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R. Shane Tubbs, Paul Grabb, Alan Spooner, Wally Wilson and W. Jerry Oakes

weight of the normal adult head (approximately 6 kg) 4 any degree of flexion or extension beyond maximum tautness, with the cadaver in the prone or supine position, respectively, will routinely avulse the apical ligament. However, this avulsion was not surprising because the transverse and alar ligaments were already sectioned. In addition, we routinely found that the ligament was lax and redundant (87% of our cases) with the head in neutral position, and we could not create any degree of tautness in the ligament with cranial distraction. Furthermore, 20% of our

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R. Shane Tubbs, George Salter, Paul A. Grabb and W. Jerry Oakes

denticulate ligaments were 0.06 to 0.09 N (mean 0.08 N) at all levels except for T11–12 where forces of 0.13 to 0.18 N (mean 0.16 N) were required. These ranges of lateral forces were comparable for left and right sides. Avulsion forces were next measured at the foramen magnum and upper cervical region 0.81 to 1.0 N (mean 0.84 N), from the middle cervical region to the upper thoracic region 0.5 to 0.6 N (mean 0.5 N), and from the middle thoracic region and caudally 0.25 to 0.34 N (mean 0.3 N). Finally, with all denticulate ligaments avulsed, caudal and cephalad tensions

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R. Shane Tubbs, James W. Custis, E. George Salter, Jeffrey P. Blount, W. Jerry Oakes and John C. Wellons III

transfer to the deep motor branch of the ulnar nerve for reconstruction of high ulnar nerve injuries . J Reconstr Microsurg 18 : 459 – 464 , 2002 10 Oberlin C , Béal D , Bhatia A , Dauge MC , The ulnar nerve . Alnot JY , Narakas A : Traumatic Brachial Plexus Injuries Paris , Expansion Scientifique Française , 1996 . 46 – 49 11 Oberlin C , Béal D , Leechavengvongs S , Salon A , Dauge MC , Sarcy JJ : Nerve transfer to biceps muscle using a part of ulnar nerve for C5–C6 avulsion of the brachial plexus: anatomical study and

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R. Shane Tubbs, Mohammadali M. Shoja, Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount, W. Jerry Oakes and Bermans J. Iskandar

Orthop Relat Res 322 : 146 – 151 , 1996 5 Fournier HD , Mercier P , Menei P : Lateral interscalenic multilevel oblique corpectomies to repair ventral root avulsions after brachial plexus injury in humans: anatomical study and first clinical experience . J Neurosurgery 95 : 2 Suppl 202 – 207 , 2001 6 George B , Exposure of the upper cervical vertebral artery . in Dickman CA , Spetzler RF , Sonntag VKH : (eds) Surgery of the Craniovertebral Junction New York , Thieme , 1998 . pp 545 – 567 7 George B , Laurian C : Surgical

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John C. Wellons III, R. Shane Tubbs, Jeffrey A. Pugh, Nadine J. Bradley, Charles R. Law and Paul A. Grabb

C linically detectable trauma to the brachial plexus during birth occurs in approximately 1 of 1000 live births. 14 , 20 Spontaneous recovery is thought to occur in 90% of these infants. 13 , 20 An upper and middle trunk injury pattern (Erb palsy) is the most common finding, and a flail arm from panplexus involvement or root avulsion is the next most common. The absence of meaningful recovery by 6 months may predict the absence of long-term useful function. A major initial description of traumatic brachial plexus injury is attributed to Wilhelm Erb

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Tae Sung Park

-axillary nerve transfer in 3 patients and C-4–suprascapular nerve transfer in many patients to improve shoulder abduction. Which group of infants with birth brachial plexus injury would benefit from MPN transfer? Blaauw and Slooff 4 employed the MPN transfer in 25 infants. All of their patients had upper root avulsions, and they described the pectoral nerve transfer as “part of an extended brachial plexus reconstruction, involving transfer of the accessory nerve to the suprascapular nerve (20 cases) and/or direct repair of upper roots to improve shoulder function.” I agree

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R. Shane Tubbs, Neal Patel, Brian Vala Nahed, Aaron A. Cohen-Gadol and Robert J. Spinner

brain surgery. Later in his career, acceleration of his competency in intracranial surgery allowed him to limit his practice to brain surgery. The 3 newly described cases highlight Cushing's use of a broad armamentarium of peripheral nerve 9 and brachial plexus 15 reconstructive techniques. Other cases of ruptured brachial plexus were reported by Cushing and in the majority of these, scar tissue was removed from the operative site and appropriate nerve roots anastomosed. 28 Interestingly, one of these patients with plexus avulsion chose to have his entire upper

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James K. Liu, Lana D. Christiano, Smruti K. Patel, R. Shane Tubbs and Jean Anderson Eloy

tumor capsule with the suction instrument in one hand, and the bipolar dissection forceps in the other hand ( Fig. 4 ). It is paramount to avoid premature “pulling” of the tumor capsule before it has been completely dissected free from the surrounding brain and vascular structures, so as to avoid a catastrophic vascular avulsion. If there is tumor tissue adherent to a major vessel or perforator, it is safer to leave a small residual tumor that can be treated later with radiosurgery. Closure and Skull Base Reconstruction Successful tumor resection is not complete

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James K. Liu, Lana D. Christiano, Smruti K. Patel, R. Shane Tubbs and Jean Anderson Eloy

function is to minimize direct manipulation or trauma to the optic nerves and to avoid injury to the blood supply of the optic apparatus. 5 , 23 , 27 , 29 , 34 It is important to avoid blind pulling of the tumor capsule, as this may increase the risk of arterial avulsion or optic nerve traction if the tumor has not been adequately dissected free from the critical neurovascular structures. Gentle countertraction of the tumor capsule can be applied with the suction to identify the arachnoid plane to carry out sharp dissection from the critical structures. Once the tumor

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R. Shane Tubbs, Martin M. Mortazavi, Mohammadali M. Shoja, Marios Loukas and Aaron A. Cohen-Gadol

contributions to the study and manuscript preparation include the following. Conception and design: Tubbs, Mortazavi. Acquisition of data: Tubbs, Mortazavi. Analysis and interpretation of data: all authors. Drafting the article: Tubbs, Mortazavi. Critically revising the article: all authors. Reviewed final version of the manuscript and approved it for submission: all authors. References 1 Allieu Y , Privat JM , Bonnel F : Paralysis in root avulsion of the brachial plexus . Neurotization by the spinal accessory nerve Clin Plast Surg 11 : 133 – 136 , 1984 2