Management of infraclavicular (Chuang Level IV) brachial plexus injuries: A single surgeon experience with 75 cases

2014 ◽  
Vol 40 (6) ◽  
pp. 573-582 ◽  
Author(s):  
W. L. Lam ◽  
D. Fufa ◽  
N.-J. Chang ◽  
D.C.-C. Chuang
Keyword(s):  
Brachial Plexus ◽  
Vascular Injuries ◽  
Level Of Evidence ◽  
Nerve Grafts ◽  
Scapular Fractures ◽  
Muscle Transfers ◽  
Surgeon Experience ◽  
Nerve Recovery ◽  
External Neurolysis

Infraclavicular brachial plexus injuries (Level IV in Chuang’s classification) have special characteristics, including high incidences of associated scapular fractures, glenohumeral dislocations, and vascular injuries. In addition, there are specific difficulties in surgical dissection and nerve repairs, especially if surgery is delayed (>3 months). A total of 153 patients with Level IV brachial plexus injuries underwent surgery between 1987 and 2008 with 75 patients (average age 29 years) available for a minimum of 4 years follow-up. Accompanying fractures/dislocations were suffered by 48 (64%) patients, and 17 (23%) had associated vascular injuries. The most common nerves to be injured were the axillary and musculocutaneous nerves. Nerve grafts to the axillary, musculocutaneous, and radial nerves achieved impressive results, but less reliable outcomes were achieved with the median and ulnar nerves. Decompression and/or external neurolysis were also beneficial for nerve recovery. Some surgical tips are presented, and the use of the C-loop vascularized ulnar nerve graft and functioning muscle transfers are discussed. Level of Evidence: IV

scholarly journals Use of the Facial Artery for Free Functioning Muscle Transfers: An Alternative Pedicle for Salvage in Brachial Plexus Lesions with Vascular Injuries

2020 ◽  
Vol 53 (01) ◽  
pp. 105-111
Author(s):  
Anil Bhatia ◽  
Kaustubh Prabhune ◽  
Alex De Carvalho
Keyword(s):  
Brachial Plexus ◽  
Elbow Flexion ◽  
Facial Artery ◽  
Salvage Procedure ◽  
Vascular Injuries ◽  
Nerve Reconstruction ◽  
Nerve Grafts ◽  
Muscle Transfers ◽  
Functional Muscle Transfer

AbstractFree functional muscle transfer (FFMT) is a salvage procedure recommended in cases of brachial plexus injury with late presentations or failures of primary nerve reconstruction. The workhorse for most authors is the gracilis, and the most common indication is the restoration of elbow flexion. For successful revascularization of the muscle, donor vessels must be in proximity of the site of the muscle fixation and allow direct coaptation to a donor nerve, ideally without the use of nerve grafts. A major problem occurs when patients have sustained concomitant vascular injuries to the subclavian and/or axillary arteries and had previous surgical dissections in the area where the most common vascular pedicles are located. The authors report the use of the rerouted facial vessels as donors in these complex cases. The surgical technique is presented, along with three cases where the procedure was used. The flaps survived in all the patients and grade > 3/5 muscle contraction was observed in the two patients who had adequate follow-up. Conclusion: the use of the facial vessels as donor vessels is an option to revascularize a FFMT in the setting of severe vascular injury to the subclavian and axillary arteries.

Nerve grafts bridging the thenar branch of the median nerve to the ulnar nerve to enhance nerve recovery: a report of three cases

2016 ◽  
Vol 42 (3) ◽  
pp. 281-285 ◽  
Author(s):  
B. Gesslbauer ◽  
G. J. Furtmüller ◽  
O. Schuhfried ◽  
A. D. Roche ◽  
M. Sporer ◽  
...  
Keyword(s):  
Median Nerve ◽  
Ulnar Nerve ◽  
Nerve Transection ◽  
Level Of Evidence ◽  
Nerve Grafts ◽  
Motor Testing ◽  
Before And After ◽  
Nerve Recovery ◽  
Intrinsic Muscles

We report a nerve graft procedure bridging the thenar branch of the median nerve to the ulnar nerve in three patients with ulnar nerve transection and defect at the mid-forearm. Ulnar nerve function was evaluated with electroneurography and quantitative sensory-motor testing before and after surgery, and at a 6-year follow-up. After surgery all patients showed electroneurographic evidence of median nerve innervation of the intrinsic muscles normally innervated by the ulnar nerve. The average strength was Grade 4 in the intrinsic muscles originally supplied by the ulnar nerve at the final follow-up. Our results indicate that the thenar branch of the median nerve may support ulnar nerve regeneration and so help prevent intrinsic muscles from irreversible atrophy, but our report is preliminary. This procedure should be validated by future clinical data, especially those with complete ulnar nerve transection at or above the elbow. Level of evidence: IV

RESULTS OF END-TO-SIDE NERVE COAPTATION IN SEVERE OBSTETRIC BRACHIAL PLEXUS LESIONS

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 656-663 ◽  
Author(s):  
Willem Pondaag ◽  
Alain Gilbert
Keyword(s):  
Brachial Plexus ◽  
Nerve Repair ◽  
Multiple Root ◽  
Axonal Outgrowth ◽  
Distal Stump ◽  
Nerve Grafts ◽  
Small Series ◽  
Obstetric Brachial Plexus ◽  
Plexus Lesion

