Intravenous Access in Infants Undergoing Bilateral Sural Nerve Grafts for Primary Brachial Plexus Exploration.

BACKGROUND: Intravenous access (IVA) in infants undergoing primary brachial plexus exploration may be difficult. Both lower limbs are prepared and draped for sural nerve graft harvesting. The injured upper limb is also prepared and draped and is not available for IVA. In difficult IVA from the remaining upper limb, we have been using one of the feet for IVA. The infection rate and problems of intravenous infusions in this setting have never been studied in the literature. This study documents the infection rate and problems of intravenous infusions in these infants when a foot (within the sterile field) is used for IVA. METHODS: This is a retrospective study of 63 consecutive infants undergoing primary brachial plexus exploration, and in whom IVA was obtained from one of the feet. Infection rate and problems of intravenous infusions were recorded. RESULTS: No surgical wound infection and no infection of the IVA site were noted. There were no instances of accidental dislodgement of the intravenous cannula and no instances of extravasation. CONCLUSION: The use of one of the feet (within the sterile filed) for IVA is safe and acceptable in infants undergoing primary brachial plexus exploration and bilateral sural nerve grafting.

Intraoperative Nerve Stimulation During Brachial Plexus Surgery: Comparison Between a Totally Disposable Nerve Stimulator and Nerve Stimulator Normally Used for Nerve Blocks.

BACKGROUND: Intraoperative nerve stimulation is done routinely in brachial plexus and peripheral nerve surgery as well as in selective neurectomy in spastic patients. OBJECTIVE: The current study compares the use of 2 different devices for nerve stimulation: a totally disposable nerve stimulator and a nerve stimulator used for nerve blocks by anesthetists. METHODS: A retrospective study of 60 patients who underwent brachial plexus surgery: In 30 patients, we used the totally disposable nerve stimulator (group 1) and in another 30 patients, we used the anesthesia device (group 2). The cost of disposable materials used for nerve stimulation was calculated in each group. The same surgeon performed all operations, and he was asked to give his subjective opinion regarding the convenience and ease of use of the device in each group. RESULTS: The main advantages of the totally disposable device are its placement totally within the sterile field, and it is operated by the surgeon without the need to communicate with the anesthetist. However, the totally disposable device had several major disadvantages when compared to the anesthesia device. Firstly, the disposable stimulator can only deliver 0.5, 1.0, and 2.0 mA stimuli, while the anesthesia device can deliver stimuli of 0.1 to 5 mA (in 0.1 mA increments). Secondly, the disposable stimulator frequently fails to operate during surgery, and this is not experienced with the anesthesia device. Finally, the cost of disposables is less using the anesthesia device. CONCLUSION: Our center has stopped using the disposable nerve stimulator in favour for the anesthesia device.

HISTORIQUE: La stimulation nerveuse intraopératoire est utilisée régulièrement lors d'opérations du plexus brachial et des nerfs périphériques, de même que lors de neurectomies sélectives chez les patients spastiques. OBJECTIF: La présente étude visait à comparer deux dispositifs différents pour la stimulation nerveuse, soit un stimulateur nerveux entièrement jetable et un stimulateur nerveux qu'utilisent les anesthésistes pour les blocages nerveux. MÉTHODOLOGIE: Les chercheurs ont effectué une étude rétrospective auprès de 60 patients qui avaient subi une opération du plexus brachial. Chez 30 patients, ils ont utilisé le stimulateur nerveux entièrement jetable (groupe I) et chez 30 autres, le dispositif d'anesthésie (groupe II). Les chercheurs ont calculé le coût des fournitures jetables utilisées pour la stimulation nerveuse dans chaque groupe. Le même chirurgien a effectué toutes les opérations et a été invité à donner son avis subjectif sur le caractère pratique et la facilité d'utilisation du dispositif dans chaque groupe. RÉSULTATS: Les dispositifs complètement jetables ont comme principaux avantages de se situer entièrement dans le champ stérile et d'être utilisés par le chirurgien sans qu'il communique avec l'anesthésiste. Cependant, ils comportent plusieurs désavantages par rapport au dispositif d'anesthésie. D'abord, ils peuvent seulement délivrer un stimulus de 0,5 mA, 1,0 mA et 2,0 mA, alors que les dispositifs d'anesthésie en délivrent de 0,1 mA à 5 mA (par incréments de 0,1 mA). Ensuite, le stimulateur jetable est souvent défaillant pendant la chirurgie, ce qui ne se produit pas avec le dispositif d'anesthésie. Enfin, le dispositif d'anesthésie réduit le coût des fournitures jetables. CONCLUSION: Le centre des chercheurs a cessé d'utiliser le stimulateur nerveux jetable au profit du dispositif d'anesthésie.

