Fibrolipomatous hamartoma of the median nerve: An unusual cause of carpal tunnel syndrome.

Fibrolipomatous hamartoma is a rare benign tumor-like condition that affects most commonly the median nerve. The diagnosis is usually confirmed through its typical appearance on magnetic resonance imaging (MRI) without the need for a nerve biopsy. There are divergent views regarding treatment of this entity, but open carpal tunnel release for nerve decompression currently constitutes the standard care for alleviation of compressive neuropathy of the median nerve. In this report, we describe a case of fibrolipomatous hamartoma that was diagnosed via MRI and underwent open carpal tunnel release, with alleviation of the patient's symptoms.

The nerve to the levator scapulae muscle as donor in brachial plexus surgery: an anatomical study and case series.

OBJECTIVE: Nerve transfers are commonly used in treating complete injuries of the brachial plexus, but donor nerves are limited and preferentially directed toward the recovery of elbow flexion and shoulder abduction. The aims of this study were to characterize the anatomical parameters for identifying the nerve to the levator scapulae muscle (LSN) in brachial plexus surgery, to evaluate the feasibility of transferring this branch to the suprascapular nerve (SSN) or lateral pectoral nerve (LPN), and to present the results from a surgical series. METHODS: Supra- and infraclavicular exposure of the brachial plexus was performed on 20 fresh human cadavers in order to measure different anatomical parameters for identification of the LSN. Next, an anatomical and histomorphometric evaluation of the feasibility of transferring this branch to the SSN and LPN was made. Lastly, the effectiveness of the LSN-LPN transfer was evaluated among 10 patients by quantifying their arm adduction strength. RESULTS: The LSN was identified in 95% of the cadaveric specimens. A direct coaptation of the LSN and SSN was possible in 45% of the specimens (n = 9) but not between the LSN and LPN in any of the specimens. Comparison of axonal counts among the three nerves did not show any significant difference. Good results from reinnervation of the major pectoral muscle (Medical Research Council grade ≥ 3) were observed in 70% (n = 7) of the patients who had undergone LSN to LPN transfer. CONCLUSIONS: The LSN is consistently identified through a supraclavicular approach to the brachial plexus, and its transfer to supply the functions of the SSN and LPN is anatomically viable. Good results from an LSN-LPN transfer are observed in most patients, even if long nerve grafts need to be used.

Treatment of radiation-induced brachial plexopathy with omentoplasty.

Radiation-induced brachial plexus neuropathy (RIBPN) is a rare and delayed non-traumatic injury to the brachial plexus, which occurs following radiation therapy to the chest wall, neck, and/or axilla in previously treated patients with cancer. The incidence of RIBPN is more common in patients treated for carcinoma of the breast and Hodgkin lymphoma. With the improvement in radiation techniques, the incidence of injury to the brachial plexus following radiotherapy has dramatically reduced. The currently reported incidence is 1.2% in women irradiated for breast cancer. The progression of symptoms is gradual in about two-thirds of cases; the patients may initially present with paresthesia followed by pain, and later progress to motor weakness in the affected limb. We present the case of a 68-year-old female patient with breast cancer submitted to surgery, chemotherapy, and radiotherapy in the year 2000. Eighteen years later, she developed symptoms and signs compatible with RIBPN and was successfully submitted to omentoplasty for pain control. Omentoplasty is an alternative treatment for RIBPN refractory to conservative treatment, which seems to be effective in improving neuropathic pain. However, postoperative worsening of the motor strength is a real possibility, and all candidates for this type of surgery must be informed about the risk of this complication.

Diagnostic accuracy of imaging studies for diagnosing root avulsions in post-traumatic upper brachial plexus traction injuries in adults.

