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Diagnosis

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Diagnosis

    Diagnosis

    ChineseJournalofTraumatology(EnglishEdition)2002;5(6):329-332?329?

    Diagnosisandoperativetreatmentofradiation-induced brachialplexopathy

    LULaijin路来金,GONGXu宫旭,LIUZhigang刘志刚,WANGDongsheng王东生

    andZHANGZhixin

    张志新

    Objective:Toexplorethediagnosisandoperative treatmentofradiation-inducedbrachialplexopathy. Methods:NineCASESofradiation-inducedbrachial plexopathyweredividedintotwogroups,4cases undergoingneurolysisofbrachialplexusasGroupAand5 casesundergoingtransferofmyocutaneousflapsafter neurolysisasGroupB.InGroupB,4casesweretreated withlatissimusdorsimyocutaneousflapsfabout20cm×20

    clln)and1casewithpectoralismajormyocutaneousflap (about8cm×6cm).

    Resaits:AUthe9CASESofradiation-inducedbrachial plexopathywerefollowedupforaperiodof2to5years, withanaverageof2.3years.Asfaraspainre.efand Breastcancerhasthehighestoccurrenceinfemaletumors.Radiotherapyisanancillarymetho

    dtopreventtherecurrenceandlymphmetastasisafter radicalmastectomy.However.irradiationcanalso iniurethelocaltissuesandnerves.especiallythe brachialplexusnervesinthesuDraclavicularand axillaryregions.whichiscalledradiation-induced brachialplexopathy(RBP).ThetreatmentofRBPis

difficultandtheprognosisispoor.Simultaneously,

    thediagnosisofRBPshouldbedifierentiatedfromthat ofneoplasticbrachialplexopathy(NBP),becausethe symptomsandphysicalexaminationsofbothdiseases alesimilar.Thisarticlediscussesthepathogenesis, diagnosisandoperativeoutcomesofRBPthrougha reviewof10casesinourhospita1.

    METHoDS

    Clinicaldata

    Atotalof10caseswereincludedintheseries. whichconsistedof1maleand9females.Theirages DepartmentofHandSurgery,FirstHospitalAffiliatedto JilinUniversity,Changchun130021,China(LuU,GongX, LiuZG.WangDSandZhangZX)

    Correspondingauthor:Tel:0431-5612817:Email:

    Lulaijin@public.cc.j1.cn

    functionrecoverywereconcerned,theresultsofGroupB werebetterthanthoseofGroupA.

    Conclusions:BasedOlltheresultsofGroupBinthe series.wesuggestthattheprocedureofcoveringthe woundswithtransferredmyocutaneousflapsafter neurolys~ofthebrachiaiplexusshouldbeperformedto thoseadvancedpatien~.Theproceduremayimprovethe bloodsupplyofthefibroticbrachiaiplexusbyreestablishing agoodnervebed.

    Keywords:Radiationinjuries;Brachiaiplexus; Nervoussystem;Musculocutaneousnerve;Surgicalflaps ChinJTraumatof(EngEd)2002;5(6):329-332 rangedfrom42to62years,withanaverageof52 years.A1lthecasesreceivedradicalmastectomy

    becauseofbreastcancer.Thelesionof4caseswasin theleft.4casesinthefightandtheother2casesin bothsides.A1lthecasesexperiencedCoradiation therapyinthepostoperative65-90days,withan averageof73days.Thesitesofirradiationwerethe axillaryandsupraclavicularregions.andthetotal dosagewas53Gy,withanaverageof2.5Gyevery day.TheintervalbetweentheinitialsymptomsofRBP andtheoperationrangedfrom4to50months,withan averageof20months.Initially,thepatients complainedofspontaneouspainandedemainthe upperextremitiesprogressively,accompaniedby sensorydisturbanceanddyskinesiaoftheaffected upperextremities.Thesymptomsconsistedof lymphedema,weaknessandspontaneouspaininthe affectedlimbs.Physicalexaminationshowedmildor moderatelymphedemain7casesandsevere

    lymphedemain3cases.Theskinintheaxillaryand supraclavicularregions,whichwaslackofelasticity andmobility,presentedindurationsandwashard.The regionofbrachialplexusshowedapositiveTinel'ssign butanegativeHomer'ssign.Atrophyoftheaffected upperextremitieswasnotpredominantbecauseof seriouslymphedema.However,atrophyoftheintrinsic musclesofthehandwassignificantin8cases.Sensory

