No abstract

Successful re-innervation of proximal limb peripheral nerve injuries is rare. Axons regenerate at ~1 mm/day, reaching hand muscles by 24 months, finding them atrophied and fibrosed. Peripheral nerve injury repair is often delayed waiting for spontaneous recovery. This waiting time should not be longer than 6 months as after 18 months reinnervation will not achieve effective muscular function. When spontaneous recovery is impossible, referral too late or damage too severe, other options like a transfer from a nearby healthy nerve to the injured one must be considered. They are very successful, and the deficit in the donor site is usually minimal. The most common nerve transfers are a branch of the spinal nerve to the trapezius muscle to the suprascapular nerve, a branch of the long head of the triceps to the axillary nerve, a fascicle of the ulnar nerve to the motor branch of the biceps muscle, two branches of the median nerve to the posterior interosseous nerve and the anterior interosseous nerve to the ulnar nerve. There are many more options that can suit particular cases. Introduced in brachial plexus injury repair, they are now also applied to lower limb, to stroke and to some spinal cord injuries.

Brachial plexus injuries are commonly followed by chronic pain, mostly with neuropathic characteristics. This is due to peripheral nerve lesions, particularly nerve root avulsions, as well as upper limb amputations, and complex regional pain syndrome (CRPS). The differential diagnosis between CRPS and neuropathic pain is essential as the treatment is different for each of them. Medical treatments are the first step, but for refractory cases there are two main types of surgical alternatives: ablative techniques and neuromodulation. The first group involves destruction of the posterior horn deafferented neurons and usually provides a better pain control but has a 10% complication rate. The second group provides pain control with function preservation but with limited effectiveness. Each case has to be thoroughly evaluated to apply the treatment modality best suited for it. due to iatrogenia [8][9][10][11][12][13][14][15][16], particularly during lymph node biopsy [17, 18] or treatment of some malignancies [19]. The pain is chronic [20], persistent [7], constant [21], burning [22] and throbbing [17], with paroxysmal discharges [3, 6, 23], particularly upon gentle rubbing the affected area [4].The pain is distributed in the distal areas of the upper limb, covering several dermatomes, mostly the caudal ones [24] and particularly the hand [5, 17, 23, 25]. The paroxysmal pain is felt in the arm [26]. Allodynia, hypersensitivity and electric-like discharges are present at the border between the normal and affected dermatomes [17,[26][27][28][29], particularly between T 1 and T 2 at the posterior aspect of the elbow [26].The pain severity correlates with the magnitude of the brachial plexus injury [2,3] and to the number of avulsed nerve roots [2-4, 21, 26, 30-33], particularly when the lower roots are affected [24,34,35]. Nevertheless, Bertelli et al. [21] found that in isolated C 8 and T 1 nerve root avulsions, there was no pain at all.The pain does not appear immediately after the injury but a few days later [24] and no longer than 3 months after it [5, 6, 24, 26,35,36].The neuropathic pain can be associated with phantom [37] or stump pain [38] in case of upper limb amputation, or to complex regional pain syndrome (CRPS) [6], inducing a complex pain condition rather difficult to control [19,30,31].Self-mutilation has been described in 5-29% of obstetric brachial plexus injury cases [39,40].The quality of life is seriously impaired with sleep disorders, family troubles, unemployment, chronic depression and social withdrawal [2, 5, 6, 17, 21,[41][42][43][44]. Additionally, the chronic pain is a further hindrance to comply with a good rehabilitation programme, impairing a possible functional recovery [6,45,46]. Among all the disabilities induced by the brachial plexus injury, the pain has been found to be the symptom that most negatively affects the quality of life [47].Treatment of this chronic pain can be troublesome, as the response to the different treatment modalities is poor and not all of them allow preservatio...

Purpose. Effective treatment of medical conditions relies on proper diagnosis. Clinical trials show the safety and effectiveness of sacroiliac joint (SIJ) fusion in patients with chronic SI joint dysfunction. To what extent is the condition under recognised? Objective. To determine whether under recognition of SIJ pain affects healthcare trajectories in Spanish patients with low back pain. Methods. Retrospective study of characteristics and consequences of 189 patients with persistent SIJ pain seen in an outpatient neurosurgery clinic. Results. Patients with SIJ pain who were denied surgical treatment had a longer pain duration, higher likelihood of prior lumbar fusion, and a high rate (63%) of lumbar fusion within 2 years prior to SIJ pain diagnosis, which, in most cases, provided little benefit. Conclusions. Lack of knowledge of the role of the SIJ in chronic low back pain probably results in diagnostic confusion and may lead to misdirected treatment.

Nerve root avulsion is the most severe form of brachial or lumbosacral plexus injury. Spontaneous recovery is extremely rare, and when all the nerve roots of the affected plexus are avulsed, the therapeutic options are very limited. Nerve root reimplantation has been attempted since the 1990s, first in experimental animal models and afterwards in human beings. Currently, only partial recovery of the proximal limb muscles has been achieved. New therapeutic strategies have been developed to improve motor neuron survival and axonal regeneration, with promising results. Neurotrophic factors and some drugs have been used successfully to improve the regenerating ability, but long-term studies in humans are needed to develop complete recovery of the affected limb.