Neurological thoracic outlet syndrome (TOS) can be challenging to diagnose, particularly given its described subtypes of neurogenic TOS (NTOS) and disputed TOS (DTOS) that exhibit variable clinical presentations and etiologies. The diagnostic workup of TOS often includes magnetic resonance neurography (MRN) of the brachial plexus. Specific MRN imaging modifications for TOS evaluation are required to maximize spatial and contrast resolution to increase the conspicuity of nerve segments and their relationships to surrounding osseous structures. Dynamic assessment with arm positioning is used to evaluate outlet narrowing and compression of the plexus. Individual nerve segments are interrogated for their longitudinal and cross-sectional morphologies and signal characteristics. In patients with NTOS, MRN may reveal focal impingement of the C8/T1 nerve roots and/or lower trunk with accompanying abnormal T2-weighted signal hyperintensity. Predisposing anatomical entities include cervical ribs, rib synostoses, hypertrophic callous following clavicular fracture, remnant first thoracic rib from prior incomplete resection, and variable perineural scarring. In comparison, DTOS patients frequently demonstrate signal hyperintensity and enlargement of the mid plexus (trunk and division level), with narrowing of the costoclavicular interval. Following comprehensive diagnostic workup that frequently includes electrodiagnostic testing, patients are directed to different management pathways. Nonsurgical management is considered for all cases of DTOS; all patients with NTOS or DTOS who fail conservative treatment warrant referral for a surgical opinion. If surgery is pursued, MRN can be helpful in preoperative planning.

BACKGROUND: Brachial plexus birth injury (BPBI) is common and while most recover, 8-36% of patients experience permanent impairment. Typically, adolescents with untreated BPBI lack active and passive external shoulder rotation (ER) and overhead shoulder function. Limited shoulder function is due to 1) nonoperative BPBI 2) untreated BPBI or 3) unrecognized glenohumeral joint dysplasia. We describe a technique for achieving reanimation in adolescents who did not receive timely/effective BPBI care, a postoperative rehabilitation protocol, and results from a series of eight patients who underwent shoulder reanimation.
METHODS: A comprehensive shoulder reanimation approach is performed. Anteriorly, the pectoralis minor, major, and anterior capsule necessitate release. In severe dysplasia, a coracoidectomy, posterior glenoid osteotomy, and/or subscapularis slide may be necessary. Acromial dysplasia is also common, frequently necessitating osteoplasty. The deltoid is usually nonfunctional, and we use a bipolar latissimus muscle transfer for reanimating abduction and forward flexion. To assist with ease of rehabilitation we will often transfer the tendon of the teres major. Levator scapulae transfer to the supraspinatus is often performed to assist with the initiation of abduction. For external rotation, the ipsilateral lower trapezius is used. Finally, ipsilateral rhomboid advancement and contralateral lower trapezius muscle transfer is performed for dynamic scapular stabilization. After surgery, all patients participated in our rigorous postoperative rehabilitation protocol.
RESULTS: Eight patients (13.8±5.6 years, 35±24 weeks follow-up) were included. All patients participated in our rehabilitation protocol. Preoperatively, patients generally achieved 0° ER from neutral and in maximum abduction. Postoperatively, patients achieved an average of 71° (30-90°) ER from neutral and an average of 82° (65-90°) ER in maximum abduction. Preoperatively, patients generally had 0-20° of abduction, which they achieved through scapulothoracic motion. Postoperatively, patients could achieve an average of 115° (90-180°) of abduction. Preoperatively, patients had 0-20° of FF that was mediated through scapulothoracic motion. Postoperatively, patients\' FF increased to an average of 91° (20-170°).
CONCLUSIONS: This technique is intended to restore a congruent glenohumeral joint and reanimate structures allowing for abduction, FF, and ER. While we advocate for early treatment of BPBI, applying this technique to undertreated/untreated adolescent patients paired with our rehabilitation protocol results in significant functional improvement, allowing for an improved quality of life.