BACKGROUND: There is no consensus about which type of imaging study, computed tomography myelography (CTM) or magnetic resonance imaging (MRI), provides better information concerning root avulsion in adult brachial plexus injuries. METHODS: Patients with upper brachial plexus traumatic injuries underwent both CTM and MRI and surgical exploration. The imaging studies were analyzed by two independent radiologists and the data were compared with the intraoperative findings. The statistical analysis was based on dichotomous classification of the nerve roots (normal or altered). The interobserver agreement was assessed using Cohen's Kappa. The accuracy of CTM and MRI in comparison with the intraoperative findings was evaluated using the same methodology. RESULTS: Fifty-two adult patients were included. CTM tended to yield slightly higher percentages of alterations than MRI The interobserver agreement was better on CTM than on MRI for all nerve roots: C5, 0.9960 (strong) vs. 0.145 (poor); C6, 0.970 (strong) vs. 0.788 (substantial); C7, 0.969 (strong) vs. 0.848 (strong). The accuracy regarding the intraoperative findings was also higher on CTM (moderate, kappa 0.40-0.59) than on MRI (minimal, kappa 0.20-0.39) for all nerve roots. Accordingly, the overall percentage concordance (both normal or both altered) was superior in the CTM evaluation (approx. 70-75% vs. 60-65%). CTM was superior for both sensitivity and specificity at all nerve roots. CONCLUSION: CTM had greater interobserver agreement and higher diagnostic accuracy than MRI in adult patients with root avulsions due to brachial plexus injury.

Restoration of shoulder external rotation by means of the infraspinatus muscle reinnervation with a radial nerve branch transfer.

Background: Although reinnervation of the suprascapular nerve is frequently obtained through brachial plexus surgery, reestablishment of infraspinatus muscle function is rarely achieved.Methods: The viability of transfer of the radial nerve to the nerve branch to the infraspinatus muscle was determined anatomically, including histomorphometrical analysis on 30 adult cadavers. Eleven adult patients were then treated using the proposed nerve transfer.Results: The branch to the medial head was more suitable for the nerve transfer. In one cadaver, nerve transfer was impossible because there was no donor of sufficient length. According to axon counts, the branches to the lateral and medial heads had sufficient numbers of axons (means = 994.2 ± 447.6 and 1030.8 ± 258.5, respectively) for reinnervation of the branch to the infraspinatus (means = 830.2 ± 241.2 axons). In the surgical series, one patient was lost in the follow-up and only two patients achieved a good result from the transfer. Recovery of external shoulder rotation started 14 months after surgery in one patient and 8 months in the other. The first patient reached 90° of external rotation 6 months later and the second, achieved 120°of shoulder external rotation 6 months after surgery . Four other patients recovered small amounts of movement: 20, 35, 40 and 45°.Conclusions: Although anatomically feasible, the proposed nerve transfer resulted in a small number of good clinical outcomes.

Treatment of radiation-induced brachial plexopathy with omentoplasty

Radiation-induced brachial plexus neuropathy (RIBPN) is a rare and delayed non-traumatic injury to the brachial plexus, which occurs following radiation therapy to the chest wall, neck, and/or axilla in previously treated patients with cancer. The incidence of RIBPN is more common in patients treated for carcinoma of the breast and Hodgkin lymphoma. With the improvement in radiation techniques, the incidence of injury to the brachial plexus following radiotherapy has dramatically reduced. The currently reported incidence is 1.2% in women irradiated for breast cancer. The progression of symptoms is gradual in about two-thirds of cases; the patients may initially present with paresthesia followed by pain, and later progress to motor weakness in the affected limb. We present the case of a 68-year-old female patient with breast cancer submitted to surgery, chemotherapy, and radiotherapy in the year 2000. Eighteen years later, she developed symptoms and signs compatible with RIBPN and was successfully submitted to omentoplasty for pain control. Omentoplasty is an alternative treatment for RIBPN refractory to conservative treatment, which seems to be effective in improving neuropathic pain. However, postoperative worsening of the motor strength is a real possibility, and all candidates for this type of surgery must be informed about the risk of this complication.

Functional outcome of spinal accessory nerve transfer to the suprascapular nerve to restore shoulder function: Results in upper and complete traumatic brachial plexus palsy in adults.

