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Background: Peripheral nerve stimulation (PNS) has emerged as a promising treatment for refractory neuropathic pain in the upper extremities, particularly for patients unresponsive to conventional therapies. This systematic review and meta-analysis aims specifically to evaluate the effectiveness and safety of nerve stimulation of the brachial plexus (BP) for managing chronic neuropathic pain in the upper extremities.

Methods: A comprehensive literature search was conducted following PRISMA guidelines across major databases, including PubMed, Scopus and Embase. Five studies met the inclusion criteria, encompassing a total of 157 patients with BP or other peripheral nerve injuries. The primary outcome measures included pain reduction and quality of life improvement, assessed through validated pain scales such as the Numerical Rating Scale (NRS) and patient-reported outcomes.

Results: This meta-analysis demonstrated significant reductions in pain scores following BP nerve stimulation (MD: −4.88, 95% CI: −5.80 to −3.96, p < 0.05). Additionally, improvements in quality of life were observed, with over 30% enhancement in Short Form (SF)-36 scores. The overall complication rate was low, with only 9.2% of patients experiencing adverse events, such as lead migration or postoperative infection.

Conclusions: These findings suggest that PNS at the level of the BP is both a safe and effective intervention for the management of refractory neuropathic pain in the upper extremities.

Level of Evidence: Level IV (Therapeutic)

Nerve transfers Oberlin-type are currently used in upper brachial plexus lesions to recover elbow flexion. Is the regained active motion sufficient to resume heavy manual activities? Five adult patients (mean age 37 years) operated of a nerve transfer to recover elbow flexion (transfer of a motor fascicle of the ulnar nerve to the motor branch of the biceps; in three patients, additional transfer from the median to the motor nerve of the brachialis) were clinically and isokinetically evaluated, after a mean follow-up of 47 months. The median Constant-Murley score was 22/100, the DASH 56/100 and the MEPI 60/100. For isokinetic tests the most significant finding was a severe deficit of elbow strength, of about 80%. No patient was able to maintain an isometric contraction during sufficient time to evaluate fatigability. This preliminary study suggests that major functional impairments persist despite early recovery of elbow flexion. These results should be confirmed in a study on a larger group of patients.

Background: A lack of shoulder abduction in spontaneously recovered birth brachial plexus palsy (BBPP) is a common presentation. We have performed a soft tissue release operation in these patients to remove the tethering effect of the tight and cocontracting shoulder adductors. This study was undertaken in order to assess the outcome of this surgical procedure.

Methods: We performed a retrospective analysis of 120 patients who displayed spontaneous recovery from BBPP and subsequently underwent soft tissue release procedure to improve shoulder abduction. The operation involved release of the pectoralis major, latissimus dorsi (LD) and teres major (TM) with axillary nerve neurolysis and transfer of LD and TM to teres minor at a lower position. Outcomes were assessed at a minimum follow up of two years. The primary outcome measures were range of shoulder abduction and Mallet score. Parents were interviewed and their satisfaction was graded on a Likert scale. We also explored prognostic factors responsible for better outcomes namely, age at operation, extent of involvement; preoperative shoulder abduction range, internal rotation deformity, triceps power and Mallet score.

Results: The average patient age was 5.8 years(range 1–17). Follow up ranged from 2–6 years. Average preoperative shoulder abduction was 85° (range 30°–140°). Postoperatively the average shoulder abduction was 161° (range 80°–180°). The mean improvement in abduction was 76° (range 20°–110°) [p < 0.001]. Mallet score improved from 16.4 to 19.5 (p < 0.001). High parental satisfaction was recorded by Likert scale assessment. Regression analysis indicated a favourable outcome in patients who are younger, have a better preoperative abduction range and a preoperative triceps power > grade 3.

Conclusions: Soft tissue release procedure employed in this series is effective in improving shoulder abduction. Patients who are of younger age, have better preoperative abduction and triceps power of > grade 3 are expected to achieve the best outcome.

