Pericardio-diaphragmatic avulsion and concomitant rupture of the central tendon of the diaphragm.

Two patients, treated for blunt thoracoabdominal trauma with ruptured diaphragm and concomitant avulsion of the pericardial sac in its entirety from the central tendon of the diaphragm, are presented. We do not think this entity has been reported before. We explain this type of lesion on the basis of embryological development of the pericardium at the level of the central tendon of the diaphragm.

Update on peripheral nerve injuries.

Experimental work relating to factors affecting nerve regeneration is reviewed. There is increasing evidence that the nerve sprouts are preprogrammed for their peripheral reinnervation; old endoneurial tubes being discarded. Fascicular suture shows no significant improvement in function compared with epineural suture.

The assessment and management of the failed back, Part II.

Despite adequate surgery a number of patients have a return of back pain and sciatica following operation, the so-called failed back. The results of a prospective study of 101 patients entering an intensive rehabilitation programme for the failed back is described. The programme consists of a team approach to the patient and his problems, using a variety of techniques to produce pain relief.

The assessment and management of the failed back, Part I.

The 'failed back' represents a major clinical problem. Among the causes recognized for the 'failed back' is lateral root stenosis which has led to the use of electromyography (EMG) in the diagnosis of root compression. One hundred and thirty-two patients selected for surgical decompression were compared with 25 undergoing spinal fusion.

Rehabilitation of conversion paralysis.

Three patients referred for rehabilitation of brachial plexus lesions and two referred with leg weakness associated with sciatica were found to have conversion paralysis. The diagnosis was made by demonstrating normal motor nerve conduction to the clinically weak muscles. The weakness was treated by intensive physical rehabilitation with complete and sustained recovery in all cases.

Brachial plexus injuries.

There can be few more distressing situations than when a young man sustains a total and irreversible paralysis in his dominant arm. Not only is he left with a useless and anaesthetic limb, but in a high proportion of cases suffers intractable pain. This article will discuss the diagnosis and management of such injuries.

Rehabilitation of patients following traction lesions of the brachial plexus.

The management of patients with brachial plexus lesions requires a multidisciplinary approach. We insist on admission to our rehabilitation ward for a full assessment by the physiotherapist, occupational therapist, rehabilitation officer, and social worker when necessary. We confirm the diagnosis by clinical, electrophysiologic, and radiologic techniques and set out a plan of action, either involving definitive surgery or a conservative program involving functional splintage, relief of pain when possible, and return to work.

Clinical trial of propranolol in post-traumatic neuralgia.

In view of several case reports of relief of various neuralgias by propranolo, a double-blind cross-over trial using this drug was conducted in 10 patients with severe persistent pain and paraesthesiae following upper limb peripheral nerve injuries. The patients received up to 240 mg of propranolol per day. Only one patient reported pain relief, but this patient withdrew from the trial.

Pain in avulsion lesions of the brachial plexus.

Traction lesions of the brachial plexus are becoming more frequent. Many of the lesions involve avulsion of nerve roots from the spinal cord. This very often results in severe pain which is associated with deafferentation.