AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

Magnetic Resonance Imaging Diagnosis of Nerve Root Avulsion in Birth-Related Brachial Plexus Injury
Institution where the work was prepared: Children's Healthcare of Atlanta, Atlanta, GA, USA
Ann Schwentker, MD; William Boydston, MD, PhD; Denis Atkinson, MD; Children's Healthcare of Atlanta
Eighteen infants with birth-related brachial plexus injury underwent preoperative evaluation of the cervical spine using a dedicated MRI protocol with coronal,
saggital and axial T1- and T2-weighted images. Thin-section axial 3D FIESTA images were obtained to delineate ventral and dorsal nerve rami. Nerve root
avulsion was strongly suggested by the presence of a pseudomeningocele at the corresponding level, with or without lateralization of the dorsal root ganglion
or lack of nerve root continuity. Operative reconstruction of the brachial plexus was indicated by either severe total plexus injury (Toronto score < 3.5 at 3
months of age) or nonrecovery of the biceps before 9 months (failed cookie test) in all children. At operation, the supraclavicular plexus was explored and note
was made of the anatomy. Findings of an extraforaminal dorsal root ganglion or empty foramen confirmed nerve root avulsion. A structurally normal nerve
root that did not stimulate the extremity at 2 mA was considered to represent an intraforaminal avulsion when this diagnosis was consistent with physical
examination. The presence of extraforaminal dorsal root ganglia was confirmed with intraoperative frozen section. Sensitivity of MRI in diagnosing avulsion
was 81% with a specificity of 96%. Positive predictive value was 92% and negative predictive value 91%. These results are comparable to those of CT myelogram,
currently the gold standard for imaging in these patients. Use of a 3.0 Tesla magnet improved image quality, often allowing visualization of nerve rami
and ganglia. Routine use of the 3.0 Tesla magnet would be expected to improve the validity of MRI for diagnosing nerve root avulsions in this patient population.
The small patient size and low body fat content of infants complicates imaging of the extraspinal brachial plexus.
Severe Obstetric Brachial Plexus Injuries can be Identified Easily and Reliably at One Month of Age
Institution where the work was prepared: Leiden University Medical Center, Leiden, Netherlands
Martijn J.A. Malessy; W Pondaag; S.M Hofstede-Buitenhuis; S. le Cessie; J.G. van Dijk; Leiden University Medical Center
Background
Effective early management of infants with obstetric brachial plexus injury (OBPI)is undermined by an inability to assess lesion severity reliably early in life. We
sought to identify predictors for a poor outcome.
Methods
We performed a prospective study in 48 OBPI infants with a minimal follow-up of two years. Infants were examined around one week, one month and three
months of age. Thirteen dichotomous parameters were gathered each visit concerning four joint movements, skin crease asymmetry at three locations of the
upper limb, and findings of needle electromyography in three muscles. The severity of the lesion was assessed by clinical examination and surgery between
three and seven months of age. Surgery was performed when specified clinical patterns indicated poor prognosis. A poor outcome was defined as the presence
of a neurotmesis or avulsion of spinal nerves C5 and C6 requiring nerve repair, irrespective of a C7-T1 lesion. All other outcomes were defined as good, conforming
to axonotmesis of C5 and C6 spinal nerves with good spontaneous recovery. Predictors for poor outcome were identified using a two-step hierarchical
forward logistic regression analysis based on likelihood-ratios.
Results
The mean age at visit one was 9 days (median 9, range 12), at visit two 32 days (median 31, range 29) and at visit three 87 days (median 87, range 29). Surgery
was performed in 23 of 48 (48%) infants. The mean age at surgery was 143 ± 30 (median 139) days. Outcome was poor in 20 (42%) infants and good in 28
(58%). Results Prediction at one month of age was better than at one week or three months. At one month, three parameters (elbow extension, elbow flexion
and motor unit potentials in the biceps muscle) correctly predicted outcome in 44/47 (93.6%) of infants, with a sensitivity of 1.0 and a specificity of 0.88.
Conclusions
The severity of OBPI lesions can be reliably predicted at one month of age in the majority of the infants by testing elbow extension, elbow flexion and performing
needle elecromyography of the biceps muscle. The results can be used in routine practice to identify OBPI infants with severe lesions who may benefit
from surgical treatment.
A 5 Year Fallow up of End to Side Vascularized Ulnar Nerve Graft for Brachial Plexus Roots Avulsion
Institution where the work was prepared: Iran Medical Sciences University, Tehran, Iran
Kamal S. Forootan, MD, FICS; Lida Jafari Saraf; Ahmad Maghari; Iran Medical Sciences University
Introduction:
Vascularized nerve graft was introduced in 1976. We suggested end to side vascularized ulnar nerve graft (VUNG) in Heidelburg in 2002. In our study, we present
the outcome of our patients after 5 years.
Material and methods:
13 reconstructions with end to side VUNG were operated on in our center for brachial plexus injuries from 1998 to 2001. 2 teams worked simultaneously; one
in intact brachial plexus and the other harvested the ulnar nerve with its vessels in involved hand. The ulnar nerve with its vessels was raised from the wrist to
about 5cm above the elbow with dividing the vessels in bifurcation and observing the bleeders in both ends of the nerve. The median, musculocutaneaus and
radial nerves should be identified. One end of the nerve, which is closer to the vessels, was coaptated to posteromedial side of the upper and middle trunks
through a proper subcutaneous tunnel to other side in the chest wall. The artery and vein were hooked up to any vessels. The other end was coaptated to
median nerve end to end. An interposition of the nerve graft was applied between split spinal accessory and musculocutaneous nerves in involved side. 3 intercostals
nerves were raised as long as possible; and, coaptated to radial nerve directly.
Results:
Only 7cases could be fallowed up to 5 years. Almost all were disappointed and quite not cooperative because of long term results. The tinnel sign was fast for
vascularized ulnar nerve, about 3-4 mm/day for the first 3-4 months, and then slow down. The median sensation was good but two points discrimination was
disappointing. Muscle strength improvements were + for median, ++ for radial, and +++ for musculocutaneous.
Conclusion:
After such studies we found that end to side VUNG should be only sacrificed for median nerve not for whole the nerve in the involved brachial plexus which
we presented in Heidelburg. The more studies with more cases and fallow up for more time are suggested.
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