Clinical findings in C5-C6 and C5-C7 root palsies with brachial plexus traction lesions

2012 ◽  
Vol 38 (3) ◽  
pp. 237-241 ◽  
Author(s):  
J. A. Bertelli ◽  
M. F. Ghizoni
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Elbow Flexion ◽  
Clinical Findings ◽  
Hand Strength ◽  
Shoulder Abduction ◽  
Finger Extension ◽  
Root Injury ◽  
Flexion Extension

Stretch injuries of the C5-C7 roots of the brachial plexus traditionally have been associated with palsies of shoulder abduction/external rotation, elbow flexion/extension, and wrist, thumb, and finger extension. Based on current myotome maps we hypothesized that, as far as motion is concerned, palsies involving C5-C6 and C5-C7 root injuries should be similar. In 38 patients with upper-type palsies of the brachial plexus, we examined for correlations between clinical findings and root injury level, as documented by CT tomomyeloscan. Contrary to commonly held beliefs, C5-C7 root injuries were not associated with loss of extension of the elbow, wrist, thumb, or fingers, but residual hand strength was much lower with C5-C7 vs C5-C6 lesions.

C5–8 brachial plexus root injury: the “T-1 hand”

2012 ◽  
Vol 116 (2) ◽  
pp. 409-413 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Marcos Flávio Ghizoni
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Elbow Flexion ◽  
Clinical Findings ◽  
Pinch Strength ◽  
Shoulder Abduction ◽  
Wrist Flexion ◽  
Extensor Pollicis Longus ◽  
Root Injury ◽  
Flexion Extension

Object Classically, C5–7 root injuries of the brachial plexus have been associated with palsies of shoulder abduction/external rotation, elbow flexion/extension, and wrist, thumb, and finger extension. However, current myotome maps generally indicate that C-8 participates in the innervation of thumb and finger extensors. Therefore, the authors have hypothesized that, for palsies of the thumb and finger extensors, the injury should affect the C-5 through C-8 roots. Methods The authors tested their hypothesis in 30 patients with upper-type palsies of the brachial plexus. They traced a correlation between clinical findings and root injury, as documented by CT myelography, direct visualization during surgery, and electrophysiological studies. Results In C5–8 root injuries, shoulder abduction and external rotation were paralyzed, and in all patients, wrist extensors were paralyzed. However, in 22 of the 30 patients, wrist extension was possible, because of contraction of the extensor digitorum communis and extensor pollicis longus. Wrist flexion and pronation also were preserved. The T-1 root contributed significantly to innervation of the thumb and finger flexors, ensuring 34% grasping and 40% pinch strength relative to the normal side. Hand sensation was largely preserved. Conclusions Based on the authors' observations, they suspect that the clinical scenario previously attributed to a C5–7 root injury is, in fact, a C5–8 root injury. The authors propose referring to this partial palsy of the brachial plexus as a “T-1 hand.”

Neurolysis alone as the treatment for neuroma-in-continuity with more than 50% conduction in infants with upper trunk brachial plexus birth palsy

2014 ◽  
Vol 13 (2) ◽  
pp. 229-237 ◽  
Author(s):  
Emily Andrisevic ◽  
Marshall Taniguchi ◽  
Michael D. Partington ◽  
Julie Agel ◽  
Ann E. Van Heest
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Severe Disease ◽  
Treatment Algorithm ◽  
Elbow Flexion ◽  
Functional Improvement ◽  
Shoulder Abduction ◽  
Active Movement ◽  
Nerve Injuries

