Obstetric complications are a common cause of brachial plexus injuries in neonates. Failure to restore sensation leads to trophic injuries and poor limb function. It is not known whether the infant suffers chronic neuropathic or spinal cord root avulsion pain; in adults, chronic pain is usual after spinal root avulsion injuries, and this is often intractable. The plexus is repaired surgically in severe neonatal injures; if no spontaneous recovery has occurred by 3 months, and if neurophysiological investigations point to poor prognosis, then nerve trunk injures are grafted, while spinal cord root avulsion injuries are treated by transferring an intact neighbouring nerve (e.g. intercostal) to the distal stump of the damaged nerve, in an attempt to restore sensorimotor function. Using a range of non-invasive quantitative measures validated in adults, including mechanical, thermal and vibration perception thresholds, we have assessed for the first time sensory and cholinergic sympathetic function in 24 patients aged between 3 and 23 years, who had suffered severe brachial plexus injury at birth. While recovery of function after spinal root avulsion was related demonstrably to surgery, there were remarkable differences from adults, including excellent restoration of sensory function (to normal limits in all dermatomes for at least one modality in 16 out of 20 operated cases), and evidence of exquisite CNS plasticity, i.e. perfect localization of restored sensation in avulsed spinal root dermatomes, now presumably routed via nerves that had been transferred from a distant spinal region. Sensory recovery exceeded motor or cholinergic sympathetic recovery. There was no evidence of chronic pain behaviour or neuropathic syndromes, although pain was reported normally to external stimuli in unaffected regions. We propose that differences in neonates are related to later maturation of injured fibres, and that CNS plasticity may account for their lack of long-term chronic pain after spinal root avulsion injury.
Introduction: Shoulder relocation is commonly performed for the subluxating or dislocated shoulder secondary to Obstetric Brachial Plexus Palsy (OBPP). We have observed that even when relocation is performed at a young age, remodelling of the immature, dysplastic glenoid is often unreliable, resulting in recurrent incongruity and requiring treatment of the glenoid dysplasia. Methods and results: In a series of 19 patients, we used a posterior bone block to buttress the deficient glenoid at the time of shoulder relocation. At a mean follow up of 28 months (6–73 months), we describe failure in at least 50% with erosion of the bone block, progressive subluxation and resultant pain. A different technique of glenoplasty is now used. An osteotomy of the glenoid is performed postero-inferiorly, elevating the glenoid forward to decrease its volume. Bone graft, often taken from an enlarged and resected coracoid is then packed into the osteotomy and the whole assembly is held with a plate. In a series of 11 patients with a mean age of 6.7 years (1–18 years) we describe good results at short term followup, suggesting that this is a technique warranting further investigation. Conclusion: We believe that where a deficient glenoid is found at surgery for relocation of the shoulder in OBPP, a glenoplasty should be performed at the same time whatever the age of the patient, as glenoid remodelling will not reliably occur. We no longer advocate posterior bone block in these cases as it has a significant failure rate.
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We describe seven cases of permanent neurological damage following interscalene block used in post-operative analgesia after operations at the shoulder. MRI, Nerve Conduction Studies and Quantitative assessments of function confirmed that in all there was infarction of the anterior spinal cord, resulting in a spinothalamic and corticospinal tract defect especially at segments C7, C8 and T1. We think that these lesions were caused by injury to radicular arteries. Domisse has demonstrated the anatomy of the radicular vessels joining the anterior spinal artery to supply the anterior two thirds of the cord. They are branches of the vertebral, ascending cervical and deep cervical arteries which pass through the inter-vertebral foramina with the C7, C8 and T1 roots predominantly. Chakravorty has shown that radicular vessels contribute to the blood supply of the lower cervical cord. Injury to them can cause ischaemia, leading to Anterior Spinal Artery Syndrome. We suggest tamponade of the radicular vessels by infusion of fluid under pressure deep to the prevertebral fascia as the main mechanism but neurotoxicity and vasospasm can be other possible explanations. In a second group there was an additional interference with the vertebral artery presenting with transient bulbar and cranial nerve symptoms. We had 2 patients with such combined lesions. Complications of interscalene blocks are well documented but most are reversible and transient. In our cases the damage has been permanent and disabling. The innervation of the gleno-humeral joint is largely through the 4th, 5th and 6th cervical nerves and we suggest more appropriate placing of the blockade should be adapted and use of this technique for post-operative analgesia should be abandoned.
In this study, we discuss 68 cases in which peripheral nerve trunks were inadvertently divided by surgeons. Most of these accidents occurred in the course of planned operations. Delay in diagnosis and in effecting repair was common. We list the nerves particularly at risk and the operations in which special care is needed. We recommend steps to secure prompt diagnosis and early treatment.
Suetonius quotes at Tiberius 21. 4–7 a number of passages from letters of Augustus to Tiberius showing the high regard in which he professed to hold him, despite his reservations about the darker side of his character, once he had decided to adopt him ‘rei publicae causa’ in a.d 4. They seem to have attracted little critical comment, although Seager connects them with the handling by Tiberius of the Pannonian revolt in a.d. 6–9. suggesting that in view of their fulsome character they were probably written towards the end of this period, when the crisis was past, rather than earlier when Augustus may (Dio 55.31) have been critical of Tiberius’ caution in prosecuting the war. But he does not attempt a more detailed appraisal of the possible dates of the individual letters quoted. Sections 21. 4 and 5 in particular present interesting textual difficulties, mainly arising from the transmission of Greek in a predominantly Latin text: this article discusses these with a view to throwing greater light on the historical significance of the letters. First, the text, to which I have appended a limited apparatus which concentrates on the points of greatest difficulty (the manuscript references are as in Ihm's edition).
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