Suprascapular neuropathy has become increasingly recognized entity which is often overlooked and mistaken for other causes of shoulder pain and dysfunction like rotator cuff injury, shoulder impingement syndrome, cervical spondylosis and brachial plexopathy. It can be caused by a variety of anatomic and pathologic entities as the nerve courses from the brachial plexus through the suprascapular and spinoglenoid notches to innervate the supraspinatus and infraspinatus muscles. Because of the widespread availability of high-field MRI scanners now it is possible to detect the subtle perineural pathology, thereby excluding the other common causes of shoulder pain. There are scattered case reports and reviews describing suprascapular nerve (SSN) abnormalities using MRI. This article comprehensively reviews different pathologic abnormalities involving the SSN and illustrates their MR features, clinical presentation, correlation with electrophysiologic studies and surgical findings based on a review of 24 cases. We found the different clinical entities which includes trauma and a spectrum of nontraumatic etiology such as idiopathic, mass lesions compressing the nerve, intrinsic lesion like intraneural ganglion cysts of SSN, repetitive overuse, viral neuritis and chemotherapy induced neuropathy.

Background: The objective of this paper was to determine the validity, reliability and internal consistency of the translated FILIPINO DASH (FIL-DASH) questionnaire in patients with traumatic brachial plexus injuries.

Methods: Thirty-five adult patients with traumatic brachial plexus injury were enrolled in the validation stage. The same questionnaire was given to the patient between 7 to 14 days for the test-retest reliability. The validated Filipino version of the SF-36 was used as the gold standard to determine the construct validity of the translated DASH. We also compared the DASH score with the SF-36 total and subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Acuity Scale (VAS) for Pain.

Results: The internal consistency was adequate, with Cronbach’s Alpha for the 30 items of 0.93 and an average inter-item covariance of 0.399. The test-retest reliability was 0.87 (p < 0.001). There was no significant difference in establising the validity of the translated DASH against SF-36 total and Subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Analogue Scale (VAS).

Conclusions: The translated DASH (FIL-DASH) questionnaire was internally consistent and showed no difference in testing for test-retest reliability and validity against functional outcome measures and pain scales validated for adult Filipinos.

A 25-year-old man sustained a right-sided brachial plexus injury from a high-velocity motocross accident. Physical examination and electromyography were consistent with a pan-brachial plexopathy with no evidence of axonal continuity. The patient underwent a spinal accessory to suprascapular nerve transfer and an intercostal to musculocutaneous nerve transfer with interpositional sural nerve grafts. He recovered MRC 4/5 elbow flexion and MRC 2/5 shoulder abduction and external rotation. Twenty-two months post-injury the patient displayed a flicker of flexion of his flexor pollicis longus and flexor digitorum profundus to his index finger – he went on to recover a functional pinch. Thirty-six months post-injury the patient displayed a flicker of contraction in brachioradialis with motor unit potentials on electromyography. This case demonstrates that some patients may have capacity for functional recovery after prolonged denervation and highlights the potential impact of anatomical anomalies in the assessment and treatment of peripheral nerve injuries.

Background: Trapezius transfer has shown promise to restore shoulder movements and has stood through the passage of time. We here in describe a modification of trapezius transfer technique and review the current literature available.

Methods: The modified trapezius transfer in which the trapezius muscle is extended with folded tensor fascia lata graft and attached as distally possible to the deltoid insertion was done in twelve patients at tertiary health care centre in India. Post-operative splinting and staged physiotherapy were given.

Results: Results were described in the form of improvement in degree of shoulder abduction and Disabilities of the Arm, Shoulder and Hand (DASH) score. Six months post-surgery there were improvement in shoulder abduction and DASH score with mean 116 degrees (10–180 degree) and 38 (23–58) respectively. One patient showed poor results due to poor compliance in post-operative period. There were no major complications observed.

Conclusions: The modified technique of trapezius transfer described here is a feasible option with good biomechanical outcomes. The technique is simple and can be adopted easily by emerging brachial plexus surgeon as a technique for secondary reconstruction of shoulder joint.

As the brachial plexus traverses the costoclavicular space, it is susceptible to compression by pathologies affecting the clavicle. Clavicle nonunions with hypertrophic callus may cause a delayed onset of brachial plexus palsy. We present a rare case of a floating shoulder injury causing medial and posterior cord brachial plexus palsy two months after initial injury. After the diagnosis was established, the patient was treated successfully with expeditious brachial plexus decompression, callus excision, and rigid osteosynthesis, with healing of the clavicle nonunion and scapular fracture, and recovery of sensory and motor deficits.

