Penetrating missile injuries of the brachial plexus (original) (raw)
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Management of Brachial Plexus Missile Injuries
Acta Clinica Croatica
Missile injuries are among the most devastating injuries in general traumatology. Traumatic brachial plexus injuries are the most diffi cult injuries in peripheral nerve surgery, and most complicated to be surgically treated. Nevertheless, missile wounding is the second most common mechanism of brachial plexus injury. Th e aim was to evaluate functional recovery after surgical treatment of these injuries. Our series included 68 patients with 202 nerve lesions treated with 207 surgical procedures. Decision on the treatment modality (exploration, neurolysis, graft repair, or combination) was made upon intraoperative fi nding. Results were analyzed in 60 (88.2%) patients with 173 (85.6%) nerve lesions followed-up for two years. Functional recovery was evaluated according to functional priorities. Satisfactory functional recovery was achieved in 90.4% of cases with neurolysis and 85.7% of cases with nerve grafting. Insuffi cient functional recovery was verifi ed in ulnar and radial nerve lesions after neurolysis, and in median and radial nerve lesions when graft repair was done. We conclude that the best time for surgery is between two and four months after injury, except for the gunshot wound associated with injury to the surrounding structures, which requires immediate surgical treatment. Th e results of neurolysis and nerve grafting were similar.
Our results of Management of Brachial Plexus Missile Injuries
Introduction Missile wounding of the brachial plexus is the second most common cause of the brachial plexus injuries BPI) in peacetime , may be caused by low or high velocity missiles, the former being characterized by projectile velocity lower than 700 m/s (hand guns, revolvers and shell fragments) . Nerve elements are damaged by small shock waves, temporary cavitations, and sometimes, by direct impact. Unless the nerve is transected by direct impact spontaneous recovery can take place in the majority of cases, even in those patients with severe neurologic defi cit at presentation. These lesions are related to Libyan war and fighting. Contrary to this, high-velocity missiles (over 700 m/s, averaging 1000 m/s) produced by modern rifles, machine guns, etc. cause more extensive damage. Th e destructive effect depends on the energy released, which is determined by mass, velocity, tumble and angle of incidence of a bullet . Nerve elements are rarely injured by direct impact, nevertheless, shock waves and cavitation cause extensive damage through compression and stretching, also involving soft tissues, blood vessels and bones. Spontaneous recovery may sometimes occur, when the nerve elements are only partially injured. Many of the contemporary series are evaluating functional recovery of patients operated for BPI, regardless of the cause of the injury, mainly due to rarity of these injuries Missile injuries of the brachial plexus occur almost inextricably with war, while also carrying along specific associated injuries, and difficulties in diagnosing the injury and estimating the extension and level of severity. The aim of this study was to present functional recovery of patients operated on after missile caused BPI, as well as to describe the surgical decision-making process. method prospective study , A comprehensive sample will be taken including all patients with missle injury to brachial plexus during a period of 16 months exclusion criteria : We excluded from the study: (1) any patient with brachial plexuses injury due to blunt trauma or heavy object injury (other than missile injury ) or due to missile injury before or after time of study Inclusion criteria any patient with brachial plexuses injury due to missile injury at time of study (between October 2014 – December 2020 ) Results In each case of shotgun blast, there was a complex heat (burn) or metal induced wounds. In four patients, there was severe and diffuse neurological injury; two sustained intradural injury. Two patients predominantly caused complex heat (burn) wounds but, in comparison to shotgun blast, there were fewer disruptions of the plexus (53%) and most were single nerve injuries. Shrapnel fragments (3 patients) usually caused small wounds. Rupture or avulsion of elements of the plexus was observed in eight patients with fragment wounds, and vital structures were damaged in seven patients. All patients are above age of 18-year old. About 45% patients with age more than 30-year old . One or more elements of the plexus was repaired in 5 patients. There were two good 40% , and three poor results (60%) ( schedule 1) Repair of the upper, middle and lower trunks produced good or useful results in one patient (33%). Poor in two patients (66%). (73%) These included six grafts of the lateral cord and Nerve grafts though using of sural nerves done in three cases. Repairs of the cords and trunks were less successful; only two of five repairs were rated as useful or better. A poor result was obtained in a fragment wound (multiple site of injury) after grafting of a lesion of the posterior cord in