Search

We sought to systematically review and summarize dosimetric factors associated with radiation-induced brachial plexopathy (RIBP) after stereotactic body radiation therapy (SBRT) or hypofractionated image guided radiation therapy (HIGRT). From published studies identified from searches of PubMed and Embase databases, data quantifying risks of RIBP after 1- to 10-fraction SBRT/HIGRT were extracted and summarized. Published studies have reported <10% risks of RIBP with maximum doses (D max ) to the inferior aspect of the brachial plexus of 32 Gy in 5 fractions and 25 Gy in 3 fractions. For 10-fraction HIGRT, risks of RIBP appear to be low with D max < 40 to 50 Gy. For a given dose value, greater risks are anticipated with point volume-based metrics (ie, D 0.03-0.035cc : minimum dose to hottest 0.03-0.035 cc) versus D max . With SBRT/HIGRT, there were insufficient published data to predict risks of RIBP relative to brachial plexus dose-volume exposure. Minimizing maximum doses and possibly volume exposure of the brachial plexus can reduce risks of RIBP after SBRT/HIGRT. Further study is needed to better understand the effect of volume exposure on the brachial plexus and whether there are location-specific susceptibilities along or within the brachial plexus structure., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such injury. The objectives of this study were therefore to aggregate cases of BPI after CS, and to illuminate risk factors for BPI., Methods: Pubmed Central, EMBASE and MEDLINE databases were searched using free text: ("brachial plexus injury" or "brachial plexus injuries" or "brachial plexus palsy" or "brachial plexus palsies" or "Erb's palsy" or "Erb's palsies" or "brachial plexus birth injury" or "brachial plexus birth palsy") and ("caesarean" or "cesarean" or "Zavanelli" or "cesarian" or "caesarian" or "shoulder dystocia"). Studies with clinical details of BPI after CS were included. Studies were assessed using the National Institutes for Healthy Study Quality Assessment Tool for Case Series, Cohort and Case-Control Studies., Main Results: 39 studies were eligible. 299 infants sustained BPI after CS. 53% of cases with BPI after CS had risk factors for likely challenging handling/manipulation of the fetus prior to delivery, in the presence of considerable maternal or fetal concerns, and/or in the presence of poor access due to obesity or adhesions., Conclusions: In the presence of factors that would predispose to a challenging delivery, it is difficult to justify that BPI could occur due to in-utero, antepartum events alone. Surgeons should exercise care when operating on women with these risk factors., (© 2023. The Author(s).)

Purpose: This pilot study investigated the efficacy of passive range of motion (PROM) during the first year of life to prevent development of shoulder contractures in children with brachial plexus birth injury (BPBI) and identified facilitators and barriers to caregiver adherence with daily PROM., Methods: Five caregivers of children with upper trunk BPBI participated in retrospective interviews about the frequency with which they performed PROM during their child's first year of life including facilitators and barriers to daily adherence. Medical records were reviewed for documentation of caregiver-reported adherence and documented evidence of shoulder contracture by age one., Results: Three of the five children had documented shoulder contractures; all three had delayed initiation or inconsistent PROM in the first year of life. Two without shoulder contractures received consistent PROM throughout the first year of life. Making PROM part of the daily routine was a facilitator to adherence while family contextual factors were barriers., Conclusion: Absence of shoulder contracture may be related to consistent PROM throughout the first year of life; decreased frequency of PROM after the first month of life did not increase the risk of shoulder contracture. Consideration of family routines and context may facilitate adherence with PROM.

Objective: This study aimed to evaluate the outcomes associated with the implementation of simulation exercises to reduce the sequela of shoulder dystocia., Data Sources: Electronic databases (Ovid MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature database, and Scopus) were initially queried in June 2020 and updated in November 2020. The following 3 concepts were introduced and refined using the controlled vocabulary of the database: vaginal birth, shoulder dystocia, and simulation training. There were no limitations to the year of publication as part of the search strategy., Study Eligibility Criteria: We included all studies that reported on the frequency of shoulder dystocia and the associated complications before and after the implementation of interventional exercises to improve outcomes., Methods: Two authors independently assessed the abstracts and full-text articles of all studies for eligibility and evaluated the quality of the included studies using the Newcastle-Ottawa Scale. Any inconsistencies related to study evaluation or data extraction were resolved by a third author. The coprimary outcomes of this systematic review and meta-analysis were neonatal brachial plexus palsy diagnosed following deliveries complicated by shoulder dystocia and persistence of brachial palsy at 12 months or later. The secondary outcomes were the frequency of shoulder dystocia and cesarean delivery. Study effects were combined using a Bayesian meta-analysis and were reported as risk ratios and 95% credible intervals (Crs)., Results: Of the 372 articles reviewed, 16 publications, which included 428,552 deliveries with 217,713 (50.8%) deliveries during the preintervention and 210,839 (49.2%) deliveries during the postinterventional period, were included in the meta-analysis. The incidence of neonatal brachial plexus palsy after shoulder dystocia decreased from 12.1% to 5.7% (risk ratio, 0.37; 95% Cr, 0.26-0.57; probability of reduction 100%). The overall proportion of neonatal brachial plexus palsy decreased, but with less precision, from 0.3% to 0.1% (risk ratio, 0.53; 95% Cr, 0.21-1.26; probability of reduction 94%). Two studies followed newborns with brachial plexus palsy for at least 12 months. One study that reported on persistent neonatal brachial plexus palsy at 12 months among 1148 shoulder dystocia cases noted a reduction in persistent neonatal brachial plexus palsy from 1.9% to 0.2% of shoulder dystocia cases (risk ratio, 0.13; 95% confidence interval, 0.04-0.49). In contrast, the study that reported on persistent neonatal brachial plexus palsy at 12 months for all deliveries noted that it did not change significantly, namely from 0.3 to 0.2 per 1000 births (risk ratio, 0.77; 95% confidence interval, 0.31-1.90). Following the implementation of shoulder dystocia interventional exercises, the diagnosis of shoulder dystocia increased significantly from 1.2% to 1.7% of vaginal deliveries (risk ratio, 1.39; 95% Cr, 1.19-1.65; probability of increase 100%). Compared with the preimplementation period, the cesarean delivery rate increased postimplementation from 21.2% to 25.9% (risk ratio, 1.22; 95% Cr, 0.93-1.59; probability of increase 93%). We created an online tool (https://ccrebm-bell.shinyapps.io/sdmeta/) that permits calculation of the absolute risk reduction and absolute risk increase attributable to the intervention vis-à-vis the incidence of shoulder dystocia, neonatal brachial plexus palsy, and cesarean deliveries., Conclusion: Introduction of shoulder dystocia interventional exercises decreased the rate of neonatal brachial plexus palsy per shoulder dystocia case; the data on persistence of neonatal brachial plexus palsy beyond 12 months is limited and contradictory. Implementation of the interventions was associated with an increase in the diagnosis of shoulder dystocia and rate of cesarean deliveries., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study is to identify the advancing role of Intraoperative Neurophysiological Monitoring (IONM) in detecting and preventing nerve injuries during shoulder surgery procedures. Methods: We performed a retrospective analysis of IONM data from ten shoulder procedures. The patients consisted of nine females and one male with ages ranging from 67 to 81 years (median: 74 years). IONM modalities utilized were bilateral Somatosensory Evoked Potentials (SSEP), Transcranial Motor Evoked Potentials (TCeMEP), ipsilateral Electromyogram (EMG) from upper extremity muscles and Train of four (TOF) recordings. Results: A decrease in signals was noted in three patients (30%). Only upper SSEP amplitude decreased in one patient; both upper extremity SSEP and TCeMEP decreased in two patients. Only one patient had poor baseline radial nerve SSEP that improved during the surgery. We performed spontaneous EMG (s-EMG) in all ten patients and successfully recorded triggered (t-EMG) in seven patients (71.4%). In one patient, SSEP and TCeMEP did not improve, and the patient woke up with deficits. Conclusions: In this small series, we were able to identify real-time impending nerve injury. The use of IONM alerted and may have prevented intraoperative nerve injury in 30% of the patients in this series. In one patient, SSEP and TCeMEP did not recover even after the intervention due to severe blood loss. The patient woke up with sensory and motor deficits. The utilization of multimodality IONM can be helpful due to signal changes, therefore minimizing the frequency of nerve injury and deficits.