Background: Isolated lower (C8T1) brachial plexus injury (BPI) is uncommon and the aim of treatment is to achieve a satisfactory grasp enabling the use of the hand for daily activities. The aim of this study is to report the outcomes of the transfer of brachioradialis (BR) to flexor pollicis longus (FPL) and biceps to the flexor digitorum profundus (FDP) for an isolated lower BPI.

Methods: This is a retrospective study of all patients with an isolated lower BPI who underwent a BR to FPL and biceps to FDP transfer for restoration of digital flexion over a 1-year period from May 2019 to June 2020. Patient demographic and injury data were collected at the presentation. Outcomes data included the ability to grasp and perform activities of daily living and DASH score.

Results: The study included three patients (all men) with an average age of 30.3 years. All sustained an isolated lower BPI following a road traffic accident and tendon transfers were performed at a mean of 9.3 months after the initial injury. At a mean of 1-year follow-up, all three recovered grade M4 motor power of digital flexion, achieved good grasp function with pulp-to-palm distance of <1 cm. All are able to use the hand for independent as well as bimanual activities. The individual DASH scores were 36, 30 and 30.

Conclusions: BR to FPL for thumb flexion and biceps to FDP using fascia lata graft to restore finger flexion is simple and effective surgeries in patients with isolated lower BPI.

Level of Evidence: Level V (Therapeutic)

Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexus injury (BPI). This internally rotated posture of the limb becomes more apparent and functionally limiting once the patient recovers elbow flexion resulting in the hand striking the abdomen on attempted flexion (‘tummy flexion’). This precludes hand-to-mouth reach, resulting in an inability to eat with the involved hand. The aim of this study is to present the outcomes of an external rotation osteotomy of the humerus in adult BPI.

Methods: All BPI patients who underwent an external rotation osteotomy of the humerus at our institution over a 5-year period from January 2015 to December 2020 were included in this study. Data with regard to the age, gender, type of BPI, time from injury to nerve surgery and from nerve surgery till external rotation osteotomy, degree of pre- and postoperative external rotation, time to union, patient satisfaction and complications were recorded.

Results: The study included 19 patients (18 men and one woman) with an average age of 30 years (range 20–58). The average time interval from the injury to the nerve surgery was 3.8 months, and between the nerve surgery and the external rotation osteotomy was 29.5 months. No patient had any preoperative external rotation and all attained a resting posture of 15°–20° of external rotation, were able to reach the mid-line of the body, and none complained of loss of internal rotation. There was an implant failure in one patient that was managed with splinting till union and removal of implants later.

Conclusions: External rotation osteotomy of the humerus is a simple and effective procedure to place the limb in a better aesthetic and functional position.

Level of Evidence: Level IV (Therapeutic)

Thoracic outlet syndrome (TOS) caused by a primary brachial plexus tumour is very rare. A male politician in his 40s presented with numbness, left limb pain and positive Wright and Roos test results. Magnetic resonance imaging (MRI) revealed a tumour located just below the clavicle, compressing the subclavian artery during left arm elevation. Despite concerns regarding postoperative nerve deficits, surgery was performed because of worsening symptoms during the election campaigns. The pathology report revealed a schwannoma. Few reports have described TOS caused by primary tumours of the brachial plexus. While the decision to perform surgery for primary tumours of the brachial plexus requires careful consideration, surgery may be indicated in cases where the tumour location causes such symptoms.

Level of Evidence: Level V (Therapeutic)