METHODS: This case demonstrates a 2-year-old boy with a rare benign supraclavicular mass diagnosed as neuromuscular choristoma through open biopsy. Postoperatively, he underwent semiannual surveillance with ultrasound without development of neurological complaints, limb deformity, or recurrence at 2-year follow-up.
CONCLUSIONS: Neuromuscular choristoma involving the brachial plexus is a rare tumor that should be in the differential diagnosis of pediatric peripheral nerve-based tumors. The intimate association with neural elements limits complete resection. Therefore, open biopsy with partial resection is recommended. While postoperative fibromatosis may occur, open biopsy remains the gold standard for definitive diagnosis. Ultrasound can be used to monitor recurrence.

UNASSIGNED: Chronic neuropathic pain has a prevalence between 7 and 11% of the population. Management typically involves pharmacologic agents, however, a high number needed to treat (NNT) and undesirable side effects limit their utility. Neuromodulation techniques, such as peripheral nerve (PNS) and spinal cord stimulators (SCS), have been utilized successfully in the treatment of chronic neuropathic pain syndromes. To date, there is limited evidence supporting use of PNS for cancer-related neuropathic pain.
UNASSIGNED: An 83 year old male presented to the outpatient pain clinic after experiencing worsening pain related to brachial plexus invasion from a left anterior chest wall metastatic lesion from a primary lung cancer. His treatment had included a left upper lobectomy followed by radiation and an initial round of chemotherapy. The chest wall metastatic lesion was unable to be resected. After subsequent tumor progression, the mass caused a worsening dull, achy pain in his left shoulder radiating down his left arm. A PNS system was implanted targeting the inferior trunk of the brachial plexus. The patient\'s pain score decreased after activation of the device and he was able to rely solely on the stimulator for pain management until his eventual death.
UNASSIGNED: This patient experienced a substantial reduction in pain and improvement in his quality of life through his eventual death suggesting PNS as a viable palliative pain option for neuropathic pain due to tumor invasion.

Contrast-enhanced magnetic resonance neurography (CE-MRN) holds promise for diagnosing brachial plexopathy by enhancing nerve visualization and revealing additional imaging features in various lesions. This study aims to validate CE-MRN\'s efficacy in improving brachial plexus (BP) imaging across different patient cohorts. Seventy-one subjects, including 19 volunteers and 52 patients with BP compression/entrapment, injury, and neoplasms, underwent both CE-MRN and plain MRN. Two radiologists assessed nerve visibility, with inter-reader agreement evaluated. Quantitative parameters such as signal intensity (SI), contrast-to-noise ratio (CNR), and contrast ratio (CR) of the C7 nerve were measured. Both qualitative scoring and quantitative metrics were compared between CE-MRN and plain MRN within each patient group. Patient classification followed the Neuropathy Score Reporting and Data System (NS-RADS), summarizing additional imaging features for each brachial plexopathy type. Inter-reader agreement for qualitative assessment was strong. CE-MRN significantly enhanced BP visualization and nerve-tissue contrast across all cohorts, particularly in volunteers and patients with injuries. It also uncovered additional imaging features such as hypointense signals in ganglia, compressed nerve sites, and neoplastic enhancements. CE-MRN effectively mitigated muscle edema and vascular contamination, enabling precise classification of BP injuries. Overall, CE-MRN consistently enhances BP visualization and provides valuable imaging features for accurate diagnosis.

Nerve transfer surgery utilizes the redundant and synergistic innervation of intact muscle groups to rehabilitate motor function. This is achieved by transferring functional nerves or fascicles to damaged nerves near the target area, thereby reducing the reinnervation distance and time. The techniques encompass both proximal and distal nerve transfers, customized according to the specific injury. Successful nerve transfer hinges on accurate diagnosis, innovative surgical approaches, and the judicious choice of donor nerves to maximize functional restoration. This study explores nerve transfer strategies and their integration with other procedures, emphasizing their importance in enhancing outcomes in brachial plexus injury management.

暂无摘要。

Ulnar nerve originates from the lower trunk as a branch from anterior division, continuing as a branch from medial cord of the brachial plexus. It receives fibres from anterior rami of cervical nerve root 8 and the first thoracic nerve root. Ulnar nerve injury accounts for being the most common vessel of upper limb that results in hospitalisation. Knowing the variability in the anatomical pattern of ulnar nerve and its communication with various branches of nerves in the vicinity can have implications. The current narrative review comprised literature search on Google, Google Scholar and PubMed databases for articles published between 2015 and 2023 on the subject. The insight and understanding of the related ulnar nerve anatomy is likely to be of prodigious help to anatomists, surgeons, physicians and radiologists in preventing unexpected outcomes in the future.