Objectives/hypothesis: The potential for brachial plexopathy due to arm positioning is a major concern regarding the robotic transaxillary approach. Intraoperative nerve monitoring via somatosensory evoked potential (SSEP) has been suggested to prevent such injury. In this study, we examined the use of SSEP in detecting imminent brachial plexus traction during robotic transaxillary thyroid and parathyroid surgery., Study Design: Retrospective case series., Methods: A analysis was performed for all patients undergoing robotic transaxillary surgery with continuous intraoperative SSEP monitoring at a North American institution between 2015 and 2017. A significant intraoperative SSEP change was defined as a decrease in signal amplitude of >50% or an increase in latency of >10% from baseline established during preoperative positioning., Results: One hundred thirty-seven robotic transaxillary surgeries using SSEP monitoring were performed on 123 patients. Seven patients (5.1%) developed significant changes, with an average SSEP amplitude reduction of 73% ± 12% recorded at the signals' nadir. Immediate arm repositioning resulted in recovery of signals and complete return to baseline parameters in 14.3 ± 9.2 minutes. There was no difference in age (40.4 ± 9.4 years vs. 44.5 ± 13.4 years; P = .31) or body mass index (27.3 ± 3.7 kg/m 2 vs. 26.9 ± 6.1 kg/m 2 ; P = .79) between cases with and without SSEP change. Operative time was shorter for patients with significant SSEP change (131.6 ± 14.7 minutes vs. 146.5 ± 46.7 minutes; P = .048). There were no postoperative positional brachial plexus injuries., Conclusions: SSEP is a novel, safe, and reliable tool in detection of position-related brachial plexus neuropathy. Intraoperative monitoring using SSEP can play a vital role in early recognition and prevention of injury during robotic transaxillary thyroid and parathyroid surgery., Level of Evidence: 4 Laryngoscope, 129:2663-2668, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The aim of this study was to evaluate the differences in transcranial electric motor-evoked potentials - TceMEP on upper limbs and the incidences of postoperative brachial plexopathy between patients with kyphotic and scoliotic trunk shapes., Methods: In the period of January 2011-January 2017, 61 consecutive patients (mean age: 18.4 years ± 4.4 years (range: 10-32)) with pediatric spinal deformity underwent surgery in our Department. Eight of them had a kyphotic trunk deformity (Scheuermann kyphosis, neurofibromatosis, posterior thoracic hemivertebra), and the rest of the 53 patients had a scoliotic trunk deformity (mostly adolescent idiopathic scoliosis - AIS, lateral hemivertebra). The TceMEP recordings in all four limbs were analyzed every 30 min, or upon the surgeon's command. Upper limb TceMEP recordings were used as a control of systemic and anesthetic related changes, and as the indicator of positioning brachial plexopathy., Results: Four out of 8 patients (50.0%) from the kyphotic group experienced noteworthy decreases in TceMEP amplitude (≥65%) in one or both arms, and only 2 out of 53 patients (3.8%) from the scoliotic group, confirming significant statistical difference (Chi-square 16.75, p < 0.05). Two out of 8 patients with decreases in TceMEP amplitude suffered from transitory postoperative brachial plexopathy, and both of them were from the kyphotic group., Conclusion: It seems that kyphotic trunks have a higher risk for positioning-related brachial plexopathy, probably due to distribution of trunk's weight onto only four points (two iliac bones and two shoulders), compared to the scoliotic trunks that have wider weight-bearing areas. We emphasize the importance of proper patient positioning and close intraoperative neuro-monitoring of all four limbs in more than one channel per limb., Level of Evidence: Level IV Therapeutic Study., (Copyright © 2019 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

Background: Brachial plexopathy is not uncommon after shoulder surgery. Although thought to be due to stretch neuropathy, its etiology is poorly understood. This study aimed to identify arm positions and maneuvers that may risk causing brachial plexopathy during shoulder arthroplasty., Methods: Tensions in the cords of the brachial plexuses of 6 human cadaveric upper limbs were measured using load cells while each limb was placed in different arm positions and while they underwent shoulder hemiarthroplasty and revision reverse arthroplasty. Arthroplasty procedures in 4 specimens were performed with standard limb positioning (unsupported), and 2 specimens were supported from under the elbow (supported). Each cord then underwent biomechanical testing to identify tension corresponding to 10% strain (the stretch neuropathy threshold in animal models)., Results: Tensions exceeding 15 N, 11 N, and 9 N in the lateral, medial, and posterior cords, respectively, produced 10% strain. Shoulder abduction >70° and combined external rotation >60° with extension >50° increased medial cord tension above the 10% strain threshold. Medial cord tensions (mean ± standard error of the mean) in unsupported specimens increased over baseline during hemiarthroplasty (sounder insertion [4.7 ± 0.6 N, P = .04], prosthesis impaction [6.1 ± 0.8 N, P = .04], and arthroplasty reduction [5.0 ± 0.7 N, P = .04]) and revision reverse arthroplasty (retractor positioning [7.2 ± 0.8 N, P = .02]). Supported specimens experienced lower tensions than unsupported specimens., Conclusions: Shoulder abduction >70°, combined external rotation >60° with extension >50°, and downward forces on the humeral shaft may risk causing brachial plexopathy. Retractor placement, sounder insertion, humeral prosthesis impaction, and arthroplasty reduction increase medial cord tensions during shoulder arthroplasty. Supporting the arm from under the elbow protected the brachial plexus in this cadaveric model., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Lymphangiomas are rare malformations of the lymphatic system and can often be found in the neck region, where its proximity to the brachial plexus may cause compressive neuropathy and possible iatrogenic injuries during dissection. We report 4 cases of lymphangiomas with compression of the brachial plexus that were successfully removed without permanent nerve injuries and present a literature review of the preoperative approach and surgical techniques. A preoperative multidisciplinary approach can help surgeons predict what they may encounter during the surgery. A careful and stepwise dissection of the vital structures surrounding the tumor, especially the brachial plexus anatomy, is critical to avoiding severe complications. Incomplete resection or leakage of the lymph could result in higher rate of recurrence.

