Panupan Songcharoen

Spinal accessory neurotization for restoration of elbow flexion in avulsion injuries of the brachial plexus

Traumatic root avulsion brachial plexus injuries in 216 patients were treated with spinal accessory-musculocutaneous neurotization to restore elbow flexion. The average postoperative follow-up period was 6 years, with a minimum of 2 years for all patients. The percentage of satisfactory biceps recovery (MRC III or better) was 72.5%. The average interval between the operation and MRC III motor recovery was 17 months. The percentage of poor results increased from 25.5% to 62.5% in patients who underwent operation later than 9 months after injury. This method of neurotization produces a result comparable with, if not better than, the results of other types of neurotization in restoration of elbow flexion.

NEUROPATHIC PAIN IN BRACHIAL PLEXUS INJURY

BACKGROUND In Thailand, brachial plexus injury is a common traumatic injury that affects the function of the upper extremity. The current treatments focus mainly on improving the motor and sensory function. Apart from the motor and sensory deficit, these patients usually suffer from pain. OBJECTIVE The purpose of this study was to determine the prevalence and factors that relate to neuropathic pain in patients with brachial plexus injury. METHODS We collected data from March 2008 to July 2011. The DN4 Questionnaire was used to diagnose neuropathic pain in 95 patients. RESULTS The prevalence of neuropathic pain was as high as 76%. Majority of patients presented with hypoesthesia to pin prick, hypoesthesia to touch and numbness. Severity of neuropathic pain was significantly correlated with the type of brachial plexus injury. There was no difference between demographic characteristics of patients. CONCLUSION Our study showed that the prevalence of neuropathic pain was high in brachial plexus injured patients. Therefore, surgeons should be aware of this common, yet underestimated, problem in brachial plexus injured patients.

Diaphragmatic height index: new diagnostic test for phrenic nerve dysfunction

OBJECT The diaphragmatic height index (DHI) was developed to measure the difference in diaphragm levels. The purpose of this study was to set definite DHI values and test the accuracy of these values for use as a new diagnostic test for phrenic nerve dysfunction. METHODS All data for this study were obtained from medical charts and retrospectively reviewed. RESULTS One hundred sixty-five patients with brachial plexus injury who had undergone nerve transfers between 2005 and 2008 were divided into Groups A and B. Group A consisted of 40 patients (mean age 28.0 years) who had sustained concomitant injury of the brachial plexus and phrenic nerves. Patients in Group A1 had right phrenic nerve injury and those in Group A2 had left phrenic nerve injury. Intraoperative direct electrical stimulation of the phrenic nerve was considered the gold standard in assessing nerve function in all patients with brachial plexus injury. Group B consisted of 125 patients (mean age 28.7 years) with brachial plexus injury and normal phrenic nerve function. Group C, the control group, consisted of 80 patients with nonbrachial plexus injury (mean age 34.0 years) who had undergone other kinds of orthopedic operations between April and June 2009. Standard posteroanterior chest radiographs were blindly interpreted using the Siriraj inhouse picture archiving and communication system in all 245 patients in the study. First, a reference line (R line) was drawn along the inferior endplate of T-10. Then, 2 lines (lines A and B) were drawn through the highest point of each diaphragm and parallel to the R line. The difference between these 2 lines divided by the height of T-10 was defined as the DHI. The cutoff points of the DHI for diagnosing right and left phrenic nerve dysfunction were analyzed with a receiver operating characteristic curve. The accuracy of these DHI values was then evaluated. The DHI in Group C was 0.64 ± 0.44, slightly higher than the DHI in Group B, with no significant difference. Diaphragmatic height indexes in Groups A1 and A2 were 2.0 ± 0.99 and -1.04 ± 0.83, respectively, which were significantly different from those in Groups B and C (p < 0.05). The cutoff point of the DHI for diagnosing right phrenic nerve dysfunction was > 1.1, and that for left phrenic nerve dysfunction was < 0.2. The sensitivity and specificity of right and left DHI values were 90.5% and 86.3%, and 94.7 and 88.3%, respectively. CONCLUSIONS Data in this study show that diaphragm paralysis can be simply and reliably predicted by the DHI. Diaphragmatic height index values > 1.1 and < 0.2 are proposed as the new diagnostic test for right and left phrenic nerve dysfunction with a high degree of accuracy. This index is applicable in diagnosing phrenic nerve dysfunction that occurs concomitantly with brachial plexus injury or from other etiologies.

Capture of the screw during percutaneous screw insertion

The simple technique to maintain the engagement of the screw and the screw driver during percutaneous locking screw insertion is presented. The method can capture the screw when the screw becomes disengaged. This will be helpful when percutaneous screw insertion is performed in the narrow and deep location of the bone such as a locking screw at the upper part of the femur during retrograde femoral nailing.