination. The patient was treated with dipyridamole and aspirin for 9 months, but later died of gastrointestinal hemorrhage. We reviewed currently available case reports on cranial nerve involvement in malignant atrophic papulosisis and emphasized the importance of skin biopsy in diagnosing this disease.