Scarring of the C8-T1 roots with partial avulsion in situ in total obstetric brachial plexus palsy.

BACKGROUND: Primary exploration of the brachial plexus in infants with obstetric palsy may reveal scarring of the lower roots with evidence of partial avulsion-in-situ. As we have been treating this lesion by neurolysis only, we aimed to investigate the recovery of hand function following such approach. METHODS: A series of 14 cases of total obstetric palsy with with evidence of partial avulsion-in-situ of the lower roots were included. All lesions were treated by neurolysis only (with no neurotization of the lower roots). Management of the injured upper roots was done by neurotization. Recovery was assessed as per our motor grading system. RESULTS: After a minimum follow-up of 4 years, hand functional recovery was considered good in 7 patients and excellent in the remaining 7 patients. CONCLUSIONS: We highlight the scarring of lower roots with evidence of partial avulsion-in situ in obstetric palsy. We also document that neurolysis is an acceptable approach to such lesions. Level of Evidence: Level IV, therapeutic study.

Preeclampsia: A review of the pathogenesis and possible management strategies based on its pathophysiological derangements.

This review is divided into three parts. The first part briefly describes the pathogenesis of preeclampsia. This is followed by reviewing previously reported management strategies of the disease based on its pathophysiological derangements. Finally, the author defines the safe and acceptable methods/medications that may be used to 'prevent' preeclampsia (in high risk patients) and those that may be used to 'treat' preeclampsia (meant to prolong the pregnancy in patients with established preeclampsia). The review concludes that multi-center trials are required to include multiple drugs in the same management protocol.

The outcome of primary brachial plexus reconstruction in extended Erb's obstetric palsy when two roots are available for intraplexus neurotization.

BACKGROUND: The outcome of primary brachial plexus reconstruction in extended Erb's obstetric palsy with single root avulsion has not been specifically documented in the literature. METHODS: A series of 46 consecutive cases of extended Erb's obstetric palsy with single root avulsion was retrospectively reviewed. The upper and middle trunks were reconstructed with nerve grafts from the available two roots. No nerve transfers were used. The percentage of a satisfactory motor recovery was documented. RESULTS: The postoperative motor recovery was excellent (over 97%) satisfactory outcome for elbow flexion, elbow extension, and digital extension. A satisfactory wrist extension was noted in 84.8% of children. The lowest rates of satisfactory outcomes were for shoulder external rotation (65.2%) and shoulder abduction (56.5%). CONCLUSIONS: In extended Erb's obstetric palsy with single root avulsion, two ruptured roots are available for intraplexus neurotization of the upper and middle trunks. The surgeon gives a priority to elbow flexion and this is translated in an excellent outcome for elbow flexion. The triceps and digital extensors get a major contribution form the unaffected C8 root, and this is also translated in an excellent outcome for these two functions. Fewer cable grafts are available for reconstruction of the posterior division of upper trunk and the middle trunk, resulting in a lower rate of satisfactory outcomes at the shoulder for wrist extension. Level of Evidence: Level IV, therapeutic study.

Evidence of the Effectiveness of Primary Brachial Plexus Surgery in Infants With Obstetric Brachial Plexus Palsy-Revisited.

A recent systematic review questioned the effectiveness of primary surgery in infants with obstetric brachial plexus palsy. At our center, the indication for primary surgery in infants with upper Erb's obstetric palsy is the lack of active elbow flexion at age 4 months. The current study compares the outcome of motor recovery in 2 groups of infants with upper Erb's palsy: one group (n = 9) treated surgically between age 4 and 5 months, and another group (n = 9) treated conservatively despite the lack of active elbow flexion at age 4 months. The only reason for not doing the surgery in the latter group was refusal by the parents. The scores of motor recovery were collected at the 2-year follow-up visit, and they were significantly better in the surgical group. The study demonstrates the effectiveness of primary surgery in infants with upper Erb's obstetric palsy compared to conservative management.

Myofibroblast-Mediated Contraction.

