Telerobotic Manipulation of the Brachial Plexus

Publicado em: 12 de junho de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Nervos Periféricos, Trabalhos Científicos - Robótica

Case Reports J Reconstr Microsurgery

. 2012 Sep;28(7):491-4. doi: 10.1055/s-0032-1313761.Epub 2012 May 24.

Telerobotic Manipulation of the Brachial Plexus

Jose Carlos Garcia Jr 1Frederic LebaillyGustavo MantovaniLeonardo Alves MendoncaJesely GarciaPhilippe LiverneauxAffiliations expand

Abstract

Objective: This study demonstrates the new technology of the robotic telesurgery on three brachial plexus reconstructions. We also discuss the implications, problems, and benefits of robotically assisted brachial plexus surgery.

Methods: After the first experimental experience in a cadaveric model, the authors performed three brachial plexus reconstructions. The surgery followed the traditional brachial plexus approach. From the moment that nervous sutures would be performed, the Da Vinci® (Intuitive Surgical™, Sunnyvale, CA) equipment was docked at the patients, positioned behind the patient’s head, and the microsurgical steps were performed by using robotic telemanipulation.

Results: The first procedure was performed in a cadaver to gain experience and establish a surgical protocol by using the robot. In all the three living patients, the goals of the surgical procedure were achieved using the telerobotic manipulation.

Conclusion: Robot-assisted surgery allows performance of high-dexterity surgical operations with the help of robotic arms and it improves the surgery due to tremor filtration, motion scaling, and ergonomics. The benefit of using the robot on microsurgery was reached, but its entire potential was not realized because the instruments used on those first experimental and clinical cases were not specifically designed for microsurgery.

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Endoscopic Release of the Brachial Plexus.

Publicado em: 12 de junho de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Nervos Periféricos, Trabalhos Científicos - Ombro

Endoscopic Release of the Brachial Plexus. Aceito para publicação na Arthroscopic Techniques

Abstract

Thoracic outlet syndrome(TOS) is a debilitating condition, impairing the function of the upper limb, and can be  considered as an entrapment of neurovascular structures dedicated to the upper limb. Its open treatment uses large approaches and to this date just structures under the clavicle have been endoscopically approached. 

The purpose of this technical note is to describe an endoscopic all brachial plexus decompression of at all possible entrapment areas, between the neck and the arm. 

Introduction

Thoracic Outlet Syndromes(TOS)  is a debilitating condition, impairing the function of the upper limb, and can be  considered as an entrapment of neurovascular structures dedicated to the upper limb1,2.

 The entrapment can be situated at different levels, between the neck and the arm, including the interscalenic triangle, the upper border of the first rib (by the rib itselt or a hypertrophic transverse cervical process with or without fibrous bands) the costo clavicular space, the retro coracoid, pectoralis minor and the penetration point of the neurovascular bundle at the level of the brachialis fascia1. The exact location of the entrapment can be difficult to access as well as the etiology of the compression and the structures involved like brachial plexus, subclavicular vein and artery. 

The TOS pathophysiology is multifactorial, including anatomical variations, cervical rib, fibrous bands, anomalous muscles, joint hypermobility, or biomechanical dysfunctions of the neck and scapular girdle related to labor, post-traumatic or sports gesture3. On this scenario the bony compression by a narrowing space between the clavicle and the first rib or a cervical rib, that was previously considered the main entrapment cause, will be responsible for just 20-30% of the cases1,2

TOS diagnosis remains difficult and controversial. No consensus have been reached to establish objective criteria proving the diagnose of TOS. Indeed it is mainly dynamic compression, therefore dynamic assessments seem to be more adapted, eventhough these assessments may be difficult or even present high rates of false negative results4.

Among the TOS types, the most common is the neurogenic(nTOS) one. Some of the clinical characteristics of the nTOS are pain, paraesthesia and weakness4.

The pain is usually neuropathic, affecting the posterior cervical area, trapezius and pectoral regions. It may also be felt on the entire upper limb. Weakness may also be described by these patients 1,4,5.Reports of pain, weakness and paraesthesia associated with irritative maneuvers will strongly suggest the nTOS diagnosis4,6.

Complementary exams can be used, mainly to exclude other diagnoses (i.e roots compression at the cervical spine, peripheral nerve tumors, distal entrapment syndromes). One of the main situation that would suggest nTOS is the dynamic arterial subclavian duplex velocity assessment. This assessment compares the differences between the arterial subclavian flux in rest and during the stress maneuvers. The proximity between the brachial plexus and subclavian artery can provides one with an indirect suggest a brachial plexus entrapment6-8. It can be useful even in patients with no vascular apparent compromise. Trained radiologists are also able to evaluate this entrapment by analysing the amont of fat tissue around the brachial plexus, and comparing its size between the resting and abduction and external rotation of the shoulder

The classical treatment for these patients is conservative6,7, consisting on pharmacological measures, shoulder girdle rehabilitation and ergonomic readjustment for working or exercising1,7

Surgery is indicated in cases refractory to the conservative treatment, after a long period of rehabilitation8. Surgical techniques should be directed to the structures that cause this entrapment. The most common procedures mention the resection of the cervical rib, scalenectomy and release of the pectoralis minor tendon next to the coracoid7-10.

Endoscopic soft tissue decompression of the brachial plexus has been performed initially in cadaveric models11. In vivo to this moment only subclavicular decompression of the brachial plexus was performed. The suprascapular space had been released so far through the trans trapezial portals, starting from a release of the suprascapular nerve, and moving proximaly to the interscalenic area, without performing any scalenectomy, nor exposing the phrenic, long thoracic and dorsal scapular nerves4.

The purpose of this technical note is to describe an endoscopic brachial plexus decompression on suffering from nTOS at all possible entrapment areas, between the neck and the arm. 

Surgical Technique

The procedure is performed in lateral decubitus under general anesthesia associated with interscalene plexus block. The upper limb – is set up with a traction allowing a positionning of the shoulder in anterior elevation, and slight abduction of respectively 30° and 15°.

 A standard bipolar radiofrequency was used, VAPR®(DePuy Synthes, Raynham, USA). Saline infusion is used, just by gravity through 4-way equipment with no pump.