association with an injury to the spinal cord. Vascular repair in two patients. Normal circulation to the involved limb was restored in both of them. In four patients, decompression and repair of a subclavian or axillary aneurysm or fistula, and repair or neurolysis of the plexus significantly improved neurological function. The relief of pain. Satisfactory relief of pain was achieved in five of 11 patients. Pain was abolished or significantly relieved in five patients by dealing with the associated vascular lesion. In 3 patients surgery to the nerve lesion alone relieved pain, but it persisted in two after grafting of the cord or trunk . Gradual improvement was noted in one patient with an incomplete injury of the suprascapular nerve with neurostenalgia. Conclusion and Recommendations: Gunshot wounds usually leave lesions in continuity and these may cause incomplete loss of the involved element(s), which may recover spontaneously with time, although often they may not. Plexus injury should be evaluated by elements involved in addition to the plexus as a whole. Elements not in continuity should be repaired in several weeks. Operative intervention to gun shot wounds of the brachial plexus should be delayed 8wks to 12 wks for the following reasons: (1) if there is a serious deficit with complete loss of function in one or more elements that fails to improve (2) if there is incomplete loss that does not improve after a few months accompanied by pain of a Non complex regional pain syndrome nature not helped by conservative management (3) if there is a pseudoaneurysm, clot, or fistula compressing or involving the plexus (4) if true (complex regional pain syndrome) occurs requiring sympathectomy. Intraoperative (nerve action potentials (NAP) by NCS MACHINE should be performed on elements in continuity and if nerve action potentials (NAP)are negative, then these lesions should be resected and repaired by suture or graft
Recent advances in the management of brachial plexus injuries
Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 2014
Management of brachial plexus injury is a demanding field of hand and upper extremity surgery. With currently available microsurgical techniques, functional gains are rewarding in upper plexus injuries. However, treatment options in the management of flail and anaesthetic limb are still evolving. Last three decades have witnessed significant developments in the management of these injuries, which include a better understanding of the anatomy, advances in the diagnostic modalities, incorporation of intra-operative nerve stimulation techniques, more liberal use of nerve grafts in bridging nerve gaps, and the addition of new nerve transfers, which selectively neurotise the target muscles close to the motor end plates. Newer research works on the use of nerve allografts and immune modulators (FK 506) are under evaluation in further improving the results in nerve reconstruction. Direct reimplantation of avulsed spinal nerve roots into the spinal cord is another area of research in brachi...
Nerve Transfers in Adult Brachial Plexus Injuries
Advances in Spine Surgery [Working Title]
Brachial plexus injuries are semi-emergency conditions that require early intervention. Nerve transfers in adult brachial plexus injuries have become the standard treatment that gives reasonably good results if performed before the degeneration of muscle end plates. A clinical diagnosis based on clinical examinations supported by radiological and electrophysiological investigations is required that guides the specific procedures to be chosen. The surgeons must prioritize the objectives of reconstruction and keeping the different lifeboats for the use in future before choosing a specific nerve transfer. Also, it is important to be familiar with different nerve transfers so that one can select and perform a specific one based on pre-operative examinations and intraoperative findings of nerve stimulations. The author aims to describe the approach for exploring and dissecting the brachial plexus and different surgical techniques of nerve transfers used for different muscle reinnervation...
Mechanisms of injury in operative brachial plexus lesions
Neurosurgical FOCUS, 2004
Object The authors focus on injury mechanisms involved in 1019 operative brachial plexus injuries (BPIs) managed between 1968 and 1998 at Louisiana State University Health Sciences Center (LSUHSC). Methods Data regarding these mechanisms of injury were obtained via retrospective chart reviews of patients who had undergone operations at LSUHSC. Five main mechanisms of injury to the brachial plexus occurred in the series. These included 509 stretch/contusion injuries (49%) with four patterns of presentation in 366 patients: 208 C5–T1 nerve injuries; 75 C5–7, 55 C5–6 injuries; and 28 involving the C8–T1 or C7–T1 nerves. Stretch/contusion injury was followed in frequency by gunshot wound (GSW), resulting in 118 injuries (12%). Most of the 293 involved plexus elements had some gross continuity when surgically exposed. Seventy-one lacerations involved the brachial plexus (7%), including 83 sharp lacerations caused by knives or glass; 61 blunt transections due to automobile metal, fan, and...
