Search Results (66)

Brachial plexus injuries are challenging conditions. Over the past decades, nerve transfer surgery has progressively evolved from proximal nerve reconstruction toward selective distal neurotization strategies, considerably expanding the possibilities for functional restoration. As the number of described donor–recipient combinations has increased, the literature has become increasingly fragmented, often focusing on isolated techniques or specific functional targets. The aim of the present study was to provide a comprehensive state-of-the-art overview of currently available motor nerve transfer strategies for upper-limb reinnervation in BPI. A literature review was conducted according to PRISMA guidelines using PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science databases. Studies concerning motor nerve transfers for upper-limb reconstruction were systematically reviewed and categorized according to recipient nerve and functional target, including shoulder function, scapular stabilization, elbow flexion and extension, wrist and finger extension, wrist and finger flexion, intrinsic hand function, and extraplexal donor nerve reconstruction. A total of 250 studies met the inclusion criteria. Both intraplexal and extraplexal donor strategies were identified for most reconstructive targets. Intraplexal distal nerve transfers currently represent the preferred approach whenever feasible because of shorter reinnervation distances and more predictable outcomes. Extraplexal donors, including the spinal accessory, intercostal, contralateral C7, and phrenic nerves, remain essential in complete BPIs and root avulsion injuries. Despite substantial advances, restoration of intrinsic hand function and reliable distal reinnervation remain major reconstructive challenges. Motor nerve transfers represent an increasingly versatile and function-oriented reconstructive strategy that should be tailored to the individual injury pattern, available donor nerves, and functional priorities. Full article

Background/Objectives: Selective transfer of an ulnar nerve fascicle to the motor branch of the musculocutaneous nerve (Oberlin technique) is widely used to restore elbow flexion following upper brachial plexus injury. Intraoperative neurophysiological mapping allows quantitative recording of compound muscle action potentials (CMAPs) during donor fascicle selection; however, its prognostic relevance remains unclear. This study evaluated whether intraoperative flexor carpi ulnaris (FCU) CMAP amplitude is associated with time to electromyographic reinnervation of the biceps brachii and with final functional outcomes. Methods: A retrospective observational study was conducted including patients who underwent selective nerve transfer to the biceps brachii between 2006 and 2025 at two tertiary referral centers. Donor fascicles were selected using intraoperative neurophysiological mapping with quantitative CMAP recordings from three ulnar-innervated muscles. Primary outcomes were time to electromyographic evidence of reinnervation and final elbow flexion strength assessed using the British Medical Research Council grading system. Associations were analyzed using nonparametric statistical methods. Results: Twenty patients met the inclusion criteria. Higher intraoperative FCU CMAP amplitudes were associated with a shorter time to electromyographic reinnervation (Spearman ρ = −0.572, p = 0.0106). No association was observed between CMAP amplitude and final elbow flexion strength (Spearman ρ = −0.168, p = 0.479), or between time to reinnervation and final functional outcome (Spearman ρ = −0.276, p = 0.253). A positive association was found between the injury-to-surgery interval and intraoperative CMAP amplitude (Spearman ρ = 0.681, p = 0.000943). Conclusions: The intraoperative FCU CMAP amplitude facilitates objective donor fascicle selection and is associated with earlier electromyographic reinnervation. Nevertheless, it was not associated with final elbow flexion strength in this cohort and should be interpreted as a technical adjunct rather than a standalone prognostic indicator. Functional recovery following nerve transfer appears to reflect multifactorial biological and temporal determinants beyond a single intraoperative neurophysiological measurement. These findings should be interpreted cautiously given the limited sample size. Full article

Background: Assessment and treatment of brachial plexus injury in polytrauma patients is often challenging due to concomitant injuries requiring life-saving interventions. Furthermore, the role of immediate nerve exploration in closed postganglionic nerve injuries remains debated. Case presentation: We present the case of a 21-year-old male with an infraclavicular brachial plexus injury, floating shoulder and axillary artery rupture following a motorcycle accident. Early multidisciplinary intervention included vascular repair, bone stabilization and brachial plexus exploration. Nerve reconstruction using grafts and transfers led to significant functional recovery, preventing degenerative changes, and facilitating early rehabilitation. Conclusions: This case highlights the benefits of early exploration and management of complex brachial plexus injuries in polytrauma patients to improve functional outcomes and quality of life. Full article