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    330?ChineseJournalofTraumatology(EnglishEdition)2002;5(6):329-332

    examinationshowedparesthesiain2cases, hypesthesiamastectomy.

    in6casesandnumbnessin2cases.Motorfuncti0n examinationshowedthemusclestrengthof2caseswas M0inthearlnandforearmandM,intheintrinsic musclesofthehand.Themusclestrengthsofthe0ther 8caseswereM2M4intheaffectedupperextremities. In1case.therewere2masses(3cm×3cmand2cm

    ×2cm.respectively)withtendernessinthe supraclavicularandaxillaryregions,whichwere confirmedtobemetastatictumorsafteroperation. Electr0my0graphy(EMG)wasusedtoidentifythe injuryofthebrachialplexusin4cases.The conductionvelocityofthesensorynervebetweenthe supraclavicularandinfraclavicularsitesdecreasedby 50%.ascomparedwiththatofthecontralateralside. Theamplitudeofevokedmuscleactionpotential (EMAP)decreased,andthelatencyelongatedas comparedwiththatofthecontralateralside. Surgicalproceduresandfindings

    Theprocedureswerecarriedoutwiththepatients undergeneralanesthesia.Ninecases(onewas excludedbecauseNBPwasidentifiedoperatively)were dividedintotwogroups,4casesundergoingneurolysis ofbrachialplexusasGroupAand5casesundergoing transferofmyocutaneousflapsafterneurolysisasGroup B.Thesurgicalfindingsof9patientswereidentica1. Universaladhesionsbetweenskinandsubcutane0us tissuesexistedinthesupraclavicularandaxillary regions.Defectsofthepectoralismajorandminor muscleswerefoundearlyinallcases,exceptone, whosemostpectoralismajormusclewasleft.Fibrosis

    oftheanteriorandmiddlescalenemuscleswas apparent.Proliferationandfibrosisofbrachialplexus existed,whichpresentedpallorcolorandhardtexture duringoperation.Adhesionsanddensescartissues aroundthenerveandaxillaryvesselsexisted universally.Thebrachialplexuswasexploredfromthe cervicalrootstothedistalbranches,untilthewhole brachialplexuswasinspectedandreleasedunderloupe magnification,thelengthofwhichwasabout25cm. ThewoundwascloseddirectlyinGroupA,andclosed bytransferofthemyocutaneousflapsinorderto reestablishagoodnervebedinGroupB,inwhich4 casesweretreatedwithlatissimusdorsimyocutaneous flaps(20cm×20cm)and1casewithpectoralis

    majormyocutaneousflap(8cm×6cm)afterradical

    RESULTS

    Allthe9patientswithRBPidentifiedoperatively werefollowedupfor2-5years,withanaverageof2.3 years.Theoperativeresultsweredifferentbetweenthe twogroups.Theoperativeresultsofallthe4casesin GroupAweresatisfied.Thespontaneouspainofthe affectedupperlimbswasrelievedpostoperatively,but analgesicmedicationswerestilltakenbecauseof moderatepaininthefirstpostoperativemonth.Follow

    upinthethirdpostoperativemonthshowedthe spontaneouspainwasnotrelievedsignificantlyas comparedwiththatinthefirstmonthinall4cases. Sensoryexaminationshowedhyperesthesiain2cases, whilethemotorfunctionwasnotimprovedascompared withthepreoperativepalsy.Thesensibilityandmotor