Object The debate addressed in this article is that of surgical treatment methods for a neuroma-in-continuity. The authors of this study chose to test the hypothesis that more severe nerve injuries, as distinguished by < 50% conduction across a neuroma-in-continuity, could be treated with neuroma resection and grafting, whereas less severe nerve injuries, with > 50% conduction across the neuroma, could be treated with neurolysis alone. Methods The goal of this study was to compare preoperative and postoperative Active Movement Scale (AMS) scores in children with upper trunk brachial plexus birth injuries treated with neurolysis alone if the neuroma's conductivity was > 50% on intraoperative nerve testing. Seventeen patients (7 male, 10 female) met the criteria for inclusion in this study. Surgery was done when the patients were an average of 10 months old (range 6–19 months). The authors analyzed AMS scores from the preoperative assessment, 1-year postoperative follow-up visit, and subsequent follow-up assessment as close to 3 years after surgery as possible (referred to in this paper as > 2-year postoperative scores). Results Comparison of preoperative and 1-year follow-up data showed significant improvement in shoulder abduction, flexion, external rotation, and internal rotation; elbow flexion and supination; and wrist extension. Comparison of preoperative findings and results of assessment at > 2-year follow-up showed significant improvement in shoulder abduction, flexion, external rotation; and elbow flexion and supination. At final follow-up, useful function (AMS score of 6 or 7) was achieved for elbow flexion in 14 of 16 patients, shoulder flexion in 11 of 15 patients, shoulder abduction in 11 of 16 patients, and shoulder external rotation in 5 of 15 patients. Conclusions This report indicates that there is a subgroup of patients who can benefit clinically, with functional improvement of shoulder and elbow function, from treatment with neurolysis alone for upper trunk lesions demonstrating more than 50% conduction across the neuroma on intraoperative nerve testing. Patients with less than 50% conduction, indicating more severe disease, are treated with nerve resection and grafting in the authors' treatment algorithm.

Navigating the gray zone: a guideline for surgical decision making in obstetrical brachial plexus injuries

2009 ◽  
Vol 3 (3) ◽  
pp. 173-180 ◽  
Author(s):  
James R. Bain ◽  
Carol DeMatteo ◽  
Deborah Gjertsen ◽  
Robert D. Hollenberg
Keyword(s):  
Decision Making ◽  
Brachial Plexus ◽  
External Rotation ◽  
Elbow Flexion ◽  
Complete Recovery ◽  
Shoulder Abduction ◽  
Active Movement ◽  
Gray Zone ◽  
Surgical Decision ◽  
Surgical Decision Making

Object In the literature, the best recommendations are imprecise as to the timing and selection of infants with obstetrical brachial plexus injury (OBPI) for surgical intervention. There is a gray zone (GZ) in which the decision as to the benefits and risks of surgery versus no surgery is not clear. The authors propose to describe this category, and they have developed a guideline to assist surgical decision-making within this GZ. Methods The authors first performed a critical review of the medical literature to determine the existence of a GZ in other clinical publications. In those reports, 47–89% of infants with OBPI fell within such a GZ. Complete recovery in those reported patients ranged from 9 to 59%. Using a prospective inception cohort design, all infants referred to the OBPI Clinic at McMaster Children's Hospital were systematically evaluated up to 3 years of age. The Active Movement Scale scores were compared for surgical and nonsurgical groups of infants in the GZ to identify any important trends that would guide surgical decision-making. Results In the authors' population of infants with OBPI, 81% fell within the GZ, of whom 44% achieved complete recovery. Mean scores differed significantly between surgery and no surgery groups in terms of total Active Movement Scale score and shoulder abduction and flexion at 6 months. Elbow flexion and external rotation differed at 3 months. Conclusions There is compelling evidence that there is a group of infants with OBPI in whom the assessment of the risk/benefit ratio for surgical versus nonsurgical treatment is not evident. These infants reside within what the authors have called the GZ. Based on their results, a guideline was derived to assist clinicians working with infants with OBPI to navigate the GZ.