Background: Glenohumeral arthrodesis (GHA) and extraplexal tendon transfers (TT) have been described as options for secondary shoulder stabilization and reanimation following adult traumatic brachial plexus injury (BPI) with delayed presentation or failure of primary nerve reinnervation. This study aimed to evaluate the outcomes and complication profiles of these two approaches to shoulder reanimation to better understand the indications, anticipated outcomes, and complication risks of each for traumatic brachial plexus injury. Methods: A systematic search of six databases (PubMed, EMBASE, SCOPUS, CINAHL, SPORTDiscus, Cochrane Library) was conducted in March 2025 following PRISMA guidelines. Studies reporting clinical outcomes in adults undergoing GHA or TT for traumatic BPI were included. Pooled mean range of motion and proportional complication and reoperation rates were calculated using random- and fixed-effects models, as appropriate. Results: A total of 22 studies involving 269 TT procedures and 194 GHA procedures were analyzed. Mean shoulder abduction was 81° (95% CI 54–108°) in the TT group and 51° (95% CI 37–65°) in the GHA group. Mean forward flexion was 88° (95% CI 51–124°) in the TT group and 56° (95% CI 44–68°) in the GHA group. The pooled complication rate was 4.8% (95% CI 2.6–8.6%) after TT and 26.4% (95% CI 18.5–36.1%) after GHA. The pooled reoperation rate was 3.2% (95% CI 1.5–6.6%) after TT and 17% (95% CI 10.8–25.7%) after GHA. Notably, TT cohorts generally had shorter follow-up durations, which may underrepresent late complications or reoperations. Conclusions: TT results in significantly lower complication and reoperation rates and demonstrates similar range-of-motion outcomes compared to GHA, suggesting that TT can be considered a first-line salvage option for motion preservation, while GHA remains an option for persistent instability, pain, or inability to achieve functional positioning of the hand in patients with traumatic BPIs. Additional comparative studies with higher levels of evidence are warranted to validate these findings. Full article

Background: Non-transected and partially transected peripheral nerve injuries (neuromas-in-continuity) are relatively common but understudied. Their optimal surgical management and expected outcomes remain unclear. We conducted a literature review of surgical repairs in such lesions and illustrate a case to guide decision-making. Systematic searches of PubMed and Google Scholar identified 70 eligible reports (Level I = 2, Level II = 5, Level III = 37, Level IV = 20, Level V = 4). Across studies, neurolysis of NAP-positive lesions often restored antigravity strength, while direct repair or grafting of nonconductive segments yielded meaningful recovery in ~75%. After neurolysis or reconstruction, ~77–92% of brachial plexus/axillary neuromas-in-continuity reached LSUHSC Grade ≥3. Median/ulnar lesions treated with neurolysis, biologic/vascularized coverage, or reconstruction showed reliable pain relief but variable sensory/motor recovery. Radial/PIN lesions improved in some series irrespective of NAPs. Earlier intervention, shorter gaps, distal sites, and younger age correlated with superior outcomes. Meanwhile, prolonged observation risking end-organ atrophy degraded results. Adjuncts such as electrical stimulation and wraps may aid reinnervation or reduce scarring, though high-quality evidence is limited. Conclusions: For non-transected and partially transected PNIs, a pragmatic approach emerges: Observe low-grade injuries with serial examinations. Explore early if recovery stalls (≈3–6 months). Use NAP-guided neurolysis for conductive lesions. Perform tension-free repair or grafting for nonconductive segments, adding anti-adhesive coverage when appropriate. Standardized reporting and prospective trials are needed to refine timing, technique selection, and patient-reported outcomes. Full article

Background/Objectives: This article discusses the clinical–surgical relevance of vascular anatomical variations, such as fenestrations—the division of a vessel into multiple channels that subsequently rejoin distally. Although rare in peripheral veins, these variations, which originate from the incomplete condensation of the embryonic capillary plexus, can predispose thrombosis and necessitate preoperative recognition to avert complications during routine procedures. This study aims to report a rare case of dual origin and double fenestration of the cephalic vein. Methods: During a cadaveric dissection, a variation of the cephalic vein was identified. Results: In this case, an origin of the cephalic vein was observed arising from the dorsal venous network of the hand. It exhibited a double fenestration in the forearm, where a branch of the medial cutaneous nerve of the forearm perforated it before draining into the brachial vein. The second, a proximal origin, arose from the convergence of two tributaries—one originating from the subcutaneous tissue lateral to the brachial muscle and the other from the biceps brachii muscle, forming a single trunk that drained into the subclavian vein. Conclusions: This rare variation of the cephalic vein (dual origin and fenestration) carries significant hemodynamic implications, including an increased risk of turbulence and thrombosis. The atypical anatomical relationship between the nerve and the fenestrated vein also heightens the potential for iatrogenic injuries. In-depth knowledge of such anomalies is crucial for healthcare professionals to minimize complications and optimize the success of procedures like venous access and arteriovenous fistulas, ultimately ensuring patient safety. Full article

