Microsurgical Reconstruction for Devastating Brachial Plexus Injuries

Abstract

Forty-four patients with brachial plexus injuries were treated in the period between Jun 1999 and Nov 2004. The ages of these patients ranged from 15 to 57 years (average 26 yrs). Most of the cases (72%) were caused by high velocity motor vehicle accidents. Gunshot and splinter injuries, direct hit from a motor vehicle (pedestrians), fall from height were responsible for rest of the cases (28%). Associated skeletal and vascular injuries were present in 43% of cases. The denervation time ranged from 4 months to 11 months. Majority of the patients had injuries in the upper brachial plexus involving C5, C6 & C7 roots. Global palsy was present in 8 cases. Reconstructive procedures included microneurolysis in 13 cases, nerve grafting in 7 and neurotization in 24 cases. Motors for neurotization included accessory nerve, inter-costal nerves, phrenic nerve, ulnar nerve fascicles and motor branch of radial nerve to triceps. Useful results were obtained in 64% of cases. Almost all patients had pain relief following surgery. In none of the case results worsened after surgery. Microsurgical techniques can obtain gratifying results in traumatic lesions of brachial plexus, provided surgical intervention is undertaken at an early stage.

Keywords

autologous nerve graft - brachial plexus - microneurolysis - neurotization

• References

• 1 Seddon H J. Nerve grafting. J Bone Joint Surg 45B 1963; 447-461
• 2 Tung T H H, Mackinnon S E. Brachial plexus injuries. Clin Plast Surg 30 2003; 269-287
• 3 Terzis J K, Verkris MD, Soucacos P N. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr Surg 104 1999; 1221-1241
• 4 Alnot JY. Traumatic brachial plexus lesions in adult. Hand Clin 11 1995; 623-631
• 5 Allie Y, Cenac P. Neurotization via the spinal accessory nerve in complete paralysis due to multiple avulsion injuries of the brachial plexus. Clin Orthop 237 1983; 67-74
• 6 Narakas A O, Hentz VR. Neurotization in brachial plexus injuries: Indications and results. Clin Orthop 237 1988; 43-56
• 7 Nagano A, Truyama N, Ochias N, Takahashi T Hara. Direct nerve crossing with the intercostal nerve to treat avulsion injuries of the brachial plexus. J Hand Surg 14A 1989; 980-985
• 8 Brunelli G, Monini L. Neurotization of avulsed roots of brachial plexus by means of anterior nerves of the cervical plexus. Clin Plast Surg 11 1984; 149-152
• 9 Gu Y D, Ma MK. Use of the phrenic nerve for brachial plexus reconstruction. Clin Orthop Res 323 1996; 119-121
• 10 Oberlin C, Beal D, Leechavengvengs S, Salon A, Dauge MC, Sarcy J J. Nerve transfer to biceps muscle using a part of ulnar nerve for C5–C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg 19A 1994; 232-237
• 11 Bertelli J A, Ghizoni MF. Selective motor hyperreinnervation by using contralateral C7 motor rootlets in the reconstruction of an avulsion injury of the brachial plexus. J Neurosurg 90 1990; 1133-1136
• 12 Zancolli E, Mitra H. Latissimus dorsi transfer to restore elbow flexion. J Bone Joint Surg 55A 1973; 1265-1275
• 13 Ruhmann O, Wirth C J, Gosse F, SChmolke S. Trapezius transfer after brachial plexus palsy. J Bone Joint Surg 80 B 1998; 109-113
• 14 Mohammed NSL. A simple method of shoulder arthrodesis. J Bone Joint Surg 80-B 1998; 620-623
• 15 Akasaka Y, Hara T, Takahashi M. Free muscle transplantation combined with intercostal nerve crossing for reconstruction of elbow flexion and wrist extension in brachial plexus injuries. Microsurgery 12 1991; 346-351