Infraclavicular brachial plexus block effects on respiratory function and extent of the block

Epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha) promote the differentiation and proliferation of epithelia as well as the proliferation and chemotaxis of fibroblasts. Additionally, EGF promotes wound healing in tissues composed largely of epithelial cells and fibroblasts. We hypothesized that EGF and TGF-alpha regulate the differentiation and proliferation of the epithelial lining and the migration and proliferation of fibroblasts in the subepithelial space of the middle ear mucosa in children with otitis media. As an initial test of this hypothesis, EGF and TGF-alpha concentrations were measured in 82 middle ear effusions of children undergoing tympanostomy tube placement. EGF was present in 45% of these effusions, and TGF-alpha was present in 6%. The mean concentration +/- SEM values for EGF and TGF-alpha were 19+/-7.6 and 3.7+/-7.9 pg/mL, respectively. In addition, neutrophils, macrophages, and lymphocytes in middle ear effusions stained for EGF by immunocytochemistry. We conclude that growth factors are frequently present in middle ear effusions of children with otitis media.     

Chronic relapsing brachial plexus neuropathy with persistent conduction block

Idiopathic brachial plexus neuropathy (BPN) is an immune-mediated disorder characterized by an acute onset of painful weakness in one or both upper extremities. The course is usually monophasic with gradual improvement over months; however, occasionally BPN can recur. Electrophysiologic studies suggest the pathogenesis is primarily axonal in the majority of cases. We describe an unusual case of BPN in which the patient had a chronic and relapsing course of painless weakness associated with conduction blocks and other electrophysiologic features of demyelination across the brachial plexus. The patient improved following treatment with intravenous immunoglobulin. The neuropathy falls within the spectrum of chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy.     

The practical use of axillary brachial plexus block for hand surgery

A retrospective study of 178 patients undergoing axillary brachial plexus block (ABPB) for hand surgery used information gathered by a computer-aided anaesthetic record keeping system. The practical use of local techniques to augment the block meant that only two of the 178 patients required a general anaesthetic, giving a success rate of 98.8%. There were no significant complications.     

A new approach to the brachial plexus: clinical results

Chlamydia pneumoniae was isolated from the pharyngeal swab of a 15-year-old patient with acute bronchitis. The serum IgM antibody against C.pneumoniae was elevated up to 160-fold in the acute phase and decreased to 20-fold in the convalescent phase using the microimmunofluorescence (MIF) test. IgG antibody titers in the acute phase and the convalescent phase were 40-fold and 160-fold respectively using the MIF test. The patient recovered from the bronchitis without any effective treatment, indicating spontaneous cure of the disease.     

Anatomic basis of continuous axillary block of the brachial plexus with thoracic reservoir

Although continuous axillary block is effective for periods of up to four to six weeks, pain clinic patients with severe chronic pain in the upper extremities, mainly resulting from neuropathic disease, can require continuous drug delivery by catheter-reservoir for up to three months or longer. We studied possible locations for implanting reservoirs or catheters from the perivascular axillary space in fresh cadavers, checking for possible vascular or nerve damage after applying the usual technique for reservoir implantation. The ideal location for the reservoir is the subcutaneous tissue of the homolateral infraclavicular space of the anterior side of the thorax. The customary procedures for inserting the catheter along the subcutaneous route that extends from the perivascular axillary space to the reservoir carry no risk of damaging vascular or nerve structures.     

Alkalinization of lidocaine does not hasten the onset of axillary brachial plexus block

We assessed the onset of sensory and motor blockade as well as the distribution of sensory blockade after axillary brachial plexus block with 1.5% lidocaine hydrochloride 1:200,000 epinephrine with and without sodium bicarbonate in 38 patients. The onset of analgesia and anesthesia was recorded over the distributions of the median, ulnar, radial, and medial cutaneous nerves of the forearm, medial cutaneous and lateral cutaneous nerves of the arm, and musculocutaneous nerve. The onset of motor blockade of elbow and wrist movements was also recorded. Data were analyzed by using survival techniques and compared by using log rank tests. Only the onset of analgesia in the medial cutaneous nerves of the arm and forearm, and the onset of anesthesia in the medial cutaneous nerve of the arm were significantly faster (P < 0.05) with alkalinization of lidocaine. Our study showed that alkalinization of lidocaine does not significantly hasten block onset in most terminal nerve distributions. IMPLICATIONS: We examined whether alkalinizing a local anesthetic would quicken the onset of a regional upper limb nerve blockade. We found that alkalinization of lidocaine did not offer a significant clinical advantage in axillary brachial plexus blockade.     

Blocking of the brachial plexus: which technique(s) should be chosen?]