Background: Brachial plexopathies comprise a diverse array of illnesses with multifactorial etiologies, including trauma, inflammation, neoplasia, and iatrogenic damage, frequently manifesting with nonspecific clinical symptoms. Precise and prompt imaging evaluation is essential for diagnosis, treatment planning, and monitoring. Objective: To equip radiologists with interpretative tools for a systematic assessment of the brachial plexus utilizing advanced imaging modalities, specifically ultrasound (US) and magnetic resonance imaging (MRI), while emphasizing techniques, indications, limitations, and critical radiologic signs for differential diagnosis. Imaging Techniques: This narrative review concentrates on US and MRI. High-frequency linear probes with multiplanar dynamic scans provide US visualization of trunks, cords, and terminal branches in superficial areas. Specialized MRI procedures (T1, T2, STIR, DWI, contrast-enhanced) provide comprehensive evaluation of spinal roots and deep tissues, differentiating preganglionic from postganglionic lesions. A combined US–MRI methodology can enhance diagnostic efficacy. Findings: Ultrasound is excellent for superficial and dynamic assessment, especially in post-traumatic and iatrogenic lesions, while MRI is the gold standard for deep structures and complex disorders. The integration of two modalities enhances lesion identification and treatment direction. Emerging methodologies further enhance diagnostic and prognostic capabilities. Conclusions: The synergistic application of US and MRI, emphasizing nerve injury patterns and muscle denervation indicators, facilitates precise and prompt diagnosis of brachial plexopathies. Standardizing imaging standards and incorporating modern techniques are essential for interdisciplinary, customized patient care. Full article

Background/Objectives: Upper limb amputation presents considerable physical and psychological challenges, especially in young, active individuals. This case study outlines the rehabilitation journey of a 33-year-old patient, an Italian national Paralympic snowboard cross athlete, who underwent elective transradial amputation followed by advanced surgical and prosthetic interventions. The objective was to assess the combined impact of upper limb Targeted Sensory Reinnervation (ulTSR) and the Adam’s Hand prosthetic system on functional recovery and user satisfaction. Methods: After a partial brachial plexus injury caused complete paralysis of his right hand, the patient opted for transradial amputation. He subsequently underwent ulTSR, performed by plastic surgeon, Alexander Gardetto, MD, which involved rerouting sensory nerves to defined regions of the residual limb in order to reestablish a phantom limb map. This reinnervation was designed to facilitate improved prosthetic integration. The Adam’s Hand, a myoelectric prosthesis with AI-based pattern recognition, was selected for its compatibility with TSR and intuitive control. Outcomes were evaluated using the OPUS questionnaire, the DASH, and patient feedback. Results: ulTSR successfully restored meaningful sensory input, allowing intuitive and precise control of the prosthesis, with minimal cognitive and muscular effort. The patient regained the ability to perform numerous activities of daily living such as dressing, eating, lifting, and fine motor tasks—which had been impossible for over 15 years. OPUS results demonstrated significant improvements in both function and satisfaction. Conclusions: This case highlights the synergistic benefits of combining ulTSR with user-centered prosthetic technology. Surgical neurorehabilitation, paired with advanced prosthetic design, led to marked improvements in autonomy, performance, and quality of life in a high-performance amputee athlete. Full article

The treatment of shoulder dysplasia resulting from brachial plexus birth injury (BPBI) remains a matter of debate within pediatric orthopedic and neurosurgical communities. Various approaches have been proposed to address the muscular imbalance and joint incongruity that develop in affected children, with special attention paid to the roles of humeral head reduction and tendon transfers. Background/Objectives: These procedures aim to correct the disproportionate strength between internal and external rotators of the shoulder. However, the specific contribution of skeletal procedures such as glenoid osteotomy to restoring shoulder mechanics remains controversial. Glenoid osteotomy, a technique that involves surgically reorienting the glenoid cavity, is hypothesized to promote better containment of the humeral head and allow more physiological joint development. On one hand, altering the glenoid axis could enhance joint congruency and facilitate remodeling during growth. On the other hand, there is limited evidence supporting its efficacy and safety. Methods: This review aims to assess the available literature to determine whether glenoid osteotomy represents a safe and effective procedure for patients with BPBI-associated shoulder dysplasia. A comprehensive literature search yielded 1380 titles. After excluding studies focused on adults and those failing to meet inclusion criteria, only three studies were selected for final analysis. Due to the limited data and variability in study design, no statistical meta-analysis could be performed. Results: Findings suggest that glenoid osteotomy, particularly when combined with tendon transfers, may lead to improvements in shoulder abduction and external rotation. However, outcomes are often difficult to interpret in isolation, and the specific benefits attributable to the osteotomy remain unclear. The lack of standardized imaging, follow-up, and scoring systems limits the strength of current conclusions. Conclusions: Further multicenter, prospective studies are needed to evaluate the long-term efficacy of glenoid osteotomy, its role in skeletal remodeling, and its contribution to overall shoulder stability and function. Such studies would help clarify the true potential of this surgical technique in the broader context of BPBI treatment. Full article