Partial Ipsilateral C7 Transfer to the Upper Trunk for C5-C6 Avulsion of the Brachial Plexus

Neurosurgery ◽  
2011 ◽  
Vol 70 (5) ◽  
pp. 1176-1182 ◽  
Author(s):  
Hua-Wei Yin ◽  
Su Jiang ◽  
Wen-Dong Xu ◽  
Lei Xu ◽  
Jian-Guang Xu ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Elbow Flexion ◽  
Suprascapular Nerve ◽  
Long Term Results ◽  
Shoulder Abduction ◽  
Novel Approach ◽  
Group A ◽  
Group B

Abstract BACKGROUND: Ipsilateral whole C7 root transfer has been reported in treating C5-C6 avulsion. To minimize donor deficits, partial ipsilateral C7 (PIC7) transfer was developed. OBJECTIVE: To investigate the long-term results of PIC7 transfer to the upper trunk in treating C5-C6 avulsion of the brachial plexus. METHODS: We prospectively studied 8 young adults with C5-C6 avulsion. Five patients (group A) who also had spinal accessory nerve (SAN) injury underwent PIC7 transfer to the upper trunk. The other 3 patients (group B) without SAN injury underwent a combination of PIC7 to the upper trunk and the SAN to the suprascapular nerve (SSN). Postsurgical evaluations including donor deficits, functional recovery, and co-contraction of the muscles were performed 1 week later and then at intervals of 3 months. RESULTS: After a mean period of 39.2 months, all subjects were found to have gained elbow flexion of 110 to 150° with muscle strength of M4-5. The patients in group B achieved external rotation of 60 to 70° at M3-4, and 2 achieved shoulder abductions approaching 180° at M4. The patients in group A showed no active external rotation and shoulder abduction of 25 to 50° at M2-3. The temporary deficits caused by PIC7 transfer disappeared in all subjects within the first 3 months. Co-contraction of the latissimus dorsi against the deltoid was recorded in group A but not in group B. CONCLUSION: PIC7 transfer, when combined with SAN transfer to SSN as a novel approach, is a safe, easy, and efficacious surgical procedure for patients with simple C5-C6 avulsion.

Multiple nerve transfers for the reanimation of shoulder and elbow functions in irreparable C5, C6 and upper truncal lesions of the brachial plexus

2008 ◽  
Vol 05 (02) ◽  
pp. 95-104 ◽  
Author(s):  
PS Bhandari ◽  
LP Sadhotra ◽  
P Bhargava ◽  
AS Bath ◽  
MK Mukherjee ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Suprascapular Nerve ◽  
Shoulder Function ◽  
Spinal Nerve ◽  
Shoulder Abduction ◽  
Nerve Branch ◽  
Nerve Transfers

AbstractIn irreparable C5, C6 spinal nerve and upper truncal injuries the proximal root stumps are not available for grafting, hence repair is based on nerve transfer or neurotization. Between Feb 2004 and May 2006, 23 patients with irreparable C5, C6 or upper truncal injuries of the Brachial Plexus underwent multiple nerve transfers to restore the shoulder and elbow functions. Most of them (16 patients) sustained injury following motor cycle accidents. The average denervation period was 5.3 months. Shoulder function was restored by transfer of distal part of spinal accessory nerve to suprascapular nerve, and transfer of radial nerve branch to long head of triceps to the anterior branch of axillary nerve. Elbow function was restored by transfers of ulnar and median nerve fascicles to the biceps and brachialis motor branches of musculocutaneous nerve. All patients recovered shoulder abduction and external rotation; 7 scored M4 and 16 scored M3. Range of abduction averaged 1230(range, 800-1700). Full elbow flexion was restored in all 23 patients; 15 scored M4 and 8 scored M3. Patients with excellent results could lift 5 kgs of weight. Selective nerve transfers close to the target muscle provide an early and good return of functions. There is negligible morbidity in donor nerves. These intraplexal transfers are suitable in all cases of upper brachial plexus injuries.

