Electroacupuncture attenuates neuropathic pain after brachial plexus injury

Electroacupuncture has traditionally been used to treat pain, but its effect on pain following brachial plexus injury is still unknown. In this study, rat models of an avulsion injury to the left brachial plexus root （associated with upper-limb chronic neuropathic pain） were given electroacupuncture stimulation at bilateral Quchi （LIll）, Hegu （LI04）, Zusanli （ST36） and Yanglingquan （GB34）. After electroacupuncture therapy, chronic neuropathic pain in the rats＇ upper limbs was significantly attenuated. Immunofluorescence staining showed that the expression of β-endorphins in the arcuate nucleus was significantly increased after therapy. Thus, experimental findings indi- cate that electroacupuncture can attenuate neuropathic pain after brachial plexus injury through upregulating β-endorphin expression.

Small-worldness of brain networks after brachial plexus injury: a resting-state functional magnetic resonance imaging study

Research on brain function after brachial plexus injury focuses on local cortical functional reorganization,and few studies have focused on brain networks after brachial plexus injury.Changes in brain networks may help understanding of brain plasticity at the global level.We hypothesized that topology of the global cerebral resting-state functional network changes after unilateral brachial plexus injury.Thus,in this cross-sectional study,we recruited eight male patients with unilateral brachial plexus injury（right handedness,mean age of 27.9±5.4years old）and eight male healthy controls（right handedness,mean age of 28.6±3.2）.After acquiring and preprocessing resting-state magnetic resonance imaging data,the cerebrum was divided into 90 regions and Pearson’s correlation coefficient calculated between regions.These correlation matrices were then converted into a binary matrix with affixed sparsity values of 0.1–0.46.Under sparsity conditions,both groups satisfied this small-world property.The clustering coefficient was markedly lower,while average shortest path remarkably higher in patients compared with healthy controls.These findings confirm that cerebral functional networks in patients still show smallworld characteristics,which are highly effective in information transmission in the brain,as well as normal controls.Alternatively,varied small-worldness suggests that capacity of information transmission and integration in different brain regions in brachial plexus injury patients is damaged.

Total brachial plexus injury： contralateral C7 root transfer to the lower trunk versus the median nerve

Contralateral C7（cC7） root transfer to the healthy side is the main method for the treatment of brachial plexus root injury. A relatively new modification of this method involves cC7 root transfer to the lower trunk via the prespinal route. In the current study, we examined the effectiveness of this method using electrophysiological and histological analyses. To this end, we used a rat model of total brachial plexus injury, and cC7 root transfer was performed to either the lower trunk via the prespinal route or the median nerve via a subcutaneous tunnel to repair the injury. At 4, 8 and 12 weeks, the grasping test was used to measure the changes in grasp strength of the injured forepaw. Electrophysiological changes were examined in the flexor digitorum superficialis muscle. The change in the wet weight of the forearm flexor was also measured. Atrophy of the flexor digitorum superficialis muscle was assessed by hematoxylin-eosin staining. Toluidine blue staining was used to count the number of myelinated nerve fibers in the injured nerves. Compared with the traditional method, cC7 root transfer to the lower trunk via the prespinal route increased grasp strength of the injured forepaw, increased the compound muscle action potential maximum amplitude, shortened latency, substantially restored tetanic contraction of the forearm flexor muscles, increased the wet weight of the muscle, reduced atrophy of the flexor digitorum superficialis muscle, and increased the number of myelinated nerve fibers. These findings demonstrate that for finger flexion functional recovery in rats with total brachial plexus injury, transfer of the cC7 root to the lower trunk via the prespinal route is more effective than transfer to the median nerve via subcutaneous tunnel.

Nerve transfer helps repair brachial plexus injury by increasing cerebral cortical plasticity

In the treatment of brachial plexus injury, nerves that are functionally less important are transferred onto the distal ends of damaged crucial nerves to help recover neuromuscular function in the target region. For example, intercostal nerves are transferred onto axillary nerves, and accessory nerves are transferred onto suprascapular nerves, the phrenic nerve is transferred onto the musculocutaneous nerves, and the contralateral C7 nerve is transferred onto the median or radial nerves. Nerve transfer has become a major method for reconstructing the brachial plexus after avulsion injury. Many experiments have shown that nerve transfers for treatment of brachial plexus injury can help reconstruct cerebral cortical function and increase cortical plasticity. In this review article, we summarize the recent progress in the use of diverse nerve transfer methods for the repair of brachial plexus injury, and we discuss the impact of nerve transfer on cerebral cortical plasticity after brachial plexus injury.

