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Introduction: Compressive neuropathy of the brachial plexus is a common issue following laparoscopic and robotic surgeries.Case Report: A 71-year-old male, post-lumbar spinal surgery, presented with excruciating right upper extremity pain and paresthesias. A supraclavicular brachial plexus (SBP) block with bupivacaine provided significant pain relief, lasting 36 hours. Subsequent physical therapy led to gradual pain and weakness improvement in compressive neuropathy.Discussion: The SBP block, facilitated by ultrasound guidance, is a safe procedure with few serious complications. It proves beneficial for managing postoperative compressive neuropathy, allowing patients to break pain cycles and participate in rehabilitation.Conclusion: The SBP block is an effective addition to the management of postoperative compressive neuropathy, given its ease, safety, and potency. Although regional anesthesia provides only temporary relief, patients can experience a break in debilitating pain cycles associated with compressive neuropathy.

ObjectiveThis study aimed to evaluate the incidence of brachial plexus birth injury (BPBI) and its associations with maternal demographic factors. Additionally, we sought to determine whether longitudinal changes in BPBI incidence differed by maternal demographics.Study designWe conducted a retrospective cohort study of over 8 million maternal-infant pairs using California's Office of Statewide Health Planning and Development Linked Birth Files from 1991 to 2012. Descriptive statistics were used to determine BPBI incidence and the prevalence of maternal demographic factors (race, ethnicity, age). Multivariable logistic regression was used to determine associations of year, maternal race, ethnicity, and age with BPBI. Excess population-level risk associated with these characteristics was determined by calculating population attributable fractions.ResultsThe incidence of BPBI between 1991 and 2012 was 1.28 per 1,000 live births, with peak incidence of 1.84 per 1,000 in 1998 and low of 0.9 per 1,000 in 2008. Incidence varied by demographic group, with infants of Black (1.78 per 1,000) and Hispanic (1.34 per 1,000) mothers having higher incidences compared with White (1.25 per 1,000), Asian (0.8 per 1,000), Native American (1.29 per 1,000), other race (1.35 per 1,000), and non-Hispanic (1.15 per 1,000) mothers. After controlling for delivery method, macrosomia, shoulder dystocia, and year, infants of Black (adjusted odds ratio [AOR] = 1.88, 95% confidence interval [CI] = 1.70, 2.08), Hispanic (AOR = 1.25, 95% CI = 1.18, 1.32), and advanced-age mothers (AOR = 1.16, 95% CI = 1.09, 1.25) were at increased risk. Disparities in risk experienced by Black, Hispanic, and advanced-age mothers contributed to a 5, 10, and 2% excess risk at the population level, respectively. Longitudinal trends in incidence did not vary among demographic groups. Population-level changes in maternal demographics did not explain changes in incidence over time.ConclusionAlthough BPBI incidence has decreased in California, demographic disparities exist. Infants of Black, Hispanic, and advanced-age mothers are at increased BPBI risk compared with White, non-Hispanic, and younger mothers.Key points· The incidence of BPBI has decreased over time.. · Demographic disparities in BPBI incidence and risk exist.. · Infants of Black, Hispanic, and advanced age mothers are at greatest risk of BPBI..

Purpose: Peripheral nerve sheath tumors (PNSTs) are rare in pediatric patients, especially in the brachial plexus. Research on PNSTs is lacking. This article presents a retrospective cohort study of pediatric patients diagnosed and treated with PNSTs, specifically brachial plexus tumors. Methods: All pediatric patients intervened in a single center between 2007 and 2023 with brachial plexus tumors were systemically analyzed. Results: Eleven pediatric patients with 14 brachial plexus PNSTs were studied. The gender distribution was 64% female and 36% male, with an average age of 10.7 years. Ninety-one percent had a previous NF-1 diagnosis. Right brachial plexus presented a higher prevalence (64%). Pain, Tinel's sign, and stiffness masses were common during diagnosis. Motor deficits were noted in 43% of the patients. Surgery was indicated for symptoms, particularly pain and rapid growth, increasing malignancy risk. Due to suspected malignancy, an en bloc resection with safety margins was performed. Among the patients, 57% received a histopathological diagnosis of MPNST (malignant peripheral nerve sheath tumor). Treatment included radiotherapy and chemotherapy. Clinical follow-up was conducted for all cases, involving clinical and oncological evaluations for all MPNSTs. Conclusions: This article present a series of pediatric brachial plexus tumors, especially in NF-1, and emphasizes the importance of thorough evaluation for this group. Swift diagnosis is crucial in pediatrics, enabling successful surgery for small lesions with limited neurological symptoms, improving long-term outcomes. Prompt referral to specialized services is urged for suspected masses, irrespective of neurological symptoms. Benign tumor postsurgical progression shows better outcomes than MPNSTs, with complete resection as the primary goal. Needle-guided biopsy is not recommended. [ABSTRACT FROM AUTHOR]

Purpose: Brachial plexus birth injuries (BPBI) can have lifelong effects on the development and functional use of the upper extremity. Currently there is no agreement with regards to what patient-reported outcome (PRO) measures should be used. Therefore, the ability to compare the effects of treatment between individuals and institutions is challenging. This study aimed to achieve consensus among clinicians on the use of PRO measures within this patient group to allow for improved comparison of treatments and outcomes in the future. Materials and Methods: Online, a 3 round Delphi survey was completed by 35 international multi-disciplinary specialist centers. Results: All respondents (100%) agreed that PRO measures are useful for clinical evaluation and patient treatment. None of the outcome measures scored >75% agreement for ability to assess responsiveness and current state in children with BPBI as most outcome measures were judged as not specific for BPBI. Additionally, participant centers were asked their perspective on the best available PRO option for each of the 3 categories: functional use of the upper limb, quality of life and pain. This resulted in endorsement by the participant centers of the Brachial Plexus Outcome Measure – Self-Evaluation, the Pediatric Quality of Life Inventory, and Visual Analogue Scale/Brief Pain Inventory respectively. Conclusion: International specialists in BPBI agree that PRO measures are important to use both clinically and in research in children aged 5 years and above. IMPLICATIONS FOR REHABILITATION: Patient-reported outcome measures were judged as useful both in clinic and in research for brachial plexus birth injury (BPBI), according to a panel of specialized centers. Currently available outcome measures were judged as not specific for BPBI. The panel endorsed the following measures as best available: the Brachial Plexus Outcome Measure – Self-Evaluation scale for functional evaluation, the Pediatric Quality of Life Inventory for disease-related quality of life and the Faces Pain Scale - Revised/Visual Analogue Scale/Brief Pain Inventory for pain [ABSTRACT FROM AUTHOR]

To develop an ultrasound (US)-guided ventral approach to the brachial plexus (BP) and evaluate nerve anatomy and staining in barred owl cadavers. Prospective, cadaveric study. Eleven adult male and female barred owl cadavers with a body mass of 0.43–0.98 kg. Eleven frozen cadavers were thawed for 48 hours, weighed and assigned a body condition score. Ten cadavers were placed in dorsal recumbency with wings abducted. US-guided visualization of the BP was achieved by placing a 13-6 MHz linear probe over the ventral aspect of the scapulohumeral joint, parallel to the sternum. A 22 gauge, 50 mm insulated needle was advanced in-plane in a caudal-to-cranial direction. In each owl, injection targeting one BP was performed with 0.4 mL kg–1 of a 1:1 0.5% ropivacaine and 1% methylene blue solution. Dissection was performed 15 minutes postinjection. Nerve staining was deemed successful if ≥ 1 cm of circumferential staining was achieved. The eleventh owl cadaver was injected with a 1:1 solution of 1% methylene blue and 74% ioversol contrast into both wings, and computed tomography (CT) was performed just before and 15 minutes after injection. The BP was clearly identified ultrasonographically in cadavers weighing > 0.5 kg. An injectate volume of 0.4 mL kg–1 provided complete staining of the BP branches in all cadavers. CT scan revealed no contrast within the coelomic cavity. The US-guided BP injection using a ventral approach was easily performed in barred owl cadavers weighing > 0.5 kg. The injection of 0.4 mL kg–1 of a ropivacaine–dye solution resulted in complete staining of the BP branches in all wings, suggesting that this technique could provide analgesia for structures distal to the scapulohumeral joint. Clinical studies are necessary to confirm the safety and efficacy of this technique in barred owls and other bird species. [ABSTRACT FROM AUTHOR]