Restoration of active pick-up function in patients with total brachial plexus avulsion injuries

2017 ◽  
Vol 43 (3) ◽  
pp. 269-274 ◽  
Author(s):  
Feng Li ◽  
Shu-feng Wang ◽  
Peng-cheng Li ◽  
Yun-hao Xue ◽  
Ji-yao Zou ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Elbow Flexion ◽  
Suprascapular Nerve ◽  
Shoulder Abduction ◽  
Level Of Evidence ◽  
Lower Trunk ◽  
Brachial Plexus Avulsion ◽  
Nerve Transfers ◽  
Finger Extension ◽  
Posterior Division

We designed multiple nerve transfers in one surgery to restore active pick-up function in patients with total brachial plexus avulsion injuries. Forty patients with total brachial plexus avulsion injuries first underwent multiple nerve transfers. These included transfer of the accessory nerve onto the suprascapular nerve to recover shoulder abduction, contralateral C7 nerve onto the lower trunk via the modified prespinal route with direct coaptation to restore lower trunk function and onto the musculocutaneous nerve with interpositional bridging by medial antebrachial cutaneous nerve arising from lower trunk to restore elbow flexion, and the phrenic nerve onto the posterior division of lower trunk to recover elbow and finger extension. At least three years after surgery, the patients who had a meaningful recovery were selected to perform secondary reconstruction to restore active pick-up function. Active pick-up function was successfully restored in ten patients after they underwent multiple nerve transfers combined with additional secondary functional hand reconstructions. Level of evidence: IV

Analysis of human acellular nerve allograft combined with contralateral C7 nerve root transfer for restoration of shoulder abduction and elbow flexion in brachial plexus injury: a mean 4-year follow-up

2020 ◽  
Vol 132 (6) ◽  
pp. 1914-1924 ◽  
Author(s):  
Liang Li ◽  
Jiantao Yang ◽  
Bengang Qin ◽  
Honggang Wang ◽  
Yi Yang ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Nerve Root ◽  
Functional Outcomes ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Allograft Reconstruction ◽  
Acellular Nerve Allograft ◽  
The Mean ◽  
Monofilament Test

OBJECTIVEHuman acellular nerve allograft applications have increased in clinical practice, but no studies have quantified their influence on reconstruction outcomes for high-level, greater, and mixed nerves, especially the brachial plexus. The authors investigated the functional outcomes of human acellular nerve allograft reconstruction for nerve gaps in patients with brachial plexus injury (BPI) undergoing contralateral C7 (CC7) nerve root transfer to innervate the upper trunk, and they determined the independent predictors of recovery in shoulder abduction and elbow flexion.METHODSForty-five patients with partial or total BPI were eligible for this retrospective study after CC7 nerve root transfer to the upper trunk using human acellular nerve allografts. Deltoid and biceps muscle strength, degree of shoulder abduction and elbow flexion, Semmes-Weinstein monofilament test, and static two-point discrimination (S2PD) were examined according to the modified British Medical Research Council (mBMRC) scoring system, and disabilities of the arm, shoulder, and hand (DASH) were scored to establish the function of the affected upper limb. Meaningful recovery was defined as grades of M3–M5 or S3–S4 based on the scoring system. Subgroup analysis and univariate and multivariate logistic regression analyses were conducted to identify predictors of human acellular nerve allograft reconstruction.RESULTSThe mean follow-up duration and the mean human acellular nerve allograft length were 48.1 ± 10.1 months and 30.9 ± 5.9 mm, respectively. Deltoid and biceps muscle strength was grade M4 or M3 in 71.1% and 60.0% of patients. Patients in the following groups achieved a higher rate of meaningful recovery in deltoid and biceps strength, as well as lower DASH scores (p < 0.01): age < 20 years and age 20–29 years; allograft lengths ≤ 30 mm; and patients in whom the interval between injury and surgery was < 90 days. The meaningful sensory recovery rate was approximately 70% in the Semmes-Weinstein monofilament test and S2PD. According to univariate and multivariate logistic regression analyses, age, interval between injury and surgery, and allograft length significantly influenced functional outcomes.CONCLUSIONSHuman acellular nerve allografts offered safe reconstruction for 20- to 50-mm nerve gaps in procedures for CC7 nerve root transfer to repair the upper trunk after BPI. The group in which allograft lengths were ≤ 30 mm achieved better functional outcome than others, and the recommended length of allograft in this procedure was less than 30 mm. Age, interval between injury and surgery, and allograft length were independent predictors of functional outcomes after human acellular nerve allograft reconstruction.