Background: C5 palsy is a serious complication after cervical decompression surgery in which the patient shows a deterioration in power of the deltoid or biceps brachii by at least one grade in the manual muscle test without aggravation of lower extremity function. Although there are several hypotheses regarding the etiology of C5 palsy, the pathogenesis and preventive measures remain unidentified and many other controversies remain., Objective: To systematically review the clinical features, risk factors, mechanism, and preventive measures of C5 palsy after posterior cervical decompression surgery., Materials and Methods: PubMed was searched to identify eligible studies that contained more than 10 cases and focused on C5 palsy. Microsoft Excel was used to analyze the data. Statistical comparisons were made when appropriate., Results: Out of 718 papers involving C5 palsy, 28 met the inclusion criteria. The average incidence rate was 7.8% (range, 1.4-23.0%). Risk factors for C5 palsy included age, male gender, ossification of the posterior longitudinal ligament, and stenosis of the C4-C5 intervertebral foramen. C5 palsy occurred from immediately to 2 months after surgery, and recovery time ranged from 48 h to 41 months. Hypotheses for the mechanism of C5 palsy included root involvement and spinal cord impairment. Foraminotomy and intraoperative neuromonitoring were the two main methods used to prevent C5 palsy., Conclusion: C5 palsy is a serious complication occurring at the early stage after cervical decompression surgery. Foraminotomy and intraoperative neuromonitoring were the two main methods to prevent C5 palsy. The incidence of C5 palsy is low, but it can place a serious burden on the patients' quality of life and finances. The risk factors and mechanism of C5 palsy are still controversial. However, under conservative therapy, the prognosis is usually good. Higher quality studies are necessary for drawing more reliable and convincing conclusions about this disease.

Given the ballistic opportunities it offers, intensity-modulated radiotherapy has emerged as the gold standard treatment for head and neck cancers. Protection of organs at risk is one of the objectives of optimization during the planning process. The compliance of dose constraints to the nervous system must be prioritized over all others. To avoid complications, it is recommended to respect a maximum dose of 50Gy to the spinal cord, and 60Gy to the brachial plexus using conventional fractionation of 2Gy per fraction. These constraints can be adapted depending on the clinical situation; they will probably be refocused by the follow-up of the IMRT studies., (Copyright © 2016. Published by Elsevier SAS.)

Objectives/hypothesis: During robot-assisted transaxillary thyroidectomy, the patient's arm is maintained in an overhead flexed position for a prolonged time, which poses a risk of postoperative brachial plexopathy. The aim of the study was to identify the causes of brachial plexopathy and to assess the benefit of intraoperative neurophysiological monitoring (IONM) in preventing positional brachial plexopathy in this setting., Study Design: Retrospective case series., Methods: The computerized database of a tertiary medical center was searched for all consecutive patients who underwent robot-assisted transaxillary thyroidectomy between 2012 and 2014. Clinical, operative, and outcome parameters were collected from the medical files. Findings were compared between patients operated with and without IONM., Results: The cohort included 30 patients, 14 operated with IONM and 16 without. Three events of impending brachial plexopathy were detected in the monitored group. The monitored group had significantly better shoulder movement (P = .003), a lower rate of hypoesthesia (P = .011), less pain (P = .001) in the early postoperative period than the nonmonitored group and higher quality of life in the early postoperative period (P = .012). The monitored group was significantly younger than the nonmonitored one (P = .02) and had a significantly larger diameter of thyroid nodule than the nonmonitored group (P = .043)., Conclusions: IONM during robot-assisted transaxillary thyroidectomy may improve short-term postoperative pain and shoulder movement and longer-term quality of life., Level of Evidence: 4 Laryngoscope, 126:2187-2193, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Editorial Note: It has been brought to the authors' attention that there may be an error in the data (Analysis 1.9). This is currently under investigation, and a correction will be made if the data are found to be incorrect. Details can be found in the comments., Background: Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section., Objectives: To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies., Selection Criteria: Randomised trials of induction of labour for suspected fetal macrosomia., Data Collection and Analysis: Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach., Main Results: We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias.Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate-quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low-quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate-quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high-quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low-quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five-minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low-quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate-quality evidence, respectively). Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) -178.03 g, 95% CI -315.26 to -40.81; 1190 infants; four studies; I(2) = 89%). In one study with data for 818 women, third- and fourth-degree perineal tears were increased in the induction group (RR 3.70, 95% CI 1.04 to 13.17).For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates., Authors' Conclusions: Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The unexpected observation in the induction group of increased perineal damage, and the plausible, but of uncertain significance, observation of increased use of phototherapy, both in the largest trial, should also be kept in mind.Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents.Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.

OBJECTIVE Neonatal brachial plexus palsy (NBPP) occurs due to the stretching of the nerves of the brachial plexus before, during, or after delivery. NBPP can resolve spontaneously or become persistent. To determine if nerve surgery is indicated, predicting recovery is necessary but difficult. Historical attempts explored the association of recovery with only clinical and electrodiagnostic examinations. However, no data exist regarding the neonatal and peripartum factors associated with NBPP persistence. METHODS This retrospective cohort study involved all NBPP patients at the University of Michigan between 2005 and 2015. Peripartum and neonatal factors were assessed for their association with persistent NBPP at 1 year, as defined as the presence of musculoskeletal contractures or an active range of motion that deviated from normal by > 10° (shoulder, elbow, hand, and finger ranges of motion were recorded). Standard statistical methods were used. RESULTS Of 382 children with NBPP, 85% had persistent NBPP at 1 year. A wide range of neonatal and peripartum factors was explored. We found that cephalic presentation, induction or augmentation of labor, birth weight > 9 lbs, and the presence of Horner syndrome all significantly increased the odds of persistence at 1 year, while cesarean delivery and Narakas Grade I to II injury significantly reduced the odds of persistence. CONCLUSIONS Peripartum/neonatal factors were identified that significantly altered the odds of having persistent NBPP at 1 year. Combining these peripartum/neonatal factors with previously published clinical examination findings associated with persistence should allow the development of a prediction algorithm. The implementation of this algorithm may allow the earlier recognition of those cases likely to persist and thus enable earlier intervention, which may improve surgical outcomes.

Interscalene brachial plexus block (IBPB) has been widely used in shoulder surgical procedures. The incidence of postoperative neural injury has been estimated to be as high as 3 %. We report a long-term neurologic deficit after a nerve stimulator assisted brachial plexus block. A 55 year-old male, with right shoulder impingement syndrome was scheduled for elective surgery. The patient was given an oral dose of 10 mg of diazepam prior to the nerve stimulator assisted brachial plexus block. The patient immediately complained, as soon as the needle was placed in the interscalene area, of a sharp pain in his right arm and he was sedated further. Twenty-four hours later, the patient complained of severe shoulder and arm pain that required an increased dose of analgesics. Severe peri-scapular atrophy developed over the following days. Electromyography studies revealed an upper trunk plexus injury with severe denervation of the supraspinatus, infraspinatus and deltoid muscles together with a moderate denervation of the biceps brachii muscle. Chest X-rays showed a diaphragmatic palsy which was not present post operatively. Pulmonary function tests were also affected. Phrenic nerve paralysis was still present 18 months after the block as was dysfunction of the brachial plexus resulting in an inability to perform flexion, abduction and external rotation of the right shoulder. Severe brachial plexopathy was probably due to a local anesthetic having been administrated through the perineurium and into the nerve fascicles. Severe brachial plexopathy is an uncommon but catastrophic complication of IBPB. We propose a clinical algorithm using ultrasound guidance during nerve blocks as a safer technique of regional anesthesia.