Diagnosis of neurogenic thoracic outlet syndrome (nTOS) remains a challenge. The role of electrodiagnostic studies (EDX) in the workup of nTOS remains controversial. The aim of this study was to report the EDX findings in a cohort of patients who underwent surgery for nTOS and also analyze patient-related and intraoperative factors associated with positive EDX findings supportive of nTOS diagnosis. Baseline characteristics of patients, including age, sex, duration of symptoms, type of nTOS, and pattern of brachial plexus involvement, were gathered and analyzed. All patients received a preoperative EDX evaluation and were divided into two groups based on positive or negative EDX results for comparison. A total of 30 consecutive patients were included in this study comprising 11 (36.7%) men and 19 (63.3%) women, with a mean age of 44.6 ± 17.6 years. Twenty-two (73.3%) patients had type 1 nTOS with muscle weakness and atrophy, followed by 7 (23.4%) patients with type 3, and 1 (3.3%) patient with type 2 nTOS. In terms of nTOS pattern, 26 (86.7%) patients had lower plexus pattern of involvement (C8-T1), followed by 17 (56.7%) with upper-middle plexus pattern (C6-C7), and 13 (43.3%) with upper plexus pattern (C5-dorsal scapular nerve (DSN)). When comparing the characteristics of patients with positive and negative EDX findings suggestive of nTOS, only older age and type 1 nTOS (P < 0.05) were significantly associated with positive EDX findings. Currently, EDX assessment may not be the best modality for diagnosis of nTOS. Interindividual variation in findings reported by different clinicians performing the EDX remains a significant limiting factor. Older patients and those with more severe nTOS (type 1) are more likely to have positive results with EDX. [ABSTRACT FROM AUTHOR]

Radiation-induced brachial plexopathy (RIBP) is a rare long-term complication of radiation therapy often causing pain, motor deficit, and overall quality of life reduction for affected patients. While a standard treatment for RIBP is yet to be established, management consists mostly of symptom management through the use of medications and physical therapy. There is a lack of evidence regarding the efficacy of surgical treatment. Omentoplasties and other vascularized flaps are commonly discussed options for eliminating neuropathic pain associated with RIBP. However, these approaches show no meaningful improvement in motor function. While limited, current literature suggests that nerve transfers may be an option for relief of neuropathic pain as well as restoration of motor function. This review of literature explores the options available to those affected by RIBP with a focus on the role of surgery. [ABSTRACT FROM AUTHOR]

Background: For children with upper brachial plexus birth injury (BPBI; C5, C6, ±C7 roots), most clinics first recommend nonsurgical treatment followed by primary and/or secondary surgical interventions in selected patients. Since 2008, we have used an infant shoulder repositioning protocol (supination-external rotation [Sup-ER]) designed to prevent shoulder internal rotation contracture and its potential effects on the shoulder joint. This study characterizes our clinic's current choice, number, and timing of primary and secondary procedural interventions (including Botox) and compares Sup-ER protocol patients with those of our historical controls. Methods: The records of all patients with upper BPBI who underwent procedures from 2001 to 2018 were retrospectively reviewed and grouped into a historical (2001-2007, n = 20) and recent (2008-2018, n = 23) cohort. Patient demographics, procedure types and timing, and functional outcomes were collected and analyzed. Results: Since the 2008 institution of the Sup-ER protocol, fewer brachial plexus exploration and grafting (BPEG) surgeries were performed and none in later infancy, where nerve transfers were preferred. There were more and earlier Botox injections. There were fewer tendon transfers, and the preoperative indications were from a higher level of function. Conclusions: We now see fewer indications for BPEG surgeries overall. After the 3-month-age group, more direct nerve transfers are indicated instead of the BPEG surgery if nerve surgery is required at all. Shoulder tendon transfer rates have decreased. Humeral osteotomies are not seen in our recent group. Glenoid osteotomies within tendon transfers are rare in both groups. [ABSTRACT FROM AUTHOR]

Background: Acute pain is a major concern after arthroscopic shoulder surgery, supraclavicular brachial plexus blockade has shown favorable postoperative analgesic effects. However, its duration of analgesia does not meet clinical needs. We aimed to explore whether the combination of different local anesthetic adjunct can prolong the analgesic duration of supraclavicular brachial plexus block for arthroscopic shoulder surgery. Methods: In this prospective randomized controlled trial, we allocated 80 patients into four groups: Group DMD (dexamethasone 10 mg + ropivacaine 100 mg + dexmedetomidine 50 µg + magnesium sulfate 250 mg), Group DM (ropivacaine 100 mg + dexmedetomidine 50 µg + magnesium sulfate 250 mg), Group M (ropivacaine 100 mg + magnesium sulfate 250 mg) and Group D (ropivacaine 100 mg + dexmedetomidine 50 µg). The primary outcome was the time to first request for analgesia. Secondary outcome measures included cumulative opioid consumption at 6, 12, 18, 24, and 48 h postoperatively, VAS scores at 6, 12, 18, 24, and 48 h postoperatively and so on. Results: The time to first request for analgesia in Group DMD was significantly longer than Group DM (P = 0.011) and Group M (P = 0.003). The cumulative opioid consumption at 18 h postoperatively in Group DMD was significantly lower than in Group DM (P = 0.002) and Group M (P = 0.007). The cumulative opioid consumption at 24 h postoperatively in Group DMD was significantly lower than in Group DM (P = 0.016). The VAS score at 6 h postoperatively in Group DMD was significantly lower than in Group DM and Group M. The VAS score at 12 h postoperatively in Group DMD was significantly lower than in Group M. For American Shoulder and Elbow Surgeons Score, Group DMD had a better score than Group DM and Group D. Conclusions: The analgesic efficacy of supraclavicular brachial plexus blockade combined with dexamethasone, magnesium sulfate, and dexmedetomidine is significantly superior to the combination of magnesium sulfate and dexmedetomidine, and significantly superior to the use of magnesium sulfate alone. Trial registration: This trial was registered in Chinese Clinical Trial Registry. (ChiCTR2200061181, Date of registration: June 15, 2022, http://www.chictr.org.cn) [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsConclusions\nIMPLICATIONS FOR REHABILITATIONTo translate and culturally adapt the Brachial Assessment Tool (BrAT) into Swedish and evaluate the internal consistency, and internal content validity using Rasch analysis in patients with traumatic brachial plexus injuries (TBPI).The translation was made in accordance with international guidelines. TBPI patients were identified in clinical records. The BrAT-Swe was sent out to patients by post. Internal consistency was assessed using Cronbach alpha and content validity using Rasch analysis evaluating fit to the Rasch model, threshold response, local dependency, dimensionality, differential item functioning (DIF), and targeting.The translation of the BrAT was completed without major discrepancies. A total of 164 patients completed the BrAT-Swe. Internal consistency ranged from 0.90 to 0.98. Rasch analysis supported the content validity. All subscales demonstrated fit to the model with no local dependency, minimal disordered thresholds and no unidimensionality. Uniform DIF for item 6 by age, was identified. Minimal differences in hierarchical ordering were identified.This study presents a Swedish translation of the BrAT (BrAT-Swe) and has demonstrated that the translated BrAT-Swe is well adapted for Swedish circumstances. Analysis supports the internal content validity of the BrAT-Swe as a unidimensional targeted PROM designed to assess activity limitation after TBPI.The Swedish translation of the Brachial Assessment Tool (BrAT), the BrAT-Swe, is a valid instrument that can be used in a Swedish context.The BrAT-Swe subscales can be used independently or as a total score, similar to the original BrAT.The BrAT-Swe may be used to guide rehabilitation and for goal setting for patients with traumatic brachial plexus injury.The Swedish translation of the Brachial Assessment Tool (BrAT), the BrAT-Swe, is a valid instrument that can be used in a Swedish context.The BrAT-Swe subscales can be used independently or as a total score, similar to the original BrAT.The BrAT-Swe may be used to guide rehabilitation and for goal setting for patients with traumatic brachial plexus injury. [ABSTRACT FROM AUTHOR]

Background: Congenital shoulder dislocation due to shoulder girdle malformation is called true congenital shoulder dislocation. It is an extremely rare disorder as compared with traumatic dislocation or secondary to brachial plexus injury. Case presentation: We report a case of atraumatic true congenital shoulder dislocation, one of the few reported cases across the world. The baby was born of a preterm caesarean section at 30 weeks of gestation, ruling out any perinatal trauma. The baby presented with a lateral shoulder crease and reduced movements of the affected upper limb. The diagnosis was confirmed with radiographs and a sonography that ruled out physeal injury. Treatment involved prompt closed reduction and stabilization by swathing in an adducted internally rotated position for two weeks. Conclusion: Owing to the rarity of this condition, the case is being reported to be archived with a handful of other such cases. [ABSTRACT FROM AUTHOR]

