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Mark G. Burnett and Eric L. Zager

Clinicians caring for patients with brachial plexus and other nerve injuries must possess a clear understanding of the peripheral nervous system's response to trauma. In this article, the authors briefly review peripheral nerve injury (PNI) types, discuss the common injury classification schemes, and describe the dynamic processes of degeneration and reinnervation that characterize the PNI response.

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Mario K. Teo, Venkatesh S. Madhugiri, and Gary K. Steinberg

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Zarina S. Ali, Eric L. Zager, Gregory G. Heuer, and Sherman C. Stein

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Jennifer Hong, Jared M. Pisapia, Zarina S. Ali, Austin J. Heuer, Erin Alexander, Gregory G. Heuer, and Eric L. Zager

OBJECTIVE

Neurogenic thoracic outlet syndrome (nTOS) is an uncommon compression syndrome of the brachial plexus that presents with pain, sensory changes, and motor weakness in the affected limb. The authors reviewed the clinical presentations and outcomes in their series of pediatric patients with surgically treated nTOS over a 6-year period.

METHODS

Cases of nTOS in patients age 18 years or younger were extracted for analysis from a prospective database of peripheral nerve operations. Baseline patient characteristics, imaging and neurophysiological data, operative findings, and outcomes and complications were assessed.

RESULTS

Twelve patients with 14 cases of nTOS surgically treated between April 2010 and December 2016 were identified. One-third of the patients were male, and 2 male patients underwent staged, bilateral procedures. Disabling pain (both local and radiating) was the most common presenting symptom (100%), followed by numbness (35.7%), then tingling (28.6%). The mean duration of symptoms prior to surgery was 15.8 ± 6.6 months (mean ± SD). Sports-related onset of symptoms was seen in 78.6% of cases. Imaging revealed cervical ribs in 4 cases, prominent C-7 transverse processes in 4 cases, abnormal first thoracic ribs in 2 cases, and absence of bony anomalies in 4 cases. Neurophysiological testing results were normal in 85.7% of cases. Conservative management failed in all patients, with 5 patients reporting minimal improvement in symptoms with physical therapy. With a mean follow-up after surgery of 22 ± 18.3 months (mean ± SD), pain relief was excellent (> 90%) in 8 cases (57.1%), and good (improved > 50%) in 6 cases (42.9%). On univariate analysis, patients who reported excellent pain resolution following surgery at long-term follow-up were found to be significantly younger, and to have suffered a shorter duration of preoperative symptoms than patients who had worse outcomes. Lack of significant trauma or previous surgery to the affected arm was also associated with excellent outcomes. There were 4 minor complications in 3 patients within 30 days of surgery: 1 patient developed a small pneumothorax that resolved spontaneously; 1 patient suffered a transient increase in pain requiring consultation, followed by hiccups for a period of 3 hours that resolved spontaneously; and 1 patient fell at home, with transient increased pain in the surgically treated extremity. There were no new neurological deficits, wound infections, deep vein thromboses, or readmissions.

CONCLUSION

Pediatric nTOS commonly presents with disabling pain and is more frequently associated with bony anomalies compared with adult nTOS. In carefully selected patients, surgical decompression of the brachial plexus results in excellent pain relief, which is more likely to be seen in younger patients who present for early surgical evaluation.

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Luke Macyszyn, Mark Attiah, Tracy S. Ma, Zarina Ali, Ryan Faught, Alisha Hossain, Karen Man, Hiren Patel, Rosanna Sobota, Eric L. Zager, and Sherman C. Stein

OBJECTIVE

Moyamoya disease (MMD) is a chronic cerebrovascular disease that can lead to devastating neurological outcomes. Surgical intervention is the definitive treatment, with direct, indirect, and combined revascularization procedures currently employed by surgeons. The optimal surgical approach, however, remains unclear. In this decision analysis, the authors compared the effectiveness of revascularization procedures in both adult and pediatric patients with MMD.

METHODS

A comprehensive literature search was performed for studies of MMD. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment using a direct and indirect revascularization technique. Utility values for the various outcomes and complications were extracted from the literature examining preferences in similar clinical conditions. Sensitivity analysis was performed.

RESULTS

A structured literature search yielded 33 studies involving 4197 cases. Cases were divided into adult and pediatric populations. These were further subdivided into 3 different treatment groups: indirect, direct, and combined revascularization procedures. In the pediatric population at 5- and 10-year follow-up, there was no significant difference between indirect and combination procedures, but both were superior to direct revascularization. In adults at 4-year follow-up, indirect was superior to direct revascularization.

CONCLUSIONS

In the absence of factors that dictate a specific approach, the present decision analysis suggests that direct revascularization procedures are inferior in terms of quality-adjusted life years in both adults at 4 years and children at 5 and 10 years postoperatively, respectively. These findings were statistically significant (p < 0.001 in all cases), suggesting that indirect and combination procedures may offer optimal results at long-term follow-up.

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Willem Pondaag and Martijn J. A. Malessy

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Zarina S. Ali, Gregory G. Heuer, Ryan W. F. Faught, Shriya H. Kaneriya, Umar A. Sheikh, Idrees S. Syed, Sherman C. Stein, and Eric L. Zager

OBJECT

Adult upper trunk brachial plexus injuries result in significant disability. Several surgical treatment strategies exist, including nerve grafting, nerve transfers, and a combination of both approaches. However, no existing data clearly indicate the most successful strategy for restoring elbow flexion and shoulder abduction in these patients. The authors reviewed the literature to compare outcomes of the three surgical repair techniques listed above to determine the optimal approach to traumatic injury to the upper brachial plexus in adults.

METHODS

Both PubMed and EMBASE databases were searched for English-language articles containing the MeSH topic “brachial plexus” in conjunction with the word “injury” or “trauma” in the title and “surgery” or “repair” as a MeSH subheading or in the title, excluding pediatric articles and those articles limited to avulsions. The search was also limited to articles published after 1990 and containing at least 10 operated cases involving upper brachial plexus injuries. The search was supplemented with articles obtained through the “Related Articles” feature on PubMed and the bibliographies of selected publications. From the articles was collected information on the operation performed, number of operated cases, mean subject ages, sex distribution, interval between injury and surgery, source of nerve transfers, mean duration of follow-up, year of publication, and percentage of operative success in terms of elbow flexion and shoulder abduction of the injured limb. The recovery of elbow flexion and shoulder abduction was separately analyzed. A subanalysis was also performed to assess the recovery of elbow flexion following various neurotization techniques.

RESULTS

As regards the restoration of elbow flexion, nerve grafting led to significantly better outcomes than either nerve transfer or the combined techniques (F = 4.71, p = 0.0097). However, separating the Oberlin procedure from other neurotization techniques revealed that the former was significantly more successful (F = 82.82, p < 0.001). Moreover, in comparing the Oberlin procedure to nerve grafting or combined procedures, again the former was significantly more successful than either of the latter two approaches (F = 53.14; p < 0.001). In the restoration of shoulder abduction, nerve transfer was significantly more successful than the combined procedure (p = 0.046), which in turn was significantly better than nerve grafting procedures (F = 5.53, p = 0.0044).

CONCLUSIONS

According to data in this study, in upper trunk brachial plexus injuries in adults, the Oberlin procedure and nerve transfers are the more successful approaches to restore elbow flexion and shoulder abduction, respectively, compared with nerve grafting or combined techniques. A prospective, randomized controlled trial would be necessary to fully elucidate differences in outcome among the various surgical approaches.