Preoperative care

Patients who have an upper trunk or complete brachial plexus lesion often require support to prevent or minimize the inferior glenohumeral subluxation, which results from paralysis of the deltoid, supraspinatus, and infraspinatus muscles. A universal sling, envelope sling, or hemisling may be used for this purpose (Fig. 1). Maintaining normal capsular integrity is important to improve glenohumeral motion once shoulder girdle muscular function recovers. In addition, patients feel more secure...

Strategy of surgical management for different root injuries

Shoulder abduction can be achieved by the following types of transfers one donor nerve transfer, such as spinal accessory nerve transfer to the suprascapular nerve two donor nerve transfer, such as spinal accessory nerve and phrenic nerve combined transfers or three donor nerve transfer, such as a combined phrenic, spinal accessory nerve, and cervical motor branch nerve transfer to the distal C5 spinal nerve. The more donor nerves used, the higher the success rate. A single C6 avulsion is...

References

The surgical management of brachial plexus injuries. In Daniel RK, Terzis JK, editors. Reconstructive microsurgery. Boston Little, Brown 1977. p. 443-68. 2 Millesi H. Brachial plexus lesions classification and operative technique. In Tubiana R, editor. The hand. Philadelphia WB Saunders 1988. p. 645-55. 3 Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr Surg 1999 104 1221-40. 4 Alnot JY....

Preoperative planning

Once the decision has been made to operate, careful preoperative planning with the entire surgical team is essential (Box 1). Clinical records should be examined with special attention to the patient's postinjury physical examination and subsequent recovery, if any. Careful and repeated evaluation of upper extremity motor and sensory function is mandatory. When evaluating supraclavicular lesions, it is important to differentiate between avulsion and extraforaminal injuries. Although abrasions...

Reconstructive strategy of nerve transfers philosophy experiences and strategy changes

The anatomy and surgical access of the available donor nerves have been described 8,9,17 . Reconstructive strategies for neurotization procedures have changed over time. The following sections describe the philosophy, experiences, and reconstructive strategy evolution at the author's institution The relative priority of active shoulder abduction or adduction depends on an individual surgeon's philosophy. Shoulder adduction provides an increase in shoulder-to-trunk grasp power, but strong...

Biofeedback

When active muscle contractions appear, biofeedback may be used to help the patient key in on the muscle contraction and increase his or her ability to fire the muscle. Again, to decrease the number of supervised sessions, there are portable biofeedback units that the patient may use at home (Fig. 4). In later stages of re-education, biofeedback may also be in the form of visual and palpatory monitoring of the transferred or re-neurotized muscle. The patient's opposite hand or a mirror may also...

Materials and methods

Brachial Plexus Avulsion

From October 1984 to October 2003, 1449 adult patients with traumatic brachial plexus palsy were treated at Siriraj Hospital (Bangkok, Thailand). There were 1157 nerve transfers performed in these patients to restore the affected limb function. Restoring elbow flexion has been the main functional priority, followed by shoulder abduction. Hand sensibility and prehension are next considered as part of strategic surgical planning. For the upper arm type of brachial plexus injury with C5,6 or...

General principles for nerve transfers

There is no generally agreed-on reconstructive algorithm for nerve transfer cases. Choices are made based on each surgeon's philosophy, knowledge, and experience. Patient-related factors are important as well, including elapsed time and severity of injury, age, and ability to cooperate with sometimes arduous rehabilitation. Finally, practicalities such as available facilities, equipment, and supplies, and availability of a knowledgeable and skilled rehabilitation therapist, are important...

Injury classification

Brachial plexus injuries can be divided into two broad categories supraclavicular injuries and infraclavicular injuries (Fig. 1). Supraclavicular injuries are more common and represent 70 to 75 of traumatic brachial plexus injuries. These injuries result most often from a traction mechanism, and patients are unlikely to recover without surgery. Half of supraclavicular injuries involve all five spinal levels (C5-T1) 1 . Of these complete five-level injuries, most (60 ) are upper trunk (C5-C6 7)...