Background: To assess the efficacy of preoperative halo-gravity traction (HGT) in treating severe spinal deformities, evaluating radiological outcomes, pulmonary function, and nutritional status. Methods: This study retrospectively included 33 patients with severe spinal deformity who were admitted to our department from April 2018 to January 2022. All the patients underwent HGT prior to the posterior spinal fusion corrective surgery, with no patients having undergone anterior or posterior release procedures. The correction of deformity, pulmonary function tests (PFTs), and nutritional status data were collected and analyzed before and after HGT. Results: A total of 33 patients (9 males, 24 females) were finally included in this study with an average age of 17.79 ± 7.96 (range 12–29) years. Among them, 20 patients were aged ≤ 16 years. The traction weight started from 1.5 kg and raised to 45.2 ± 13.2% of body weight on average progressively, with the average traction duration of 129 ± 63 days. After traction, the main curve was corrected from an average of 120.66 ± 3.89° to 94.88 ± 3.35°, and to 52.33 ± 22.36° (53%) after surgery(P < 0.05). PFTs also showed a significant increase in FVC%, FEV1%, and MEF% after traction [43.46 ± 14.76% vs. 47.33 ± 16.04%, 41.87 ± 13.68% vs. 45.19 ± 15.57%, and 40.44 ± 15.87% vs. 45.24 ± 17.91%, p < 0.05]. Total protein, albumin, and BMI were used as indicators of nutritional status. TP and albumin were significantly improved after traction, from 67.24 ± 5.43 g/L to 70.68 ± 6.98 g/L and 42.40 ± 3.44 g/L 45.72 ± 5.23 g/L, respectively(P < 0.05). No significant difference was found in deformity correction and lung function improvement between patients with traction for more or less than three months (p > 0.05). Two patients developed transient brachial plexus palsy during traction. Conclusions: Halo-gravity traction can partially correct spinal deformity, enhance pulmonary function. And HGT has been shown to facilitate an improved nutritional status in these patients. It could be used as a preoperative adjuvant treatment for severe spinal deformity. However, according to the study, a traction period longer than three months may not be necessary. [ABSTRACT FROM AUTHOR]

Background: Obstetric brachial plexus injuries (OBPIs) not only lead to severe and life changing sequelae regarding motor impairment but can also be responsible for multi-characteristic pain. In everyday routine, questions regarding pain of the developing child with an OBPI are often overseen and neglected. We aimed to elucidate this specific question and analyzed all patients with OBPI treated in our center to unmask initially non-observed pain and ultimately put pain in correlation to the surgical reconstructive treatment performed. Methods: This single center retrospective study analyzes patients with OBPI treated in our center over the past 20 years. Patients were surveyed by the adolescent pediatric pain tool assessment to evaluate pain over their entire life span by excluding potential postoperative pain episodes. Results: A total of 95 patients were initially contacted of which 78 returned the questionnaire (53.8% female, 46.2% male). In our patient cohort, the vast majority constituting 84.6 percent did not experience pain in the affected upper extremity over the years up to the date of their examination. Most of the patients describing pain had not been microsurgically treated for brachial plexus reconstruction in their neonate period. Merely, 33.3 percent of all OBPI experiencing pain had been microsurgically reconstructed at a median age of 7 months. Conclusions: Pain interrogation in patients with OBPI is often overseen during daily clinical routine. Adequate age-appropriate analgesic therapy regimens adapted to the individual are highly recommended. Timely microsurgical brachial plexus reconstruction may result in reduced lifetime pain experiences. [ABSTRACT FROM AUTHOR]

In this study, we evaluated the functional outcomes of nerve reconstruction for nerve gaps exceeding 7 cm, using sural nerve autografts. The cases primarily involved brachial plexus injuries and peripheral nerve injuries. The most frequent causes of these injuries were motorcycle accidents and workplace incidents, predominantly affecting young individuals. The best outcomes for nerve injuries are achieved through primary coaptation. All the patients in our study underwent delayed nerve reconstruction rather than primary repair for various reasons, resulting in outcomes that were not as favourable as those of primary repair. Despite using avascular nerve grafts to bridge long nerve gaps, many of our patients still experienced meaningful recovery. Motor function recovery outperformed sensory function recovery across all types of reconstructions. Hence, in situations where facilities and expertise for vascularized nerve grafts are unavailable, attempting reconstruction with an extended nerve graft for long nerve gap is justified. [ABSTRACT FROM AUTHOR]

Background: An obstetric brachial plexus injury (OBPI) occurs when the brachial plexus is subjected to severe traction during the labor and delivery procedure. These individuals may see considerable improvements in shoulder function and glenohumeral congruity after undergoing the triangle tilt operation. This research aimed to assess the clinical, functional as well as radiological outcomes of managing obstetric brachial plexus injury using triangle tilt surgery. Methods:Eighteen patients who were treated for obstetric brachial plexus injury using triangle tilt surgery technique in this prospective clinical study with follow up period of at least 2 years clinically and radiological by x-ray and CT of shoulder joints. Postoperative evaluation was performed according to Mallet Score. Results: Posterior supination significantly increased after intervention from 14.16±2.25 to 25.50±2.72 (p<0.001). The measurements of the glenoid version showed significant improvement which was about 29.55±3.27 and improved to be about 22.66±2.95 (p<0.001). There was significant improvement in the abduction angle while preoperative was 78.05±10.72 and became post operative 149±9.85 (p<0.001). There was significant improvement in SHEAR deformity grades while preoperative was grade 3 and grade 4 and became post operative grade 2 (p<0.001). Glenoid version significantly improved from preoperative compared to post operative (p<0.001). Abduction angle significantly increased from pre to post as 78.05±10.72 to 149±9.85 (p<0.001). Nonunion of the clavicular osteotomy happened in 3 cases only and was managed by wire fixation. Conclusions: This study underscores that triangle tilt surgy could be a safe as well as effective method for management of secondary deformities of obstetric brachial plexuses injury in children in different ages. [ABSTRACT FROM AUTHOR]

Background: Children who had been delivered with brachial plexus injury often presented with debilitating condition when their shoulder becomes stuck in an inwardly rotated position. Instances of inadequate recuperation following physiotherapy necessitate several surgical alternatives, such as soft tissue interventions like muscle releases and/or transfers, which can rectify this deformity. The current study aimed to present the clinical and radiological outcome after arthroscopic release of shoulder internal rotation contracture in cases of brachial plexus injury during birth. Methods: The current study was done in Zagazig University hospitals and had been included thirty-five participants presented by brachial plexus injury since delivery associated with shoulder internal rotation contracture with subluxation of the humeral head. Results: Mallet score; improved as the median of pre-operative Mallet score was 11 (2) and significantly increased to 16 (3) at the post-operative follow up, external rotation; improved as the median of pre-operative external rotation was 2 (1) and increased to 4 (1) post-operatively (P<0.001). Increase in elevation; as median of pre-operative elevation was 3 (1) and increased to 4 (1) post-operatively (P=0.003). Conclusion: The optimal time to do the arthroscopic release is before the child reaches two years old in order to achieve the greatest range of motion improvement of shoulder and to prevent additional bone alterations such as glenoid retroversion or displacement of the humeral head posteriorly, according to our perspective. [ABSTRACT FROM AUTHOR]

Background: The one-bone forearm procedure has been considered as a potential treatment for severe forearm deformities. However, its primary limitation lies in the elevated risks of nonunion and infection. In order to enhance union rates, a technical modification was introduced, aiming not only to establish end-to-end radio-ulnar fixation but also to incorporate an additional overlay and fixation between the proximal and distal radius osteotomy stumps. This technique, initially applied in a heterogeneous patient population including individuals with neurological, tumoral, and congenital conditions, yielded promising results, achieving a consolidation rate of 100% and enabling supination corrections of up to 120°. Methods: In this study, we present a retrospective cohort of 28 patients, with an average age of 9 years, all afflicted by forearm supination contracture exceeding 90° secondary to neonatal brachial plexus injury. These patients underwent treatment with the modified technique. Results: The mean correction achieved in forearm rotation was 116°, and the average follow-up period extended to 43 months. Remarkably, all patients exhibited bone union within an average period of 6.6 weeks, without any complications. Conclusion: Our findings underscore the efficacy of this modified technique, which enables substantial rotational corrections, boasts a high union rate, and maintains a low incidence of complications. This approach is particularly valuable for young patients suffering from neonatal brachial plexus injury with severe fixed supination deformities. Case series, Level of evidence: IV [ABSTRACT FROM AUTHOR]

Consequences of brachial plexus injuries (BPI) would likely impact participation, but outcomes are not well understood. This exploratory study aimed to report the participation in productive, leisure and social roles for individuals following BPI. Fourteen male participants were diagnosed with a traumatic, BPI. Descriptive data reported included demographic, injury, surgical, and participation measures. Two-sample t-tests were conducted for comparative analysis with other studies following life altering conditions. Just over two-thirds reported feeling satisfied to very satisfied with their participation in everyday life. This long-term follow up study found on-going and profound impact on participation in a range of life situations for this diagnostic group. Participation in productive roles, home duties, and physical exercise were particularly impacted and need to be prioritized during rehabilitation. [ABSTRACT FROM AUTHOR]

