RESUMO
BACKGROUND: Ultrasound guidance is increasingly being used for neurolytic procedures that have traditionally been done with electrical stimulation (e-stim) guidance alone. Ultrasound visualization with e-stim-guided neurolysis can potentially allow adjustments in injection protocols that will reduce the volume of neurolytic agent needed to achieve clinical improvement. OBJECTIVE: This study compared e-stim only to e-stim with ultrasound guidance in phenol neurolysis of the musculocutaneous nerve (MCN) for elbow flexor spasticity. We also evaluated the ultrasound appearance of the MCN in this population. DESIGN: Retrospective review. SETTING: University hospital outpatient clinic. PARTICIPANTS: Adults (N = 167) receiving phenol neurolysis to the MCN for treatment of elbow flexor spasticity between 1997 and 2014 and adult control subjects. METHODS: For each phenol injection of the MCN, the method of guidance, volume of phenol injected, technical success, improved range of motion at the elbow postinjection, adverse effects, reason for termination of injections, and details of concomitant botulinum toxin injection were recorded. The ultrasound appearance of the MCN, including nerve cross-sectional area and shape, were recorded and compared between groups. MAIN OUTCOME MEASURES: The volume of phenol injected and MCN cross-sectional area and shape as demonstrated by ultrasound. RESULTS: The addition of ultrasound to e-stim-guided phenol neurolysis was associated with lower doses of phenol when compared to e-stim guidance alone (2.31 mL versus 3.69 mL, P < .001). With subsequent injections, the dose of phenol increased with e-stim guidance (P < .001), but not with e-stim and ultrasound guidance (P = .95). Both methods of guidance had high technical success, improved ROM at elbow postinjection, and low rates of adverse events. In comparing the ultrasound appearance of the MCN in patients with spasticity to that of normal controls, there was no difference in the cross-sectional area of the nerve, but there was more variability in shape. CONCLUSIONS: Combined e-stim and ultrasound guidance during phenol neurolysis to the MCN allows a smaller volume of phenol to be used for equal effect, both at initial and repeat injection. The MCN shape was more variable in individuals with spasticity; this should be recognized so as to successfully locate the nerve to perform neurolysis. LEVEL OF EVIDENCE: IV.
Assuntos
Estimulação Elétrica/métodos , Espasticidade Muscular/terapia , Nervo Musculocutâneo/fisiopatologia , Bloqueio Nervoso/métodos , Fenol/farmacologia , Ultrassonografia/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Espasticidade Muscular/fisiopatologia , Nervo Musculocutâneo/diagnóstico por imagem , Nervo Musculocutâneo/efeitos dos fármacos , Estudos Retrospectivos , Soluções Esclerosantes/farmacologia , Resultado do TratamentoRESUMO
OBJECT: The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. METHODS: Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90 degrees and 92 degrees in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70 degrees. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3 + and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. CONCLUSIONS: Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.
Assuntos
Plexo Braquial/lesões , Plexo Braquial/cirurgia , Transferência de Nervo , Escápula/inervação , Raízes Nervosas Espinhais/cirurgia , Nervo Acessório/fisiopatologia , Nervo Acessório/cirurgia , Adolescente , Adulto , Plexo Braquial/fisiopatologia , Articulação do Cotovelo/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Nervo Musculocutâneo/fisiopatologia , Nervo Musculocutâneo/cirurgia , Nervo Frênico/fisiopatologia , Nervo Frênico/cirurgia , Amplitude de Movimento Articular/fisiologia , Recuperação de Função Fisiológica/fisiologia , Articulação do Ombro/fisiopatologia , Resultado do Tratamento , Nervo Ulnar/fisiopatologia , Nervo Ulnar/cirurgiaRESUMO
Peripheral nerve lesions with a long segment defect need a grafiting conduit to heal. Although autogenous nerve grafting is still considered the best method for bridging nerve defects, several alternative types of conduits (biological and synthetic) have been studied. We have demonstrated in previous experimental research in rats that a graft made using a vein (providing a guide for nerve regeneration) filled with fresh skeletal muscle (to prevent vein collapse and support axon regeneration) gave similar results to traditional nerve grafts. On this basis, we decided to use the muscle-vein-combined grafts in clinical cases. From 1993 to 1997, this technique was applied for bridging both sensory and mixed nerve defects (21 cases). We report good results in 85% of our cases with a minimum follow-up of 14 months. These results, obtained on nerve defects ranging from 0.5 to 6 cm in length, seem to be superior to those report with other kinds of artificial or biological conduits
Assuntos
Humanos , Nervo Musculocutâneo/anormalidades , Nervo Musculocutâneo/fisiopatologia , Veias/anatomia & histologia , Veias/anormalidades , Veias/cirurgiaRESUMO
This study is a stereological analysis, by the 2-D disector method, on the long-term regeneration of myelinated nerve fibers of the rat sciatic nerve repaired by muscle-vein combined graft, a surgical technique that has been shown to be a valid tool for the repair of peripheral nerve defects with substance loss. Quantitative analysis showed that the total number and mean density of regenerated myelinated nerve fibers was significantly higher than in control nerves. The contrary was true for fiber mean size. The morpho-quantitative parameters of regenerated fibers from nerves repaired by the muscle-vein-combined graft were similar to those observed in rats where nerve defects were repaired by direct nerve suture thus confirming the validity of this surgical techique