Surgical Steps

The first step is the insertion of the video scope through the posterior portal for joint and subacromial space evaluation. In the bursal space, the lateral portal is done, followed by bursectomy. The coracoacromial ligament is identified and removed. The optic passes to the lateral portal, coracoid process and pectoralis minor tendon is identified. An anterioinferior portal is done in the axillary line, about 2 cm below the coracoid lateral to the conjoint tendon is done with the help of a needle under visualization control.

The coracoid is exposed using radiofrequency device through the anterioinferior portal, dissecting the space posterior to the pectoralis major, progressively moving medially until the pectoralis minor insertion can be visualized and released. The upper part of the pectoralis minor is exposed, along with the cords of the brachial plexus coming from a lateral and medial areas. Under visualization control, the medial portal is made, 5 cm medial to the anterioinferior portal.  The optic is moved to the anterioinferior portal(Fig. 1), then the radiofrequency device is inserted through the medial portal and is used to detach the pectoralis minor tendon, allowing the visualization of the terminal branch of the musculocutaneous nerve and the neurovascular bundle. 

At this step, three structures are visualized going from the brachial plexus towards the deltoid muscle: lateral pectoralis nerve, thoracoacromial artery branch and cephalic vein. If fibroses or adhesions are found they can be released in this region.

The costoclavicular space is then reached. Using the lateral pectoralis nerve as a landmark, the plane between the brachial plexus and the subclavian muscle is identified. Anatomical variations of the subclavian muscle or the presence of the pectoralis minimus muscle may entrap the plexus in this area. Radiofrequency myotomy of the subclavius muscle can be performed until the clavicle is reached(Fig. 2). Using the soft tissue shaver(Razek, São Carlos, Brazil) with no aspiration will increase muscle resection and increase the cervical space view. In some selected cases (distance between the plexus clavicle less than 1 cm), partial resection of the clavicle may also be performed by using a bony shaver.

Through this same portal, the optics advances proximally to the cervical region between the plexus and the clavicle. Using a blunt dissector, the first cervical portal is done, just above the clavicle, supraclavicular portal, over the brachial plexus (Fig. 3). A particular attention to the transverse cervical vessels, which are left in a more superficial plane is needed. Optic can be inserted through the medial portal and devices through the supracavicular portal. Identification of the upper plexus trunk, and emergence of the suprascapular nerve(Fig. 4) raising laterally and posteriorly towards the coracoid notch is done. At this anatomical location the suprascapular artery can cross the plexus over the upper trunk or between the upper and middle trunk. More inferiorly the dorsal scapular artery can be found at the level of the midle trunk.

Adhesions and/or a thickened fascia can be visualized between the scalene muscles and the brachial plexus. This fascia must be released, allowing visualization of the scalene muscles. Then suprascapular nerve neurolysis can also be performed at this point.

The cervical portal is made about 2.5 cm from the supraclavicular portal. and the radiofrequency device is inserted and used to increase the space around the entry point. Distance parameters may vary, but as usual, the portal is created under 

vizualisation control, with the aim to create access between the middle and anterior scalenes. The optics is moved to the supraclavicular portal. The release of the sheath to the scalene hiatus is continued using radiofrequency through the cervical portal(Fig. 5). Regarding the phrenic nerve which course is on the anterior border of the anterior scalene muscle, it is not easy nor necessary to visualize this nerve by endoscopy, however if visualized it needs to be protected.  The middle scalene is dissected(Fig. 6) and one can identifies the dorsal scapular nerve and/or the long thoracic nerve. They actually have a very similar origin, but their directions are different, the dorsal scapular nerve goes posteriorly and medially and the long thoracic nerve goes inferiorly, more anterior and above the first rib.

These nerves usually present an intramuscular path, the middle scalene myotomy can be done by direct visualization in order to release them. One can use the nerve stimulator in order to better understand which nerve is going to be released.

Subclavian artery can be visualized after the complete release of the anterior and middle scalenus muscles(Fig. 7)(Film. 1). Portals developed to this technique are as in the Fig. 8.

Thereafter revision of hemostasis and additional scalene myotomies may be performed with radiofrequency. A needle is positioned between the 2 cervical portals for infiltration of a betametasone, tramadol, tranexamic acid and magnesium sulfate solution.

The extubation requires additional care because sometimes infused fluid can compress the airways.

Rehabilitation

For neuropathic analgesia, drugs are administered according to the patient’s needs, including pregabalin, nortriptyline, vitamin C, prednisone, opioids and anti-inflammatory drugs. Ten days after surgery, the stitches are removed and the patient is able to remove the sling.

Tips and Tricks are in Table. 1, comparison with open surgery in Table. 2.

Discussion 

Endoscopic release of the brachial plexus as suggested in this technical note offers advantages compared to an open technique or to previoulsy described endoscopic techniques. It provides indeed a better visualization of the neurologic structures with magnification thanks to the arthroscope, almost equivalent to a microsope. It allows a three-level release, i.e. supraclavicular, retroclavicular in the costoclavicular outlet, and infraclavicular. It allows multiple level release without multiple approaches as required in case of an open scalenectomy and pectoralis minor tenotomy11, and thus less scar tissue formation since minimally invasive. 

Endoscopic techniques have been described before4 however they mainly managed retro clavicular and infra clavicular decompression. The supraclavicular decompression was addressed in those techniques though a different approach starting from the subacromial space, reaching the suprascapular nerve and the interscalenic area, up to the upper trunk, managing a local fibrous band section, and a neurolysis, but lacking two main aspects which are capital to the Thoracic outlet syndrome management: Scalenectomy, and exposition of the middle and inferior trunks. As described in the previous articles4,12 safe approach of the middle and inferior trunks, and correct exposition of the subclavicular artery, phrenic, long thoracic, and dorsal scapular nerves was not achievable. Meanwhile, Garcia et al11, had described in 2012 an anatomical exposition of the previously cited structures, using a different technique and mainly a different surgical strategy. The procedure presented on this technical note has showed an improvement on the clinical scores which was greater than the previously published series4[JCGJ1] . It seems obvious that the release addressed on this technical note is more exhaustive, but the thorough release of the whole brachial plexus affords better clinical results. The main difference and benefit brought by this technique is the ability to perform a scalenectomy. The scalene muscles are clearly identified as compressors in this pathology. Scalenectomy is indeed a mandatory step of the open surgical procedure13. 