Brachial plexus root avulsion [BPRA] and concomitant spinal cord injury [SCI] represent devastating injuries that come with limited hope for recovery owing to the adult spinal cord’s loss of intrinsic ability to spontaneously regenerate. BPRA/SCI is an enormous public health issue the world over, and its catastrophic impact goes beyond the patient, the family, businesses, and national health budgets, draining billions of dollars annually. The rising population and economic growth have seen the incidence of SCI surging. Genomic, transcriptomic, and proteomic studies have yielded loads of information on the various molecular events that precede, regulate, and support both regenerative and degenerative pathways post-SCI. Metabolomics, on the other hand, comes in as the search for a cure and the objective monitoring of SCI severity and prognosis remains on the horizon. Despite the large number of review articles on metabolomics and its application fields such as in cancer and diabetes research, there is no comprehensive review on metabolite profiling to study disease mechanisms, biomarkers, or neuroprotection in SCI. First, we present a short review on BPRA/SCI. Second, we discuss potential benefits of metabolomics as applied in BPRA/SCI cases. Next, a look at the analytical techniques that are used in metabolomics. Next, we present an overview of the studies that have used metabolomics to reveal SCI metabolic fingerprints and point out areas of further investigation. Finally, we discuss future research directions. Full article

A stinger is the transient sensory and motor loss of one upper extremity caused by a stretch or compression injury to the brachial plexus or the exiting cervical nerve roots. Athletes from contact sports like American football, rugby, wrestling, and horseback riding are most affected. Given today’s competitive athletic culture and recent advancements in sports medicine, understanding the clinical, diagnostic, and therapeutic aspects of stingers is crucial. Thus, this narrative review highlights current knowledge of pathology, clinical features, diagnostic modalities, radiologic measurements, management, rehabilitation, and return-to-play protocols. Recent and prominent English publications on adult athletes revealed that the brachial plexus upper roots (C5 and C6) are most affected. Stingers accounted for 62.2% of neck injuries in National Football League athletes and affected up to 50.3% of football players. Grading is based on injury severity to the nerves. Most stingers are mild, lasting a few seconds to minutes. Return-to-play protocols remain controversial; however, stingers have promising prognoses and can mostly be resolved with conservative treatment and rehabilitation. Severe injuries require surgical intervention but rarely occur in athletics. In conclusion, many recent developments in the evaluation and treatment of stingers impact current treatment plans, return-to-play decisions, and the future of athletes. Full article

Background: A brachial plexus avulsion occurs when the nerve root separates from the spinal cord during birthing trauma, such as shoulder dystocia or a difficult vaginal delivery. A complete paralysis of the affected levels occurs post-brachial plexus avulsion. Despite being reported in 10–20% of brachial plexus birthing injuries, it remains poorly diagnosed during the acute stages of injury, leading to poor intervention approaches. The poor diagnosis of brachial plexus avulsion injury can be attributed to the currently unavailable biomechanics of brachial plexus avulsion. While the biomechanical properties of neonatal brachial plexus are available, the forces required to avulse a neonatal brachial plexus remain unknown. Methods: This study aims to provide detailed biomechanics of the required forces and corresponding strains for neonatal brachial plexus avulsion. Biomechanical tensile testing was performed on an isolated, clinically relevant piglet spinal cord and brachial plexus complex, and the required avulsion forces and strains were measured. Results: The reported failure forces and corresponding strains were 3.9 ± 1.6 N at a 27.9 ± 6.5% strain, respectively. Conclusion: The obtained data are required to understand the avulsion injury biomechanics and provide the necessary experimental data for computational model development that serves as an ideal surrogate for understanding complicated birthing injuries in newborns. Full article

