Repair of ruptured spinal nerve roots in a brachial plexus lesion (original) (raw)
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Experimental studies on surgical treatment of avulsed spinal nerve roots in brachial plexus injury
The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand, 1991
This review summarises studies aiming at a surgical treatment of spinal nerve root avulsions from the spinal cord in bra&al plexus lesions. After dorsal root injury, regrowth of nerve fibres into the spinal cord occurs only in the immature animal. After ventral root avulsion and subsequent implantation into the spinal cord, neuroanatomical and neurophysiological data show that motoneurons are capable of producing new axons which enter the implanted root. Intra-neuronal physiological experiments demonstrate that new axons can conduct action potentials and elicit muscle responses. The neurons are reconnected in segmental spinal cord activity and respond to impulses in sensory nerve fibres. In primate experiments, implantation of avulsed ventral roots in the bra&al plexus resulted in functional restitution. These studies indicate the possibility of surgical treatment of ventral root avulsion injuries in bra&al plexus lesions in humans.
Repairing spinal roots after brachial plexus injuries
Paraplegia, 1995
The problems of repairing spinal roots after brachial plexus avulsion injuries are discussed in the light of current surgical diagnosis and treatment. An advancing understanding of the cellular mechanisms of nerve regeneration and progress in surgical technology indicates a possibility for the repair at least of ventral roots with grafts which may be of neural or non-neural origin. Enhancement of the regenerative properties may further be made possible by the application of neurotrophic factors at the repair site or centrally. The short and long-term implications of current research into these methods are discussed.
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...
Nerve Root Grafting and Distal Nerve Transfers for C5-C6 Brachial Plexus Injuries
The Journal of Hand Surgery, 2010
Purpose To investigate the results of distal nerve transfer, with and without nerve root grafting, in C5-C6 palsy of the brachial plexus. Methods We prospectively studied 37 young adults with C5-C6 brachial plexus palsy who underwent surgical repair an average of 6.3 months after trauma. In 7 patients, no nerve roots were available for grafting, so reconstruction was achieved by transferring the accessory nerve to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps branches to the axillary nerve (a triple nerve transfer). In 24 patients, C5 nerve root grafting to the anterior division of the upper trunk was combined with triple nerve transfer. In 6 patients, the C5ϩC6 nerve roots were grafted to the anterior and posterior divisions of the upper trunk, the accessory nerve was transferred to the suprascapular nerve, and ulnar nerve fascicles were connected to the biceps motor branch. The range of shoulder abduction/ external rotation recovery and elbow flexion strength were evaluated between 24 and 26 months after surgery. Results Both full abduction and full external rotation of the shoulder were restored in one of the 7 patients in the C5 and C6 nerve root avulsion group, in 14 of 21 patients who received C5 nerve root grafting, and in 2 of 6 patients in the C5ϩC6 nerve root graft group. The average percentages of elbow flexion strength recovery, relative to the normal, contralateral side, were 27%, 43%, and 59% for the C5-C6 nerve root avulsion, C5 nerve root graft, and C5ϩC6 nerve root graft groups, respectively. Conclusions We repaired C5-C6 brachial plexus palsies using a combination of strategies depending on the site of root injury (ie, intradural vs extradural). Patients with injuries that were able to be reconstructed with both root grafting and nerve transfers had the best function. These results suggest that the combined use of nerve transfers and root grafting may enhance outcomes in the reconstruction of C5-C6 injuries of the brachial plexus.
Concepts of nerve regeneration and repair applied to brachial plexus reconstruction
Microsurgery, 2006
Brachial plexus injury is a serious condition that usually affects young adults. Progress in brachial plexus repair is intimately related to peripheral nerve surgery, and depends on clinical and experimental studies. We review the rat brachial plexus as an experimental model, together with its behavioral evaluation. Techniques to repair nerves, such as neurolysis, nerve coaptation, nerve grafting, nerve transfer, fascicular transfer, direct muscle neurotization, and end-to-side neurorraphy, are discussed in light of the authors' experimental studies. Intradural repair of the brachial plexus by graft implants into the spinal cord and motor rootlet transfer offer new possibilities in brachial plexus reconstruction. The clinical experience of intradural repair is presented. Surgical planning in root rupture or avulsion is proposed. In total avulsion, the authors are in favor of the reconstruction of thoraco-brachial and abdomino-antebrachial grasping, and on the transfer of the brachialis muscle to the wrist extensors if it is reinnervated. Surgical treatment of painful conditions and new drugs are also discussed. V V C 2006 Wiley-Liss, Inc. Microsurgery 26:230-244, 2006.
Journal of Neurosurgery, 2009
Object In this study, the authors evaluated the efficacy of a new surgical strategy for reconnecting the injured brachial plexus with the spinal cord using fibrin glue containing acidic fibroblast growth factor as an adhesive and neurotrophic agent. Methods Eighteen patients with preganglionic brachial plexus injuries, each with varying degrees of upper limb dysfunction, underwent cervical laminectomy with or without sural nerve grafting. The treatment of each avulsed root varied according to the severity of the injury. Some patients also underwent a second-stage operation involving supraclavicular brachial plexus exploration for reconnection with the corresponding segment of cervical spinal cord at the trunk level. Muscle strength was graded both pre- and postoperatively with the British Medical Research Council scale, and the results were analyzed with the Friedman and Wilcoxon signed-rank tests. Results Muscle strength improvements were observed in 16 of the 18 patients after 24 ...
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).
Microsurgery, 2014
We conducted a clinical study to evaluate the effects of neurotization, especially comparing the total contralateral C7 (CC7) root transfer to hemi-CC7 transfer, on total root avulsion brachial plexus injuries (BPI). Methods: Forty patients who received neurotization for BPI were enrolled in this prospective study. Group 1 (n 5 20) received hemi-CC7 transfer for hand function, while group 2 (n 5 20) received total-CC7 transfer. Additional neurotization included spinal accessory, phrenic, and intercostal nerve transfer for shoulder and elbow function. The results were evaluated with an average of 6 years follow-up. Results: Group 1 had fewer donor site complications (15%) than group 2 (45%); group 2 had significantly better hand M3 and M4 motor function (65%) than group 1 (30%; P 5 0.02). There was no difference in sensory recovery. Significantly, better shoulder function was obtained by simultaneous neurotization on both suprascapular and axillary nerves. Conclusions: Total-CC7 transfer had better hand recovery but more donor complications than hemi-CC7. Neurotization on both supra-scapular and axillary nerves improved shoulder recovery.