Transplantation of human amniotic epithelial cells repairs brachial plexus injury:pathological and biomechanical analyses

A brachial plexus injury model was established in rabbits by stretching the C6 nerve root. Imme- diately after the stretching, a suspension of human amniotic epithelial cells was injected into the injured brachial plexus. The results of tensile mechanical testing of the brachial plexus showed that the tensile elastic limit strain, elastic limit stress, maximum stress, and maximum strain of the injured brachial plexuses were significantly increased at 24 weeks after the injection. The treatment clearly improved the pathological morphology of the injured brachial plexus nerve, as seen by hematoxylin eosin staining, and the functions of the rabbit forepaw were restored. These data indicate that the injection of human amniotic epithelial cells contributed to the repair of brachial plexus injury, and that this technique may transform into current clinical treatment strategies.

Phrenic nerve transfer to the musculocutaneous nerve for the repair of brachial plexus injury: electrophysiological characteristics

Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we per-formed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduc-tion function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regener-ated potentials ifrst appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering ‘ex-cellent’ and ‘good’ muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The func-tional recovery of a transplanted nerve can be dynamically observed after the surgery.

Restoration and protection of brachial plexus injury: hot topics in the last decade

Brachial plexus injury is frequently induced by injuries, accidents or birth trauma. Upper limb function may be partially or totally lost after injury, or left permanently disabled. With the de- velopment of various medical technologies, different types of interventions are used, but their effectiveness is wide ranging. Many repair methods have phasic characteristics, i.e., repairs are done in different phases. This study explored research progress and hot topic methods for pro- tection after brachial plexus injury, by analyzing 1,797 articles concerning the repair of brachial plexus injuries, published between 2004 and 2013 and indexed by the Science Citation Index database. Results revealed that there are many methods used to repair brachial plexus injury, and their effects are varied. Intervention methods include nerve transfer surgery, electrical stimula- tion, cell transplantation, neurotrophic factor therapy and drug treatment. Therapeutic methods in this field change according to the hot topic of research.

Substance P mRNA expression in the rat spinal cord following selective brachial plexus injury

BACKGROUND： The neuropeptide, substance P, has various bioactivities and is widely distributed in the central nervous system. Substance P participates in neural transmission in the spinal cord and plays an important role in regeneration and repair of nerve injury. OBJECTIVE： To investigate substance P mRNA expression in the anterior horn of the spinal cord following brachial plexus injury. DESIGN, TIME AND SETTING： A molecular cell biology randomized controlled study was performed at the Department of Anatomy, Zhongshan Medical College, Sun Yat-sen University and the DaAn Gene Laboratory in May 2005. MATERIALS： A total of 29 adult male Sprague Dawley rats were randomly assigned to a control group （n = 5） and an injury group （n = 24）. METHODS： The injury group was divided into three subgroups. In subgroup A, the right seventh cervical vertebra （C7） anterior root was avulsed, and the residual nerve root at the distal end was removed. In subgroup B, the right C7 anterior root was avulsed, and the right C5 first thoracic vertebrae （T1） posterior root was incised. Thus afferent pathways of the posterior root that connected with the anterior horn motor neurons were blocked. In subgroup C, the right C7 anterior root was avulsed, and a right C56 hemisection was performed. Thus the descending fiber pathways of the cortex that connected with anterior horn motor neurons were blocked. In the control group, the C5-T1 vertebral plate was opened, and then the skin was sutured. MAIN OUTCOME MEASURE： Substance P mRNA expression in the anterior horn of the spinal cord was quantified using fluorescent quantitative reverse transcription-polymerase chain reaction. RESULTS： Substance P mRNA expression was low in the anterior horn of the rat spinal cord in the control group. Substance P mRNA expression in the anterior horn of the spinal cord was upregulated and was significantly higher in the injury group compared with the control group （P 〈 0.01）. Substance P mRNA expression was highest in subgroup B. CONCLUSION： Brachial plexus anterior root avulsion is responsible for increased substance P expression in the anterior horn of the rat spinal cord. Pathway disjunction in efferent fibers of the posterior root or cortex does not have an effect on substance P expression in the anterior horn of the spinal cord.

