Retrospective Study of 57 Patients Submitted to Dorsal Root Entry Zone Lesioning by Radiofrequency for Brachial Plexus Avulsion Pain.

BACKGROUND: Dorsal root entry zone (DREZ) lesioning may be used to treat neuropathic pain in patients with traumatic brachial plexus injuries. The clinical outcome after surgery is variable in the medical literature. We aimed to report the surgical outcome after DREZ lesioning by radiofrequency and to analyze prognostic factors such as the presence of a spinal cord injury identified before surgery. METHODS: We conducted a retrospective study that included 57 patients who had experienced traumatic brachial plexus injuries and exhibited neuropathic pain that did not respond to conservative treatment methods. They were submitted to DREZ lesioning. We defined the inclusion and exclusion criteria, collected sociodemographic and clinical characteristics, and identified and classified spinal cord lesions based on magnetic resonance imaging. We applied statistical tests to evaluate the association between pain intensity after surgery and the radiological profile and sociodemographic characteristics. RESULTS: Immediately after surgery, the pain outcome was considered good or excellent in 50 patients (89.28%). At the last follow-up, it was good or excellent in 39 patients (68.43%). There was no association (P > 0.05) between the pain outcome and the variables analyzed (time interval between trauma and DREZ lesioning, presence of spinal cord injury, age, the number of avulsed roots, and the type of pain). CONCLUSIONS: DREZ lesioning using radiofrequency represents a significant therapeutic approach for managing neuropathic pain after a traumatic brachial plexus injury. Importantly, we found that the presence of a spinal cord injury is not associated with the surgical outcome.

Validity of range of motion, muscle strength, sensitivity, and Tinel sign tele-assessment in adults with traumatic brachial plexus injury.

BACKGROUND: The COVID-19 pandemic and the need for social distancing created challenges for accessing and providing health services. Telemedicine enables prompt evaluation of patients with traumatic brachial plexus injury, even at a distance, without prejudice to the prognosis. The present study aimed to verify the validity of range of motion, muscle strength, sensitivity, and Tinel sign tele-assessment in adults with traumatic brachial plexus injury (TBPI). METHODS: A cross-sectional study of twenty-one men and women with TBPI admitted for treatment at a Rehabilitation Hospital Network was conducted. The participants were assessed for range of motion, muscle strength, sensitivity, and Tinel sign at two moments: in-person assessment (IPA) and tele-assessment (TA). RESULTS: The TA muscle strength tests presented significant and excellent correlations with the IPA (the intra-rater intraclass correlation coefficient, ICC ranged between 0.79 and 1.00 depending on the muscle tested). The agreement between the TA and IPA range of motion tests ranged from substantial to moderate (weighted kappa coefficient of 0.47-0.76 (p < 0.05) depending on the joint), and the kappa coefficient did not indicate a statistically significant agreement in the range of motion tests of supination, wrist flexors, shoulder flexors, and shoulder external rotators. The agreement between the IPA andTA sensitivity tests of all innervations ranged from substantial to almost perfect (weighted kappa coefficient 0.61-0.83, p < 0.05) except for the C5 innervation, where the kappa coefficient did not indicate a statistically significant agreement. The IPA versus TA Tinel sign test showed a moderate agreement (weighted kappa coefficient of 0.57, p < 0.05). CONCLUSIONS: The present study demonstrated that muscle strength tele-assessment is valid in adults with TBPI and presented a strong agreement for many components of TA range of motion, sensitivity, and Tinel sign tests.

Neuromuscular Choristoma: Report of Five Cases With CTNNB1 Sequencing.

Neuromuscular choristoma (NMC) are lesions of the peripheral nervous system characterized by an admixture of skeletal muscle fibers and nerves fascicles that are frequently associated with desmoid fibromatosis (DF). Mutations in CTNNB1, the gene for ß-catenin protein, are common in DF and related to its pathogenesis. They are restricted to exon 3, with 3 point mutations: T41A, S45F, and S45P. To understand the pathogenesis of NMC, we tested CTNNB1 status in 5 cases of NMC whether or not they were associated with DF. The screening of mutations in CTNNB1 gene was based on amplicon deep sequencing using the ION Proton platform. Three patients had the S45F mutation; in 2 the mutation was common to both lesions and in one the DF was wild type while the NMC had the S45F mutation. One patient had a T41A mutation in the NMC and no associated DF. In the last patient, the DF lesion had a T41A mutation; there was no lesion with the S45P mutation. The presence of similar CTNNB1 mutations in NMC/DF-associated lesions and sporadic DF reinforces the relationship between both lesions and points to a common pathogenic mechanism.

Intercostal to musculocutaneous nerve transfer in patients with complete traumatic brachial plexus injuries: case series.

BACKGROUND: To recover biceps strength in patients with complete brachial plexus injuries, the intercostal nerve can be transferred to the musculocutaneous nerve. The surgical results are very controversial, and most of the studies with good outcomes and large samples were carried out in Asiatic countries. The objective of the study was to evaluate biceps strength after intercostal nerve transfer in patients undergoing this procedure in a Western country hospital. METHODS: We retrospectively analyzed 39 patients from 2011 to 2016 with traumatic brachial plexus injuries receiving intercostal to musculocutaneous nerve transfer in a rehabilitation hospital. The biceps strength was graded using the British Medical Research Council (BMRC) scale. The variables reported and analyzed were age, the time between trauma and surgery, surgeon experience, body mass index, nerve receptor (biceps motor branch or musculocutaneous nerve), and the number of intercostal nerves transferred. Statistical tests, with a significance level of 5%, were used. RESULTS: Biceps strength recovery was graded ≥M3 in 19 patients (48.8%) and M4 in 15 patients (38.5%). There was no statistical association between biceps strength and the variables. The most frequent complication was a pleural rupture. CONCLUSIONS: Intercostal to musculocutaneous nerve transfer is a safe procedure. Still, biceps strength after surgery was ≥M3 in only 48.8% of the patients. Other donor nerve options should be considered, e.g., the phrenic or spinal accessory nerves.

Outcome following phrenic nerve transfer to musculocutaneous nerve in patients with traumatic brachial palsy: a qualitative systematic review.

BACKGROUND: The phrenic nerve can be transferred to the musculocutaneous nerve in patients with traumatic brachial plexus palsy in order to recover biceps strength, but the results are controversial. There is also a concern about pulmonary function after phrenic nerve transection. In this paper, we performed a qualitative systematic review, evaluating outcomes after this procedure. METHOD: A systematic review of published studies was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Data were extracted from the selected papers and related to: publication, study design, outcome (biceps strength in accordance with BMRC and pulmonary function) and population. Study quality was assessed using the "strengthening the reporting of observational studies in epidemiology" (STROBE) standard or the CONSORT checklist, depending on the study design. RESULTS: Seven studies were selected for this systematic review after applying inclusion and exclusion criteria. One hundred twenty-four patients completed follow-up, and most of them were graded M3 or M4 (70.1 %) for biceps strength at the final evaluation. Pulmonary function was analyzed in five studies. It was not possible to perform a statistical comparison between studies because the authors used different parameters for evaluation. Most of the patients exhibited a decrease in pulmonary function tests immediately after surgery, with recovery in the following months. Study quality was determined using STROBE in six articles, and the global score varied from 8 to 21. CONCLUSIONS: Phrenic nerve transfer to the musculocutaneous nerve can recover biceps strength ≥M3 (BMRC) in most patients with traumatic brachial plexus injury. Early postoperative findings revealed that the development of pulmonary symptoms is rare, but it cannot be concluded that the procedure is safe because there is no study evaluating pulmonary function in old age.