Objective: Cardiopulmonary bypass (CPB) via the right axillary artery (RAA) has become an alternative perfusion strategy, especially in complex aortic procedures. This study delineates our technique and outcome with direct axillary cannulation utilizing the Seldinger technique, which we adopted as the standard perfusion strategy in the sternum-sparing minimally invasive total coronary revascularization via left anterior thoracotomy (TCRAT) using CPB. Methods: From November 2019 to December 2023, a total of 413 consecutive patients underwent nonemergent isolated coronary artery bypass grafting (CABG) via left anterior minithoracotomy on CPB with peripheral cannulation via the RAA and cardioplegic cardiac arrest, using this technique as a default strategy in the daily routine. All patients had multivessel coronary artery disease. The primary outcome was intraoperative cannulation-related complications (bleeding, revision, ischemia, wound healing complications). The secondary outcome was cannulation-related events during follow-up (blood pressure differences, incidence of brachial plexus injury, clinical signs of circulatory problems of arm and hand, re-interventions). Mean midterm follow-up was 18.7 ± 12.3 [1.1–51.2] months. During follow-up, 16 patients died. Overall, a total of 397 patients (344 male; 67.6 ± 9.7 [32–88]) were included for follow-up (100%). Results: The RAA was successfully cannulated in 100% of patients. A cannula size of 16 Fr was used in 34.6%, 18 Fr in 63.9% and 20 Fr in 1.5% of all patients. There was no intraoperative bleeding complication. In two patients, intraoperative revision of the RAA was required, necessitating a venous patch repair. At follow-up, there were no differences between the systolic and diastolic blood pressure or the pressure gradients between the right and left arm. Transient numbness of the right hand was observed in two patients. Permanent numbness was not observed. No patient needed further intervention or surgical revision of the RAA. Conclusions: The right axillary cannulation is feasible and safe in terms of vascular injury and brachial plexus injury with excellent in-hospital and follow-up outcome. Full article

Background: Thoracic outlet syndrome (TOS) is an uncommon condition defined by the compression of neurovascular structures within the thoracic outlet. When conservative management strategies fail to alleviate symptoms, surgical decompression becomes necessary. The purpose of this study is to evaluate and compare the efficacy and safety of regional anesthesia (RA) using spontaneous breathing in contrast to general anesthesia (GA) for patients undergoing surgical intervention for TOS. Methods: We conducted a retrospective comparative study involving 68 patients who underwent trans-axillary first rib resection for TOS. The patient cohort was divided into two groups: 29 patients in the GA group and 39 patients in the RA group. The RA technique employed consisted of supraclavicular brachial plexus (SBP) and pectoral nerve (PECS II) blocks, accompanied by deep sedation. Key outcome measures such as pain scores, opioid consumption, and various perioperative parameters were systematically analyzed. Results: Postoperative pain levels recorded in the recovery room were significantly lower in the RA group, with a median numerical rating scale (NRS) score of zero compared to two in the GA group (p = 0.0443). Additionally, both intraoperative and postoperative opioid consumption showed a marked reduction in the RA group, with p-values of less than 0.001 and 0.0418, respectively. The RA approach was associated with shorter surgical durations (p = 0.0008), a decrease in the incidence of postoperative nausea and vomiting (PONV) (p = 0.0312), and a lower occurrence of intraoperative lung injuries (p < 0.0001). Furthermore, the length of hospital stay was significantly reduced for patients in the RA group. Conclusions: Although both groups reported low postoperative pain scores, the regional anesthesia approach exhibited distinct advantages in terms of opioid consumption, surgical duration, and overall perioperative outcomes. The utilization of SBP and PECS II blocks facilitated surgical procedures and mitigated complications, thereby positively influencing the postoperative recovery trajectory. Future prospective studies are essential to validate these findings further and to investigate long-term outcomes associated with the use of regional anesthesia in TOS surgery. Full article

Radiation therapy is widely recognized as an efficacious modality for treating neoplasms located within the craniofacial region. Nevertheless, this approach is not devoid of risks, predominantly concerning potential harm to the neural structures. Adverse effects may encompass focal cerebral necrosis, cognitive function compromise, cerebrovascular pathology, spinal cord injury, and detriment to the neural fibers constituting the brachial plexus. With increasing survival rates among oncology patients, evaluating post-treatment quality of life has become crucial in assessing the benefits of radiation therapy. Consequently, it is imperative to investigate therapeutic strategies to mitigate cerebral complications from radiation exposure. Current management of radiation-induced cerebral damage involves corticosteroids and bevacizumab, with preclinical research on antioxidants and thalidomide. Despite these efforts, an optimal treatment remains elusive. Recent studies suggest the gut microbiota’s involvement in neurologic pathologies. This review aims to discuss the causes and existing treatments for radiation-induced cerebral injury and explore gut microbiota modulation as a potential therapeutic strategy. Full article