The level and influencing factors of quality of life in patients with brachial plexus injury

Purpose:To investigate the overall quality of life level and identify influencing factors in patients with traumatic brachial plexus injury.Methods:One hundred three patients with brachial plexus injury were assessed using the World Health Organization Quality of Life-BREF(WHOQOL-BREF)and Family Adaptability and Cohesion Evaluation Scale(FACESII-CV)questionnaires.Results:The overall quality of life score from patients with brachial plexus injury was 65.78
15.2.The scores for the physical,psychological and environmental factors were significantly lower than the norm(Ps<0.05).Regression analysis showed that age,injury located ipsilateral to the dominant hand,upper limb function score,score of family intimacy and family income were all factors influencing the of quality of life.Conclusions:A brachial plexus injury significantly compromises an individual’s quality of life.Multiple factors influence this quality,which should be targeted to augment the physical and psychological care provided.

Expression of nitric oxide synthase in the spinal cord after selective brachial plexus injury

BACKGROUND: Some researches showed that motoneurons in spinal cord anterior horn wound die following brachial plexus injury, but the concrete mechanism of motoneurons death remains unclear. OBJECTIVE: To observe the expression of nitric oxide synthase (NOS) and survival of C7 motoneurons in spinal cord of rats after selective brachial plexus injury. DESIGN: A randomized controlled animal experiment. SETTING:Department of Anatomy, Sun Yet-sen Medical College, Sun Yet-sen University. MATERIALS: Totally 35 adult healthy male Sprague-Dawley rats with the body mass of 200-300 g were provided by Experimental Animal Center, Sun Yet-sen Medical College, Sun Yat-sen University. The rats were divided into control group (n =5) and experimental group(n =30) by random number table method, and the experimental group was divided into three injury subgroups: anterior root avulsion group, dorsal root transection group and spinal cord hemisection group, 10 rats in each group. There were horse anti-neuronal NOS (nNOS) polycolonal antibody (Sigma company) and nicotina mideadeninedinucleotide phosphate (NADPH-d) (Sigma Company). METHODS: The experiment was performed at Department of Anatomy, Sun Yet-sen Medical College, Sun Yet-sen University between September 2004 and April 2005. ①After anesthetizing the rats, the spinous process of second thoracic vertebra as a marker, the vertebra was exposed from C5 to T1 and the lamina of vertebra was unclenched, and spinal dura mater was carved to expose the spinal nerve dorsal roots of C5-T1. The right ventral root of C7 was avulsed, and the residual root was removed in anterior root avulsion group. The right ventral root of C7 was avulsed and the right dorsal roots of brachial plexus (C5-T1) were cut off in dorsal root transection group. In spinal cord hemisection group, the hemisection between the C5 and C6 spinal segment on right side and avulsion of right ventral root of C7 were made. In the control group, the vertebra from C5 to T1 was unclenched and the skin of wound was sutured. ②Three weeks after operation, behavior of rats was observed. The rats were killed after anesthesia. The C7 segment of spinal cord was removed and treated with NADPH-d staining, neutral red counterstaining and NOS immunohistochemistry staining to detect the expression of NOS. MAIN OUTCOME MEASURES: The expression of NOS and survival of C7 motoneurons in spinal cord of rats 3 weeks after operation. RESULTS: Among the 35 included rats, 3 rats died 2 weeks following operation, so totally 32 rats were involved in the result analysis. ①NADPH-d positive neurons of in anterior horn of C7 in the three groups: The NADPH-d positive neurons could be found in anterior horn of C7 in the three groups. The percentage of that in anterior root avulsion group to that of non-injury side of spinal cord was(20.98±2.65)%, (29.43±6.81)% in dorsal root transection group and (31.74±6.80)% in spinal cord hemisection group. There was significant difference among the three injury groups(F =5.135,P =0.016). There was significant difference in anterior root avulsion group with dorsal root transection group and spinal cord hemisection group (t =2.562,3.167,P < 0.05). There was no significant difference between the dorsal root transection group and spinal cord hemisection group (P =0.534). ②survival rate of motoneurons in anterior horn of C7: There were dead motoneurons in the three injury groups, the percentages of surviving motoneurons to that of non-injured side of spinal cord were (69.22±4.04)%,(62.01±3.82)% and (56.74±6.86)%, respectively. There were significant differences among the three groups (F =9.508,P =0.002). The anterior root avulsion group was significantly different from the other two groups(t =2.764,4.587,P < 0.05). There was no significant difference between the dorsal root transection group and spinal cord hemisection group(P =0.073). CONCLUSION: The selective brachial plexus injury can induce the up-regulation of NOS expression in motorneurons of spinal cord anterior horn and block descending pathway of cortex to cause the more significant up-regulation of NOS and low survival rate in motoneurons. It indicates that descending pathway of cortex can inhibit the NOS expression in motorneurons of spinal cord anterior horn, and the high NOS expression might induce the death of motorneurons in spinal cord anterior horn.