Introduction: Shoulder dystocia is a severe obstetric emergency that can cause substantial neonatal and maternal complications. This study aims to assess the performed obstetric maneuvers and their frequency, success, and association with maternal and neonatal complication rates. Material and methods: The study population was collected among all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352) by searching for ICD‐10 codes for shoulder dystocia, brachial plexus injury and clavicle fracture. Shoulder dystocia cases (n = 537) were identified by reviewing the medical records. Shoulder dystocia cases treated with one or two maneuvers were compared with those treated with at least three. Medical records of a matched control group constituting of 566 parturients without any of the forementioned ICD‐10 codes were also scrutinized. Results: Using the four most common obstetric maneuvers (McRoberts maneuver, suprapubic pressure, rotational maneuvers, the delivery of the posterior arm) significantly increased during the study period with individual success rates of 61.0%, 71.9%, 68.1% and 84.8%, respectively. Concurrently, the rate of brachial plexus injury and combined neonatal morbidity significantly declined from 50% to 24.2% (p = 0.02) and from 91.4% to 48.5% (p < 0.001). Approximately 75% of shoulder dystocia cases treated with maneuvers were resolved by the McRoberts maneuver and/or suprapubic pressure, but each of the four most performed maneuvers significantly increased the cumulative success rate individually and statistically (p < 0.001). The rates of brachial plexus injury and combined neonatal morbidity were at their highest (52.9% and 97.8%) when none of the maneuvers were performed and at their lowest when two maneuvers were performed (43.0% and 65.4%). The increasing number (≥3) of maneuvers did not affect the combined maternal or neonatal morbidity or brachial plexus injury but increased the risk for third‐ or fourth‐degree lacerations (odds ratio 2.91, 95% confidence interval 1.17 to 7.24). Conclusions: The increased use of obstetric maneuvers during the study period was associated with decreasing rates of neonatal complications; conversely, the lack of obstetric maneuvers was associated with the highest rate of neonatal complications. These emphasize the importance of education, maneuver training and urgently performing shoulder dystocia maneuvers according to the international protocol guidelines. [ABSTRACT FROM AUTHOR]

Pediatric acquired and congenital conditions leading to shoulder pain and dysfunction are common. Objective, quantitative musculoskeletal imaging-based measures of shoulder health in children lag recent developments in adults. We review promising applications of quantitative imaging that tend to be available for common pediatric shoulder pathologies, especially brachial plexus birth palsy and recurrent shoulder instability, and imaging-related considerations of musculoskeletal growth and development of the shoulder. We highlight the status of quantitative imaging practices for the pediatric shoulder and highlight gaps where better care may be provided with advances in imaging technique and/or technology. [ABSTRACT FROM AUTHOR]

Background Nerve transfers from one common donor nerve to recipient nerves with multiple target branches can yield slower and unpredictable recovery in the target nerves. Our hypothesis is that steal phenomenon exists when multiple nerve neurotization comes from one donor nerve. Methods In 30 Sprague-Dawley rats, the left ulnar nerve (UN) was selected as the donor nerve, and the musculocutaneous nerve (MCN) and median nerve (MN) as the recipient target nerves. The rats were separated into three groups (10 rats in each): group A, UN-to-MCN (one-target); group B, UN-to-MN (one-target); and group C, UN-to-MCN and MN (two-target). The right upper limbs were nonoperative as the control group. Outcome obtained at 20 weeks after surgery included grooming test, muscle weight, compound muscle action potential, tetanic muscle contraction force, axon counts, and retrograde labeling of the involved donor and target nerves. Results At 20 weeks after surgery, muscles innervated by neurotization resulted in significant worse outcomes than the control side. This was especially true in two-target neurotization in the parameter of muscle weight and forearm flexor muscle contraction force outcome when compared to one-target neurotization. Steal phenomenon does exist because flexor muscle contraction force was significantly worse during two-target neurotization. Conclusion This study proves the existence of steal phenomenon in multiple target neurotization but does not significantly affect the functional results. Postoperative rehabilitative measures (including electrical stimulation, induction exercise) and patient compliance (ambition and persistence) are other crucial factors that hold equivalent importance to long-term successful recovery. [ABSTRACT FROM AUTHOR]

BACKGROUND: According to the literature, the brachial plexus presents a high rate of anatomical variations in the human neural system. The musculocutaneous nerve, a vital component of the brachial plexus, exhibits significant anatomical variations that hold clinical relevance across multiple medical disciplines. This case report, with a comprehensive review, explores the different variations in the course, branching patterns, and clinical implications of the musculocutaneous nerve. Understanding these variations is essential for surgeons, radiologists, and clinicians to enhance surgical precision, improve diagnostic accuracy, and reduce the risk of iatrogenic complications. CASE REPORT: During an anatomical dissection we observed a very rare anatomical variation of the musculocutaneous nerve. Based on this discovery, we performed research in the literature with the aim of finding if this variation has been previously described. Firstly, we identified various classifications of anatomical variations of communicating branches between the musculocutaneous and median nerves, and then we observed that these variations corresponded to various rates of frequency. Our finding is a rare undescribed anatomical variant within the variants classified as Type II according to Le Minor, which is observed in 6.8-10.7% of cases. CONCLUSIONS: The peculiar position of anatomical variations and anastomosis has clinical and functional relevance. Healthcare professionals must be aware of these variations to minimize surgical complications, accurately diagnose neurovascular pathologies, and optimize patient management. Further research into the genetic and embryological underpinnings of these variations may provide additional insights into this intriguing aspect of human anatomy. [ABSTRACT FROM AUTHOR]

Restoration of pinch and grasp is a chief concern of patients with cervical spinal cord injury or peripheral nerve injury involving the anterior interosseous nerve (AIN). We hypothesize that supinator nerve-to-AIN (Sup-AIN) nerve transfer is a viable option for AIN neurotization. We performed a retrospective review of patients who received Sup-AIN. Reported outcomes included Medical Research Council strength of the flexor digitorum profundus and flexor pollicis longus and passive range of digit motion. Patients with <12 months of follow-up were excluded. Eleven patients underwent Sup-AIN, eight with peripheral nerve injury, and three with spinal cord injury. Three patients were excluded because of insufficient follow-up. Average follow-up was 17 months (range: 12–25 months). Six patients had M4 recovery (75%), one patient had M3 recovery (12.5%), and one did not recover function because of severe stiffness (12.5%). We observed no complications or donor site morbidity in our patients. The Sup-AIN nerve transfer is an effective option to restore digital flexion in patients with peripheral nerve injury or spinal cord injury involving the AIN motor distribution. In comparison to previously described extensor carpi radialis brevis to AIN and brachialis to AIN nerve transfers, Sup-AIN offers the benefits of a more expendable donor nerve and shorter regenerative distance, respectively. The one failed Sup-AIN in our series highlights the importance of patient selection. Therapeutic V. [ABSTRACT FROM AUTHOR]

An 11‐year‐old Belgian shepherd presented with progressive right thoracic limb lameness. Computed tomography and magnetic resonance imaging revealed a brachial plexus neoplasm and cytology was suggestive of a sarcoma. The patient underwent forequarter amputation and hemilaminectomy of the fifth cervical to first thoracic vertebrae with nerve root transection. Histopathology confirmed extraskeletal osteosarcoma. Twelve months post‐operatively, the dog was exercising normally, and computed tomography did not identify local recurrence or metastatic disease. This is the first recorded case of canine brachial plexus extraskeletal osteosarcoma. [ABSTRACT FROM AUTHOR]

The presentation, management and outcomes of brachial plexus injuries are likely to be subject to regional differences across the globe. A comprehensive literature search was performed to identify relevant articles related to spinal accessory to suprascapular, intercostal to musculocutaneous, and ulnar and/or median nerve fascicle to biceps and/or brachialis motor branch nerve transfers for treatment of brachial plexus injuries. A total of 6007 individual brachial plexus injuries were described with a mean follow-up of 38 months. The specific indication for accessory to suprascapular and intercostal to musculocutaneous transfers were considerably different among regions (e.g. upper plexus vs. pan-plexal), while uniform for fascicular transfer for elbow flexion (e.g. upper plexus +/− C7). Similarly, functional recovery was highly variable for accessory to suprascapular and intercostal to musculocutaneous transfers, while British Medical Research Council grade ≥3 strength after fascicular transfer for elbow flexion was frequently obtained. Overall, differences in outcomes seem to be inherent to the specific transfer being utilized. Level of evidence: III [ABSTRACT FROM AUTHOR]

Objectives: The incidence of hemidiaphragmatic paresis (HDP) in superior trunk block (STB) usually depends on the dose of local anesthetic. This study aimed to further evaluate the impact of a lower volume (10 mL) of the same low concentration (0.25%) ropivacaine compared to a conventional volume (15 mL), on diaphragmatic function and analgesic efficacy under a multimodal analgesia regimen for shoulder arthroscopy. Methods: Patients scheduled to undergo shoulder arthroscopy were randomized allocated to receive either 10 mL or 15 mL of 0.25% ropivacaine in the STB under ultrasound guidance prior to general anesthesia. The primary outcome was the percentage reduction in diaphragm excursion (ΔDE) between baseline and 30 min after block. Secondary outcomes included DE and diaphragm thickening fraction (DTF) before and after block, incidence of HDP, onset of sensory/motor block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity, pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, and adverse events post-surgery. Results: Compared with 15 mL volume, 10 mL ropivacaine significantly reduced the incidence of post-block HDP (as measured by ΔDE: 39.47% vs. 64.10%; and by post-block DTF: 13.16% vs. 33.33%). There was no significant difference in onset of sensory block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity between the two groups, except that the onset of motor block was significantly slower in the 10 mL group than in the 15 mL group. Pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, or postoperative adverse events were not significantly different between the two groups. Conclusion: In shoulder arthroscopy, STB with 10 mL of ropivacaine can reduce the incidence of HDP with no significant difference in analgesic effects under a multimodal analgesia regimen compared with 15 mL. Trial registration: We registered the study at chictr.org (ChiCTR2200057543 , 14/03/2022. https://www.chictr.ogr.cn [ABSTRACT FROM AUTHOR]