BACKGROUND: Shoulder stability, abduction and external rotation are vital for the performance of usual daily tasks. AIMS: To compare the functional outcomes in the shoulder following spinal accessory to suprascapular nerve transfer (SASNT). PATIENTS AND METHODS: Comparison of the outcome of adult patients with upper traumatic brachial plexus palsy undergoing SASNT with patients with complete palsy submitted to the same procedure. STATISTICAL ANALYSIS: Ranges of motion were compared via the Mann-Whitney U test. The percentages of patients with a favorable outcome were compared by the chi-square test. All tests were two-tailed and P values <0.05 were considered statistically significant. RESULTS: SASNT was performed in 76 patients: 23 cases (30.2%) of upper-plexus injuries and 53 cases (69.7%) of complete brachial plexus palsy. Good shoulder abduction was achieved in 15 patients (65.2%) with upper plexus palsy and a good external rotation in 5 (21.7%). In those patients with a good recovery, the average range of motion (ROM) was 53° for shoulder abduction and 71.2° for external rotation. Thirty-six patients (67.9%) with complete palsy had a good shoulder abduction recovery with 30.7° of average ROM, but only 3 patients (5.6%) recovered a good shoulder external rotation with 68.3° of average ROM. There was no statistical difference for the abduction outcome, but the external rotation outcome was superior in the upper plexus palsy group. CONCLUSION: SASNT is a consistent procedure to achieve functional recovery of shoulder abduction after a partial or complete plexus injury, but the outcomes of external rotation were quite disappointing in both the groups.

Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children.

PURPOSE: The outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14 years. METHODS: We made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6 months after birth and total lesions around 3 months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24 months. RESULTS: The majority of cases were complete lesions (56/53.8%). Erb's palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb's palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases. CONCLUSIONS: There is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature).

Restoration of Elbow Flexion in Traumatic Upper Brachial Plexus Palsy in Adults: Outcome with Intraplexus Distal Nerve Transfers in 78 Patients

Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n » 43), or a fascicle of themedian nerve (group B, n » 16) or a combination of both (group C, n » 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar þ median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer. Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.

Good sensory recovery of the hand in brachial plexus surgery using the intercostobrachial nerve as the donor.

OBJECTIVE: Restoration of the sensitivity to sensory stimuli in complete brachial plexus injury is very important. The objective of our study was to evaluate sensory recovery in brachial plexus surgery using the intercostobrachial nerve (ICBN) as the donor. METHODS: Eleven patients underwent sensory reconstruction using the ICBN as a donor to the lateral cord contribution to the median nerve, with a mean follow-up period of 41 months. A protocol evaluation was performed. RESULTS: Four patients perceived the 1-green filament. The 2-blue, 3-purple and 4-red filaments were perceptible in one, two and three patients, respectively. According to Highet's scale, sensation recovered to S3 in two patients, to S2+ in two patients, to S2 in six patients, and S0 in one patient. CONCLUSION: The procedure using the ICBN as a sensory donor restores good intensity of sensation and shows good results in location of perception in patients with complete brachial plexus avulsion.

Good sensory recovery of the hand in brachial plexus surgery using the intercostobrachial nerve as the donor / Boa recuperação da sensibilidade da mão usando o nervo intercostobraquial como doador em cirurgia do plexo braquial

ABSTRACT Objective: Restoration of the sensitivity to sensory stimuli in complete brachial plexus injury is very important. The objective of our study was to evaluate sensory recovery in brachial plexus surgery using the intercostobrachial nerve (ICBN) as the donor. Methods: Eleven patients underwent sensory reconstruction using the ICBN as a donor to the lateral cord contribution to the median nerve, with a mean follow-up period of 41 months. A protocol evaluation was performed. Results: Four patients perceived the 1-green filament. The 2-blue, 3-purple and 4-red filaments were perceptible in one, two and three patients, respectively. According to Highet's scale, sensation recovered to S3 in two patients, to S2+ in two patients, to S2 in six patients, and S0 in one patient. Conclusion: The procedure using the ICBN as a sensory donor restores good intensity of sensation and shows good results in location of perception in patients with complete brachial plexus avulsion.