Clinical research of comprehensive rehabilitation in treating brachial plexus injury patients

Background Brachial plexus injury is one of the difficult medical problems in the world. The aim of this study was to observe the clinical therapeutic effect of comprehensive rehabilitation in treating dysfunction after brachial plexus injury. Methods Forty-three cases of dysfunction after brachial plexus injury were divided into two groups randomly. The treatment group, which totaled 21 patients （including 14 cases of total brachial plexus injury and seven cases of branch brachial plexus injury）, was treated with comprehensive rehabilitation including transcutaneous electrical nerve stimulation, mid-frequency electrotherapy, Tuina therapy, and occupational therapy. The control group, which totaled 22 patients （including 16 cases of total brachial plexus injury and six cases of branch brachial plexus injury）, was treated with home-based electrical nerve stimulation and occupational therapy. Each course was of 30 days duration and the patients received four courses totally. After four courses, the rehabilitation effect was evaluated according to the brachial plexus function evaluation standard and electromyogram （EMG） assessment. Results In the treatment group, there was significant difference in the scores of brachial plexus function pre- and post-treatment （P 〈0.01） in both ＂total＂ and ＂branch＂ injury. The scores of two ＂total injury＂ groups had statistical differences （P 〈0.01）, while the scores of two ＂branch injury＂ groups had statistical differences （P 〈0.05） after four courses. EMG suggested that the appearance of regeneration potentials of the recipient nerves in the treatment group was earlier than the control group and had significant differences （P 〈0.05）. Conclusion Comprehensive rehabilitation was more effective in treating dysfunction after brachial plexus injury than nonintegrated rehabilitation.

Experimental Study on Mechanical Vibration Massage for Treatment of Brachial Plexus Injury in Rats

Objective: To investigate the curative effect of the self-made mechanical vibration massage instrument for treatment of brachial plexus injury in rats and to explore its mechanism. Methods: Brachial plexus injury models were made in 144 Wistar rats and one week after natural healing of the wound, they were randomly divided into 3 groups, mechanical vibration treatment group (MV group), nerve growth factor treatment group (NGF group) and model group, 48 rats in each group. Then again, the each group was randomly divided into 4 subgroups, 7-day group, 14-day group, 21-day group and 28-day group, 12 rats in each subgroup. The MV group were treated by mechanical vibration at acupoints on three-yang and three-yin channels of the hand with the mechanical vibration massage instrument; The NGF group were treated with injection of NGF into musculus pectoralis major on the affected side; And the model group were normally fed with no treatment. After treatment for 7, 14, 21 and 28 days, the diameter of both forelimbs were measured, the electrophysiological examination on the brachial plexus in vitro and the ultrastructure observation with electron microscope on the affected side were carried out, the motor nerve conduction velocity (MNCV) and motor nerve action potential (MNAP) of the brachial plexus on the affected side, NGF content of submaxillary gland as well as muscular Na+, K+-ATPase activity were determined respectively. Results: The different rates of the forelimb diameter in the MV group and the NGV group on the 14th d, 21st d and 28th d were better than those in the model group (P<0.05 or P<0.001), and in the MV group were better than those in the NGF group on the 21st d and the 28th d (P<0.05). MNCV in the MV group and the NGV group on the 21st d and 28th d was better than that in the model group (P<0.05 or P<0.001), and in the MV group was better than that in the NGF group on the 28th d (P<0.05). MNAP in the MV group and the NGV group on the 14th d, 21st d and 28th d was better than that in the model group (P<0.05 or P<0.001), and in the MV group was better than that in the NGF group on the 21st d and 28th d (P<0.05). The NGF mean gray index of submaxillary gland in the model group was higher than that in the MV group and the NGF group on the 7th d (P<0.05); in the NGF group and the model group was higher than that in the MV group on the 14th d (P<0.05); and in the NGF group and the MV group was higher than that in the model group on the 21st d and 28th d (P<0.05). Na+, K+-ATPase activity in the model group and the MV group was higher than that in the NGF group (P<0.05) on the 14th d, and in the MV group was higher than that in the model group on the 28th d (P<0.05). Conclusion: As compared with the NGF group and the model group, mechanical vibration treatment can effectively accelerate repair of injured brachial plexus, slow down atrophy of skeletal muscle, and promote secretion of NGF in submaxillary gland.