Background: Obstetric brachial plexus palsy (OBPP) is a condition impairing limb function caused by birth injury. In 20 to 30% of cases, severe OBPP can cause life constraints in feeding, grooming, and clothing tasks. Objective: The present study, using voxel- and surface-based morphometry (VBM and SBM), examined the brain structure of pediatric OBPP patients to better understand the effects of this peripheral motor deficit on early brain development. Methods: Thirty-six T1-weighted images of 18 patients (2-17 years old, mean age = 11.3, 8 females) and 18 healthy controls (2-17 years old, mean age = 10.1, 8 females) were collected for this study. MRI data were processed and analyzed using the Statistical Parametric Mapping 12 (SPM12) toolbox. The custom pediatric tissue probability map was created with the CerebroMatic (COM) toolbox. The results were considered significant if they survived whole-brain family-wise error correction (P <.05). Results: We have found differences in grey matter volumes in the bilateral anterior hippocampus (left P <.001 and right P =.01) and left cerebellum exterior (Crus I) (P <.001). We have also found differences in cortical thickness in the bilateral parahippocampal gyri (left P =.001 and right P =.005) and right orbitofrontal cortex (OFC) (P <.001). Conclusions: These structural differences might be linked to the altered environmental adaptation that children with OBPP face due to their primary motor deficit. Our findings hint at a complex interplay between motor capabilities, brain structure development, and cognitive functions. However, more research combining neuroimaging, behavioral, cognitive, and clinical data is needed to support stronger conclusions on this subject. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Two cases of neonatal splenic hemorrhage with acute cardiorespiratory failure are described in this report. The first case involves a full-term neonate who was found unresponsive without any witnesses and could not be successfully resuscitated. A postmortem diagnosis revealed a splenic hemorrhage. Second case is an extremely premature neonate who experienced a witnessed cardiovascular collapse on the 14th day of life. Rapid cardiovascular support was administered, resulting in a positive outcome. While splenic hemorrhage is commonly associated with traumatic events, these cases highlight the need of considering spontaneous splenic hemorrhages as a potential cause of acute neonatal compromise, even in the absence of birth-related trauma (e.g., asphyxia, prolonged labor, clavicle fractures, brachial plexus injuries). This report emphasizes the importance of including splenic hemorrhage timely in the differential diagnosis of neonatal cardiorespiratory instability, especially in the absence of more common diagnoses, and discusses the challenges associated with its recognition and treatment. [ABSTRACT FROM AUTHOR]

AbstractPurposeMaterial and methodsResultsConclusion\nIMPLICATIONS FOR REHABILITATIONTo translate and cross-culturally adapt The Brachial Assessment Tool (BrAT) into Danish and assess its content validity and reproducibility in adults with traumatic brachial plexus injury (BPI).Translation followed international guidelines. BrAT(DK) were cognitive tested with 19 adults with traumatic BPI to evaluate cross-cultural understanding, relevance, comprehensiveness and comprehensibility. Content validity and reproducibility were evaluated following the COnsensus-based Standards for the selection of health Measurement INstruments guideline. Participants were recruited from an outpatient hand clinic. Test-retest reliability was assessed using intra-class-correlation coefficient (ICC) and the smallest detectable change (SDC). Internal consistency was evaluated using Cronbach’s alpha.Minor cultural differences were observed in the content validity analysis of BrAT(DK). Cognitive testing revealing no significant issues. All participants found the items relevant and important. 63 participants with traumatic BPI were recruited; 49 completed the retest. ICC values for the sub-scales and the total score ranged from 0.91 to 0.95 (95% CI 0.85 to 0.97). Internal consistency ranged from 0.87 to 0.98. SDC ranged from 4.16 to 9.63 for subscales and 16.01 for the total score.BrAT(DK) appeared to be content valid and reliabel as a measure of activity limitation in adults with traumatic BPI.The Brachial Assessment Tool (BrAT) has been cross-cultural translated into DanishBrAT(DK) shows adequate content validity for activity limitation in adults with traumatic brachial plexus injuryBrAT(DK) is a reliable measure, with a smallest detectable change of 16.01 points for the total scaleWe recommend the use of BrAT(DK) in clinical practice to inform goal setting and future interventions and treatment evaluationsThe Brachial Assessment Tool (BrAT) has been cross-cultural translated into DanishBrAT(DK) shows adequate content validity for activity limitation in adults with traumatic brachial plexus injuryBrAT(DK) is a reliable measure, with a smallest detectable change of 16.01 points for the total scaleWe recommend the use of BrAT(DK) in clinical practice to inform goal setting and future interventions and treatment evaluations [ABSTRACT FROM AUTHOR]

Background and Aims Methods Results Interpretation Ultrasound nerve cross‐sectional area (CSA) of patients affected with axonal neuropathy usually shows normal value. Cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) seems to represent an exception, showing smaller CSA, but previous reports did not test for biallelic RFC1 gene repeat expansions.We compared nerve CSA from CANVAS patients (tested positive for biallelic RFC1 gene repeat expansions) with the CSA from a group of patients with chronic idiopathic axonal polyneuropathy (CIAP) who tested negative for RFC1 gene repeat expansions, hereditary axonal neuropathy (Charcot‐Marie‐Tooth type 2, CMT2), and Friedreich ataxia (FRDA).We enrolled 15 CANVAS patients (eight men, mean age 66.3 ± 11.5 years, mean disease duration 9.3 ± 4.1 years), affected with sensory axonal neuronopathy. Controls consisted of 13 CIAP (mean age 68.5 ± 12.8 years, seven men), seven CMT2 (mean age 47.9 ± 18.1 years, four men), 12 FRDA (mean age 33.7 ± 8.8, five men). Nerve ultrasound was performed at median, ulnar, sciatic, sural, and tibial nerves and brachial plexus, bilaterally. The nerve CSA from CANVAS patients was significantly smaller than the one from the other cohorts at several sites with significant and high accuracy at Receiver‐operating characteristic (ROC) curve analyses. RFC1 AAGGG pentanucleotide expansion, disease duration, and disability did not correlate with CSA at any site, after Bonferroni correction.Decreased sonographic nerve sizes, in arms and legs, in patients with sensory neuropathy and normal motor conduction studies could point to CANVAS‐spectrum disease and help guide appropriate genetic testing. [ABSTRACT FROM AUTHOR]

The main objective of the research consists in providing evidence that a long-term rehabilitation protocol is favorable for the patient. In adult brachial plexus (BP) palsies, after several surgical attempts, the lack of results in the upper limb's functionality leads to less compliance to rehabilitation therapy. The upper limb's functionality of 22 patients with posttraumatic operated chronic BP paresis (either on the right or left, regardless the dominant limb) was assessed retrospectively. The patients were evaluated regarding MRC scaling, dynamometric tests and electroneuromyographic examination. All patients have gone through at least one rehabilitation interval (10 days) after an initial evaluation, and were evaluated again, by same methods, at a second session, at least 6 months later, but no more than one year. Mild and inconstant improvements were obtained in a total of 9 patients, especially in better dynamometric results and improved amplitudes of motor and sensory action potentials. The electrodiagnosis correlates with dynamometric parameters (muscle strength) and slight amelioration of the motor deficit. Given the small sample size as a limitation, as well as no standardized therapeutic protocol, it should be noted that the 9 patients were the only ones who either attended more than one interval or did more procedures as frequency in time (more often meaning 3 times weekly for 6 months, in 6 patients). Although the most frequent procedures were neuromuscular electrical stimulation (NMES) and proprioceptive neuromuscular facilitation (PNF), the results suggest that regardless of the techniques, the more active patients had better results. Proving the need for long-term rehabilitation, even contrary to the less visible results, can be the trigger point for future research and therapy strategies, as the results suggest central mechanisms involved, adding the cortical ongoing plasticity into the equation. [ABSTRACT FROM AUTHOR]

Purpose: Extensive lesions of the brachial plexus, or late cases, require free functional muscle grafts because the expected recovery time exceeds the critical threshold of 1.5 years, beyond which irreversible damage may be expected in the distal nerve stump and in the muscle. The reconstructive concept consists of a two-stage procedure where, in the first step, a nerve transfer is performed (from ipsi- or contralateral donor nerves). In the second step, after successful axonal regeneration within the graft has been confirmed, a free muscle transfer is performed. These grafts often exceed 40 cm in length, particularly for contralateral transfers. The purpose of this study was to assess whether robust motor recovery could be supported by such long nerve grafts. Methods: From April 2004 to April 2023, a total of 327 free functional muscle transfers were performed, the nerve graft length ranging from 0 cm (direct coaptation) to 90 cm (serial grafts). Motor recovery was evaluated 1.5 years after surgery according to the MRC scale. Results: A total of 208 patients were available for follow up. Direct coaptation yielded the best results, with 83% of patients reaching an M3 or M4 level of muscle strength. With the application of long (30–60 cm) grafts, 73% of the patients were classified as M3 or M4. The application of serial nerve grafts, however, only resulted in 18% of patients achieving a motor recovery rating of M3. Conclusions: These findings demonstrate that robust motor regeneration is supported by long (30–60 cm) nerve grafts, whereas serial nerve grafting results in a marked reduction in the quality of regeneration. [ABSTRACT FROM AUTHOR]