Traumatic Brachial Plexus Palsy in Children: Long-Term Outcome and Strategy of Reconstruction

2021 ◽  
Author(s):  
Tarek A. El-Gammal ◽  
Amr El-Sayed ◽  
Mohamed M. Kotb ◽  
Waleed Riad Saleh ◽  
Yasser Farouk Ragheb ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Hand Function ◽  
Functional Restoration ◽  
Shoulder Abduction ◽  
Wrist Flexion ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Age At Surgery ◽  
Flexion And Extension

Abstract Background Traumatic brachial plexus injuries in children represent a definite spectrum of injuries between adult and neonatal brachial plexus injuries. Their characteristics have been scarcely reported in the literature. The priority of functional restoration is not clear. Materials and Methods In total, 52 children with surgically treated traumatic brachial plexus injuries, excluding Erb's palsy, were reviewed after a minimum follow-up of 2 years. All children except nine were males, with an average age at surgery of 8 years. Forty-five children had exclusive supraclavicular plexus injuries. Twenty-one of them (46%) had two or more root avulsions. Seven children (13.5%) had infraclavicular plexus injuries. Time from trauma to surgery varied from 1 to 15 months (mean = 4.7 months). Extraplexal neurotization was the most common surgical technique used. Results Shoulder abduction and external rotation were restored to an average of 83 and 26 degrees, respectively. Elbow flexion and extension were restored to grade ≥3 in 96 and 91.5% of cases, respectively. Finger flexion and extension were restored to grade ≥4 in 29 and 32% of cases, respectively. Wrist flexion and extension were restored to grade ≥4 in 21 and 27% of cases, respectively. Results of neurotization were superior to those of neurolysis and nerve grafting. Among the 24 children with insensate hands, 20 (83.3%) recovered S3 sensation, 3 recovered S2, and 1 recovered S1. No case complained of neuropathic pain. Functional recovery correlated negatively but insignificantly with the age at surgery and time from injury to surgery. Conclusion Brachial plexus injuries in children are associated with a high incidence root avulsions and no pain. Neurotization is frequently required and the outcome is not significantly affected by the delay in surgery. In total plexus injuries, some useful hand function can be restored, and management should follow that of obstetric palsy and be focused on innervating the medial cord.

Transfer of a Motor Fascicle From the Ulnar Nerve to the Branch of the Radial Nerve Destined to the Long Head of the Triceps for Restoration of Elbow Extension in Brachial Plexus Surgery

Neurosurgery ◽  
2011 ◽  
Vol 70 (2) ◽  
pp. E516-E520 ◽  
Author(s):  
Leandro Pretto Flores
Keyword(s):  
Computed Tomography ◽  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Radial Nerve ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Elbow Extension ◽  
Long Head ◽  
Brachial Plexus Surgery

Abstract BACKGROUND AND IMPORTANCE: Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks. CLINICAL PRESENTATION: Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases. CONCLUSION: The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.

Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction

2004 ◽  
Vol 101 (5) ◽  
pp. 770-778 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Marcos Flávio Ghizoni
Keyword(s):  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Phrenic Nerve ◽  
Cranial Nerve ◽  
External Rotation ◽  
Elbow Flexion ◽  
Content Type ◽  
Nerve Transfers ◽  
Contralateral Motor ◽  
Fine Print

Object. The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. Methods. Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90° and 92° in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70°. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3+ and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. Conclusions. Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.

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