Human amniotic epithelial cell transplantation for the repair of injured brachial plexus nerve: evaluation of nerve viscoelastic properties

The transplantation of embryonic stem cells can effectively improve the creeping strength of nerves near an injury site in animals. Amniotic epithelial cells have similar biological properties as em-bryonic stem cells; therefore, we hypothesized that transplantation of amniotic epithelial cells can repair peripheral nerve injury and recover the creeping strength of the brachial plexus nerve. In the present study, a brachial plexus injury model was established in rabbits using the C6root avulsion method. A suspension of human amniotic epithelial cells was repeatedly injected over an area 4.0 mm lateral to the cephal and caudal ends of the C6 brachial plexus injury site （1 × 106 cells/mL, 3μL/injection, 25 injections） immediately after the injury. The results showed that the decrease in stress and increase in strain at 7,200 seconds in the injured rabbit C6 brachial plexus nerve were mitigated by the cell transplantation, restoring the viscoelastic stress relaxation and creep properties of the brachial plexus nerve. The forepaw functions were also signiifcantly improved at 26 weeks after injury. These data indicate that transplantation of human amniotic epithelial cells can effec-tively restore the mechanical properties of the brachial plexus nerve after injury in rabbits and that viscoelasticity may be an important index for the evaluation of brachial plexus injury in animals.

Influence of species,age and weight on the establishment of a murine model of brachial plexus root avulsion

BACKGROUND： Animal models of brachial plexus root avulsion are required for the study of brachial plexus root injuries. The established ventral approach results in slight injuries, and is similar to mechanisms underlying human brachial plexus root avulsion.OBJECTIVE： To analyze the effects of weight, age, and species on the success rate of brachial plexus root avulsion, and to determine the perfect method for establishing models of brachial plexus root avulsion.DESIGN, TIME AND SETTING： A randomized, block design was performed at the Laboratory of Professor Lihua Zhou, Zhongshan School of Medicine, Sun Yat-sen University, China from June 2008 to June 2009.MATERIALS： Sprague Dawley （SD） rats, golden hamsters, and BALb/C mice were used in the present study.METHODS： All animals were randomly subjected to classical brachial plexus root avulsion and modified brachial plexus root avulsion.MAIN OUTCOME MEASURES： Success rate of brachial plexus root avulsion. RESULTS： The success rate of brachial plexus root avulsion was greater in the modified group than in the classical group （P〈0.01）. Moreover, the difference was significant in 15-day-old SD rats, 5-week-old SD rats, and 3-month-old BALb/C mice （P〈0.01）. The success rate of brachial plexus root avulsion was greater in the same weight, 15-day-old juvenile SD rats, than in the 3-month-old BALb/C mice （classical group, P〈0.01; modified group, P〈0.05）. The success rate of brachial plexus root avulsion was significantly greater in 3-month-old golden hamsters than in 5-week-old SD rats in the classical group （P〈0.05）. The success rate of brachial plexus root avulsion was significantly lower in the 15-day-old SD rats compared with the 5-week-old and 3-month-old SD rats in the classical group （P〈0.01）. However, there was no significant difference in the success rate of brachial plexus root avulsion between various ages of SD rats in the modified group （P〉0.05）.CONCLUSION： Modified surgery to induce brachial plexus root avulsion significantly increases the success rate of model establishment. Species, age, and weight affect the success rate of brachial plexus root avulsion, and species plays an important role in the success rate.