Background: Supraclavicular brachial plexus blockade (SBPB) is commonly performed regional anesthetic technique for forearm and hand surgeries, and its blockage provides good surgical anesthesia. Aim: Considering the efficacy of adjuvant for ropivacaine in SBPBs, we designed a double-blind randomized control study to compare the characteristics and side effects of ropivacaine along with dexamethasone versus dexmedetomidine in SBPBs in patients scheduled for upper limb surgeries. Material and Methods: Present study was single-center, prospective, randomised, double blind study, conducted patients aged 18-70 years, belonging to American Society of Anaesthesiologists physical status (ASA) of I or II, scheduled for Upper limb surgeries under SBPB. Results: In present study, 108 patients were studied, 54 patients received 20 ml 0.5% Ropivacaine with 50 mcg Dexamethasone (Group A, n=54), while other 54 patients received 20 ml 0.5% Ropivacaine with 50 mcg Dexmedetomidine (Group B, n=54). Age, weight, gender, ASA grade & duration of surgery were comparable in both groups. Dexamethasone group has earlier onset of sensory block, earlier onset of motor block, prolonged duration of sensory block & prolonged duration of motor block as compared to dexmedetomidine group & difference was statistically significant (p< 0.05). Dexamethasone group duration of analgesia, delayed first rescue analgesic requirement & less doses of rescue analgesia required as compared to dexmedetomidine group & difference was statistically significant (p< 0.05). Conclusion: Dexamethasone is a better alternative than dexmedetomidine since it shortens the onset of sensory and motor block, prolongs the duration of sensory and motor block and prolongs the duration of analgesia. [ABSTRACT FROM AUTHOR]

To compare efficacy and safety of two different doses of Dexmedetomidine as an adjuvant to Ropivacaine compared to Ropivacaine in block and intravenously Dexmedetomidine in upper limb surgeries under supraclavicular brachial plexus block. INTRODUCTION Supraclavicular block is a reliable, rapid-onset approach to brachial plexus anaesthesia. The supraclavicular block provides anesthesia and analgesia to the upper extremity below the shoulder. It is an excellent choice for elbow and hand surgery. Adjuvants are added to local anesthetics in peripheral nerve blocks to fasten the onset of action, to prolong the duration of action and improve the quality of blockade. Various adjuvants like morphine, fentanyl, sufentanil, clonidine, midazolam, ketamine, neostigmine, dexmedetomidine are added to local anesthetics. Since dexmedetomidine has α2:α1 selectivity ratio of 1620:1 as compared to 220:1 for clonidine, it decreases unwanted side effects of α1 and much more sedative and analgesic. Ropivacaine is a long-acting amide local anaesthetic agent and first produced as a pure enantiomer structurally related to Bupivacaine. Dexmedetomidineis d-enantiomer of medetomidine. It belongs to imidazole subclass of α2 receptor agonist. It is a newer α2-adrenoreceptor agonist is currently in focus for its sedative, anxiolytic and analgesic properties.It is rapidly distributed and metabolized in liver, excreted in urine and faeces. [ABSTRACT FROM AUTHOR]

Background: Musculocutaneous nerve (MCN) is a mixed nerve arising from the lateral cord of brachial plexus having root values C5, 6, and 7. It supplies the muscles of the flexor compartment of the arm namely; coracobrachialis, most part of brachialis and both heads of biceps brachii. It is cutaneous to the lower lateral part of forearm. Variations in the origin, course, branching pattern, termination, and connections of MCN are very common. Knowledge about these variations is important while evaluating unusual presentations of peripheral nerve injuries, during surgical procedures such as arthroscopy of shoulder joint, corrections of fracture humerus, brachial plexus block, and so on. Aims and Objectives: The study was conducted to find out any variations in the origin, course, branching pattern of the MCN. The secondary objective was to understand about the communication of the MCN with any other nerve. Materials and Methods: A descriptive study was conducted in 60 upper limb specimens dissected from 10% formalin embalmed 30 cadavers (adult) in the Department of Anatomy, Government Medical College, Kottayam. All limbs were carefully dissected and studied about the origin, course, termination, and variations of MCN. Results: Out of 60 specimens studied, in 46 specimens MCN Originate from lateral cord, eight from medial cord, and in six from the lateral root of the median nerve (MN). In 52 specimens, MCN supplies coracobrachialis but only in 34 it pierces this muscle. In four specimens, there is a communication between MCN and MN was seen. Conclusion: The MCN has significant variations and knowledge of these variations is clinically important in diagnosis and management of peripheral nerve injuries as well as surgical interventions in the arm. [ABSTRACT FROM AUTHOR]

Conventionally, neural transfer of the spinal accessory nerve to the suprascapular nerve for shoulder abduction in traumatic brachial plexus injury is performed via the anterior approach. However, important advantages of the posterior approach have made it an alternative option, such as the proximity of neural coaptation to the muscle to be reinnervated and negating the effects of a second injury to the suprascapular nerve. Retrospective data was collected from 30 patients with brachial plexus injury who underwent spinal accessory nerve to suprascapular nerve transfer over 4 years. There were 15 patients in the anterior-approach group (group A) and 15 in the posterior-approach group (group B). Functional outcome at the shoulder was measured as muscle power and active range of motion at 18 months, and data on patients' satisfaction levels and surgeons' perceptions was also collected. No statistical difference was found in the muscle strength achieved in the 2 groups (P = 0.34), but significant recovery was found in the external rotation achieved by group B (P = 0.02). Statistical difference was insignificant in the 2 groups' active range of motion during abduction and external rotation. The satisfaction index of patients was 86.7% in group B as compared to 68% in group A. Surgeons' perspective showed a faster speed of suprascapular nerve exploration in the posterior approach, with better visibility of supraspinatus muscle contraction, and overall surgeons preferred the posterior approach. External rotation at the shoulder is better via the posterior approach, but no difference in abduction was noted. Patients who underwent the posterior approach were more satisfied with the recovery, and surgeons preferred the posterior approach. [ABSTRACT FROM AUTHOR]

The reader will come to appreciate that Simulation Based Education: • Is an important tool in delivering high quality, evidence-based education to healthcare workers. • Should be evaluated against real patient outcomes and have led to significant improvements in the care of patients in neonatology and paediatrics. • Can be used the enhance clinical skill acquisition, acute care management, teamwork, leadership, communication and for quality improvement. There is increasing use of clinical Simulation Based Education (SBE) in healthcare due to an increased focus on patient safety, the call for a new training model not based solely on apprenticeship, a desire for standardised educational opportunities that are available on-demand, and a need to practice and hone skills in a controlled environment. SBE programs should be evaluated against Kirkpatrick level 3 or 4 criteria to ensure they improve patient or staff outcomes in the real world. SBE programs have been shown to improve outcomes in neonatology – reductions in hypoxic ischaemic encephalopathy, in brachial plexus injury, rates of school age cerebral palsy, reductions in 24hr mortality and improvements in first pass intubation rates. In paediatrics SBE programs have shown improvements in paediatric cardiac arrest survival, PICU survival, reduced PICU admissions, reduced PICU length of stay and reduced time to critical operations. SBE can improve the non-technical tasks of teamwork, leadership and communication (within the team and with patients and carers). Simulation is a useful tool in Quality and Safety and is used to identify latent safety issues that can be addressed by future programs. In high stakes assessment simulation can be a mode of assessment, however, care needs to be taken to ensure the tool is validated carefully. [ABSTRACT FROM AUTHOR]

Background/Objectives: Secondary problems in BPBI occur due to decreased muscle strength in the upper extremities. Comprehensive assessment methods are necessary to understand structural problems and to plan appropriate interventions in children with BPBI. We investigated the relationship between distal muscle strength, range of motion (ROM), and functionality by comparing distal muscle strength on the affected and unaffected sides in patients with BPBI who underwent shoulder tendon transfer. Methods: A total of 25 children with BPBI, 13 (52%) girls and 12 (48%) boys, aged 4–7 years (mean age: 5.98 ± 1.27 years), who had undergone shoulder tendon transfer surgery at least one year prior to the study were included. The muscle strength of the elbow, forearm, and wrist were assessed using the MicroFET®2 Digital Hand Dynamometer. The ROM of the elbow, forearm, and wrist were measured using the universal goniometer. The Pediatric Evaluation of Disability Inventory (PEDI) was used for functionality assessment. Results: The strength of the elbow flexor–extensor, forearm pronator–supinator, and wrist extensor muscles on the affected side was greater than on the unaffected side in all children (p < 0.001). No correlation was found between muscle strength, ROM, and functionality in the affected extremity (p > 0.005). Conclusions: Although children with BPBI have good shoulder function after shoulder tendon transfer, structural problems in the distal joints may affect their functionality during daily life. Distal joint strengthening and ROM exercises, as well as bimanual functional activities, should be included in the rehabilitation programs of children with BPBI after shoulder tendon transfer. [ABSTRACT FROM AUTHOR]