Background: The mode of delivery in term singleton breech presentation has been debated for more than half a century and has been examined in both randomised and observational studies., Objective: To determine the absolute and relative risks of perinatal mortality and morbidity in planned vaginal breech delivery., Search Strategy: A computer-based literature search was conducted mainly in the databases of HINARI, PubMed and Google scholar for studies comparing planned vaginal delivery and planned caesarean section., Selection Criteria: Studies that assessed the perinatal mortality and morbidity in relation to the term singleton breech mode of delivery between 1993 and 2014 were included., Data Collection and Analysis: In this meta-analysis, 27 articles with a total sample size of 258 953 women were included. Relative and absolute risks of perinatal mortality and morbidity in relation to mode of delivery were determined., Main Results: The relative risk of perinatal mortality and morbidity was about two- to five-fold higher in the planned vaginal than in the planned caesarean delivery group. The absolute risks of perinatal mortality, fetal neurologic morbidity, birth trauma, 5-minute Apgar score <7 and neonatal asphyxia in the planned vaginal delivery group were 0.3, 0.7, 0.7, 2.4 and 3.3%, respectively., Conclusion: Perinatal mortality and morbidity in the planned vaginal breech delivery were significantly higher than with planned caesarean delivery. Even taking into account the relatively low absolute risks of vaginal breech delivery, the current study substantiates the practice of individualised decision-making on the route of delivery in a term breech presentation., Tweetable Abstract: Although vaginal breech delivery is controversial, this review has shown low absolute risk., (© 2015 Royal College of Obstetricians and Gynaecologists.)

This is the first of a two-part article discussing loadcarriage- related paresthesias, including brachial plexus lesions (rucksack palsy), digitalgia paresthetica, and meralgia paresthetica. Paresthesias are sensations of numbness, burning, and/or tingling, usually experienced as a result of nerve injury, compression, traction, or irritation. Rucksack palsy is a traction or compression injury to the brachial plexus, caused by the shoulder straps of the rucksack. The patient presents with paresthesia, paralysis, cramping with pain, and muscle weakness of the upper limb. Muscle-strength losses appear to be greater in those carrying heavier loads. Hypothetical risk factors for rucksack palsy include improper load distribution, longer carriage distances, and load weight. Nerve traction, compression, and symptoms may be reduced by use of a rucksack hip belt; wider, better-padded, and proper adjustment of the shoulder straps; reduction of weight in the rucksack; a more symmetric distribution of the load; and resistance training to improve the strength and hypertrophy of the shoulder muscles. Assessment and neck joint and nerve mobilization may relieve brachial plexus tension and reduce symptoms. Another load-carriage-related disorder is digitalgia paresthetica, likely caused by compression of the sensory digital nerves in the foot during load carriage. Patients have paresthesia in the toes. Although no studies have demonstrated effective prevention measures for digitalgia paresthetica, reducing loads and march distances may help by decreasing the forces and repetitive stress on the foot and lower leg. Specialty evaluations by a physical therapist, podiatrist, or other healthcare provider are important to rule out entrapment neuropathies such as tarsal tunnel syndrome. Part 2 of this article will discuss meralgia paresthetica., (2016.)

Background: Poor outcomes after breech birth might be the result of underlying conditions causing breech presentation or due to factors associated with the delivery., Objectives: To assess the effects of planned caesarean section for singleton breech presentation at term on measures of pregnancy outcome., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015)., Selection Criteria: Randomised trials comparing planned caesarean section for singleton breech presentation at term with planned vaginal birth., Data Collection and Analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy., Main Results: Three trials (2396 participants) were included in the review. Caesarean delivery occurred in 550/1227 (45%) of those women allocated to a vaginal delivery protocol and 1060/1169 (91%) of those women allocated to planned caesarean section (average risk ratio (RR) random-effects, 1.88, 95% confidence interval (CI) 1.60 to 2.20; three studies, 2396 women, evidence graded low quality). Perinatal or neonatal death (excluding fatal anomalies) or severe neonatal morbidity was reduced with a policy of planned caesarean section in settings with a low national perinatal mortality rate (RR 0.07, 95% CI 0.02 to 0.29, one study, 1025 women, evidence graded moderate quality), but not in settings with a high national perinatal mortality rate (RR 0.66, 95% CI 0.35 to 1.24, one study, 1053 women, evidence graded low quality). The difference between subgroups was significant (Test for subgroup differences: Chi² = 8.01, df = 1 (P = 0.005), I² = 87.5%). Due to this significant heterogeneity, a random-effects analysis was performed. The average overall effect was not statistically significant (RR 0.23, 95% CI 0.02 to 2.44, one study, 2078 infants). Perinatal or neonatal death (excluding fatal anomalies) was reduced with planned caesarean section (RR 0.29, 95% CI 0.10 to 0.86, three studies, 2388 women). The proportional reductions were similar for countries with low and high national perinatal mortality rates.The numbers studied were too small to satisfactorily address reductions in birth trauma and brachial plexus injury with planned caesarean section. Neither of these outcomes reached statistical significance (birth trauma: RR 0.42, 95% CI 0.16 to 1.10, one study, 2062 infants (20 events),evidence graded low quality; brachial plexus injury: RR 0.35, 95% CI 0.08 to 1.47, three studies, 2375 infants (nine events)).Planned caesarean section was associated with modestly increased short-term maternal morbidity (RR 1.29, 95% CI 1.03 to 1.61, three studies, 2396 women,low quality evidence). At three months after delivery, women allocated to the planned caesarean section group reported less urinary incontinence (RR 0.62, 95% CI 0.41 to 0.93, one study, 1595 women); no difference in 'any pain' (RR 1.09, 95% CI 0.93 to 1.29, one study, 1593 women,low quality evidence); more abdominal pain (RR 1.89, 95% CI 1.29 to 2.79, one study, 1593 women); and less perineal pain (RR 0.32, 95% CI 0.18 to 0.58, one study, 1593 women).At two years, there were no differences in the combined outcome 'death or neurodevelopmental delay' (RR 1.09, 95% CI 0.52 to 2.30, one study, 920 children,evidence graded low quality); more infants who had been allocated to planned caesarean delivery had medical problems at two years (RR 1.41, 95% CI 1.05 to 1.89, one study, 843 children). Maternal outcomes at two years were also similar. In countries with low perinatal mortality rates, the protocol of planned caesarean section was associated with lower healthcare costs, expressed in 2002 Canadian dollars (mean difference -$877.00, 95% CI -894.89 to -859.11, one study, 1027 women).All of the trials included in this review had design limitations, and the GRADE level of evidence was mostly low. No studies attempted to blind the intervention, and the process of random allocation was suboptimal in two studies. Two of the three trials had serious design limitations, however these studies contributed to fewer outcomes than the large multi-centre trial with lower risk of bias., Authors' Conclusions: Planned caesarean section compared with planned vaginal birth reduced perinatal or neonatal death as well as the composite outcome death or serious neonatal morbidity, at the expense of somewhat increased maternal morbidity. In a subset with 2-year follow up, infant medical problems were increased following planned caesarean section and no difference in long-term neurodevelopmental delay or the outcome "death or neurodevelopmental delay" was found, though the numbers were too small to exclude the possibility of an important difference in either direction.The benefits need to be weighed against factors such as the mother's preference for vaginal birth and risks such as future pregnancy complications in the woman's specific healthcare setting. The option of external cephalic version is dealt with in separate reviews. The data from this review cannot be generalised to settings where caesarean section is not readily available, or to methods of breech delivery that differ materially from the clinical delivery protocols used in the trials reviewed. The review will help to inform individualised decision-making regarding breech delivery. Research on strategies to improve the safety of breech delivery and to further investigate the possible association of caesarean section with infant medical problems is needed.