ISP and PAP4 peptides promote motor functional recovery after peripheral nerve injury

Both intracellular sigma peptide(ISP) and phosphatase and tensin homolog agonist protein(PAP4) promote nerve regeneration and motor functional recovery after spinal cord injury. However, the role of these two small peptides in peripheral nerve injury remains unclear. A rat model of brachial plexus injury was established by crush of the C6 ventral root. The rats were then treated with subcutaneous injection of PAP4(497 μg/d, twice per day) or ISP(11 μg/d, once per day) near the injury site for 21 successive days. After ISP and PAP treatment, the survival of motoneurons was increased, the number of regenerated axons and neuromuscular junctions was increased, muscle atrophy was reduced, the electrical response of the motor units was enhanced and the motor function of the injured upper limbs was greatly improved in rats with brachial plexus injury. These findings suggest that ISP and PAP4 promote the recovery of motor function after peripheral nerve injury in rats. The animal care and experimental procedures were approved by the Laboratory Animal Ethics Committee of Jinan University of China(approval No. 20111008001) in 2011.

Supplementary motor area deactivation impacts the recovery of hand function from severe peripheral nerve injury

Although some patients have successful peripheral nerve regeneration,a poor recovery of hand function often occurs after peripheral nerve injury.It is believed that the capability of brain plasticity is crucial for the recovery of hand function.The supplementary motor area may play a key role in brain remodeling after peripheral nerve injury.In this study,we explored the activation mode of the supplementary motor area during a motor imagery task.We investigated the plasticity of the central nervous system after brachial plexus injury,using the motor imagery task.Results from functional magnetic resonance imaging showed that after brachial plexus injury,the motor imagery task for the affected limbs of the patients triggered no obvious activation of bilateral supplementary motor areas.This result indicates that it is difficult to excite the supplementary motor areas of brachial plexus injury patients during a motor imagery task,thereby impacting brain remodeling.Deactivation of the supplementary motor area is likely to be a serious problem for brachial plexus injury patients in terms of preparing,initiating and executing certain movements,which may be partly responsible for the unsatisfactory clinical recovery of hand function.

Repair of brachial plexus lower trunk injury by transferring brachialis muscle branch of musculocutaneous nerve： anatomic feasibility and clinical trials

Background There are few effective methods for treating injuries to the lower trunk of brachial plexus, and the curative effect is usually poor. The purpose of this study was to provide anatomic references for transferring the brachialis muscle branch of musculocutaneous nerve （BMBMCN） for selective neurotization of finger flexion in brachial plexus lower trunk injury, and to evaluate its clinical curative effects.Methods Microanatomy and measurement were done on 50 limbs from 25 adult human cadavers to observe the origin, branch, type of the BMBMCN and median nerve, as well as their adjacent structures. Internal topographic features of the fascicular groups of the median nerve at the level of the BMBMCN were observed. In addition, the technique of BMBMCN transfer for selective neurotization of finger flexion of the median nerve was designed and tested in 6 fresh adult human cadavers. Acetylcholinesterase （AchE） staining of the BMBMCN and median nerve was done to observe the features of the nerve fibers. This technique was clinically tried to restore digital flexion in 6 cases of adult brachial plexus lower trunk injury. These cases were followed up for 3, 6, 9 and 12 months postoperatively. Recovery of function, grip strength, nerve electrophysiology and muscle power of the affected limbs were observed and measured.Results The brachialis muscle was totally innervated by the musculocutaneous nerve （MCN）. Based on the Hunter＇s line, the level of the origin of the BMBMCN was （13.18±.2.77）cm. Ache histochemical staining indicated that the BMBMCN were totally made up of medullated nerve fibers. At the level of the BMBMCN, the median nerve consistently collected into three fascicular groups as shown by microanatomy in combination with Ache stain. The posterior fascicular group was mainly composed of anterior interosseous nerves and branches to the palmaris Iongus. The technique was tested in six fresh cadavers successfully, except that stoma split occurred in one case. Five of the six cases recovered digital flexion 12 months after operation, and at the same time grip strength, muscle power, and nerve electrophysiology also recovered markedly.Conclusions The technique of transferring the BMBMCN for selective neurotization of finger flexion is anatomically safe and effective, with satisfactory clinical outcomes.