Background and Objectives: Many risk factors for postoperative C5 palsy (PC5P) have been reported regarding a "cord shift" after a posterior approach. However, there are few reports about shoulder traction as a possible risk factor of anterior cervical surgery. Therefore, we assessed the stretched nerve roots when shoulder traction was applied on cadavers. Materials and Methods: Eight cadavers were employed in this study, available based on age and the presence of foramen stenosis. After dissecting the sternocleidomastoid muscle of the cadaver, the shoulder joint was pulled with a force of 2, 5, 8, 10, 15, and 20 kg. Then, the stretched length of the fifth nerve root was measured in the extra-foraminal zone. In addition, the same measurement was performed after cutting the carotid artery to accurately identify the nerve root's origin. After an additional dissection was performed so that the superior trunk of the brachial plexus could be seen, the stretched length of the fifth and sixth nerve roots was measured again. Results: Throughout the entire experiment, the fifth nerve root stretched out for an average of 1.94 mm at 8 kg and an average of 5.03 mm at a maximum force of 20 kg. In three experiments, the elongated lengths of the C5 nerve root at 8 kg and 20 kg were 1.69/4.38 mm, 2.13/5.00 mm, and 0.75/5.31 mm, respectively, and in the third experiment, the elongated length of the C6 nerve root was 1.88/5.44 mm. Conclusions: Although this was a cadaveric experiment, it suggests that shoulder traction could be the risk factors for PC5P after anterior cervical surgery. In addition, for patients with foraminal stenosis and central stenosis, the risk would be higher. Therefore, the surgeon should be aware of this, and the patient would need sufficient explanation. [ABSTRACT FROM AUTHOR]

Background: Brachial plexus block for hand and upper extremity procedures in the obese presents a unique set of technical challenges. The authors examined how obesity affects procedural success, quality of anesthesia, and patient satisfaction. Methods: Secondary analysis of a randomized control trial comparing the retroclavicular versus supraclavicular brachial plexus block for distal upper extremity surgery was conducted. Patients were randomized to supraclavicular or retroclavicular brachial plexus block groups in the original trial. In this study, the authors dichotomized patients by obesity to compare differences in outcomes. Results: Sixteen of 117 patients (13.7%) were obese. The groups were statistically well balanced in terms of baseline and operative variables. Obese patients had increased imaging time 2.7 minutes (95% confidence interval [CI], 1.44-3.92) versus 1.9 minutes (95% CI, 1.64-2.16), P value =.05; needling time 6.6 minutes (95% CI, 5.17-7.95) versus 5.8 minutes (95% CI, 5.04-5.74), P =.02; and procedure time 9.3 minutes (95% CI, 7.04-11.46) versus 7.3 minutes (95% CI, 6.79-7.79), P =.01. Block success and complications were not statistically significant. The visual analog scores during the block, at 2 hours, and 24 hours after were not statistically different. Patient satisfaction score among obese patients was 9.1 (95% CI, 8.6-9.6) versus 9.2 (95% CI, 9.1-9.4), P =.63. Conclusion: Findings from this trial suggest that despite an increased procedural difficulty, the use of both supraclavicular and retroclavicular brachial plexus blocks is associated with comparable quality of anesthesia, similar complication profile, equal opioid requirements, and similar patient satisfaction in the obese. [ABSTRACT FROM AUTHOR]

Nerve injuries secondary to gunshot wounds (GSWs) have been traditionally thought of as neurapraxic injuries with high likelihood of complete recovery. A review of the literature, however, highlights the misconceptions surrounding ballistic nerve injuries and their treatments. Contrary to this accepted dogma, approximately 30% to 60% of GSWs to the upper extremity may result in nerve injury requiring repair or reconstruction. Surgical exploration following ballistic injury reveals that 20% to 55% of nerves were lacerated requiring repair or grafting. Despite these numbers, outcomes after nerve repair or grafting are limited, and the limited data show evidence of poor functional recovery. In our experience, delayed exploration of GSW-related nerve injuries in patients without signs of functional recovery demonstrate large neuromas in continuity often requiring meticulous dissection and excision with resulting large gaps that require reconstruction. This has led us to explore options to identify patients with nerve deficits after GSWs who may benefit from earlier exploration. Others advocate for the exploration of all ballistic nerve injuries, which would represent a logistical challenge in high volume centers and may lead to unnecessary explorations of in continuity nerves. To facilitate identification of nerve injury following GSWs, we have explored the utilization of early ultrasound to identify patients with nerve lacerations that may benefit from early exploration (1–2 weeks after injury). Earlier exploration can lead to less technically challenging surgery, shorter nerve gaps, and more time for the nerve to recover. Herein, we present a series of cases to help illustrate this approach to the patient. Although early exploration and repair versus grafting of nerves may have benefits as outlined above, there are little to no data on outcomes of nerve repair or grafting in ballistic injuries in the more acute setting, 1 to 2 weeks after injury. Further research is needed both with regards to diagnosis and utilization of ultrasound, as well as postoperative outcomes in patients with ballistic nerve injuries to help guide our ever-evolving treatment protocols.

Abstract 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.

ObjectiveTo evaluate the association of maternal delivery history with a brachial plexus birth injury risk in subsequent deliveries and to estimate the effect of subsequent delivery method on brachial plexus birth injury risk.MethodsWe conducted a retrospective cohort study of all live-birth deliveries occurring in California-licensed hospitals from 1996 to 2012. The primary outcome was recurrent brachial plexus birth injury in a subsequent pregnancy. The exposure was delivery history (parity, shoulder dystocia in a previous delivery, or previously delivering a neonate with brachial plexus birth injury). Multiple logistic regression was used to model adjusted associations of delivery history with brachial plexus birth injury in a subsequent pregnancy. The adjusted risk and adjusted risk difference for brachial plexus birth injury between vaginal and cesarean deliveries in subsequent pregnancies were determined, stratified by delivery history, and the number of cesarean deliveries needed to prevent one brachial plexus birth injury was determined.ResultsOf 6,286,324 neonates delivered by 4,104,825 individuals, 7,762 (0.12%) were diagnosed with a brachial plexus birth injury. Higher parity was associated with a 5.7% decrease in brachial plexus birth injury risk with each subsequent delivery (adjusted odds ratio [aOR] 0.94, 95% CI 0.92-0.97). Shoulder dystocia or brachial plexus birth injury in a previous delivery was associated with fivefold (0.58% vs 0.11%, aOR 5.39, 95% CI 4.10-7.08) and 17-fold (1.58% vs 0.11%, aOR 17.22, 95% CI 13.31-22.27) increases in brachial plexus birth injury risk, respectively. Among individuals with a history of delivering a neonate with a brachial plexus birth injury, cesarean delivery was associated with a 73.0% decrease in brachial plexus birth injury risk (0.60% vs 2.21%, aOR 0.27, 95% CI 0.13-0.55) compared with an 87.9% decrease in brachial plexus birth injury risk (0.02% vs 0.15%, aOR 0.12, 95% CI 0.10-0.15) in individuals without this history. Among individuals with a history of brachial plexus birth injury, 48.1 cesarean deliveries are needed to prevent one brachial plexus birth injury.ConclusionsParity, previous shoulder dystocia, and previously delivering a neonate with brachial plexus birth injury are associated with future brachial plexus birth injury risk. These factors are identifiable prenatally and can inform discussions with pregnant individuals regarding brachial plexus birth injury risk and planned mode of delivery.

Introduction: Intercostal nerve transfer is a surgical technique used to restore function in patients with total brachial plexus injury. Stem cell and secretome therapy has been explored as a potential treatment for brachial plexus injuries. This study aimed to compare the functional and histologic outcome of intercostal nerve transfer to median nerve with local stem cells or secretome injection in total type brachial plexus injuries. Materials and methods: This was a double-blinded, randomized controlled study (RCT). We included patients with neglected total type brachial plexus injury (BPI) who underwent nerve transfer and local injection of either umbilical cord-derived mesenchymal stem cells (UC-MSC) or secretome into median nerve–flexor digitorum superficialis (FDS) neuromuscular junction (NMJ). We measured preoperative and 8-month postoperative FDS muscle strength, SF-36, DASH score, and histologic assessment. We then analyzed the difference outcome between those two groups. Result: A total of 15 patients were included in this study. Our study found that after nerve transfer and implantation with either UC-MSC or secretome, significant postoperative improvements were observed in physical functioning, role limitations, energy/fatigue, emotional well-being, social functioning, pain, general health, and DASH scores, particularly in the overall cohort and the secretome group. When we compared the mean difference of clinical outcome from preoperative to postoperative between UC-MSC and secretome groups, the UC-MSC group showed better improvement of health change in SF-36 subgroup compared to secretome group. From the analysis, there was no significant difference in the histologic outcomes (inflammation, regeneration, and fibrosis) in overall cohort between preoperative and postoperative cohort. There was also no significant difference in mean change of the histologic outcomes (inflammation, regeneration, and fibrosis) preoperative and postoperatively between UC-MSC and secretome groups. Discussion and conclusion: Implantation of either UC-MSC or secretome along with nerve transfer may provide clinical improvement, while to achieve histologic improvement, further conditioning should be performed. [ABSTRACT FROM AUTHOR]

