Surgical Anatomy of the Brachial Plexus

Object There is insufficient information in the neurosurgical literature regarding the long thoracic nerve (LTN). Many neurosurgical procedures necessitate a thorough understanding of this nerve's anatomy, for example, brachial plexus exploration/repair, passes for ventriculoperitoneal shunt placement, pleural placement of a ventriculopleural shunt, and scalenotomy. In the present study the authors seek to elucidate further the surgical anatomy of this structure. Methods Eighteen cadaveric sides were dissected of the LTN, anatomical relationships were observed, and measurements were obtained between it and surrounding osseous landmarks. The LTN had a mean length of 27 ± 4.5 cm (mean ± standard deviation) and a mean diameter of 3 ± 2.5 mm. The distance from the angle of the mandible to the most proximal portion of the LTN was a mean of 6 ± 1.1 cm. The distance from this proximal portion of the LTN to the carotid tubercle was a mean of 3.3 ± 2 cm. The LTN was located a mean 2.8 cm posterior to the clavicle. In 61% of all sides the C-7 component of the LTN joined the C-5 and C-6 components of the LTN at the level of the second rib posterior to the axillary artery. In one right-sided specimen the C-5 component directly innervated the upper two digitations of the serratus anterior muscle rather than joining the C-6 and C-7 parts of this nerve. The LTN traveled posterior to the axillary vessels and trunks of the brachial plexus in all specimens. It lay between the middle and posterior scalene muscles in 56% of sides. In 11% of sides the C-5 and C-6 components of the LTN traveled through the middle scalene muscle and then combined with the C-7 contribution. In two sides, all contributions to the LTN were situated between the middle scalene muscle and brachial plexus and thus did not travel through any muscle. The C-7 contribution to the LTN was always located anterior to the middle scalene muscle. In all specimens the LTN was found within the axillary sheath superior to the clavicle. Distally, the LTN lay a mean of 15 ± 3.4 cm lateral to the jugular notch and a mean of 22 ± 4.2 cm lateral to the xiphoid process of the sternum. Conclusions The neurosurgeon should have knowledge of the topography of the LTN. The results of the present study will allow the surgeon to better localize this structure superior and inferior to the clavicle and decrease morbidity following invasive procedures.

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Clinically relevant surgical anatomy and exposures of the brachial plexus

Hand Clinics ◽

10.1016/j.hcl.2004.09.006 ◽

2005 ◽

Vol 21 (1) ◽

pp. 1-11 ◽

Cited By ~ 13

Author(s):

Alexander Y. Shin ◽

Robert J. Spinner

Keyword(s):

Brachial Plexus ◽

Surgical Anatomy

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Surgical Anatomy of the Radial Nerve at the Elbow and in the Forearm: Anatomical Basis for Intraplexus Nerve Transfer to Reconstruct Thumb and Finger Extension in C7 − T1 Brachial Plexus Palsy

Journal of Reconstructive Microsurgery ◽

10.1055/s-0036-1584687 ◽

2016 ◽

Vol 32 (09) ◽

pp. 670-674 ◽

Cited By ~ 7

Author(s):

Lei Zhang ◽

Chun-Lin Zhang ◽

Yu-Dong Gu ◽

Zhen Dong

Keyword(s):

Brachial Plexus ◽

Radial Nerve ◽

Nerve Transfer ◽

Surgical Anatomy ◽

Brachial Plexus Palsy ◽

Finger Extension ◽

Anatomical Basis

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Chapter-54 Surgical Anatomy and Management of Brachial Plexus Injuries

Ramamurthi and Tandon�s Manual of Neurosurgery ◽

10.5005/jp/books/12212_164 ◽

2014 ◽

pp. 416-421

Author(s):

Venkataswami R

Keyword(s):

Brachial Plexus ◽

Surgical Anatomy

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T2 Contributions to the Brachial Plexus

Operative Neurosurgery ◽

10.1227/01.neu.0000249234.20484.2a ◽

2007 ◽

Vol 60 (suppl_2) ◽

pp. ONS-13-ONS-18 ◽

Cited By ~ 11

Author(s):

