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Willem Pondaag, Lieven P. A. J. van der Veken, Paul J. van Someren, J. Gert van Dijk, and Martijn J. A. Malessy


A typical finding in supraclavicular exploration of infants with severe obstetric brachial plexus lesions (OBPLs) is a neuroma-in-continuity with the superior trunk and/or a root avulsion at C-5, C-6, or C-7. The operative strategy in these cases is determined by the intraoperative assessment of the severity of the lesion. Intraoperative nerve action potential (NAP) and evoked compound motor action potential (CMAP) recordings have been shown to be helpful diagnostic tools in adults, whereas their value in the intraoperative assessment of infants with OBPLs remains to be determined.


Intraoperative NAPs and CMAPs were systematically recorded from damaged and normal nerves of the upper brachial plexus in a consecutive series of 95 infants (mean age 175 days) with OBPLs. A total of 599 intraoperative NAP and 836 CMAP recordings were analyzed. The severity of the nerve lesions was graded as normal, axonotmesis, neurotmesis, or root avulsion, based on surgical, clinical, histological, and radiographic criteria.


The correlation of NAP and CMAP recordings with the severity of the lesion was assessed. The specificity of an absent NAP or CMAP to predict a severe lesion (neurotmesis or avulsion) was > 0.9. However, the sensitivity of an absent NAP or CMAP for predicting a severe lesion was low (typically < 0.3). The severity of the nerve lesion was related to CMAP and NAP amplitudes. Cutoff points useful for intraoperative decision making could not be found to differentiate between lesion types in individual patients.


Intraoperative NAP and CMAP recordings do not assist in decision making in the surgical treatment of infants with OBPLs. The authors' findings in infants cannot be generalized to adults.

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Remco J. P. Doodkorte, Ricardo Belda, Alex K. Roth, Bert van Rietbergen, Jacobus J. Arts, L. M. Arno Lataster, Lodewijk W. van Rhijn, and Paul C. Willems


Complications after adult spinal deformity surgery are common, with implant-related complications occurring in up to 27.8% of cases. Sublaminar wire fixation strength is less affected by decreasing trabecular bone density in comparison to pedicle screw (PS) fixation due to the predominant cortical bone composition of the lamina. Sublaminar fixation may thus aid in decreasing implant-related complications. The goal of this study was to compare fixation characteristics of titanium sublaminar cables (SCs), ultra–high-molecular-weight polyethylene (UHMWPE) tape, PSs, and PSs augmented with UHMWPE tape in an ex vivo flexion–bending setup.


Thirty-six human cadaver vertebrae were stratified into 4 different fixation groups: UHMWPE sublaminar tape (ST), PS, metal SC, and PS augmented with ST (PS + ST). Individual vertebrae were embedded in resin, and a flexion–bending moment was applied that closely resembles the in vivo loading pattern at transitional levels of spinal instrumentation.


The failure strength of PS + ST (4522 ± 2314 N) was significantly higher compared to the SC (2931 ± 751 N) and PS (2678 ± 827 N) groups, which had p values of 0.028 and 0.015, respectively (all values expressed as the mean ± SD). Construct stiffness was significantly higher for the PS groups compared to the stand-alone sublaminar wiring groups (p = 0.020). In contrast to SC, ST did not show any case of cortical breach.


The higher failure strength of PS + ST compared to PS indicates that PS augmentation with ST may be an effective measure to reduce the incidence of screw pullout, even in osteoporotic vertebrae. Moreover, the lower stiffness of sublaminar fixation techniques and the absence of damage to the cortices in the ST group suggest that ST as a stand-alone fixation technique in adult spinal deformity surgery may also be clinically feasible and offer clinical benefits.