However, limitations can be raised. The first and most obvious one, is the importance of the learning curve. The interscalenic area is an anatomical region which must be well known before adventuring oneself around it endoscopically. Before performing the scalenectomy, the nerves and vessels around must be identified and preserved. When a doubt regarding the identification of those structures exists, the surgeon should never hesitate to convert to an open approach. It is therefore a technique that must be managed by surgeons trained into brachial plexus and peripheral nerve surgery.

The area is also sensible to pressure variation. Indeed a balance between low blood pressure, and high inflow pressure must be reached. The surgeon needs perfect bleeding management in order to obtain good visualization, and anesthesiologists must manage the blood and water inflow pressure in order to prevent neurological complications. Indeed, compressions can occur to the pneumogastric nerve, the carotid body but also to the spinal chord. 

Overall, this technique is clearly bringing many advantages to the management of neurogenic thoracic outlet syndromes, and we recommend that it becomes the reference technique compared to open techniques or previously described endoscopic techniques14. However, we acknowledge that it must be limited to neurogenic cases, and to cases where no anatomical variations or modifications3 is identified. It should not be applied to cases where symptomatic vascular compression occurs, and it is not a technique enabling first rib resection. As a matter of fact, we have not studied yet proved that the results obtained with neurogenic syndromes are applicable to vascular syndromes. At last, anatomical knowledge of the area by the surgeon, and ability to work in the region in open surgery as well as anesthesiology cooperation is mandatory.

References

  1. Illig K, Donahue D, Duncan A, Freischlag J, Gelabert H, Johansen K, et al. Reporting standards of the society for vascular surgery for thoracic outlet syndrome. J Vasc Surg. 2016;64(3):e23-35.
  2. Levine N, Rigby B. Thoracic outlet syndrome: biomechanical and exercise considerations. Healthcare. 2018; 6(2). piiE68.
  3. Ferrante M, Ferrante N. The thoracic outlet syndromes: part 1. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes. Muscle Nerve. 2017; 55(6):782-93.
  4. Lafosse T, Hanneur M, Lafosse L. All-endoscopic brachial plexus complete neurolysis for idiopathic neurogenic thoracic outlet syndrome: surgical technique. Arthrosc Tech. 2017;6(4):e967-71. 
  5. Kuhn J, Lebus G, Bible J. Thoracic outlet syndrome. J Am Acad Orth Surg. 2015; 23(4):222-32.
  6.  Doneddu P, Coraci D, De Franco P, Paolasso I, Caliandro P, Padua L. Thoracic outlet syndrome: wide literature for few cases. Status of the art. Neurol Sci. 2016;38(3):383-8.
  7.  Altobelli GG, Kudo T, Haas BT, Chandra FA, Moy JL, Ahn SS. Thoracic outlet syndrome: pattern of clinical success after operative decompression. J vasc surg. 2005; 42(1):122–8.
  8. Chang DC, Rotellini-coltvet LA, Mukherjee D, De Leon R, Freischlag LA. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg. 2009;49(3):630–5
  9. Soukiasian H, Shouhed D, Serna-Gallgos D, Mckenna R, Bairamian B, mckenna r. A video-assisted thoracoscopic approach to transaxillary first rib resection. Innovations (Phila). 2015; 10(1):21-6.
  10.  Balderman J, Holzem K, Field B, Bottros M, Abuirqeba A, Vemuri C et al. Associations between clinical diagnostic criteria and pretreatment patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2017; 66(2):533-44.e.
  11. Garcia JC, Mantovani G, Livernaux P. Brachial plexus endoscopy: feasibility study on cadavers. Chir Main. 2012; 31(1):7-12.
  12. Lafosse T, Masmejean E, Bihel T, Lafosse L. Brachial plexus endoscopic dissection and correlation with open dissection. Chir Main. 2015; 34(6):286-93.
  13. Cheng SWK, Reilly LM, Nelken NA, Ellis WV, Stoney RJ. Neurogenic thoracic outlet decompression: rationale for sparing the first rib. Cardiovasc Surg. 1995; 3(6):617–23.

14.Ferrante M, Ferrante N. The thoracic outlet syndromes: part 2. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes. Muscle Nerve. 2017; 56(4):663-673.

Figure Legends

Fig.1: Scope through the anterioinferior portal: A) Fat over the Brachial Plexus, B) Released Pectoralis minor tendon

Fig. 2 Scope through the anterioinferior portal: A) Subclavius Muscle Released, B:Electrocautery device.

Fig. 3 Scope through the medial portal: A) Upper Trunk, B) Suprascapular artery.

Fig. 4 Scope through the medial portal: A) Suprascapular nerve, B Upper Trunk

Fig. 5 Scope through the supracavicular portal: A) Fribrous adhesion, B) Anterior Scalene Muscle

Fig. 6 Scope through the supracavicular portal: A) Scalene Muscle, B) Brachial Plexus

 Fig. 7 Scope through the supracavicular portal: A) Scalen Muscles Released, B) Subclavian Artery, C) Dorsal Scapular Artery.

Fig. 8 Special portals designed for the procedure: A) Anterioinferior, B) Medial, C) Supraclavicular, D) Cervical

Table Legends:

Table. 1 Tips and Tricks

Table. 2 Comparisson between Endoscopic and Open procecedures 

Film Legends

Endoscopic release of the Brachial plexus is a technical from NAEON Institute Sao Paulo-Brazil and Alps Surgery Institute/Clinique Générale d’Annecy-France.

After the Pectoralis Minor Release, the region of its cords and distal nerves is cleaned.

Dissection between the Pectoralis Minor and conjoined tendon is important and will expose the musculocutaneous nerve.

Here the musculocutaneous nerve is exposed.

Following key structures and the plexus one careful dissects this region until achieve the subclavius muscle’s fascia. 

The subclavius muscle’s fascia is opened and the muscle is exposed

All the muscle is released, and the clavicle is reached.

Just after the superior border of the clavicle the supraclavicular portal is made.

In the cervical direction a dissection of structures over the brachial plexus is done and the trunks of the brachial plexus are exposed.

Shaver with no aspiration can also be used.