OBJECTIVE: In this study, we evaluated the efficacy and safety of 1 μg/kg dexmedetomidine as an adjuvant treatment to ropivacaine in children undergoing upper limb surgeries under ultrasound-guided axillary brachial plexus blocks and general anesthesia.
METHODS: We enrolled 90 children (aged 1-8 years; ASA I-II) undergoing closed reduction and internal fixation for upper extremity fractures at the Xiamen Children\'s Hospital and randomly assigned them to one of two groups: L (injection with 0.25% ropivacaine) or D (injection with 0.25% ropivacaine containing 1 μg/kg dexmedetomidine) using the random number table method. The main outcome indicators recorded were the facial expression, leg activity, position, crying, and Face, Legs, Activity, Cry, and Consolability (FLACC) scale scores of children after surgery and the duration of block and analgesia maintenance. The secondary outcome indicators were vital sign data at the time of ultrasound probe placement (T1), at the time of block completion (T2), prior to the beginning of surgery (T3), 5 min after the beginning of surgery (T4), and at the end of surgery (T5), as well as the time of postoperative recovery, the number of cases of remedial analgesia, and complications.
RESULTS: There was no statistical difference between the two groups in terms of general data, block completion time, postoperative recovery time, and complications (P > 0.05). Compared to the L group, the D group had significantly lower FLACC scores at 6 h after surgery, as well as significantly lower systolic blood pressure, diastolic blood pressure, and heart rate values at T4 and T5, and significantly longer duration of postoperative analgesia maintenance (all P < 0.05).
CONCLUSIONS: Dexmedetomidine (1 μg/kg) as a local anesthetic adjuvant to ropivacaine can alleviate pain at 6 h postoperatively, prolong analgesia maintenance, and reduce intraoperative blood pressure and heart rate in pediatric patients undergoing closed reduction and internal fixation for upper extremity fractures, with no obvious complications or delayed recovery.
UNASSIGNED: Registration website: www.chictr.org.cn, Registration number: ChiCTR2200065163, Registration date: October, 30, 2022.