Brachial plexus blocks for upper extremity surgery: what are the preferred techniques? Brachial plexus anaesthesia for all types of upper extremity surgical procedures cannot be adequately achieved with a single technique. At least, two approaches are required: above the clavicle, Winnie's interscalene brachial plexus block, using a neurostimulator, has become the standard technique for shoulder surgery. Below the clavicle, midhumerus approach is the most successful approach for elbow, fore arm and hand surgery, especially for outpatient surgery. The best approach for catheter insertion along brachial plexus nerves/trunks remain controversial. The supraclavicular approach using surface landmarks might be the best approach due to its efficacy in achieving complete anaesthesia of the upper extremity and the rarity of secondary displacement of the catheter. Whatever the selected approach(es) to brachial plexus nerves, nerve location it best achieved by neurostimulation and often multiple neurostimulation. Insulated needles are being increasingly used due to accuracy but, currently, there is no general agreement concerning the type of needle bevel to be preferred in regard to both safety and accuracy.     

Comparison of the clinical efficacy of three perivascular techniques for axillary brachial plexus block

BACKGROUND AND OBJECTIVES: This study compared the efficacy of three perivascular techniques of axillary block. METHODS: In group 1, all of the local anesthetic was injected after advancing the needle through the axillary artery (back of artery, n = 20); in group 2, after withdrawing slightly from the artery (front of artery, n = 20); and in group 3, half of the anesthetic was injected after advancing through and half after withdrawing from the axillary artery (half and half, n = 20). The local anesthetic used for the axillary block was 50 ml of 1.5% mepivacaine with epinephrine 1:200,000. RESULTS: The groups did not differ significantly in the incidence of analgesia or anesthesia expected in the median nerve distribution, where there was a significantly lower incidence of anesthesia in the back of the artery group. This group also had a slower onset of anesthesia for the median and the medial antebrachial cutaneous nerves. CONCLUSIONS: There was no significant difference in the number of patients requiring supplementation, with five patients in the back group (25%), three patients in the front group (15%), and one patient in the half and half group (5%) requiring supplementation for the surgical procedure.     

Glenohumeral deformity secondary to brachial plexus birth palsy

Ninety-four patients who had brachial plexus birth palsy were entered into a prospective study to evaluate the association between persistent palsy, age-related musculoskeletal deformity, and functional limitations. Of these patients, forty-two had either computerized tomography or magnetic resonance imaging to assess the presence and degree of incongruity of the glenohumeral joint, deformity of the humeral head, and hypoplasia of the glenoid as part of the preoperative planning for a reconstructive operation. Functional ability was rated with use of the classification of Mallet, on a scale of 1 to 5. The mean glenoscapular angle (the degree of retroversion of the glenoid) on the affected side was -25.7 degrees compared with -5.5 degrees on the unaffected side. Twenty-six (62 per cent) of the forty-two shoulders had evidence of posterior subluxation of the humeral head, with a mean of only 25 per cent (range, 0 to 50 per cent) of the head being intersected by the scapular line. Progressive deformity was found with increasing age (p < 0.001). The natural history of untreated brachial plexus birth palsy with residual weakness is progressive glenohumeral deformity due to persistent muscle imbalance. The status of the glenohumeral joint must be addressed when the choice between tendon transfer and humeral derotation osteotomy for reconstruction of the shoulder is considered for these patients.     

Arm adduction does not increase block extension in anesthesia of the brachial plexus by the axillary approach

INTRODUCTION: Arm abduction of 90 degrees during injection of local anesthetic followed by adduction of the arm has been recommended traditionally to favor proximal distribution of local anesthetic and extension of the blockade in the brachial plexus by the axillary route. A recent study demonstrated that there are no clinical or radiological differences between axillary blockades performed with abduction or adduction. OBJECTIVE: To compare the extension of sensory blockade in axillary anesthesia performed with adduction or abduction. MATERIAL AND METHODS: Forty patients were randomly distributed in two groups, 20 in the adduction group and 20 in the abduction group. The axillary catheter was inserted 3 cm in the proximal direction and a mixture of 40 ml of 1.5% mepivacaine without adrenaline and 4 ml of 8.4% bicarbonate soda was injected into each patient. RESULTS: No statistically significant differences in extension of sensory blockade, including circumflex, musculocutaneous and radial nerve blockade, were observed. CONCLUSIONS: Axillary rotation of the arm is not a determining factor in sensory blockade in brachial plexus anesthesia by the axillary route.     