Neuroinflammation Mediates Faster Brachial Plexus Regeneration in Subjects with Cerebral Injury

Our previous investigation suggested that faster seventh cervical nerve(C7)regeneration occurs in patients with cerebral injury undergoing contralateral C7 transfer.This finding needed further verification,and the mechanism remained largely unknown.Here,Tinel’s test revealed faster C7 regeneration in patients with cerebral injury,which was further confirmed in mice by electrophysiological recordings and histological analysis.Furthermore,we identified an altered systemic inflammatory response that led to the transformation of macrophage polarization as a mechanism underlying the increased nerve regeneration in patients with cerebral injury.In mice,we showed that,as a contributing factor,serum amyloid protein A1(SAA1)promoted C7 regeneration and interfered with macrophage polarization in vivo.Our results indicate that altered inflammation promotes the regenerative capacity of the C7 nerve by altering macrophage behavior.SAA1 may be a therapeutic target to improve the recovery of injured peripheral nerves.

Is it necessary to use the entire root as a donor when transferring contralateral C7 nerve to repair median nerve？

If a partial contralateral C7 nerve is transferred to a recipient injured nerve, results are not satisfactory. However, if an entire contralateral C7 nerve is used to repair two nerves, both recipient nerves show good recovery. These findings seem contradictory, as the above two methods use the same donor nerve, only the cutting method of the contralateral C7 nerve is different. To verify whether this can actually result in different repair effects, we divided rats with right total brachial plexus injury into three groups. In the entire root group, the entire contralateral C7 root was transected and transferred to the median nerve of the affected limb. In the posterior division group, only the posterior division of the contralateral C7 root was transected and transferred to the median nerve. In the entire root ＋ posterior division group, the entire contralateral C7 root was transected but only the posterior division was transferred to the median nerve. After neurectomy,the median nerve was repaired on the affected side in the three groups. At 8, 12, and 16 weeks postoperatively, electrophysiological examination showed that maximum amplitude, latency, muscle tetanic contraction force, and muscle fiber cross-sectional area of the flexor digitorum superficialis muscle were significantly better in the entire root and entire root ＋ posterior division groups than in the posterior division group. No significant difference was found between the entire root and entire root ＋ posterior division groups. Counts of myelinated axons in the median nerve were greater in the entire root group than in the entire root ＋ posterior division group, which were greater than the posterior division group. We conclude that for the same recipient nerve, harvesting of the entire contralateral C7 root achieved significantly better recovery than partial harvesting, even if only part of the entire root was used for transfer. This result indicates that the entire root should be used as a donor when transferring contralateral C7 nerve.

Prevention of shoulder dystocia related birth injuries: Myths and facts

Traditionally, brachial plexus damage was attributed to excessive traction applied on the fetal head at delivery. Recently, it was proposed that most injuries occur spontaneously in utero. The author has studied the mechanism of neurological birth injuries based on 338 actual cases with special attention to(1) fetal macrosomia;(2) maternal diabetes; and(3) methods of delivery. There was a high coincidence between use of traction and brachial plexus injuries. Instrumental extractions increased the risk exponentially. Erb's palsy following cesarean section was exceedingly rare. These facts imply that spontaneous neurological injury in utero is extremely rare phenomenon. Literary reports show that shoulder dystocia and its associated injuries increased in the United States several-fold since the introduction of active management of delivery in the 1970's. Such a dramatic change in a stable population is unlikely to be caused by incidental spontaneous events unrelated to external factors. The cited investigations indicate that brachial plexus damage typically is traction related. The traditional technique which precludes traction is the optimal method for avoiding arrest of the shoulders and its associated neurological birth injuries. Effective prevention also requires meticulous prenatal care and elective abdominal delivery of macrosomic fetuses in carefully selected cases.