Suprascapular nerve is visualized at the lateral border of the brachial plexus

Continuing dissection one can expose the suprascapular artery over the upper trunk

Anterior Scalenus muscle and fibrotic bands are reached.

The Anterior Scalenus muscle is carefully released.

The Middle Scalenus muscle have to be also released with special care because the Scapular Dorsal and Thoracic Long Nerves, released in this video were in the middle of this muscle.

Subclavian artery can be visualized, however it is not mandatory.


 [JCGJ1]Just confirm this is the correct paper

Anteriorização Telerrobótica do Nervo Ulnar

Publicado em: 5 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Nervos Periféricos

Anteriorização Telerrobótica do Nervo Ulnar: Publicado no Journal of Robotic Surgery Volume 5, Number 2 (2011), 153-156, DOI: 10.1007/s11701-010-0226-7, e apresentado no congresso Brasileiro de cirurgia do ombro e cotovelo de 2010 e em aula dada no congresso mundial de microcirurgia e endoscopia robótica de Orlando-EUA 2011.

Telerobotic anterior translocation of the ulnar nerve
Jose Carlos Garcia, Gustavo Mantovani, Stephanie Gouzou and Philippe Liveneaux

Abstract
The application of telerobotics in the biomedical field has grown rapidly and is showing very promising results. Robotically assisted microsurgery and nerve manipulation are some of its latest innovations. The purpose of this article is to update the community of shoulder and elbow surgeons on that field. Simple anterior subcutaneous translocation of the ulnar nerve was first experimented in two cadavers, and then performed in one live patient who presented with cubital tunnel syndrome. This procedure is the first reported case using the robot in elbow surgery. In this paper we attempt to analyze various aspects related to human versus robotically assisted surgery.

CBCOC
A aplicação da telerrobotica no campo biomedico tem evoluído rapidamente e com resultados promissores.
As microcirurgias robo-assistidas e a manipulação nervosa são algumas das mais recentes inovações da robótica médica abrindo um campo novo dentro da ortopedia e suas subespecialidades.
A proposta desse trabalho é manter atualizados os cirurgiões do ombro e do cotovelo para o campo da robótica médica.
Para tal utilizamos o procedimento de anteriorização subcutânea do nervo ulnar inicialmente em 2 cotovelos de cadáver e após isso em um paciente com síndrome do túnel cubital.
O robo utlizado foi o Da Vinci SI®(Intuitive Co.) que apresenta 2 módulos: o console do cirurgião apresenta visão em 3 dimensões, possibilidade de aumento da visão em mais de 25 vezes e um designe ergonômico. Alguns componentes podem também obedecer ao comando de voz. O segundo módulo apresenta 3 mãos robóticas e a óptica.
O procedimento cirúrgico proposto apresentou sucesso e algumas características do robô fazem da cirurgia um ato mais ergonômico para o cirurgião além de eliminar ocasionais tremores e magnificar a imagem.
Contra o uso do robô ainda temos o alto custo, a falta de mãos robóticas especiais para procedimentos ortopédicos e a perda da sensibilidade tátil.
Entretanto uma nova geração de robôs está sendo projetada para associar a sensibilidade tátil, a confrontação de exames auxiliares em 3d sobrepondo-os com imagens reais, possibilidade de acessar a internet, fazer teleconferência, pedir auxílio a outro cirurgião a distância, novos braços adaptados para as mais diversas possibilidades cirúrgicas e até mesmo a união da robótica com a navegação em próteses.
Alguns centros universitários americanos e franceses já experimentaram a possibilidade de realizar artroplastias de grandes articulações em vivos com robótica e navegação.
A Telecirurgia robótica pode ser uma opção futura de cirurgia com a diminuição de seu custo operacional e os novos avanços científicos.

Descompressão Artroscópica do Nervo Supraescapular

Publicado em: 5 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Nervos Periféricos

A primeira técnica de descompressão do nervo supraescapular descrita nas américas.
Publicada a técnica
Dezembro de 2009 no periódico Techniques in Shoulder and Elbow Surgery, volume 10, número 4 páginas 157-159
Seguimento
Arthroscopy, October 2013 Volume 29, Issue 10, Supplement, Pages e89–e90
Suprascapular Nerve Arthroscopic Release Outcomes
Revista Brasileira de Ortopedia(Rev Bras Ortop. 2011;46(4):403-07).

Apresentado
Congresso da Associação de Artroscopia da América do Norte (AANA-Arthroscopy Association of North America)
2012-Orlando/EUA
Pôster
Congresso da Associação Internacional de Artroscopia e Trauma do Esporte (ISAKOS)
2013-Toronto/Canadá
Apresentação Oral
Congresso Brasileiro de Ombro e Cotovelo:
2012-Foz do Iguaçu – Brasil
Apresentação Oral
Congresso Brasileiro de Artroscopia e Traumatologia Desportiva:
2009-Belo Horizonte – Brasil
Apresentação Oral
Congresso Latino-Americano de Cirurgia de Ombro e Cotovelo
2009-Porto de Galinhas/Brasil
Pôster

Abstract:
Suprascapular nerve compression at the transverse scapular notch is recognised as a shoulder pain cause. Some authors have developed open surgical techniques in order to release the compressed nerve, with good results, and arthroscopic techniques have been described recently as well. We have developped an arthroscopic technique using different portals from the other authors?. Our preliminary results reveal a change of the preoperative average UCLA from 10,4 to 19,8 in the 6-month-postoperative.The SF-36 114,6 and raw scale for pain was 74% in the 6-month-postoperative. Our preliminary results achieved satisfactory outcomes and can be also another option in terms of nerve compression treatment.