Open injuries of the brachial plexus: A case for immediate exploration and repair
Penetrating injuries to the neck may be associated with damage to the brachial plexus. Primary repair is advocated for these injuries, but in practice they rarely present acutely to units with appropriate surgical expertise. The level of the injury is usually determined  expertise. The level of the injury is usually determined Imaging (MRI) scan. The MRI revealed a signal by thorough pre-operative clinical examination avoiding unnecessary investigations and delay. We present a case of a patient who sustained a stab injury to the neck. Clinical examination revealed the level of brachial plexus injury (BPI). An early exploration under general anaesthesia was undertaken and a primary repair of the brachial plexus was performed without the need for nerve grafting techniques.
Nerve transfer in brachial plexus traction injuries
Journal of Neurosurgery, 1992
✓ Brachial plexus palsy due to traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Nerve transfer is the only possibility for repair in cases of spinal nerve-root avulsion. This technique was analyzed in 37 patients with 64 reinnervation procedures of the musculocutaneous and/or axillary nerve using upper intercostal, spinal accessory, and regional nerves as donors. The most favorable results, with an 83.8% overall rate of useful functional recovery, were obtained in patients with upper brachial plexus palsy in which regional donor nerves, such as the medial pectoral, thoracodorsal, long thoracic, and subscapular nerves, had been used. The overall rates of recovery for the spinal accessory and upper intercostal nerves were 64.3% and 55.5%, respectively, which are significantly lower. The authors evaluate the results of nerv...
American Journal of Roentgenology
In the 1940s, Seddon [8, 9] popularized a three-tier classification of nerve injury. According to Seddon, neuropraxia occurs after disruption of the myelin sheath, but without distal Wallerian degeneration. Axonotmesis denotes complete axonal injury, resulting in distal Wallerian degeneration, but the continuity of the endoneurium or perineurium is maintained. Neurotmesis implies complete disruption of essential parts of a nerve with or without gross anatomic nerve discontinuity. Sunderland's classification [10] more precisely describes and predicts recovery, although there are varying opinions as to which is more important for surgical planning. Sunderland's first-degree injury [10] is equivalent to Seddon's neuropraxia [8, 9] and a complete and rapid recovery is expected. Axonotmesis (Sunderland's second-degree injury) involves axonal injury and resultant Wallerian degeneration, but the endoneurial tubes are intact. With a short gap, complete recovery is expected because the axons regenerate in the correct orientation as a result of endoneurial tube guidance [10]. Neurotmesis is further split into third-through fifthdegree injuries with increasing connective tissue injuries, beginning from the endoneurium and continuing peripherally to the epineurium. In third-degree injury, the endoneurial tubes are disrupted, allowing the chance of axonal mismatch and resulting in functional loss. Fourth-degree injuries are characterized by additional perineurium damage and
Treatment of Neuropathic Pain in Brachial Plexus Injuries
Treatment of Brachial Plexus Injuries [Working Title]
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].
Axillary nerve neurotization with the anterior deltopectoral approach in brachial plexus injuries
Microsurgery, 2012
Combined neurotization of both axillary and suprascapular nerves in shoulder reanimation has been widely accepted in brachial plexus injuries, and the functional outcome is much superior to single nerve transfer. This study describes the surgical anatomy for axillary nerve relative to the available donor nerves and emphasize the salient technical aspects of anterior deltopectoral approach in brachial plexus injuries. Fifteen patients with brachial plexus injury who had axillary nerve neurotizations were evaluated. Five patients had complete avulsion, 9 patients had C5, six patients had brachial plexus injury pattern, and one patient had combined axillary and suprascapular nerve injury. The long head of triceps branch was the donor in C5,6 injuries; nerve to brachialis in combined nerve injury and intercostals for C5-T1 avulsion injuries. All these donors were identified through the anterior approach, and the nerve transfer was done. The recovery of deltoid was found excellent (M5) in C5,6 brachial plexus injuries with an average of 134.48 abduction at follow up of average 34.6 months. The shoulder recovery was good with 1308 abduction in a case of combined axillary and suprascapular nerve injury. The deltoid recovery was good (M3) in C5-T1 avulsion injuries patients with an average of 648 shoulder abduction at follow up of 35 months. We believe that anterior approach is simple and easy for all axillary nerve transfers in brachial plexus injuries. V V