RESUMO Objetivo: A restauração da sensibilidade em pacientes com lesão completa do plexo braquial é muito importante. O objetivo desse estudo foi avaliar a recuperação sensitiva em cirurgia do plexo braquial utilizando o nervo intercostobraquial (NICB) como doador. Métodos: Onze pacientes foram submetidos a reconstrução sensitiva usando o NICB como doador para a contribuição lateral do nervo mediano, com tempo de acompanhamento pós-operatório médio de 41 meses. Um protocolo de avaliação foi realizado. Resultados: Quatro pacientes perceberam o filamento 1-verde. Os filamentos 2-azul, 3-roxo e 4-vermelho foram percebidos por um, dois e três pacientes, respectivamente. Um paciente não apresentou recuperação sensitiva. Dois pacientes obtiveram recuperação S3, dois S2+, seis S2 e um S0, pela escala de Highet. Conclusão: O procedimento usando o NICB como doador promove boa intensidade de recuperação sensitiva e bons resultados são obtidos quanto ao local de percepção em pacientes com avulsão completa do plexo braquial.

Elective amputation of the upper limb is an option in the treatment of traumatic injuries of the brachial plexus?

The treatment of complete post-traumatic brachial plexus palsy resulting in a flail shoulder and upper extremity remains a challenge to peripheral nerve surgeons. The option of upper limb amputation is controversial and scarcely discussed in the literature. We believe that elective amputation still has a role in the treatment of select cases. The pros and cons of the procedure should be intensely discussed with the patient by a multidisciplinary team. Better outcomes are usually achieved in active patients who strongly advocate for the procedure.

Elective amputation of the upper limb is an option in the treatment of traumatic injuries of the brachial plexus? / A amputação eletiva do membro superior é uma opção no tratamento das lesões traumáticas do plexo braquial?

ABSTRACT The treatment of complete post-traumatic brachial plexus palsy resulting in a flail shoulder and upper extremity remains a challenge to peripheral nerve surgeons. The option of upper limb amputation is controversial and scarcely discussed in the literature. We believe that elective amputation still has a role in the treatment of select cases. The pros and cons of the procedure should be intensely discussed with the patient by a multidisciplinary team. Better outcomes are usually achieved in active patients who strongly advocate for the procedure.

RESUMO O tratamento das paralisias completas após lesões traumáticas do plexo braquial que resultam em um membro superior completamente paralisado permanecem como um desafio aos cirurgiões de nervos periféricos. A opção de amputar o membro superior é controversa e raramente discutida na literatura. Acreditamos que a amputação eletiva ainda tem utilidade no tratamento de casos selecionados. Os prós e contras do procedimento devem ser intensamente discutidos com o paciente por uma equipe multidisciplinar. Os melhores resultados são geralmente obtidos em pacientes atuantes que reivindicam vigorosamente o procedimento.

The intercostobrachial nerve as a sensory donor for hand reinnervation in brachial plexus reconstruction is a feasible technique and may be useful for restoring sensation.

OBJECTIVE: Few donors are available for restoration of sensibility in patients with complete brachial plexus injuries. The objective of our study was to evaluate the anatomical feasibility of using the intercostobrachial nerve (ICBN) as an axon donor to the lateral cord contribution to the median nerve (LCMN). METHODS: Thirty cadavers were dissected. Data of the ICBN and the LCMN were collected, including diameters, branches and distances. RESULTS: The diameters of the ICBN and the LCMN at their point of coaptation were 2.7mm and 3.7mm, respectively. The ICBN originated as a single trunk in 93.3% of the specimens and bifurcated in 73.3%. The distance between the ICBN origin and its point of coaptation to the LCMN was 54mm. All ICBNs had enough extension to reach the LCMN. CONCLUSION: Transfer of the ICBN to the LCMN is anatomically feasible and may be useful for restoring sensation in patients with complete brachial plexus injuries.

The intercostobrachial nerve as a sensory donor for hand reinnervation in brachial plexus reconstruction is a feasible technique and may be useful for restoring sensation / O uso do nervo intercostobraquial como doador na restauração cirúrgica da sensibilidade da mão em lesões do plexo braquial é uma técnica anatomicamente viável e pode ser útil para a recuperação sensitiva

ABSTRACT Objective Few donors are available for restoration of sensibility in patients with complete brachial plexus injuries. The objective of our study was to evaluate the anatomical feasibility of using the intercostobrachial nerve (ICBN) as an axon donor to the lateral cord contribution to the median nerve (LCMN). Methods Thirty cadavers were dissected. Data of the ICBN and the LCMN were collected, including diameters, branches and distances. Results The diameters of the ICBN and the LCMN at their point of coaptation were 2.7mm and 3.7mm, respectively. The ICBN originated as a single trunk in 93.3% of the specimens and bifurcated in 73.3%. The distance between the ICBN origin and its point of coaptation to the LCMN was 54mm. All ICBNs had enough extension to reach the LCMN. Conclusion Transfer of the ICBN to the LCMN is anatomically feasible and may be useful for restoring sensation in patients with complete brachial plexus injuries.

