Direct Coaptation of the C5-C6-C7 Brachial Plexus Roots in Traumatic Tangential Spine Lesions. Personal Technique

Introduction: Cut deep wounds in the neck often interested the great vessels (jugular, carotid, axillary) and the roots of the brachial plexus (BP). Threatening vascular lesions must be solved in emergency. Lesions of BP are mandatory to repair in emergency or delayed 48-72 hours avoiding difficult dissection in secondary intention, iatrogenic risk of vessels lesion and prolonged time of denervation. Sectioned BP roots near the spine require special techniques to solve.

Methodology and Material: Retraction determined by the elasticity of the C5-6-7 roots and trunks of BP is particularly large ∼4-5 cm (which cannot be undone by a single, simple act of tightening wire approximation). Distal ends of C6- C7 roots can be retracted in the costo-clavicular space. Tangential proximal root section cause retraction of the external roots covering which will make it impossible to place stitches strong enough to approximate the stumps. According to Saint Venant law approximation wires must be placed at a distance of 1.5 nerve trunk diameter but in tangent foraminal lesions this is not possible. For this reason we choose the proximal fulcrum, vertebral body periosteum above and below the foramen. Two wires are placed cranial and caudal on distal trunk and proximal to the vertebral body periosteum above and below the foramen. Each approximation wire is tight progressive and approaching of the distal stump is done inch by inch. After 4-5 maneuvers of approximation step by step, the 2 approximation wire are tight and neurorraphy of nerve fascicles is done under magnification.

Results: We applied this technique for a single case who sustained a knife stab injury to the left side of the neck with C5-C6-C7 brachial plexus lesions. After six months the patient recovered shoulder abbduction and M3-M4 elbow flexion.

Conclusions: The surgical technique purposed by us in tangential foramen BP roots lesion by choosing the proximal fulcrum as vertebral body periosteum above and below the foramen offers a safety possibility for microsurgical primary repair. Without placing the proximal wire on the vertebral body periosteum the approaching of the distal stump will be very difficult or impossible.