Objective: To compare the postoperative analgesic effect of modified superior trunk block and traditional interscalene brachial plexus block in arthroscopic rotator cuff repair. Methods: A total of 40 patients undergoing arthroscopic rotator cuff repair in the Second Affiliated Hospital of Wenzhou Medical University from October to November 2023 were prospectively included, whose American Society of Anesthesiologists (ASA) grade were Ⅰ-Ⅱ. They were divided into modified superior trunk block group (group S) and interscalene brachial plexus block group (group I) by random number table according to different nerve block methods, with 20 cases in each group. Local anesthetics was a mixture of 1.33% liposomal bupivacaine and 0.5% levobupivacaine hydrochloride injection in equal volume. Patients in group S were injected 5 ml mixture for ultrasound-guided modified superior trunk block, and patients in group I were injected with 15 ml mixture for ultrasound-guided traditional interscalene block respectively. Both groups underwent superficial cervical plexus block (5 ml mixture). Standardized general anesthesia and standardized postoperative analgesia were followed. The primary outcome measures included 48 h resting numerical rating scale (NRS) scores after surgery and the incidence of hemidiaphragmatic paralysis (HDP) at 30 min after block. The secondary outcome measures included resting NRS scores during the post anesthesia care unit (PACU), 12, 24, and 36 h after surgery, postoperative opioid consumption and satisfaction with analgesia, pulse oxygen saturation (SpO2) at 30 min after block, sensory and motor block duration, and the incidence of perioperative adverse reactions. The non-inferiority cut-off value of resting NRS scores for patients in group S was set as\"1 point\"at each observation time point after surgery. Results: In group S, one patient was excluded because the target nerve was blocked by the subclavian vein and could not be blocked, nineteen patients [11 males and 8 females, aged (52.2±9.0) years] were eventually included. In group I, there were 7 males and 13 females, aged (55.0±5.1) years. Resting NRS scores of group S and Group I at 48 h after surgery were 0 (0, 0) and 0 (0, 0.8) point, respectively, with no statistical significance (P>0.05). The median difference was 0 (95%CI:0-0) point and the upper 95%CI was 0 point, which was lower than the preset non-inferiority cut-off value\"1 point\"(non-inferiority P<0.001). The incidence of HDP in group S and group I were 5% (1/19) and 75% (15/20), respectively, with statistically significant (P<0.001). There were no significant differences in resting NRS scores at PACU and 12, 24, 36 h after surgery, opioid dosage, satisfaction with analgesia, SpO2 at 30 min after block, sensory and motor block duration between two groups (all P>0.05). No respiratory adverse events such as hypoxemia and airway spasm occurred in two groups after extubation. One patient in group I showed symptoms of breath shortness when entering PACU, and 3 patients felt uncomfortable due to prolonged numbness and weakness of the blockade limb (>2 days). No nerve block procedures and opioid drugs relative adverse reactions and no neurological complications happened in both groups. Conclusion: Liposomal bupivacaine usage for modified superior trunk block can provide long-term postoperative analgesic effects which is noninferior to traditional interscalene brachial plexus block and causes less HDP in patients undergoing arthroscopic rotator cuff repair.
目的： 比较改良臂丛上干阻滞与传统肌间沟臂丛神经阻滞在关节镜下肩袖修补术后的镇痛效果。 方法： 前瞻性纳入2023年10至11月温州医科大学附属第二医院行关节镜下肩袖修补术患者40例，美国麻醉医师协会（ASA）分级Ⅰ~Ⅱ级。根据不同神经阻滞方法，采用随机数字表法分为改良臂丛上干阻滞组（S组）及肌间沟臂丛神经阻滞组（I组），每组20例。局部麻醉用药均为1.33%布比卡因脂质体注射液与0.5%盐酸左布比卡因等容积混合液；S组采用混合液5 ml行改良臂丛上干阻滞，I组采用混合液15 ml行肌间沟臂丛神经阻滞；两组均行颈浅丛阻滞（混合液5 ml），随后实施标准化全身麻醉及标准化术后镇痛。主要观察指标为术后48 h静息数字评定量表（NRS）评分及神经阻滞后30 min 单侧膈肌麻痹（HDP）发生率。次要观察指标包括麻醉后恢复室（PACU）期间及术后12、24、36 h静息NRS评分，术后阿片类药物消耗量及镇痛满意度，阻滞后30 min的脉搏血氧饱和度（SpO2）、感觉及运动阻滞时长、围手术期不良反应发生率。S组患者术后各观察时间点静息NRS评分的非劣效界值设定为“1分”。 结果： S组1例患者因目标神经被锁骨下静脉阻挡，无法实施阻滞而排除，最终纳入19例，男11例，女8例，年龄（52.2±9.0）岁；I组男7例，女13例，年龄（55.0±5.1）岁。S组和I组术后48 h静息NRS评分分别为0（0，0）和0（0，0.8）分，差异无统计学意义（P>0.05）；中位数差值为0（95%CI：0~0）分，95%CI上限为0分，低于预先设定的非劣效界值“1分”（非劣效性P<0.001）。S组和I组HDP发生率分别为5%（1/19）和75%（15/20），差异有统计学意义（P<0.001）。两组患者PACU期间及术后12、24、36 h静息NRS评分、术后阿片类药物使用情况及镇痛满意度、阻滞后30 min的SpO2、感觉及运动阻滞时长差异均无统计学意义（均P>0.05）。两组患者拔管后均未出现低氧血症、气道痉挛等呼吸系统不良事件。I组有1例患者入PACU时出现呼吸急促症状，有3例患者因患肢长时间（>2 d）麻木无力而感不适。两组患者均未出现神经阻滞操作、阿片类药物相关不良反应及神经系统并发症。 结论： 布比卡因脂质体行改良臂丛上干阻滞能够为关节镜下肩袖修补术患者提供不劣于传统肌间沟臂丛神经阻滞的长时间术后镇痛，同时HDP发生率更低。.