Publicado na Revista Brasileira de Ortopedia a avaliação a longo prazo

Liberação Artroscópica do Nervo Supraescapular: Técnica cirúrgica e avaliação de casos clínicos
clínicos. Rev Bras Ortop. 2011;46(4):403-07

LIBERAÇÃO ARTROSCÓPICA DO NERVO SUPRAESCAPULAR: TÉCNICA CIRÚRGICA E AVALIAÇÃO DE CASOS CLÍNICOS
ARTHROSCOPIC RELEASE OF THE SUPRASCAPULAR NERVE: SURGICAL TECHNIQUE AND EVALUATION OF CLINICAL CASES
José Carlos Garcia Júnior1, Ana Maria Ferreira Paccola2, Cristiane Tonoli2, José Luis Amin Zabeu3, Jesely Pereira Myrrha Garcia4

RESUMO
Objetivo: Descrever uma técnica cirúrgica própria de descom- pressão artroscópica do nervo supraescapular (NSE) e avaliar seus resultados preliminares. Métodos: 10 ombros de nove pacientes foram operados com uma técnica que utiliza portais diferentes das técnicas conhecidas, não usa tração e faz uso de materiais disponíveis na rede pública de saúde. Resultados: 10 ombros de nove pacientes, sendo oito à direita e dois à esquer- da, com média de idade de 69,5 anos, apresentaram mudança no escore UCLA de 11,7 para 26,1 no seguimento de 16,6 meses de pós-operatório. O questionário SF-36 teve pontuação de 122,9 e a escala bruta de dor de 88%. Conclusão: A des- compressão artroscópica do NSE, segundo a técnica descrita, é reprodutível e menos traumática que as técnicas abertas. Os pacientes obtiveram melhora em vários parâmetros avaliados, principalmente no que se refere à dor. A descompressão artros- cópica do NSE pode ser uma opção terapêutica para a patologia compressiva do NSE.

Descritores: Compressão Nervosa; Descompressão Cirúrgica; Dor de Ombro; Artroscopia/métodos; Ombro

Arthroscopy

Summary
Arthroscopic release of the suprascapular nerve is another therapeutic option for persistent shoulder pain in massive irreparable rotator cuff tears.Jump to

Introduction
Suprascapular nerve (SSN) entrapment at the suprascapular notch is a well-known cause of persistent chronic shoulder pain in patients with irreparable massive rotator cuff tears. Exploration of the SSN and release of the superior transverse scapular ligament have recently been proposed as treatment, achieving good functional outcomes and pain relief.
Natsis classified suprascapular notches based on anatomic measurements of vertical and transverse diameters. According to him, types III, IV and V are more likely to cause a suprascapular nerve entrapment.
We performed an all-arthroscopic technique for SSN decompression and presented our outcomes for this procedure.
We also correlated the Natsis’ suprascapular notch classification with SSN entrapment.Jump to Section

Methods
A series of 20 patients with massive rotator cuff tears and consistent findings for SSN compression were operated between May 2008 and November 2011.
All patients had undergone an unsuccessful physiotherapy for a minimum of 6 month.
All had MRI, EMG and positive SSN Stretch Test (Lafosse) confirming SSN entrapment.
Our surgical technique uses different portals from other Authors, a 30° angled lens arthroscope and we do not use traction to the arm.
We use a postero-medial portal for releasing the SSN.
Using a calibrated probe we measured the transversal and vertical diameters of suprascapular notches so we could classify them as Natsis’ types.
The clinical outcomes were assessed preoperatively and 6 months after surgery with UCLA scale, SF-36, raw pain scale and Simple Shoulder Test.
Results were compared using the non-parametric Wilcoxon T test, with a level of significance of 0.1% (P<.001).Jump to Section

Results
We operated 20 shoulders from 19 patients: 14 female and 5 male; 15 right and 5 left sided shoulders. Two patients were lost to follow-up and were excluded.
The mean age was 65,50 year-old (range, 42 to 81). The mean follow-up was 32,60 months (range, 6 to 56 months).
All patients had an unsatisfactory preoperative UCLA (lower than 27).
The mean preoperative and postoperative UCLA scores had risen from 13,27 to 28,27 (P<.001). All patients were satisfied with the surgery, except one, which had increased only 2 points in postoperative UCLA and graded her outcome as poor. This patient had a Natsis type II notch. Fourteen out of seventeen patients (82,35%) had satisfactory postoperative UCLA score (greater than 27). The two patients whose postoperative UCLA were below 27, rated their surgical outcome as good (satisfied). Both had a preoperative UCLA lower than 8. We believe these cases were more severe and, in spite of having elevation ROM above 70 degree, would have probably been a better indication for reverse total shoulder prosthesis. The raw pain scale improvement was 86,07% (P<.001) and the mean postoperative SF-36 was 122,90 (P>.001).
The mean postoperative Simple Shoulder Test was 8,84 (P<.001).
We performed 10 arthroscopic Mumphord procedures and 11 biceps tenodesis in association with the SSN release.
We found one Natsis Type II notch (transverse diameter greater than vertical), fifteen Type III (vertical diameter greater) and two Type IV (osseous foramen).Jump to Section

Conclusion
Arthroscopic release of the SSN can be performed and reproduced safely and effectively. It is another therapeutic option for persistent shoulder pain in massive irreparable rotator cuff tears with the benefits of been minimally invasive and having a nice esthetic outcomes.
SSN release seems to be related to the anatomic aspect of the suprascapular notch. Natsis believes notche types III, IV and V are more likely to SSN entrapment.
We confirmed that in our study. We found 94,44% notches types III and IV in our series.
The only Natsis type II notch in our study had a poor outcome. We believe there was a misdiagnosis in this case. Despite of the positive electromyographic findings for SSN entrapment, the pain origin might not had been the SSN entrapment, but arthrosis.
Probably type II notches are a contraindication to SSN decompression.
Further controlled studies comparing biceps tenodesis, arthroscopic Mumphord and SSN release will be necessary to identify which association of procedures has the better outcome.