Neurogenic thoracic outlet syndrome (nTOS) is caused by brachial plexus compression in the thoracic outlet. It accounts for 85%–95% of thoracic outlet syndrome (TOS) cases, which may also be caused by compression of the subclavian artery and vein. Compression occurs in the interscalene triangle, costoclavicular space or subpectoralis minor space, with congenital anomalies and repetitive overhead activities as contributing factors. Diagnosis is challenging due to overlapping symptoms with other conditions. Patients commonly report pain, numbness, tingling and weakness in the neck, shoulder and arm, exacerbated by arm elevation. Symptoms related to nTOS may manifest in the distribution of the upper (C5–C6), middle (C7) and lower plexus (C8–T1). Although widely used, provocative tests have varying degrees of sensitivity and specificity and may have high false-positive rates, complicating the diagnosis. Patterns on electrodiagnostic studies provide key diagnostic clues, such as reduced sensory response in the medial antebrachial cutaneous nerve and low compound motor action potential in the median nerve. Imaging techniques like magnetic resonance imaging (MRI), alongside procedures like diagnostic and therapeutic anterior scalene blocks, assist in identifying anatomical abnormalities and predicting surgical outcomes. Management of nTOS involves lifestyle changes, physical therapy, medication and botulinum toxin injections for symptomatic relief. Surgical options may include supraclavicular, transaxillary and infraclavicular approaches, each offering specific benefits based on patient anatomy and surgeon expertise. Minimally invasive techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic surgery, enhance exposure and dexterity, leading to better outcomes. Future research should focus on developing precise diagnostic tools, understanding nTOS pathophysiology, standardising diagnostic criteria and surgical approaches, comparing long-term treatment outcomes and exploring preventive measures to improve patient care and quality of life.

Level of Evidence: Level V (Therapeutic)

Background: We noted that patients with thoracic outlet syndrome (TOS) have elevation of the ipsilateral scapula and named this the scapular elevation sign (SES). The aim was to determine the prevalence of SES in a normal cohort, compare SES with other provocative tests and to determine the treatment effect on SES.

Methods: First, normal asymptomatic subjects were prospectively assessed to determine the prevalence of SES in a normal cohort. Second, patients with TOS were retrospectively examined for the presence of SES and four provocative tests: supraclavicular pressure, scalene test, elevated arm stress test (EAST) and the military brace manoeuvre. All patients were initially treated non-surgically. Surgery was offered to patients with persistent symptoms at 6 months. Patients were re-examined for the presence of the SES after treatment.

Results: The prevalence of SES in our normal cohort was 4% (2/53). Our study cohort included 20 patients with TOS. The SES was positive in 18 patients (90%). Supraclavicular pressure was positive in 11 (55%), scalene test in 13 (65%), EAST in 9 (45%) and military brace manoeuvre in 11 patients (55%). Following non-surgical treatment, six patients had symptom resolution, three had improvement, nine persistent symptoms and two were lost to follow-up. The SES was positive in one out of six patients with symptom resolution, two out of three patients with improvement and in all nine patients with persistent symptoms. Patients with persistent symptoms underwent surgery with symptom resolution in eight and improvement in one patient. The SES remained positive in two patients after surgical treatment.

Conclusions: The SES is simple and sensitive, does not rely on variations in performance of the test and suitable for diagnosis and assessment of outcomes of TOS.

Level of Evidence: Level III (Diagnostic)

Background: The transfer of latissimus dorsi (LD) and teres major (TM) have been described for restoration of external rotation (ER) and shoulder abduction in neonatal brachial plexus palsy (NBPP). The aim of this prospective randomised study is to compare the outcomes of LD versus TM transfer in the treatment of internal rotation contracture of the shoulder in children with NBPP.

Methods: The study was conducted from February 2014 to January 2018 and included NBPP patients with internal rotation contracture of the shoulder. Patients were randomised to either LD (Group 1) or TM (Group 2) tendon transfer. Patients were followed up for at least 38 months and assessed for improvements in the arc of shoulder abduction and ER.

Results: The study included 30 patients with 15 patients randomised to each group respectively. Group 1 (n = 15) included 4 boys and 11 girls with a mean age of 2 years and 8 months (range: 1.5–5) and a mean follow-up of 62 months (range: 38–68). Group 2 (n = 15) included 6 boys and 9 girls with a mean age of 2 years and 6 months (range: 1.5–4.8) and a mean follow-up of 58 months (range: 38–68). All patients showed improvement in shoulder abduction and active and passive ER. There were no differences in shoulder abduction (p = 0.467), active ER (p = 0.124) and passive ER (p = 0.756) between both groups.

Conclusions: Both LD and TM tendon transfers improved shoulder function in NBPP patients with internal rotation contracture of the shoulder.

Level of Evidence: Level II (Therapeutic)