Purpose of Review: This article reviews recent significant contributions to the literature concerning advanced operative obstetric procedures used for rotational vaginal deliveries and their alternative, primary caesarean section., Recent Findings: Rising caesarean section rates are a global concern. Caesarean section in the second stage of labour is associated with high rates of maternal and fetal morbidity. Rotational vaginal deliveries may reduce the caesarean section rate without additional adverse effects on maternal and fetal outcomes. A recent national trainees' survey highlighted that training in the management of operative birth in the second stage of labour, especially when there is malposition of the fetal head, is a priority., Summary: There is a need for evidence-based guidelines, including standardized documentation of these advanced procedures. Training strategies for junior practitioners to acquire these skills and for experienced practitioners to maintain and disseminate their skills should be prioritized. The safety of rotational delivery methods versus primary caesarean section is likely to prove difficult to assess directly, in the context of a randomized controlled trial, but may be approximated via a national prospective audit.

Purpose: The first part of the study involved data collection for the detection of geographic variations and chronologic fluctuations in the rates of shoulder dystocia. The second part of the research evaluated head-to-body delivery times in cases of arrest of the shoulders at birth that had resulted in fetal damage during the last four decades in the USA., Methods: The study of geographic and chronologic changes in the rates of shoulder dystocia rested on reported statistics coming from the USA and 11 other countries. These data were obtained by computer search. Evaluation of head-to-body delivery times rested on 104 well-documented cases that resulted in permanent neonatal damage., Results: Literary reports of shoulder dystocia indicate that the incidence of shoulder dystocia has increased in the USA about fourfold since the middle of the twentieth century. No comparable trend has been reported from most other countries. Study of head-to-body delivery times revealed that more than two-thirds of all injured fetuses had been extracted from the birth canal within 2 minutes., Conclusions: Incidents of shoulder dystocia began to escalate in the USA during the 1980s, shortly after the introduction of "active management" of the birthing process. This new technique replaced a conservative philosophy which had recommended abstinence from intervention on the part of the accoucheur. The authors consider the interventionist approach largely responsible for the exponential increase in the rates of shoulder dystocia in the USA. They recommend adherence to the traditional method of delivery on the part of obstetricians in Europe and elsewhere.

This study aimed to evaluate whether placing dose constraints on the brachial plexus (BP) could provide dosimetric benefits in patients with nasopharyngeal carcinoma (NPC) undergoing intensity-modulated radiation therapy (IMRT). Planning CT images for 30 patients with NPC treated with definitive IMRT were retrospectively reviewed. Target volumes, the BP and other critical structures were delineated; two separate IMRT plans were designed for each patient: one set no restrictions for the BP; the other considered the BP as a critical structure for which a maximum dose limit of ≤66 Gy was set. No significant differences between the two plans were observed in the conformity index, homogeneity index, maximum dose to the planning target volumes (PTVs), minimum dose to the PTVs, percentages of the volume of the PTVnx and PTVnd receiving more than 110% of the prescribed dose, or percentages of the volume of the PTVs receiving 95% and > 93% of the prescribed dose. Dose constraints significantly reduced the maximum dose, mean dose, V45, V50, V54, V60, V66 and V70 to the BP. Dose constraints significantly reduced the maximum dose to the BP, V45, V60 and V66 in both N0-1 and N2-3 disease; however, the magnitude of the dosimetric gain for each parameter between N0-1 and N2-3 disease was not significantly different, except for the V60 and V66. In conclusion, placing dose constraints on the BP can significantly decrease the irradiated volume and dose, without compromising adequate dose delivery to the target volume., (© The Author 2014. Published by Oxford University Press on behalf of The Japan Radiation Research Society and Japanese Society for Radiation Oncology.)

C5 nerve root palsy is a rare and potentially debilitating complication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication. We carried out a systematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery. Although many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely. Early detection and prevention of a C5 nerve root palsy using neurophysiological monitoring and variations in surgical technique show promise by allowing surgeons to minimise or prevent the incidence of C5 palsy. Conservative treatment is the current treatment of choice; most patients make a full recovery within two years., (©2014 The British Editorial Society of Bone & Joint Surgery.)