Endoscopia do Plexo Braquial

Publicado em: 5 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Nervos Periféricos

Endoscopia do Plexo Braquial.
Trabalho publicado  na revista CHIRURGIE DE LA MAIN
Brachial plexus endoscopy: Feasibility study on cadavers
Endoscopie du plexus brachial : étude de la faisabilité sur cadavres
J.C. Garcia Jr , G. Mantovani , P.-A. Liverneaux 
 Vol 31 – N° 1
P. 7-12 – février 2012
Doi : 10.1016/j.main.2012.01.001


Apresentado
Congresso da Associação de Artroscopia da América do Norte (AANA-Arthroscopy Association of North America)
2010-Hollywood/EUA
Trabalho publicado nos anais eletrônicos do congresso:
Congresso das Sociedades Européias de Cirurgia de Mão e Punho (European Societies of Hand and Wirst Surgery)
2009-Polônia
Apresentação oral
Congresso Latino-Americano de Cirurgia de Ombro e Cotovelo 
2009-Porto de Galinhas/Brasil
Pôster
Congresso Brasileiro de Ortopedia e Traumatologia
2009-Rio de Janeiro-Brasil
Apresentação oral

Abstract
The development of a minimally invasive technique for exploration of the brachial plexus seems a logical step towards refinement of diagnosis and treatment. For certain pathological conditions, minimally invasive techniques have become the method of choice; for others, they remain as an ancillary option for assistance during open surgery. We have developed a full endoscopic technique for brachial plexus exploration. Our endoscopic technique used saline liquid infusion in seven brachial plexus of four cadavers. Five portals have been described and the endoscopic landmarks also. We were able to demonstrate excellent views and adequate possibilities for cadaver plexus dissection and its anatomic landmarks and portals.
Level of evidence 4.

Résumé
Le développement d?une technique mini-invasive d?exploration du plexus brachial semble une étape logique pour améliorer le diagnostic et le traitement des paralysies traumatiques du plexus brachial. Dans certaines pathologies, les techniques mini-invasive sont devenues le traitement de choix ; dans d?autres, elles restent une aide technique au cours d?une chirurgie à ciel ouvert. Nous avons développé une technique entièrement endoscopique pour explorer le plexus brachial. Notre technique endoscopique a utilisé une solution saline chez sept plexus brachiaux de quatre cadavres. Cinq voies d?abord ont été décrites ainsi que les repères endoscopiques. Nous pensons avoir démontré que cette technique donnait une excellente vision des repères anatomiques, permettant la dissection du plexus brachial.
Niveau de preuve 4.
Keywords : Brachial plexus, Arthroscopy, Nerve, Endoscopy
Mots clés : Plexus brachial, Arthroscopie, Nerf, Endoscopie

Veja mais em: http://www.em-consulte.com/article/700650/alertePM

Apresentado no congresso europeu de cirurgia da mão na Polônia em 2009, CBOT 2009, CBA 2009, CLAOC 2009 e na Associação de Artroscopia da América do Norte em 2010(Hollywood-EUA).

Objetivos
Objetivamos avaliar a viabilidade da vizualização artroscopica das estruturas nervosas que compoe o plexo braquial, estudar novos portais para a abordagem, familiarizar-se com a anatomia artroscopica e avaliar os
riscos de lesoes iatrogenicas e complicacões.

Materiais e Métodos
Técnica cirúrgica: Foram utilizados 3 cadaveres humanos, explorando um total de 5 plexos braquiais. Os cadáveres foram deixados em decúbito dorsal horizontal. Realizamos 6 portais, 3 infra-claviculares e 3 supra-claviculares. O equipamento utilizado foi um artroscópio comum de 4mm. A irrigacao de solucao salina utizou uma bomba de infusão vom fluxo de 30 mmHg e fluxo máximo, seguindo os parâmetros da artroscopia de cotovelo. Um “shaver”para partes moles de 4.5 mm, um palpador comum de artroscopia e um basket foram utilizados para dissecção. Atraves dos
novos portais buscamos uma disseccao intermuscular e escalenectomia artroscópica para visualização das estruturas nervosas. O aspirador não deve ser ligado ao “shaver” afim de preservar e melhor manipular as estruturas.

Resultados
Obtivemos com os métodos acima uma boa vizualização dos fascículos lateral, arteria axilar, troncos superior, médio, inferior, nervo frênico, nervo subclávio, nervo supraescapular, raiz de C5, C6, nervo escapular dorsal e torácico longo.

Ramos mais distais do plexo como nervo axilar e a convergência para formação do nervo mediano, também foram identificados. A técnica descrita acima mostrou-se eficaz na identificação e visualização de estruturas nervosas do plexo braquial. A disseccao com o probe e o “shaver” nao causou lesões macroscopicas nas estruturas nervosas ouvasculares.

Artroscopia do Plexo Braquial, estudo em cadáveres e avaliação preliminar em vivos.

Discussão
A disseccao com o probe, o basket e o “shaver” não causou lesoes macroscópicas nas estruturas nervosas ou vasculares. Esta primeira experiência na manipulação minimamente invasiva do plexo braquial mostrou-se promissora e pode tornar-se clinicamente viável, requerendo no momento mais testes em cadáver para identificaão das demais estruturas do plexo e definicao dos portais mais apropriados.

A técnica minimamente invasiva para a vizualização do plexo vem ao encontro do surgimento de novas terapias menos agressivas de reparacao e reconstrucao do plexo, com uso de neurotubos, celulas tronco e manipulacao robótica. Em vivos a técnica já foi utilizada em 1 paciente com
neuropraxia para avaliação do fascículo lateral, 6 casos de liberação artroscópica do nervo supraescapular e 10 casos de dissecção artroscópica do nervo axilar em reconstruções do músculo subescapular.

Endoscopia Telerrobótica do Plexo Braquial

Publicado em: 5 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Nervos Periféricos

Endoscopia Telerrobótica do Plexo Braquial.

Apresentado no Congresso Brasileiro de Cirurgia do Ombro e Cotovelo 2010 e Congresso Brasileiro de Cirurgia de Mão 201
Journal of Neurosurgery

Sep 2011 / Vol. 115 / No. 3 / Pages 659-664
Veja: http://thejns.org/doi/abs/10.3171/2011.3.JNS10931

ARTICLE
Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial
Laboratory investigation
Gustavo Mantovani, M.D.1, Philippe Liverneaux, M.D., Ph.D.2, Jose Carlos Garcia Jr., M.D.3, Stacey H. Berner, M.D.4, Michael S. Bednar, M.D.5, and Catherine J. Mohr, M.D.6

1Department of Hand Surgery, ?Beneficência Portuguesa de São Paulo? Hospital; 3Division of Sports Medicine, Pontifical Catholic University of Campinas, São Paulo, Brazil; 2Department of Hand Surgery, Strasbourg University Hospitals, Illkirch, France; 4Department of Hand Surgery, Sinai Hospital of Baltimore, Maryland; 5Department of Orthopaedic Surgery, Loyola University, Maywood, Illinois; and 6Department of Surgery, Stanford School of Medicine, Stanford, California

DOI: 10.3171/2011.3.JNS10931.