Myofibroblast-mediated contraction is viewed as a cycle of four steps. The first step is stimulation of myofibroblasts by lysophospholipids leading to the activation of G proteins and ending with contraction of the actin-myosin complex. The next step is the transmission of the intracellular contractile force at the focal adhesions of myofibroblasts; a step that involves talin, vinculin, paxillin, Hic-5, and the integrin receptors. In the third step, fibronectin will act as the extracellular link between the integrin receptors and the extracellular collagen. Finally, "sensing" tension and the maintenance of myofibroblast activity represent the fourth step. The clinical relevance of each step is then discussed in the form of modalities to prevent excessive scarring/fibrosis.

Erratum to: Scarring of the C8-T1 roots with partial avulsion in situ in total obstetric brachial plexus palsy.

[This corrects the article DOI: 10.1007/s00238-017-1281-3.].

Intermediate Type of Obstetric Brachial Plexus Palsy.

Data of 829 infants with obstetric brachial plexus palsy were reviewed to identify any cases that could not be fitted into the any of the well-known types of palsy. These unusual cases were studied in detail with regard to clinical presentation and electrophysiological findings as well as management and spontaneous motor recovery. Erb's, extended Erb's, and total palsies were seen in 42.8%, 28.8%, and 28.0% of cases, respectively. Three cases (0.4%) did not fit into any of the classic types. One case had bilateral palsy, and the remaining 2 cases had unilateral palsy. All affected limbs presented with "abducted arms," "flexed forearms," and electrophysiological evidence of denervation of shoulder adductors and triceps. All cases had excellent spontaneous recovery within 6-12 months. It was concluded that these cases represent mild "intermediate" types of palsy in which the C7 root was the predominant site of injury. Good spontaneous recovery is expected.

A case of Klumpke's obstetric brachial plexus palsy following a Cesarean section.

It is generally thought that Klumpke's palsy is not seen as obstetric injury. The authors present a case of Klumpke's palsy with Horner syndrome following delivery by emergency Cesarean section. Neurolysis and nerve grafting partially corrected the paralysis.

The prognostic value of concurrent Horner syndrome in extended Erb obstetric brachial plexus palsy.

Horner syndrome may be seen in infants with extended Erb obstetric brachial plexus palsy. However, its prognostic value in these infants has not been previously investigated. A total of 220 infants with extended Erb palsy were included and divided into 2 groups: group I (n = 209) were infants with extended Erb palsy without Horner syndrome, and group II (n = 11) were infants with extended Erb palsy and concurrent Horner syndrome. The rate of good spontaneous recovery of elbow flexion was 59% in group I and 27% in group II, and the difference was significant (P = .038). The rate of good spontaneous recovery of wrist extension was 61% in group I and 0% in group II, and the difference as highly significant (P < .0001). Concurrent Horner syndrome in infants with extended Erb palsy may be considered as a poor prognostic sign for recovery of the sixth and seventh cervical roots.

Obstetric brachial plexus palsy following routine versus difficult deliveries.

Previous bio-engineering studies showed that intrapartum peak forces applied by the clinician were lower in routine deliveries than difficult deliveries. A total of 751 cases of obstetric brachial plexus palsy were included and divided into two groups: group I (248 patients) were born following routine deliveries and group II (503 patients) were born following difficult deliveries. Both groups were compared regarding the type of palsy and the rate of good/poor spontaneous motor recovery from the palsy. Group I subjects were more likely to have upper Erb palsy whereas those in group II were more likely to develop total palsy (P < .0001). The percentage of newborns with poor functional recovery was significantly higher (P < .05) in group II with regards to shoulder, wrist, and hand function. It was concluded that higher peak forces applied by the clinician in difficult deliveries affect the type of obstetric brachial plexus palsy.

Buttock necrosis and paraplegia after bilateral internal iliac artery embolization for postpartum hemorrhage.

BACKGROUND: Endovascular embolization has become part of the management of postpartum hemorrhage. CASE: We report a case of bilateral extensive gluteal skin and muscle necrosis with concurrent severe lumbosacral plexopathy after bilateral internal iliac artery embolization for postpartum hemorrhage. The ischemic plexopathy was treated conservatively, with a fair outcome. The complex gluteal wound was treated successfully with debridement and skin grafting. CONCLUSION: Pregnancy is known to increase the pelvic collateral blood vessels, and, hence, such a complication in a healthy pregnant woman is extremely rare. The risk of such a severe complication may be minimized by more selective embolization.