Marios Loukas ◽

Robert G. Louis ◽

Christopher T. Wartmann

Keyword(s):

Brachial Plexus ◽

Peripheral Nerves ◽

Intercostal Nerve ◽

Surgical Anatomy ◽

Cutaneous Nerve ◽

Sensory Innervation ◽

Nerve Grafting ◽

Human Cadavers ◽

Intercostobrachial Nerve ◽

Communicating Branches

Abstract Objective: Recent advancements in neurotization and nerve grafting procedures have led to an increasing need for knowledge of the detailed anatomy of communicating branches between peripheral nerves. Although the surgical anatomy of the axilla has been well described, little is known regarding the degree or frequency of potential contributions to or communications with the brachial plexus. The aim of our study, therefore, was to explore extrathoracic, as well as potential intrathoracic, contributions to the brachial plexus from T2. Methods: The anatomy of the ventral primary ramus of T2 and the second intercostal nerve, including its lateral cutaneous contribution as the intercostobrachial nerve, was examined in 75 adult human cadavers (150 axillae), with particular emphasis on the communications with the brachial plexus. Results: Extrathoracically, communications were observed to occur in 86% of specimens. These contributions arose variably from either the intercostobrachial nerve or one of its branches and communicated with the medial cord (35.6%), medial ante-brachial cutaneous nerve (25.5%), or posterior antebrachial cutaneous nerve (24%). Whereas the majority of specimens (68.2%) were observed to have only one extratho-racic communication, 31.7% of specimens exhibited two. Intrathoracically, communications were observed to occur in 17.3% of specimens. These communications always arose from the ventral primary ramus of T2. When combining and comparing data within individual specimens, it was observed that those axillae without an extratho-racic contribution from the intercostobrachial nerve always contained an intrathoracic communication. Conclusion: Based on our findings, we conclude that 100% of specimens contained a communication branch between T2 and the brachial plexus. Considering the possible implications of this data, with regards to sensory innervation of the arm and axilla, further studies in this area of research could prove extremely beneficial.

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Surgical Anatomy of the Posterior Intermuscular Approach to the Brachial Plexus

Hand ◽

10.1177/1558944719895619 ◽

2020 ◽

pp. 155894471989561

Author(s):

Ilhan Akaslan ◽

Ahmet Ertas ◽

Mehmet Uzel ◽

Cagatay Ozdol ◽

Kamran Aghayev

Keyword(s):

Brachial Plexus ◽

Posterior Approach ◽

Dimensional Space ◽

Trapezius Muscle ◽

Surgical Anatomy ◽

Reference Points ◽

Direct Access ◽

Lateral Border ◽

First Rib ◽

Splenius Capitis

Background: First rib resection and scalenectomy is a well-established treatment option for thoracic outlet syndrome. The posterior approach is rarely used due to extensive muscle sacrifice resulting in significant procedural morbidity. In this paper, we report the surgical anatomy of modified and less-invasive muscle-sparing posterior approach. Methods: Eleven human cadavers were used in this study. With specific care to preserve muscles’ integrity, the brachial plexus was exposed by dissecting through the posterior neck musculature. A muscular triangle was found under the trapezius muscle, which provided direct access to deeper structures. Four anatomical reference points were identified to denote a 3-dimensional space enclosing proximal brachial plexus. Results: A muscular triangle was found under the trapezius muscle in all cadavers. It was bordered infero-medially by rhomboid minor, supero-medially by splenius capitis, and laterally by levator scapula muscles. The inferomedial border (rhomboid) was 55 mm (48-80), superomedial border (splenius capitis) was 60.5 mm (42-89), and the lateral border (levator scapulae) was 99 mm (60-130). A consistent vein was present inside the triangle and could be used as an anatomical landmark. The 4 reference points were C5, T1 intervertebral foramina, transverse tubercle, and scalene tubercle of the first rib. Removal of the first rib could be performed without brachial plexus retraction. The latter was exposed from neural foramina to lateral border of the first rib. Conclusions: The posterior approach provides ample space to for exposure and manipulation with the first rib and proximal brachial plexus.

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