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A recent publication about patient reported outcomes of health-related quality of life after neonatal brachial plexus suggests that physical limitations, followed by social health, and to a lesser degree, emotional health remain significant long-term issues in these patients.42
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The presence of brachial plexus injury in polytrauma is of poor prognostic significance. Analysis of outcomes 10 years after trauma reveals that those with brachial plexus injury have lower rates of employment and worse outcome scores.46
The principal alternative to supraclavicular decompression in current practice is transaxillary first rib resection. In this operation, the first rib is approached from the side of the upper chest with the arm elevated overhead. The anterior and middle scalene muscles are divided at their attachments to the top of the first rib, after identifying and protecting the lower nerve roots of the brachial plexus (C8 and T1), as well as the subclavian artery and vein. The posterior part of the first rib is divided with protection of the lower nerve roots, and the anterior part of the first rib is divided in a location similar to that described for the supraclavicular approach. Through the transaxillary approach there is not sufficient exposure of the relevant anatomy to perform a complete scalenectomy or brachial plexus neurolysis. Although excellent results have been reported by individual surgeons with vast experience with this operation, there is evidence that these intrinsic limitations are linked to a higher rate of recurrent neurogenic TOS than that occurring after supraclavicular decompression. For surgeons who might perform this operation only on an occasional basis, the risk of nerve injury may also be considerable because of the potential for stretch-induced injury of the brachial plexus during elevated-arm positioning by mechanical retraction devices or assistants unfamiliar with the procedure.
The most frequent cause of recurrence following transaxillary first rib resection is reattachment of the previously divided anterior scalene muscle, along with formation of fibrous scar tissue, around the brachial plexus nerve roots. Formation of fibrous scar tissue around the brachial plexus is also the principal cause of recurrence after supraclavicular decompression operations, but reattachment of the anterior scalene muscle may also occur in this situation if it was not resected at the original operation. In patients in whom the first rib was not resected at the initial operation, or with a substantial remnant of the first rib (incomplete resection), the retained first rib may also be contributing to nerve compression. Reoperation may be considered in all of these situations, to include resection of any residual scalene muscle, fibrous scar tissue around the brachial plexus, and any first rib remnant.
Dr. Hadzic chose the local regional anesthesia called interscalene brachial plexus block as the main anesthesia for his own operation. Moreover, he also chose to have a catheter placed, so after the operation he could control his own pain by using an injection pump that gives him as much of a local or numbing medicine to the nerves as he needs. That is because he did not have to have general anesthesia for this operation, and the catheter after the operation could provide him with pain relief for a few days based on his needs.
We just scan approximately, until we get to the interscalene brachial plexus. Once we have identified the interscalene brachial plexus, then we inserted local anesthetic to anesthetize the skin and subcutaneous tissues. This makes the whole procedure much more comfortable to the patients. In fact, they may not even feel anything after a small pinch of local anesthetic administration.