    functionoftheother2caseswerenotimproved significantly.Thefollowupvisitinthesixth

    postoperativemonthshowedthemusclestrengthof2 casesincreased,especiallyintheaiTnandforearm, butnotintheintrinsicmusclesofthehand.However, themusclestrengthoftheother2casesgotworseas comparedwiththepreoperativefunctions.Inthelatest followup,thesensibilityandmotorfunctionofall4 caseswerenotimprovedsignificantlyascomparedwith thepreviousfollowups,andanalgesicmedications

    werestilltakentorelievemoderatespontaneouspain. InGroupB,thespontaneouspainoftheaffected upperlimbswasrelievedsignificantlywithouttaking analgesicmedicationsascomparedwithpreoperative pain.Thesensibilityandmotorfunctionofall5cases werenotimprovedsignificantlyascomparedwiththe preoperativefunctionsinthefirstpostoperative6 months.However,thefollowupinthefirst

    postoperativeyearshowedthatthesensibilityandmotor functionofallthe5caseswereimprovedsignificantly ascomparedwiththepreoperativefunctions.The spontaneouspainoftheaffectedupperlimbs disappearedin3cases,andmildpainremainedin2 cases.Inthelastfollowupvisit,themusclestrength

    wasM3M4intheaITHandforearm,butno

    improvementintheintrinsicmusclesofthehandwas found(Fig.1).

ChineseJournalofTraumatology(EnglishEdition)2002;5(6):329.332?331?

Fig.1.Radiation

    inducedbrachialplexopathy.A.Preoperativeview;B.Operativeview;C.Aftertransferofdor

    sallatissimus

    myocutaneousflaps;D.Followupat1yearafteroperation.

    DISCUSS10N

    PathogenesisofRBP

    TherearefeWreportsonRBPintheliterature, andthepathogenesisofRBPisnotclearinthepast. Clinically,thetotaldosageofregularirradiation therapyiS4553Gy.andthesafedoseofadayis1.8

    2.5Cv.Generally.thecapabilityoftheirradiation tolerationofnourishingvesselsandinvestingadipose tissuesaroundbrachialplexusiSstrong.However. radicalmastectomyneedsresectionofthepectoralis maiorandminormusclesandclearanceoftheaxillary lymphnodes,whichmayaffectthebloodsupplyfor brachialplexus.Destroyofthebloodsupplyanddefect ofthesofttissuesaroundthebrachialplexuscanimpair thecapabilityofirradiationtolerationofthebrachial plexus.Inaddition.thesiteofirradiationiSdivided intosupraclavicularandaxillaryregionsinthe irradiationtherapy.Whilethebrachialplexuslocates inthecrossregionofsupraclavicularandaxillary irradiations,andisinjuredbyhighenergyirradiation. Currently,highenergytherapeuticirradiationis performedintheirradiationtherapy.thecharacteristic ofwhichistoshifthighenergyfromtheskinintothe subcutaneoustissuesincludingbrachialplexus.SOthat irradiationinjurytothelocalskiniSminima1.andiS thereforeeasilyoverlookedbyclinicians.The

    irradiationdoesnotinjurenervesdirectly.butitleads toedema,necrosis,fibrosisandformationofscar tissuesinthebrachialplexusandthesurrounding tissues.Inaddition.proliferationofinnermembraneof thenourishingvesselsforthebrachialplexusimpairs thebloodsupplyofthebrachialplexus.Theprocess mentionedaboveisirreversable.whichisdimculttobe resolvedbyneurolysis.Theonlywaytoimprovethe surroundingenvironmentsoftheinjuredbrachialplexus istopreventprogressiveinjury.