Brachial Plexus Injury C5 C6 Ka Treatment Ka Video

Nerve injuries operative results for major nerve injuries, entrapments, and tumors. Philadelphia WB Saunders 1995. 2 Malessy MJA, van Duinen SG, Feirabend HKP, Thomeer RT. Correlation between histopathologi-cal findings in C-5 and C-6 stumps and motor recovery following nerve grafting for repair of brachial plexus injury. J Neurosurg 1999 91 636-44. 3 Seddon H. Nerve grafting. J Bone Joint Surg 1963 45 447-61. 4 Azze RJ, Mattar R, Ferreira MC, Starck R, Canedo AC....

Nontraumatic brachial plexopathy

Nontraumatic brachial plexopathy may have a wide variety of causes, including the following primary or metastatic tumors of neurogenic and other origins inflammatory conditions, such as chronic inflammatory demyelinating polyneurop-athy CIDP or brachial neuritis Parsonage-Turner syndrome or radiation fibrosis, commonly secondary to treatment for breast or lung cancer. For nontraumatic brachial plexopathy, MRI is the modality of choice for imaging 1,4,27 . The largest published review of...

Brachioplexus Mri Artifacts Ge

Mri Brachial Plexus

Traditional FSE T2-weighted cervical spine MR images TR 2800, TE 105, NEX 3, slice 4 mm skip 0 mm, 384 x 256 matrix . A Occasionally, traditional images show nerve roots quite clearly arrowheads . B More often, however, the MRI only vaguely suggests the presence of nerve roots arrows . In this patient, the right dorsal and ventral roots are not visualized arrowhead , but the physician cannot be certain if they are truly present or absent. C If a patient has prominent CSF pulsation...

Classification of nerve injury

To understand the requirements for surgery, it is first necessary to review the patterns of nerve injury. Historically, nerve injuries have been described using the Seddon and Sunderland classification scheme. Seddon's 11 original classification scheme described three possibilities for a dysfunctional nerve neuropraxia, axonotmesis, or neurotmesis. A neuropraxia is present when there is a conduction block at the site of injury, but no macroscopic injury to the nerve. There may be a...

Electrodiagnostic studies

Electrodiagnostic studies are an integral component of preoperative and intraoperative decision making when used appropriately and interpreted correctly. Electrodiagnostic studies can help confirm a diagnosis, localize lesions, define the severity of axon loss and the completeness of a lesion, eliminate other conditions from the differential diagnosis, and reveal subclinical recovery or unrecognized subclinical disorders. Electrodiagnostic studies therefore serve as an important adjunct to a...

Intraoperative electrodiagnosis

Electrodiagnosis Snap Latency

Many of the limitations of preoperative electro-diagnosis are overcome by performing similar studies on exposed nerves during brachial plexus reconstruction. In this setting, electrophysiologic studies provide additional information about the number, location, type, and severity of nerve lesions 1,2 . This information can be used to answer important questions left unresolved by preoperative electrodiagnostic studies and to help surgeons make important therapeutic decisions regarding...

Other mechanisms

Brachial Plexus Mechanism

Though less common than closed injuries, open injuries do occur. If the mechanism results in sharp division eg, by means of a knife , direct repair may be possible. Iatrogenic injuries have been reported from multiple surgical procedures, including mastectomy, first rib resection, and subclavian carotid bypass 19-21 . Emergency exploration for open trauma is usually only warranted in cases of vascular injury or sharp laceration. Lower truck injuries are more likely to have concomitant vascular...

Radiographic evaluation

After a traumatic injury to the neck or shoulder girdle region, radiographic evaluation can give clues to the existence of associated neurologic injury. Standard radiographs should include cervical spine views, shoulder views ante-roposterior, axillary views , and a chest X ray. The cervical spine films should be examined for any associated cervical fractures, which could put the spinal cord at risk. In addition, the existence of transverse process fractures of the cervical vertebrae might...