Epidemiological knowledge of the incidence, prevalence, and temporal changes of neonatal brachial plexuses palsy (NBPP) should assist the clinician, avert unnecessary interventions, and help formulate evidence-based health policies. A summary of 63 publications in the English language with over 17 million births and 24,000 NBPPs is notable for six things. First, the rate of NBPP in the US and other countries is comparable: 1.5 vs. 1.3 per 1000 total births, respectively. Second, the rate of NBPP may be decreasing: 0.9, 1.0 and 0.5 per 1,000 births for publications before 1990, 1990-2000, and after 2000, respectively. Third, the likelihood of not having concomitant shoulder dystocia with NBPP was 76% overall, though it varied by whether the publication was from the US (78%) vs. other countries (47%). Fourth, the likelihood of NBPP being permanent (lasting at least 12 months) was 10-18% in the US-based reports and 19-23% in other countries. Fifth, in studies from the US, the rate of permanent NBPP is 1.1-2.2 per 10,000 births and 2.9-3.7 per 10,000 births in other nations. Sixth, we estimate that approximately 5000 NBPPs occur every year in the US, of which over 580-1050 are permanent, and that since birth, 63,000 adults have been afflicted with persistent paresis of their brachial plexus. The exceedingly infrequent nature of permanent NBPP necessitates a multi-center study to improve our understanding of the antecedent factors and to abate the long-term sequela., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Shoulder dystocia is an obstetric emergency that occurs when the fetal shoulders become impacted at the pelvic inlet. Management is based on performing maneuvers to alleviate this impaction. A number of protocols and training mnemonics have been developed to assist in managing shoulder dystocia when it occurs. This article reviews the evidence regarding the performance, timing, and sequence of these maneuvers; reviews the mechanism of fetal injury in relation to shoulder dystocia; and discusses issues concerning documentation of the care provided during this obstetric emergency., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Neonatal brachial plexus palsy (NBPP) is an unpredictable complication of childbirth. Historic risk factors for the occurrence of NBPP have included shoulder dystocia, fetal macrosomia, labor abnormalities, operative vaginal delivery, and prior NBPP. However, whether studied alone or in combination, these risk factors have not been shown to be reliable predictors. The majority of NBPP cases occur in women with infants <4500 g who are not diabetic and have no other identifiable risk factors. Furthermore, cesarean section reduces but does not completely eliminate the risk for NBPP. In this section, the relationship of these historic obstetric risk factors to the occurrence of NBPP is further explored., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Complications of shoulder dystocia are divided into fetal and maternal. Fetal brachial plexus injury (BPI) is the most common fetal complication occurring in 4-40% of cases. BPI has also been reported in abdominal deliveries and in deliveries not complicated by shoulder dystocia. Fractures of the fetal humerus and clavicle occur in about 10.6% of cases of shoulder dystocia and usually heal with no sequel. Hypoxic ischemic brain injury is reported in 0.5-23% of cases of shoulder dystocia. The risk correlates with the duration of head-to-body delivery and is especially increased when the duration is >5 min. Fetal death is rare and is reported in 0.4% of cases. Maternal complications of shoulder dystocia include post-partum hemorrhage, vaginal lacerations, anal tears, and uterine rupture. The psychological stress impact of shoulder dystocia is under-recognized and deserves counseling prior to home discharge., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Data from a prospective screening protocol administered for patients previously irradiated for head-and-neck cancer was analyzed to identify dosimetric predictors of brachial plexus-associated neuropathy., Methods and Materials: Three hundred fifty-two patients who had previously completed radiation therapy for squamous cell carcinoma of the head and neck were prospectively screened from August 2007 to April 2013 using a standardized self-administered instrument for symptoms of neuropathy thought to be related to brachial plexus injury. All patients were disease-free at the time of screening. The median time from radiation therapy was 40 months (range, 6-111 months). A total of 177 patients (50%) underwent neck dissection. Two hundred twenty-one patients (63%) received concurrent chemotherapy., Results: Fifty-one patients (14%) reported brachial plexus-related neuropathic symptoms with the most common being ipsilateral pain (50%), numbness/tingling (40%), and motor weakness and/or muscle atrophy (25%). The 3- and 5-year estimates of freedom from brachial plexus-associated neuropathy were 86% and 81%, respectively. Clinical/pathological N3 disease (P<.001) and maximum radiation dose to the ipsilateral brachial plexus (P=.01) were significantly associated with neuropathic symptoms. Cox regression analysis revealed significant dose-volume effects for brachial plexus-associated neuropathy. The volume of the ipsilateral brachial plexus receiving >70 Gy (V70) predicted for symptoms, with the incidence increasing with V70 >10% (P<.001). A correlation was also observed for the volume receiving >74 Gy (V74) among patients treated without neck dissection, with a cutoff of 4% predictive of symptoms (P=.038)., Conclusions: Dose-volume guidelines were developed for radiation planning that may limit brachial plexus-related neuropathies., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate the pressure placed on the shoulders as a function of varying degrees of head-down tilt (the Trendelenburg position) and to compare these pressures among 3 different patient-positioning systems., Study Design: Participants were placed in the dorsal-lithotomy position with arms tucked and tilted at 5, 10, 15, 20, 25, and 30 degrees of head-down tilt. Using a manometer, we measured the pressure (centimeters of water) on the shoulders at each angle for 3 support devices: the Skytron shoulder support (Skytron, Grand Rapids, MI), the Allen shoulder support (Allen Medical Systems, Acton, MA), and the Allen Hug-u-Vac., Results: Among 23 participants, body mass index (mean ± SD) was 24.5 ± 4.3 kg/m(2). As the tilt angle increased, so did the shoulder pressure for all support systems. At a 30-degree Trendelenburg position, the Allen Hug-u-Vac transmitted less pressure to the shoulders than the Skytron (right and left, P < .001) and the Allen shoulder supports system (right, P < .001; left, P = .434). Each participant was asked, "Which system was most comfortable?" Seventy-four percent of the participants reported that they preferred the Hug-u-Vac (P < .001)., Conclusion: Shoulder pressure increases as tilt angle increases. Of the 3 support systems that were tested, the Allen Hug-u-Vac transmitted less pressure to the shoulders at a 30-degree Trendelenburg position than the Skytron and the Allen shoulder support systems., (Copyright © 2013 Mosby, Inc. All rights reserved.)

In this study, the role of valproic acid (VPA) in protecting motoneuron after brachial plexus root avulsion was investigated in adult rats. Sixty rats were used in this study, and underwent the brachial plexus root avulsion injury, which was created by using a micro-hemostat forceps to pull out brachial plexus root from the intervertebral foramen. The animals were divided into two groups, VPA group administered with VPA dissolved in drinking water (300 mg/kg) daily, and control group had drinking water every day. The spinal cords (C5-T1) were harvested at day 1, 2, 3, 7, 14, and 28 for immunohistochemistry analysis, TUNEL staining, Nissl staining, and electron microscopy, respectively. The results showed that with VPA administration, the survival of motoneurons was promoted and the cell apoptosis was inhibited. The number of c-Jun and Bcl-2 positive motoneurons was increased immediately after avulsion both in control and VPA group, however, the percent of c-Jun positive motoneurons was decreased and the percent of Bcl-2 positive motoneurons was increased by VPA treatment significantly. Our results indicated that motoneurons were protected by VPA against cell death induced by brachial plexus root avulsion through c-Jun inhibition and Bcl-2 induction., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: Accumulating evidence suggests that brachial plexopathy following head and neck cancer radiotherapy may be underreported and that this toxicity is associated with a dose-response. Our purpose was to determine whether the dose to the brachial plexus (BP) can be constrained, without compromising regional control., Methods: The radiation plans of 324 patients with oropharyngeal carcinoma (OPC) treated with intensity-modulated radiation therapy (IMRT) were reviewed. We identified 42 patients (13%) with gross nodal disease <1 cm from the BP. Normal tissue constraints included a maximum dose of 66 Gy and a D05 of 60 Gy for the BP. These criteria took precedence over planning target volume (PTV) coverage of nodal disease near the BP., Results: There was only one regional failure in the vicinity of the BP, salvaged with neck dissection (ND) and regional re-irradiation. There have been no reported episodes of brachial plexopathy to date., Conclusions: In combined-modality therapy, including ND as salvage, regional control did not appear to be compromised by constraining the dose to the BP. This approach may improve the therapeutic ratio by reducing the long-term risk of brachial plexopathy.

Background: Brachial plexopathy may be caused by malpositioning during surgery when the body's protective mechanism is lost under general anaesthesia. It is the second commonest nerve injury reported in the anaesthetized patient. The exact incidence in colorectal surgery is unclear but there have been numerous cases reported of brachial plexopathy as an adverse event following colorectal surgery. Although it is widely believed that these injuries are preventable by paying special attention to vulnerable areas during patient positioning and by careful intraoperative monitoring, it appears that nerve injury may still occur., Methods: Patients with post-operative brachial plexopathy in our prospectively kept database were identified. The patient notes were reviewed and documented., Results: In our series, five cases of brachial plexopathy were still observed despite careful precautions taken to prevent nerve injury. The proposed mechanism of nerve injury in our series is most likely due to nerve stretch. All symptoms resolved with the longest taking 7 months before resolution. During this period from 2005 to 2010 our unit performed 548 laparoscopic colorectal resections. The relative incidence of brachial plexopathy in our series is approximately 1 %., Conclusion: We recommend certain precautionary steps to follow, as well as predisposing and perioperative factors to be aware of when anticipating a laparoscopic colorectal procedure. These may all contribute to minimising brachial plexopathy which most likely is under-reported in laparoscopic colorectal surgery but is a preventable morbidity to the patient.

Introduction: Surgery and childbirth can trigger attacks of hereditary brachial plexus neuropathy (HBPN), and inflammation was suggested as a component of the pathogenesis., Methods: HBPN patients who underwent surgery or parturition from January 1, 1996 to December 31, 2009 were studied., Results: Twenty-five HBPN patients underwent 48 surgeries or parturitions. Seventeen patients (68%) had attacks, including 13 periprocedural and 7 postpartum by varied anesthesia types. Three patients who had 8 earlier combined attacks (after thyroidectomy, laminectomy, and Caesarean section) were given prophylactic immunosuppressive therapy (corticosteroids ± immunoglobulin). None suffered postoperative attacks, which is uncharacteristic of their prior experience. Five had perioperative attacks as their first HBPN manifestation. Median follow-up was 11 months (3-48 months). Attacks occurred in the operated limb (n = 6) or distant (n = 7) to surgical sites. All attacks interfered with daily living, with frequent incomplete recovery. Five patients had a SEPT9 mutation., Conclusions: Corticosteroids may prevent parturition and surgical HBPN attacks in some patients. Diverse surgeries, anesthesia, and childbirth frequently trigger HBPN attacks., (Copyright © 2012 Wiley Periodicals, Inc.)