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    332?ChineseJournalofTraumatology(EnglishEdition)2002;5(6):329-332

    Diagnosisanddifferentiation

    DiagnosisanddifferentiationofRBPhavebeen debatedformanyyears.becausetheclinicaI

    manifestationsofRBPandNBParesimilar.Byreview oftheseriesof9cases,wesuggestthediagnostic criteriashouldbebasedonirradiationhistoryand physicalexamination,combinedwithelectrodiagnostic tests.Thetime.intervalbetweentheonsetoftheinitial symptomandtheradicalmastectomyisdifferent betweenRBPandNBP.Thesymptomlessperiodof RBPrangesfrom3to36months(thelongestperiodis 20yearsintheliterature).whilethatofNBPis shorter.Intheseries,theaveragesymptomlessperiod was20months.Theinitialsymptomisusuallydifferent betweenRBPandNBP.TheinitialsymptomofRBP usuallypresentsparesthesiasornumbnessand cramping,whilethatofNBPispersistentspontaneous

    pain.Physicalexaminationsshowprogressive dysfunctionoftheaffectedlimbsinbothdiseases. PatientswithRBPpresentindurationsandfibrosisin supraclavicularandaxillaryregions,aswellas lymphedema,hypesthesiaorhyperesthesiaand tendernessintheaffectedlimbs.Musclestrengthofthe affectedlimbdecreasesintheadvancedpatients. However,anegativeHomer'ssignisfoundinthe patientswithRBP.whileapositiveoneisfoundin mostofthepatientswithNBP.Electrodiagnostictests showinjuryofthebrachialplexusaccordingtothe decreasedsensorynerveconductionvelocityand prolongedlatencyofmotornerve.MichelHarperCet alsuggestthefasciculationsormyokymiaalwaysexist inthepatientswithRBP.whichmaybeasa

    characteristicfindinginthepatientswithRBP. Considerationsofoperativetreatment

    TherearetwocharacteristicsofRBPbasedonits pathogenesismentionedabove.Thefirstisuniversal iniuryofthebrachialplexus,andthesecondis progressivedysfunctionoftheaffectedlimbs.Because seriousfibrosisofnervebedandthrombosisof nourishingvesselslcadtoirreversabledegenerationof thebrachialplexus.thepreventionofRBPshouldbe thefirstconsideration.astheirradiationtherapyis chosenasanassistanttherapyforbreastcancer. Currently,theirradiationtherapyisnotaregular therapyforradicalmastectomy.Becauseofthedifficult treatmentandpoorprognosis,

    therapyshouldbebased

thechoiceofirradiation

    onitsindications.In

    addition,thesiteanddosageofirradiationshouldbe regulatedinordertoprotectthebrachialplexus. Secondly,diagnosisandtreatmentshouldbemadeas earlyaspossibleinordertoavoidprogressiveadhesion andfibrosisanddegenerationofthebrachialplexus. Operativeresultsofadvancedpatientsarenotoptimal asweknowintheliterature,becauseneurolysiscannot stopprogressivedegenerationofnerveandfibrosis.In theseries,theoperativeresultsof5caseswho underwenttransferofthemyoeutaneousflapsshowed thatthespontaneouspaincouldberelieved

    completely,only2remainedmildpain,althoughthe dysfunctionsoftheaffectedlimbsrecovered moderately.AlthoughthereiSnostatisticalanalysisin ourresuhs,itcanstillsuggestthatimprovementofthe surroundingenvironmentwillpreventprogressive fibrosisofthebraehialplexusandrelievethepainof theaffectedlimbs.BasedonthebetterresultsofGroup Bintheseries,wesuggesttheprocedureoftransferof themyocutaneousflapsafterneurolysisofbrachial plexusmaybehelpfultorelievethespontaneouspain andtopromotethefunctionalrecoveryinadvanced patientswithRBP.Theproceduremayimproveblood supplyoffibrotiebraehialplexusbyreestablishinga goodnervebed.

    REFERENCES

    1.LuLJ,WangGJ,LiuZG,eta1.Repairofradiation

    inducedbrachialplexopathy.ChinJHandSurg1993;9:46.

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