Surgical indications in lesions of the brachial plexus

The development of microsurgery and the improved technique of nerve grafting brought new hope in cases of brachial plexus injury. Especially the Tinnel-Hofmann sign is a very helpful parameter in preoperative examination. Cases without any regeneration or no advancement should be operated between 3 and 6 months after the injury. Neurolysis or nerve grafting should be performed. In cases of avulsion of the roots a reneurotisation by nerve transfer is the technique of choice. The intercostal nerves are connected with important parts of the brachial plexus. Also in late cases (after 6 months) an epineurectomy and neurolysis may help to encourage further regeneration. Useful recovery could be achieved in a fairly high number of patients by restoration of continuity by nerve grafts or neurolysis. The functional results can further be improved by exploiting all available reconstructive techniques.     

Anatomy of the normal brachial plexus revealed by sonography and the role of sonographic guidance in anesthesia of the brachial plexus

The complete amino acid sequence of [2Fe-2S] ferredoxin from Physalis alkekengi var. francheti has been determined by automated Edman degradation of the entire Cm-protein and of the peptides obtained by trypsin and endoproteinase Asp-N digestions. This ferredoxin exhibited ten, ten, and nine differences respectively in the amino acid sequence, when compared with the ferredoxins of Datura stramonium, D. metel, and D. arborea, but 21-28 differences for other angiosperms, and 34-37 differences for fern and horsetails. These results are in harmony with the taxonomic position for these plants.     

Catheter technique in axillary plexus block. Presentation of a new method

A flexible, disposable intravenous catheter can be introduced into the neuro-vascular sheath in the axilla and used for injection of local anesthetic solution to block the axillary brachial plexus. The technique is described and the results of the first 137 consecutive catheter blocks are reported and compared to a similarly evaluated series of conventional axillary blocks. The catheter method constitutes an interesting alternative to needle techniques and offers the possibility of a continuous axillary block.     

Study on the intraneural topography of the brachial plexus

An accurate intraneural topography of the nerve fascicules in the brachial plexus provides a correct diagnosis and proper treatment of brachial nerve injuries. Four specimens of the branchial plexus were harvested from human cadavers by careful dissection and serially cross-sectioned from the nerve root level to the peripheral nerve. A spatial relationship between each nerve fascicule was observed and traced proximo-distally with a stereoscopic microscope. The main results and conclusions are as follows: 1. Four types of normal variation were identified in the composing elements of the brachial plexus. It is special interest to note the one in which both the fifth and sixth cervical nerve roots are composed of the dorsal scapular nerve. The existence of normal variations should be taken into account when determining the level and degree of branchial plexus injuries. 2. The nerve fascicules composing each peripheral nerve are most easily discerned at the cord level of the branchial plexus where there are no definite fiber exchanges between those nerve fascicules. These results would indicate that reconstructive nerve operations can be done successfully at the cord level or, at most, at the division level.     

Dyspnea resulting from phrenic nerve paralysis after interscalene brachial plexus block in an obese male--a case report

While current psychiatric taxonomies recognise a classification of amphetamine dependence, derived from the notion of an alcohol dependence syndrome, little research has validated that such a condition exists for this drug. Current amphetamine users (N = 331), were interviewed using the World Health Organization operationalisation of DSM-III-R substance dependence criteria, and a measure of the psychological components of dependence. Structural analyses indicated that a unidimensional dependence syndrome as assessed by DSM-III-R and DSM-IV criteria exists for amphetamine, and that physiological, psychological and behavioural indicators were all important in accounting for the variance in responses. It was demonstrated that the concept of a dependence syndrome is applicable to amphetamine, and that the inclusion of the amphetamine dependence syndrome in DSM-III-R and DSM-IV is valid.     

Neuroma-in-continuity resection: early outcome in obstetrical brachial plexus palsy

The short-term effect of neuroma-in-continuity resection in obstetrical brachial plexus palsy was evaluated to test the hypothesis that the neuroma does not contribute to useful limb function. Twenty-six patients with obstetrical brachial plexus palsy underwent resection of the neuroma-in-continuity and interpositional nerve grafting, and 17 patients underwent neurolysis only. The preoperative and postoperative active movement scores were recorded using an eight-point scale for 15 joint motions in each patient. Data analysis examined the change in total limb motion scores over time within patients undergoing neuroma-in-continuity resection and a comparison with those patients undergoing neurolysis. Compared with preoperative assessment, limb motion scores after neuroma resection were significantly decreased at 6 weeks, not significantly different by 3 months, and significantly improved at 12 months postoperatively. In comparison to patients undergoing neurolysis only, limb motion scores after neuroma resection were not significantly different at 3, 6, and 12 months postoperatively. These findings are unlikely to be accounted for by axonal regeneration across interpositional nerve grafts. Nerve regeneration or recovery in the nongrafted segment of the plexus must be sufficient to reproduce preoperative motion. Resection of the neuromas-in-continuity in obstetrical brachial plexus palsy does not significantly diminish motor activity.