Objectives: The incidence, diagnosis, management and outcome of face presentation at term were analysed. Methods: A retrospective, gestational age-matched case–control study including 27 singletons with face presentation at term was conducted between April 2006 and February 2021. For each case, four women who had the same gestational age and delivered in the same month with vertex position and singletons were selected as the controls (control group, n = 108). Conditional logistic regression was used to assess the risk factors of face presentation. The maternal and neonatal outcomes of the face presentation group were followed up. Results: The incidence of face presentation at term was 0.14‰. After conditional logistic regression, the two factors associated with face presentation were high parity (adjusted odds ratio [aOR] 2.76, 95% CI 1.19–6.39)] and amniotic fluid index > 18 cm (aOR 2.60, 95% CI 1.08–6.27). Among the 27 cases, the diagnosis was made before the onset of labor, during the latent phase of labor, during the active phase of labor, and during the cesarean section in 3.7% (1/27), 40.7% (11/27), 11.1% (3/27) and 44.4% (12/27) of cases, respectively. In one case of cervical dilation with a diameter of 5 cm, we innovatively used a vaginal speculum for rapid diagnosis of face presentation. The rate of cesarean section and postpartum haemorrhage ≥ 500 ml in the face presentation group was higher than that of the control group (88.9% vs. 13.9%, P < 0.001, and 14.8% vs. 2.8%, P = 0.024), but the Apgar scores were similar in both sets of newborns. Among the 27 cases of face presentation, there were three cases of adverse maternal and neonatal outcomes, including one case of neonatal right brachial plexus injury and two cases of severe laceration of the lower segment of the uterus with postpartum haemorrhage ≥ 1000 ml. Conclusions: Face presentation was rare. Early diagnosis is difficult, and thus easily neglected. High parity and amniotic fluid index > 18 cm are risk factors for face presentation. An early diagnosis and proper management of face presentation could lead to good maternal and neonatal outcomes. [ABSTRACT FROM AUTHOR]

The aim of this study was to describe the origin and branches of the brachial plexus nerves in S. villosus, as well as the innervated musculature, contributing information to the field of comparative animal anatomy and providing insights for applied studies. Fifteen adult cadavers (eight males and seven females), previously identified, sexed, and fixed with a 10% aqueous formaldehyde solution were used. The patients underwent digital radiographic examinations of the cervical region to characterize the number of cervical vertebrae. The nerves were dissected to visualize the innervation of the intrinsic and extrinsic musculature of the thoracic limb. With the assistance of a costotome, the vertebrae were removed until visualization of the spinal cord and the roots, which gave rise to the nerve branches. The specimens presented seven cervical vertebrae, and the brachial plexus was characterized as postfixed, formed by connections between the last four cervical spinal nerves (C5, C6, C7, and C8) and the first two thoracic nerves (T1 and T2). The cranial, middle, and caudal trunks originate from the suprascapularis, subscapular, axillary, musculocutaneous, radial, median, and ulnar nerves for the intrinsic musculature and from the cranial pectoral, caudal pectoral, lateral thoracic, long thoracic, and thoracodorsal nerves for the extrinsic musculature. The ventral branches that contributed the most to plexus formation in the right antimer were C5 and C8, while in the left antimer, they were C7. The resulting nerves and the innervation for extrinsic and intrinsic musculature were similar to those observed in other rodents and representatives of the Mammalia class in general. [ABSTRACT FROM AUTHOR]

Background: Although the FLASH radiotherapy (FLASH) can improve the sparing of organs‐at‐risk (OAR) via the FLASH effect, it is generally a tradeoff between the physical dose coverage and the biological FLASH coverage, for which the concept of FLASH effective dose (FED) is needed to quantify the net improvement of FLASH, compared to the conventional radiotherapy (CONV). Purpose: This work will develop the first‐of‐its‐kind treatment planning method called simultaneous dose and dose rate optimization via dose modifying factor modeling (SDDRO‐DMF) for proton FLASH that directly optimizes FED. Methods: SDDRO‐DMF models and optimizes FED using FLASH dose modifying factor (DMF) models, which can be classified into two categories: (1) the phenomenological model of the FLASH effect, such as the FLASH effectiveness model (FEM); (2) the mechanistic model of the FLASH radiobiology, such as the radiolytic oxygen depletion (ROD) model. The general framework of SDDRO‐DMF will be developed, with specific DMF models using FEM and ROD, as a demonstration of general applicability of SDDRO‐DMF for proton FLASH via transmission beams (TB) or Bragg peaks (BP) with single‐field or multi‐field irradiation. The FLASH dose rate is modeled as pencil beam scanning dose rate. The solution algorithm for solving the inverse optimization problem of SDDRO‐DMF is based on iterative convex relaxation method. Results: SDDRO‐DMF is validated in comparison with IMPT and a state‐of‐the‐art method called SDDRO, with demonstrated efficacy and improvement for reducing the high dose and the high‐dose volume for OAR in terms of FED. For example, in a SBRT lung case of the dose‐limiting factor that the max dose of brachial plexus should be no more than 26 Gy, only SDDRO‐DMF met this max dose constraint; moreover, SDDRO‐DMF completely eliminated the high‐dose (V70%) volume to zero for CTV10mm (a high‐dose region as a 10 mm ring expansion of CTV). Conclusion: We have proposed a new proton FLASH optimization method called SDDRO‐DMF that directly optimizes FED using phenomenological or mechanistic models of DMF, and have demonstrated the efficacy of SDDO‐DMF in reducing the high‐dose volume or/and the high‐dose value for OAR, compared to IMPT and a state‐of‐the‐art method SDDRO. [ABSTRACT FROM AUTHOR]

(1) Background: Although most brachial plexus birth palsies show some spontaneous recovery, secondary operations are likely to follow. Accordingly, due to the loss of muscle innervation, the growth of the affected limb and the shoulder girdle is reduced. This is associated with pathological scapula positioning and rotation. The objective of this work was to clarify the relationship between length differences of the two clavicles and different types of scapular dyskinesia. (2) Methods: Twenty-five patients suffering from brachial plexus birth palsy were included in this retrospective study. There were eighteen female and seven male patients with a mean age of 10 years (2 to 23 years). CT scans of the thoracic cage, including both shoulder joints and both clavicles, were obtained preoperatively between 2010 and 2012. Radiographic measurements were taken of the axial plane and 3D reconstructions were produced. Functional evaluations of possible movement and scapular dyskinesia were performed. (3) Results: We found an increasing difference in the length of the clavicle (both in absolute and relative terms) in the children with more pronounced scapular dyskinesia. Additionally, with increasing clavicle length differences, the scapula was positioned in a deteriorated angle compared to the healthy side. Significant positive correlations were identified for the age and absolute difference of the clavicle length and the length and width of the scapula on the affected side. (4) Conclusion: Scapular dyskinesia, which is a common finding in brachial plexus birth palsy, is strongly related to reduced clavicle growth. Reduced clavicle length (which is a relatively easily examinable parameter) compared to the healthy side can be used to estimate the extent of scapular malpositioning on the thoracic cage. The extent and severity of scapular dyskinesia increases with augmented differences in the length of the clavicle. [ABSTRACT FROM AUTHOR]

Simple Summary: MR-Linac is a novel magnetic resonance imaging (MRI)-guided radiotherapy (IGRT) that combines MRI with a linear accelerator (Linac). Although radiation therapy (RT) for lung cancer has traditionally been managed with a computed tomography (CT)-based workflow, an MR-Linac-based workflow would be able to address the many limitations of current practice. This narrative review summarizes the latest developments in MR-Linac lung cancer treatment, as well as its boundaries. Future research directions are also highlighted. Compared with computed tomography (CT), magnetic resonance imaging (MRI) traditionally plays a very limited role in lung cancer management, although there is plenty of room for improvement in the current CT-based workflow, for example, in structures such as the brachial plexus and chest wall invasion, which are difficult to visualize with CT alone. Furthermore, in the treatment of high-risk tumors such as ultracentral lung cancer, treatment-associated toxicity currently still outweighs its benefits. The advent of MR-Linac, an MRI-guided radiotherapy (RT) that combines MRI with a linear accelerator, could potentially address these limitations. Compared with CT-based technologies, MR-Linac could offer superior soft tissue visualization, daily adaptive capability, real-time target tracking, and an early assessment of treatment response. Clinically, it could be especially advantageous in the treatment of central/ultracentral lung cancer, early-stage lung cancer, and locally advanced lung cancer. Increasing demands for stereotactic body radiotherapy (SBRT) for lung cancer have led to MR-Linac adoption in some cancer centers. In this review, a broad overview of the latest research on imaging-guided radiotherapy (IGRT) with MR-Linac for lung cancer management is provided, and development pertaining to artificial intelligence is also highlighted. New avenues of research are also discussed. [ABSTRACT FROM AUTHOR]