Purpose: The purpose of this retrospective study was to determine tumor factors contributing to brachial plexus (BP) dose in head-and-neck cancer (HNC) patients treated with intensity-modulated radiotherapy (IMRT) when the BP is routinely contoured as an organ at risk (OAR) for IMRT optimization., Methods and Materials: From 2004 to 2011, a total of 114 HNC patients underwent IMRT to a total dose of 69.96 Gy in 33 fractions, with the right and left BP prospectively contoured as separate OARs in 111 patients and the ipsilateral BP contoured in 3 patients (total, 225 BP). Staging category T4 and N2/3 disease were present in 34 (29.8%) and 74 (64.9%) patients, respectively. During IMRT optimization, the intent was to keep the maximum BP dose to ≤60 Gy, but prioritizing tumor coverage over achieving the BP constraints. BP dose parameters were compared with tumor and nodal stage., Results: With a median follow-up of 16.2 months, 43 (37.7%) patients had ≥24 months of follow-up with no brachial plexopathy reported. Mean BP volume was 8.2 ± 4.5 cm(3). Mean BP maximum dose was 58.1 ± 12.2 Gy, and BP mean dose was 42.2 ± 11.3 Gy. The BP maximum dose was ≤60, ≤66, and ≤70 Gy in 122 (54.2%), 185 (82.2%), and 203 (90.2%) BP, respectively. For oropharynx, hypopharynx, and larynx sites, the mean BP maximum dose was 58.4 Gy and 63.4 Gy in T0-3 and T4 disease, respectively (p = 0.002). Mean BP maximum dose with N0/1 and N2/3 disease was 52.8 Gy and 60.9 Gy, respectively (p < 0.0001)., Conclusions: In head-and-neck IMRT, dose constraints for the BP are difficult to achieve to ≤60 to 66 Gy with T4 disease of the larynx, hypopharynx, and oropharynx or N2/3 disease. The risk of brachial plexopathy is likely very small in HNC patients undergoing IMRT, although longer follow-up is required., Competing Interests: none., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Study Design: Review article., Objective: To review the epidemiology, etiology, risk factors, prevention, and treatment of neurological complications associated with cervical spine surgery. The article focuses on C5 palsy and intraoperative neurophysiological monitoring., Summary of Background Data: Neurological problems are the complications most feared by patients and surgeons alike, but, fortunately, spinal cord injury is uncommon. C5 palsy is a less severe but much more common and perplexing problem. Intraoperative monitoring is widely used in cervical spine surgery, but it is unclear how effective it is at preventing spinal cord or nerve root injury., Methods: Narrative and review of the literature., Results: The incidence of new, severe motor weakness in 2 or more extremities occurring within 12 hours of surgery is 0.18%. The rate in the cervical spine is 3 of 1000. The incidence of isolated C5 palsy is much greater; the rate varies between 0% and 30%, depending on how the condition is defined and which patient group is being analyzed. Numerous theories have been postulated to explain the pathogenesis of C5 palsy, and preventative strategies are discussed. Approximately 70% of patients recover completely without treatment. The mean time to full recovery is 4 to 5 months. Recovery is spontaneous; no treatment has been shown to shorten the time to recovery or improve the recovery rate. A systematic review of the literature found a high level of evidence that multimodal intraoperative monitoring is effective at detecting intraoperative neurological injury. The evidence that intraoperative monitoring reduces the rate of new or worsened perioperative neurological deficits is not as strong. Algorithms help surgeons respond to monitoring alerts and manage neurological deficits that are identified postoperatively., Conclusion: The keys to managing neurological complications in cervical spine surgery are prevention through careful planning, appropriate multimodal monitoring, meticulous surgical technique, and decisive action when a problem is identified.

Purpose: To evaluate interobserver variability for contouring the brachial plexus as an organ-at-risk (OAR) and to analyze its potential dosimetric consequences in patients treated with intensity-modulated radiotherapy (IMRT) for head-and-neck cancer., Methods and Materials: Using the Radiation Therapy Oncology Group (RTOG)-endorsed brachial plexus contouring atlas, three radiation oncologists independently delineated the OAR on treatment planning computed-tomography (CT) axial scans from 5 representative patients undergoing IMRT to a prescribed dose of 70 Gy for head-and-neck cancer. Dose-volume histograms for the brachial plexus were calculated, and interobserver differences were quantified by comparing various dosimetric statistics. Qualitative analysis was performed by visually assessing the overlapping contours on a single beam's eye view., Results: Brachial plexus volumes for the 5 patients across observers were 26 cc (18-35 cc), 25 cc (21-30 cc), 29 cc (28-32 cc), 29 cc (23-38 cc), and 29 cc (23-34 cc). On qualitative analysis, minimal variability existed except at the inferolateral portion of the OAR, where slight discrepancies were noted among the physicians. Maximum doses to the brachial plexus ranged from 71.6 to 72.6 Gy, 75.2 to 75.8 Gy, 69.1 to 71.0 Gy, 76.4 to 76.9 Gy, and 70.6 to 71.4 Gy. Respective volumes receiving doses greater than 60 Gy (V60) were 8.6 to 10.9 cc, 6.2 to 8.1 cc, 8.2 to 11.6 cc, 8.3 to 10.5 cc, and 5.6 to 9.8 cc., Conclusion: The RTOG-endorsed brachial plexus atlas provides a consistent set of guidelines for contouring this OAR with essentially no learning curve. Adoption of these contouring guidelines in the clinical setting is encouraged., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: As the recommended radiation dose for non-small-cell lung cancer (NSCLC) increases, meeting dose constraints for critical structures like the brachial plexus becomes increasingly challenging, particularly for tumors in the superior sulcus. In this retrospective analysis, we compared dose-volume histogram information with the incidence of plexopathy to establish the maximum dose tolerated by the brachial plexus., Methods and Materials: We identified 90 patients with NSCLC treated with definitive chemoradiation from March 2007 through September 2010, who had received >55 Gy to the brachial plexus. We used a multiatlas segmentation method combined with deformable image registration to delineate the brachial plexus on the original planning CT scans and scored plexopathy according to Common Terminology Criteria for Adverse Events version 4.03., Results: Median radiation dose to the brachial plexus was 70 Gy (range, 56-87.5 Gy; 1.5-2.5 Gy/fraction). At a median follow-up time of 14.0 months, 14 patients (16%) had brachial plexopathy (8 patients [9%] had Grade 1, and 6 patients [7%] had Grade ≥2); median time to symptom onset was 6.5 months (range, 1.4-37.4 months). On multivariate analysis, receipt of a median brachial plexus dose of >69 Gy (odds ratio [OR] 10.091; 95% confidence interval [CI], 1.512-67.331; p = 0.005), a maximum dose of >75 Gy to 2 cm(3) of the brachial plexus (OR, 4.909; 95% CI, 0.966-24.952; p = 0.038), and the presence of plexopathy before irradiation (OR, 4.722; 95% CI, 1.267-17.606; p = 0.021) were independent predictors of brachial plexopathy., Conclusions: For lung cancers near the apical region, brachial plexopathy is a major concern for high-dose radiation therapy. We developed a computer-assisted image segmentation method that allows us to rapidly and consistently contour the brachial plexus and establish the dose limits to minimize the risk of brachial plexopathy. Our results could be used as a guideline in future prospective trials with high-dose radiation therapy for unresectable lung cancer., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Robotic assisted surgery is becoming widely used for procedures such as radical prostatectomy. The use of robotic assisted surgery to perform partial and complete thyroidectomies using a transaxillary approach is being investigated in patient populations who wish to avoid a conspicuous cervical scar. Patient positioning for this approach as well as retraction during exposure has the potential to result in postoperative brachial plexopathy similar to what is seen in other types of surgery. We report the use of ulnar nerve somatosensory evoked potentials (SSEPs) to detect and prevent positional related neuropathy in the first pediatric patient in the world to undergo this procedure. We conclude that upper extremity SSEPs should be routinely performed during robotic assisted thyroidectomy.