RESUMO Objetivo Poucos doadores estão disponíveis para a restauração da sensibilidade em pacientes com lesões completas do plexo braquial (LCPB). O objetivo deste estudo foi avaliar a viabilidade anatômica do uso do nervo intercostobraquial (NICB) como doador de axônios para a contribuição do cordão lateral para o nervo mediano (CLNM). Métodos Trinta cadáveres foram dissecados. Os dados do NICB e do CLNM foram coletados: diâmetros, ramos e distâncias. Resultados Os diâmetros do NICB e da CLNM no ponto de coaptação foram 2,7mm e 3,7mm, respectivamente. O NICB originou-se como um único tronco em 93,3% dos espécimes e bifurcou-se em 73,3%. A distância entre a origem do NICB e seu ponto de coaptação com a CLNM foi de 54mm. Todos os NICBs tiveram extensão suficiente para alcançar a CLNM. Conclusão A transferência do NICB para a CLNM é anatomicamente viável e pode ser útil para restaurar a sensibilidade em pacientes com LCPB.

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement.

PURPOSE: Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach. METHODS: We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results. RESULTS: The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers. CONCLUSION: Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.

Compressão do nervo ulnar na região do cotovelo ­ síndrome do túnel cubital: revisão da literatura / Compression of the Ulnar Nerve in the Elbow Region - Cubital Tunnel Syndrome: Review of the Literature

A síndrome do túnel cubital é responsável pela neuropatia do nervo ulnar, sendo superada em frequência apenas pela síndrome do túnel do carpo. O nervo ulnar apresenta anatomia complexa podendo sofrer compressão em distintos pontos ao longo de seu trajeto, por isso o entendimento das nuances clínicas e da anatomia pormenorizada assim como da técnica cirúrgica meticulosa torna-se essencial no tratamento desta patologia.

The cubital tunnel syndrome is responsible for the ulnar nerve neuropathy, this condition is surpassed in frequency only by carpal tunnel syndrome. The ulnar nerve has complex anatomy andmay suffer compression at different points along its path, so understanding the clinical nuances and detailed anatomy as well asmeticulous surgical technique becomes essential in the treatment of this pathology.

The epidemiology of adult traumatic brachial plexus lesions in a large metropolis.

INTRODUCTION: Adult traumatic brachial plexus lesions are devastating injuries. Their real incidence is difficult to ascertain, but are certainly growing due to the increasing number of high-speed motor-vehicle accidents, especially in big cities. OBJECTIVES: Analysis of the epidemiological characteristics of patients with traumatic brachial plexus lesions in São Paulo, Brazil, the sixth largest city in the world. METHODS: This was a retrospective analysis of the epidemiological characteristics of patients submitted to surgical treatment of traumatic brachial plexus lesions in the Peripheral Nerve Surgery Unit of the Department of Neurosurgery of the University of São Paulo Medical School. RESULTS: In the period from 2004 to 2012, 406 patients underwent surgery. There were 384 (94.6 %) men and 22 (5.4 %) women. In 45.9 % the compromised plexus was the right and in 54.1 %, the left. The average age was 28.38 years. Among the causes, the most frequent was motorcycle accidents (79 %). Most of the lesions were supraclavicular. In 46.1 % of cases the lesions were complete, in 30.1 % the lesions compromised C5/C6 roots, in 20.9 % the C5/C6/C7 roots were lesioned and in 2.9 % the lesion was in the lower roots, C8/T1. Among the associated lesions the most prevalent were head trauma, observed in 34.2 % of the cases; lesions of long bones in 38.8 %; clavicle fractures in 25.9 %; and thoracic trauma in 12.9 %. CONCLUSION: In a population of adult patients with brachial plexus lesions with surgical indication, most of them comprise young male adults involved in high-energy motorcycle accidents.