Abstract

OBJECT
The aim of this paper was to develop an effective minimally invasive approach to brachial plexus surgery and to determine the feasibility of using telerobotic manipulation to perform a diagnostic dissection and microsurgical repair of the brachial plexus utilizing an entirely endoscopic approach.

METHODS
The authors performed an endoscopic approach using 3 supraclavicular portals in 2 fresh human cadaver brachial plexuses with the aid of the da Vinci telemanipulation system. Dissection was facilitated inflating the area with CO2 at 4 mm Hg pressure. The normal supraclavicular plexus was dissected in its entirety to confirm the feasibility of a complete supraclavicular brachial plexus diagnostic exploration. Subsequently, an artificial lesion to the upper trunk was created, and nerve graft reconstruction was performed. Images and video of the entire procedure were obtained and edited to illustrate the technique.

RESULTS
All supraclavicular structures of the brachial plexus could be safely dissected and identified, similar to the experience in open surgery. The reconstruction of the upper trunk with nerve graft was successfully completed using an epineural microsurgical suture technique performed exclusively with the aid of the robot. There were no instances of inadvertent macroscopic damage to the vascular and nervous structures involved.

CONCLUSIONS
An endoscopic approach to the brachial plexus is feasible. The use of the robot makes it possible to perform microsurgical procedures in a very small space with telemanipulation and minimally invasive techniques. The ability to perform a minimally invasive procedure to explore and repair a brachial plexus injury may provide a new option in the acute management of these injuries.

http://thejns.org/doi/abs/10.3171/2011.3.JNS10931

Objetivamos avaliar a viabilidade da vizualizacao endoscópica das estruturas nervosas que compõe o plexo braquial, estudar novos portais para sua abordagem, avaliar riscos de lesões iatrogenicas e realizar suturas robóticas em lesões de plexos de cadáver

Técnica cirúrgica: Foram utilizados 2 cadáveres humanos, explorando um total de 4 plexos braquiais.
Os cadáveres foram deixados em decúbito dorsal horizontal. Realizamos 4 portais supra-claviculares baseados em trabalhos prévios de artroscopia do plexo braquial.
Foi utilizado o robô Da Vinci SI®(Intuitive Co.) que apresenta 2 módulos: o console do cirurgião apresenta visão em 3 dimensões, possibilidade de aumento da visão em mais de 25 vezes e um designe ergonômico. Alguns componentes podem também obedecer ao comando de voz. O segundo módulo apresenta 3 mãos robóticas e a óptica.
Ao invés de lançar mão de irrigação de solução salina preferimos infusão de ar.

Resultados:O procedimento cirúrgico proposto apresentou sucesso e algumas características do robô fazem da cirurgia um ato mais ergonômico para o cirurgião além de eliminar ocasionais tremores e magnificar a imagem.
Obtivemos com os métodos acima uma boa vizualização do plexo braquial.
A técnica descrita mostrou-se eficaz na identifição e vizualização de estruturas nervosas do plexo braquial e seu reparo.
A dissecção e sutura robótica não causou lesões macroscópicas nas estruturas nervosas ou vasculares.

Conclusão: Esta primeira experiência na manipulação minimamente invasiva robótica do plexo braquial mostrou-se promissora e pode tornar-se clinicamente viável, requerendo no momento mais testes em cadáver e em animais vivos.
Em humanos vivos a técnica robótica já foi utilizada em 1 paciente com lesão do plexo braquial mas ainda de forma aberta.

Plexo Braquial, Cirurgia Robótica

Publicado em: 5 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Nervos Periféricos

Plexo Braquial, Cirurgia Robótica

Apresentado Como Aula nos Congressos Mundiais de Microcirurgia Robótica 2011 Orlando-USA e 2012 Tampa-USA

J reconstr Microsurg 2012; 28(07): 491-494
DOI: 10.1055/s-0032-1313761
Veja: https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0032-1313761

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.Telerobotic Manipulation of the Brachial Plexus
Jose Carlos Garcia1, Frederic Lebailly2, Gustavo Mantovani3, Leonardo Alves Mendonca3, Jesely Garcia1, Philippe Liverneaux21Department of Shoulder and Elbow Surgery, NAEON–Center for Advanced Studies in Orthopedics and Neurosurgery, Sao Paulo, Brazil
2Department of Hand Surgery, Strasbourg University Hospitals, Strasbourg, Alsace, France
3Department of Hand Surgery, Sao Paulo Hand Center, Sao Paulo, BrazilFurther InformationAbstract
Full Text  Buy Article Permissions and Reprints

Abstract
Objective This study demonstrates the new technology of the robotic telesurgery on three brachial plexus reconstructions. We also discuss the implications, problems, and benefits of robotically assisted brachial plexus surgery.

Methods After the first experimental experience in a cadaveric model, the authors performed three brachial plexus reconstructions. The surgery followed the traditional brachial plexus approach. From the moment that nervous sutures would be performed, the Da Vinci® (Intuitive Surgical™, Sunnyvale, CA) equipment was docked at the patients, positioned behind the patient’s head, and the microsurgical steps were performed by using robotic telemanipulation.

Results The first procedure was performed in a cadaver to gain experience and establish a surgical protocol by using the robot. In all the three living patients, the goals of the surgical procedure were achieved using the telerobotic manipulation.

Conclusion Robot-assisted surgery allows performance of high-dexterity surgical operations with the help of robotic arms and it improves the surgery due to tremor filtration, motion scaling, and ergonomics. The benefit of using the robot on microsurgery was reached, but its entire potential was not realized because the instruments used on those first experimental and clinical cases were not specifically designed for microsurgery.

