Adult Traumatic Brachial Plexus Injuries (original) (raw)
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Surgical treatment of adult traumatic brachial plexus injuries: an overview
Arquivos de Neuro-Psiquiatria, 2011
Traumatic injuries to the brachial plexus in adults are severely debilitating. They generally affect young individuals. A thorough understanding of the anatomy, clinical evaluation, imaging and electrodiagnostic assessments, treatment options and proper timing of surgical interventions will enable nerve surgeons to offer optimal care to patients. Advances in microsurgical technique have improved the outcome for many of these patients. The treatment options offer patients with brachial plexus injuries the possibility of achieving elbow flexion, shoulder stability with limited abduction and the hope of limited but potentially useful hand function.
Priorities of Treatment and Rationale in Adult Brachial Plexus Injuries
Operative Brachial Plexus Surgery, 2021
In most adult brachial plexus injuries, a high-energy mechanism results in extensive longitudinal axonotmetic damage, frequently with multiple nerve root avulsions. Resources for restoring function are limited by the resulting absence of most or all proximal plexal nerves. When extradural injury permits nerve grafting, limited autogenous sources of nerve graft often prove insufficient. Delay in surgical management, slow rates of nerve regeneration, and long distances required for axon growth to reach a target muscle often prevent a successful outcome. These factors require prioritization of desired functions to make best use of limited available resources. Best options for restoring elbow, shoulder, and grasp function are discussed based upon pattern of injury, with an analysis of published results to aid the reader in evaluation and treatment of these complex and challenging injuries.
Surgical outcomes following nerve transfers in upper brachial plexus injuries
Indian Journal of Plastic Surgery, 2009
Background: Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury. Materials and Methods: We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors-radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient). Results: Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50-170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).
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...
Rehabilitation of brachial plexus injuries in adults and children
European journal of physical and rehabilitation medicine, 2012
Management of brachial plexus injury sequelae is a challenging issue in neurorehabilitation. In the last decades great strides have been made in the areas of early diagnosis and surgical techniques. Conversely, rehabilitation of brachial plexus injury is a relatively unexplored field. Some critical aspects regarding brachial plexus injury rehabilitation have to be acknowledged. First, brachial plexus injury may result in severe and chronic impairments in both adults and children, thus requiring an early and long-lasting treatment. Second, nerve damage causes a multifaceted clinical picture consisting of sensorimotor disturbances (pain, muscle atrophy, muscle weakness, secondary deformities) as well as reorganization of the Central Nervous System that may be associated with upper limb underuse, even in case of peripheral injured nerves repair. Finally, psychological problems and a lack of cooperation by the patient may limit rehabilitation effects and increase disability. In the pres...
Successful recovery of sensation loss in upper brachial plexus injuries
Acta neurochirurgica, 2018
Injuries of the upper trunk of the brachial plexus may trigger motor and sensory deficits. There exists a growing body of literature with respect to the reconstruction of motor deficits in upper trunk brachial plexus injuries by using nerve transfers; albeit to date, very few old reports have focused on the reconstruction of sensory loss resulting from upper trunk injuries. In this case series, we review six cases (five males and one female) with upper trunk brachial plexus injuries undergoing sensory nerve transfers. Sensory reconstruction was carried out by using transfer of the ulnar to the median nerves, innervating adjacent aspects of the little and ring fingers (the fourth web space) and adjacent aspects of the thumb and the index finger (the first web space), respectively. The mean age of our six patients was 30.5 ± 9 years old (range 20-45). The mean time interval between the injury and subsequent surgery was 6.6 ± 1.8 months (range 5-10). Five patients achieved S3 or S3+ in...
Microsurgery, 2019
Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury. Methods: PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed. Results: In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5-C6 injuries and total BP injuries, p = 0.018 for C5-C6-C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022). Conclusions: Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5-C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery.
Management strategy in post traumatic brachial plexus injuries
The Indian Journal of Neurotrauma, 2012
Background: Traumatic brachial plexus injury is a devastating condition resulting mainly from motor cycle accidents and primarily affecting the young adults. In the past there was a pessimistic attitude in the management of these injuries. However in last two decades with the introduction of microsurgical techniques and advances in imaging modalities, these injuries are being explored and repaired early with satisfactory to good functional out comes. Methods: Neurolysis, nerve repair, nerve grafting, nerve transfer, pedicle muscle transfer and functioning free-muscle transfer are the main surgical procedures in the management of brachial plexus injury. In the management of these injuries an immediate intervention is considered in penetrating trauma. All other common high velocity traction injuries are initially observed for a spontaneous recovery. If there are no signs of recovery by three months, surgery is indicated, as further delay will affect the ultimate results. In global brachial plexus palsy with all root avulsions, intervention is even earlier, as chances of spontaneous recovery are practically nil. Results: Good results are expected with early intervention in upper plexal lesions. Results are favorable with short nerve grafts, distal nerve transfers, and intraplexal neurotization. The aim in global brachial plexus palsy is to restore the elbow flexion and provide a stable shoulder. Restoration of a fully functional and sensate hand is still far from being a reality. Conclusion: The management of brachial plexus injury remains a challenging problem. Functional results have considerably improved in the past two decades with the incorporation of microsurgical techniques in nerve surgery, and advancements in anesthesia. Following microsurgical reconstruction many of these patients are expected to return to their original work and amputation is no longer considered a treatment option.
Late Reconstruction for Brachial Plexus Injury
Neurosurgery Clinics of North America, 2009
Traumatic brachial plexus injuries are devastating and management is complex. Treatment involves a multidisciplinary approach. Primary reconstruction involves nerve repair, grafting, and transfer techniques. Secondary reconstruction includes microneurovascular free-functioning muscle transfer, tendon transfers, and arthrodesis to improve or restore function. These procedures are indicated when patients present more than 12 months from injury or when primary reconstruction procedures fail, and should focus on elbow flexion and shoulder stability. A free-functioning muscle transfer is often indicated for elbow flexion, with double free-functioning muscle transfers providing possible prehension. Shoulder reconstruction focuses on restoring stability to the glenohumeral joint and restoring abduction. This article outlines these techniques, their principles, and important details.
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...