The use of somatosensory evoked potentials (SSEPs) to monitor upper extremity nerves during surgery is becoming more accepted as a valid and useful technique to minimize intraoperative nerve injuries. We present a case illustrating the benefit of utilizing both SSEPs and transcranial electrical motor evoked potentials (TCeMEPs) for preventing position-related injury during surgery. The patient was a 43-year-old male with a history of neck pain, along with numbness and tingling of the upper extremities. While the patient was being draped, upper extremity SSEPs diminished significantly TCeMEP responses in the hands (abductor pollicus brevis-abductor digiti minimi; APB-ADM) vanished shortly after that, followed by the biceps and left deltoid. The surgeons were notified, and the tape on the shoulders was loosened. No improvements were noted in SSEPs nor TCeMEPs due to this intervention, so all tape was removed and the patient's arms were allowed to rest naturally upon the arm boards. Upper extremity TCeMEP responses could then be elicited and SSEPs improved shortly afterward. Surgery was completed with the arms on the arm boards. All signals remained stable for the remaining three hours of the procedure. At two months follow-up, the patient was well with total pain relief and normal upper extremity function when neurological examination was performed. This report demonstrates a case in which intraoperative neurophysiological monitoring was useful in identifying and reversing impending nerve injury during cervical spine surgery. Significant changes were seen in SSEPs as well as TCeMEPs, so we recommend that TCeMEP monitoring be considered as an adjunct to SSEPs for prevention of injury to the brachial plexus.

To improve locoregional tumor control and survival in patients with locally advanced head and neck cancer (HNC), therapy is intensified using altered fractionation radiation therapy or concomitant chemotherapy. However, intensification of therapy has been associated with increased acute and late toxic effects. The application of advanced radiation techniques, such as 3D conformal radiation therapy and intensity-modulated radiation therapy, is expected to improve the therapeutic index of radiation therapy for HNC by limiting the dose to critical organs and possibly increasing locoregional tumor control. To date, Review articles have covered the prevention and treatment of radiation-induced xerostomia and dysphagia, but few articles have discussed the prevention of hearing loss, brain necrosis, cranial nerve palsy and osteoradionecrosis of the mandible, which are all potential complications of radiation therapy for HNC. This Review describes the efforts to prevent therapy-related complications by presenting the state of the art evidence regarding advanced radiation therapy technology as an organ-sparing approach.

Obstetrical brachial plexus palsies (OBPP) have been historically attributed to the impaction of the fetal shoulder behind the symphysis pubis and to excessive lateral traction of the fetal head during maneuvers to deliver the fetal shoulders in shoulder dystocia. Shoulder dystocia is indeed a major risk factor as it increases the risk for OBPP 100-fold. The incidence of OBPP following shoulder dystocia varies widely from 4% to 40%. However, a significant proportion of OBPPs are secondary to in utero injury. The propulsive forces of labor, intrauterine maladaptation, and compression of the posterior shoulder against the sacral promontory as well as uterine anomalies are possible intrauterine causes of OBPP. Many risk factors for OBPP may be unpredictable. Early identification of risk factors for shoulder dystocia, as well as appropriate management when it occurs, may improve our ability to prevent the occurrence of OBPP in those cases that are caused by shoulder dystocia., (© 2010 New York Academy of Sciences.)

Purpose: To evaluate late brachial plexopathy after primary chemoradiotherapy for locally advanced head and neck squamous cell carcinoma., Patients and Methods: Consecutive 43 disease-free patients were evaluated by a specifically developed 26-item questionnaire. Retrospectively, the brachial plexus was delineated and the dose-volume histograms were calculated., Results: After a median follow-up of 24 months, no radiation-induced brachial plexopathy was reported in these 43 patients., Conclusion: No radiation-induced brachial plexopathy was seen in the patient group, although 72.1% of the brachial plexuses received doses > 60 Gy. These findings should prompt further prospective studies and also stress the importance of trying to keep the doses to the brachial plexus as low as possible while covering the target volumes well.

Unlabelled: Obstetric brachial plexus palsy (OBPP), is an injury of the brachial plexus at childbirth affecting the nerve roots of C5-6 (Erb-Duchenne palsy-nearly 80% of cases) or less frequently the C8-T1 nerve roots (Klumpke palsy). OBPP often has medicolegal implications. In the United Kingdom and the Republic of Ireland the incidence is 0.42, in the United States 1.5, and in other western countries 1 to 3 per 1000 live births. Most infants with OBPP have no known risk factors. Shoulder dystocia increases the risk for OBPP 100-fold. The reported incidence of OBPP after shoulder dystocia varies widely from 4% to 40%. Other risk factors include birth weight >4 kg, maternal diabetes mellitus, obesity or excessive weight gain, prolonged pregnancy, prolonged second stage of labor, persistent fetal malposition, operative delivery, and breech extraction of a small baby. OBPP after caesarean section accounts for 1% to 4% of cases. Historically, OBPPs have been considered to result from excessive lateral traction and forceful deviation of the fetal head from the axial plane of the fetal body, usually in association with shoulder dystocia, which increases the necessary applied peak force and time to deliver the fetal shoulders. Direct compression of the fetal shoulder on the symphysis pubis may also cause injury. However a significant proportion of OBPPs occurs in utero, as according to some studies more than half of the cases are not associated with shoulder dystocia. Possible mechanisms of intrauterine injury include the endogenous propulsive forces of labor, intrauterine maladaptation, or failure of the shoulders to rotate, and impaction of the posterior shoulder behind the sacral promontory. Uterine anomalies, such as fibroids, an intrauterine septum, or a bicornuate uterus may also result in OBPP. It is not possible to reliably predict which fetuses will experience OBPP. Future research should be directed in prospective evaluation of the mechanisms of injury, to enable obstetricians, midwives, and other health care professionals to identify modifiable risk factors, develop preventive strategies, and improve perinatal outcomes., Target Audience: Obstetricians & Gynecologists, Family Physicians., Learning Objectives: After completion of this article, the reader will be able to summarize known risk factors for shoulder dystocia, describe the relationship between shoulder dystocia and obstetrics brachial plexus injuries, and describe three potentail explanantions for brachial plexus injuries other than lateral traction at delivery.