Preoperative electrodiagnosis

Sensory Localization Diagnosis

NCSs and needle EMG are the primary studies used to gain information on the location, number, and pathophysiology of lesions affecting the brachial plexus and other peripheral nerves before surgical exploration. NCSs are often accurate enough to localize lesions within several centimeters along the course of a nerve segment. In motor NCSs, a mixed or pure motor nerve is stimulated at several places along the nerve. The summated electrical response of all muscle fibers innervated by the...

Mechanism and pathoanatomy

Preganglionic Avulsion

Most adult brachial plexus pathology is caused by closed trauma. Nerve injury in these cases is from traction and compression, with traction accounting for 95 of injuries 14 . Following a traction injury, the nerves may rupture, be avulsed at the level of the spinal cord, or be significantly stretched but remain intact Fig. 1 . Following are five possible levels where the nerve can be injured Fig. 2 2. The anterior branches of the spinal nerves Root injuries may be further localized with...

Brachial Plexus Injuries in Adults

The loss of upper extremity function following a traumatic brachial plexus injury causes devastating functional deficits that require complex surgical reconstruction. Because of advances and innovations in surgical techniques, it is now possible to reliably restore elbow flexion and shoulder stability, provided intervention is prompt. Recently, innovations have provided additional surgical reconstructive options that can be expected to improve functional outcomes. For example, methods are...

Operative approaches to the brachial plexus

Superior Transverse Scapular Ligament

The patient is placed supine, occasionally placed in a modified beach chair position to facilitate a posterior approach to the shoulder or arm. A folded sheet is placed beneath the scapula. The neck is extended gently and turned to the opposite side. A bump is also placed beneath the buttock to externally rotate one leg should a sural nerve graft be desirable . The neck, shoulder, entire limb, chest, and both legs are prepared and draped. The supraclavicular brachial plexus can be approached...

Physical examination

Avulsion Injury

A patient with a brachial plexus injury is often seen in conjunction with significant trauma. This additional trauma can potentially delay diagnosis of any existing nerve injury until the patient is stabilized and resuscitated. A high index of suspicion for a brachial plexus injury should be maintained when examining a patient in the emergency department who has a significant shoulder girdle injury, first rib injuries, or axillary arterial injuries. Often, the patient is obtunded or sedated in...

Traumatic brachial plexopathy

Avulsion Cervical Nerve Root Mri

Traumatic brachial plexopathy, which accounts for approximately 50 of cases, can be caused by compression, stretching, or, in its most extreme form, disruption of nerves or avulsion of nerve roots, with or without fractures involving the cervical spine or clavicle 4 . If fracture is suspected, a radiograph clavicle or noncontrast CT with multiplanar reformatting cervical spine should be the initial study 4 . MRI is the study of choice for cases in which fractures of the clavicles or ribs may be...

Imaging the Brachial Plexus

Port, MD, PhDb aDivision of Body MRI, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA b Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA The brachial plexus is a network of nerves supplying sensory and motor innervation to the upper extremities extending from its origins from the C5 through T1 nerve roots laterally to the axilla. Clinically, evaluating lesions...

Pathoanatomy

Axillary Artery Relations

The anatomy of the rootlets, roots, and the vertebral foramen contributes to the type of injury avulsion versus rupture that is observed. At every level, each of the roots is formed by the joining of dorsal sensory rootlets and ventral motor rootlets off the spinal cord as they pass through the spinal foramen Fig. 5A . The cell bodies of the sensory nerves lie within ganglia outside the spinal cord ie, the dorsal root ganglia DRG . The rootlets that form the cervical roots are intraspinal and...

General overview of the brachial plexus

Prefixed Postfixed Brachial Plexus

The brachial plexus runs within the interscalene triangle formed by the anterior scalene anteriorly, the middle scalene posteriorly, and the superior border of the first rib inferiorly . The brachial plexus is also located within the posterior triangle of the neck formed by the sternocleidomastoid SCM medially, the trapezius laterally, and the clavicle inferiorly . The brachial plexus is the network of nerves that provides sensation and function to the upper extremity. It is formed from the...