Keywordsbrachial plexus – robotic microsurgery – robotic surgery

Síndrome do desfiladeiro torácico – Tratamento Cirúrgico

Publicado em: 5 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Nervos Periféricos

Tratamento cirúrgico da síndrome do desfiladeiro torácico:

Apresentado
Congresso Brasileiro de Cirurgia de Ombro e Cotovelo
2010-Campos do Jordão-Brasil
Pôster

Objetivos
A patologia conhecida como síndrome do desfiladeiro torácico(SDT) foi descrita por Peet em 1956 e é um nome geral dado para descrever os pacientes com sintomas neurovasculares relativos aos possíveis locais de compressão desse feixe
Em 95% dos casos causa sintomatologia predominantemente neurológica e pode ter sua gênese nas seguintes estruturas: músculo escaleno, costela cervical, fascia de Sibson, clavícula(geralmente sequela de fraturas), compressão no espaço retrocoracopeitoral (ou síndrome do peitoral menor), síndrome do mediano (compressão da artéria axilar entre os feixes do plexo braquial), síndrome da arcada de Langer(compressão do feixe vasculonervoso pelo músculo anômalo axilo-peitoral), iatrogênico, traumático e posicional.
O exame físico detalhado associado à história e eletroneuromiografia são importantes para o diagnóstico.
Objetivamos apresentar resultados e técnicas cirúrgicas de liberações da síndrome do desfiladiro torácico com sintomatologia neurológica em 7 casos.

Materiais e métodos
Tivemos 1 caso de compressão no espaço retrocoracopeitoral e 2 de compressão interescalênica que obteveram melhora com tratamento conservador e por isso foram eliminados desse trabalho.
De fevereiro de 2003 a março de novembro de 2009 foram operados 7 SDT.
Nos 5 casos onde houve envolvimento da clavícula na gênese a sintomatologia apresentava caráter posicional importante, enquanto os 2 casos de origem interescalênica apresentavam manifestações perenes.
Em 2 casos os pacientes apresentavam compressão do plexo por fibrose e aderências do músculo escaleno secundáias a trauma, em 2 casos por consolidação viciosa da clavícula e em 3 casos por pseudoartrose da clavícula.
Em todos os casos foi realizada liberação do plexo.
Os 5 pacientes com alterações claviculares foram submetidos a osteossíntese rígida com placas.
Nos casos de consolidação viciosa, após estudo de reconstrução tomográfica em 3D foi realizada osteotomia para correção, nas pseudoartroses osteossíntese com enxerto de ilíaco e nas compressões interescalênicas escalenectomia anterior e média parciais.

Resultados
Todos os pacientes apresentaram remissão do quadro de parestesia e dor.
Não houve complicações intra-operatórias ou perdas das osteossínteses.

Conclusão
Independente das causas da síndrome do desfiladeiro torácica neurológica além de realizar a liberação plexal o cirurgião do ombro deve atuar diretamente sobre a causa compressiva seja ela de origem óssea ou muscular.
A liberação nervosa no nível do plexo não deve ser excluída do espectro de possibilidades para a cirurgia do ombro.

Tratamento da síndrome do pronador redondo em 5 pacientes técnica e resultados

Publicado em: 5 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Nervos Periféricos

Apresentado
Congresso brasileiro de ortopedia e traumatologia
2008-Porto Alegre-Brasil
pôster

Introdução
A patologia conhecida como síndrome do pronador redondo (SPR) é um nome geral dado a compressão do nervo mediano no nível do antebraço e cotovelo. Essa compressão pode ocorrer em três níveis: lacerto fibroso do bíceps, entre as cabeças umeral e ulnar do músculo pronador redondo e na
arcada dos flexores superficiais dos dedos. O exame de eletroneuromiografia muitas vezes não ajuda a elucidar essa síndrome compressiva, sendo o exame físico de vital importância para o diagnóstico. É estimado pela literatura que ocorra em cerca de 5% dos casos onde o diagnóstico é síndrome do túnel carpal, e que seja uma das causas da falha
do tratamento da liberação do túnel carpal.

Materiais e Métodos
De fevereiro de 2003 a março de 2006 foram operados 5 SPR. Em 3 casos a paciente já havia sofrido cirurgia prévia para liberação do túnel carpal sem melhora do quadro clínico.

Desses 3 casos, 2 apresentavam eletroneuromiografia (ENMG) mostrando como resultado a síndrome do túnel carpal e 1 com eletroneuromiografia normal, ao exame clínico, em 2 desses pacientes, o sintoma foi mais expressivo no teste de pronação contra resistência no outro na flexão
contra resistência ocorreu maior sintomatologia.

Nos outros 2 casos a ENMG mostrou em 1 caso resultado positivo para SPR e 1 caso com compressão do mediano na arcada dos flexores superficiais dos dedos, esse último caso apresentava no exame de ressonância magnética presença de flexor superficial do indicador acessório com compressão
também do nervo interósseo anterior. Nos testes clínicos desses 2 casos o primeiro apresentava sintomatologia à pronação contra resistência e no segundo ao teste de flexão forçada da interfalangeana proximal do terceiro quirodáctilo e diminuição da força em comparação ao lado contralateral
pelo teste de Kiloh-Nevin.

A técnica cirúrgica consistiu em diérese no antebraço na orientação do nervo mediano de aproximadamente 9 cm por planos com liberação do lacerto fibroso, região intermuscular do pronador e abertura da arcada dos flexores superficiais dos dedos.

A melhora do quadro foi medida com padrão subjetivo 10 melhora total a 0 sem melhora dos sintomas.

Resultados
Todos os pacientes melhoraram dos sintomas compressivos, tendo esses desaparecido em 3 casos e melhorado em 2 ( com melhora para 8 e 7 de 0 a 10). Na análise subjetiva a média da melhora dos sintomas foi de 9 (8-10). Todos os pacientes ficaram satisfeitos com o tratamento. Foram operados 4 mulheres e 1 homem com idade média de 44,8 anos (56 a 30 anos). Um paciente apresentava passagem anômala do nervo mediano pelo pronador, 2 apresentavam compressão entre os ventres musculares do pronador, 1 apresentava tensão exagerada do lacerto fibroso e 1 apresentava musculatura anômala e aumento da tensão da arcada dos flexores superficiais dos dedos.

Conclusão
A conhecida síndrome do pronador redondo é na verdade um conjunto de patologias compressivas do antebraço, que devem ser mais pesquisadas e não apenas acreditar no resultado de eletroneuromiografias. Deve-se tomar cuidado com musculaturas anômalas que podem causar a sintomatologia, para a avaliação prévia adequada o exame de ressonância magnética pode ser de grande valia. Com exame físico adequado e liberação cirúrgica levando em conta a clínica os resultados mostram-se estimuladores.