Abstract OBJECTIVE Options for nerve repair are limited in brachial plexus lesions with multiple root avulsions because an insufficient number of proximal nerve stumps are available to serve as lead-out for nerve grafts. End-to-side nerve repair might be an alternative surgical technique for repair of such severe lesions. In this technique, an epineurial window is created in a healthy nerve, and the distal stump of the injured nerve is coapted to this site. Inconsistent results of end-to-side nerve repairs in traumatic nerve lesions in adults have been reported in small series. This article evaluates the results of end-to-side nerve repair in obstetric brachial plexus lesions and reviews the literature. METHODS A retrospective analysis was performed of 20 end-to-side repairs in 12 infants. Evaluation of functional recovery of the target muscle was performed after at least 2 years of follow up (mean, 33 mo). RESULTS Five repairs failed (25%). Seven times (35%) good function (Medical Research Council at least 3) of the target muscle occurred in addition to eight partial recoveries (40%). In the majority of patients, however, the observed recovery cannot be exclusively attributed to the end-to-side repair. The reinnervation may be based on axonal outgrowth through grafted or neurolyzed adjacent nerves. It seems likely that recovery was solely based on the end-to-side repair in only two patients. No deficits occurred in donor nerve function. CONCLUSION This study does not convincingly show that the end-to-side nerve repair in infants with an obstetric brachial plexus lesion is effective. Its use cannot be recommended as standard therapy.

‘Switch’ technique to restore pronation and radial deviation in 17 patients with brachial plexus birth palsy

2019 ◽  
Vol 44 (9) ◽  
pp. 905-912
Author(s):  
Türker Özkan ◽  
Hasan Utkan Aydin ◽  
Ömer Berköz ◽  
Safiye Özkan ◽  
Erol Kozanoğlu
Keyword(s):  
Brachial Plexus ◽  
Performance Measure ◽  
Occupational Performance ◽  
Level Of Evidence ◽  
Ulnar Deviation ◽  
Canadian Occupational Performance Measure ◽  
Brachial Plexus Birth Palsy ◽  
Activity Performance ◽  
Birth Palsy

We report outcomes of 17 children with brachial plexus birth palsy that underwent extensor carpi ulnaris to brachioradialis and brachioradialis to abductor pollicis longus transfers to correct supination and ulnar deviation deformity. Mean age at the time of surgery was 8.7 years and mean follow-up time was 21 months (8–44). These patients had marked increases in active forearm rotation and Canadian Occupational Performance Measure scores. Activity performance score on the measure increased from 1.1 to 6.7 and satisfaction score increased from 0.8 to 8.7 at final follow-up. We conclude from our patient series that these tendon transfers are effective in correction of the supination and ulnar deviation deformities in brachial plexus birth palsy. Level of evidence: IV

Recovery of upper extremity function following endoscopically assisted contralateral C7 transfer for obstetrical brachial plexus injury

2016 ◽  
Vol 41 (8) ◽  
pp. 863-874 ◽  
Author(s):  
G. Leblebicioglu ◽  
C. Ayhan ◽  
T. Firat ◽  
A. Uzumcugil ◽  
M. Yorubulut ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Brachial Plexus Injury ◽  
Hand Function ◽  
Grading System ◽  
Nerve Roots ◽  
Level Of Evidence ◽  
The Mean ◽  
Upper Extremity Function ◽  
Postoperative Shoulder

Transfer of the contralateral C7 nerve for reconstruction of the brachial plexus in infants with obstetrical brachial plexus injury has rarely been reported. We developed a new endoscopy-assisted technique via the prevertebral (retroesophageal) route for the transfer of the contralateral C7 nerve in reconstruction of the brachial plexus. The reconstruction was performed in 20 infants (14 boys and six girls). Motor recovery was assessed using the Gilbert and Raimondi scales. The Narakas Sensory Grading System was used to evaluate hand sensation. The mean follow-up period was 45 months (SD 18.2). Of the 20 children, nine had contralateral C7 transfer to lower nerve roots, two had transfer to upper nerve roots and nine had transfer to both upper and lower roots. The postoperative shoulder and elbow functions were good or satisfactory according to the Gilbert classification in all children whose preoperative scores were poor. All patients with lower roots reconstruction (9) had satisfactory hand function. A total of 15 children had a Narakas score of S3. Our technique enables safe contralateral C7 transfer to the avulsed roots in severe obstetrical brachial plexus injury infants with a satisfactory functional recovery. Level of evidence: Level IV

scholarly journals Functional deficits as a result of brachial plexus injury in anterior shoulder dislocation

2021 ◽  
pp. 175319342199308
Author(s):  
Rupert Jordan ◽  
Ryckie G. Wade ◽  
Gordon McCauley ◽  
Suzanne Oxley ◽  
Robert Bains ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Shoulder Dislocation ◽  
Medical Research Council ◽  
Brachial Plexus Injury ◽  
Muscle Power ◽  
Anterior Shoulder Dislocation ◽  
Nerve Reconstruction ◽  
Level Of Evidence ◽  
Functional Deficits

The incidence of brachial plexus injuries in anterior shoulder dislocation remains relatively uncommon. A retrospective study was conducted to observe the natural neurological recovery of patients following these injuries over a 2-year period. Muscle power according to the Medical Research Council scale and sensation were measured from presentation to discharge. In 28 patients, the power grade of proximal muscles supplied by nine injured nerves failed to improve over a median follow-up of 5 months. There was no statistically significant improvement in sensation over a median follow-up of 6 months. Poorer recovery in muscle power score was related to advancing age, whereby every decade increased the risk by approximately 30%. Anterior shoulder dislocation with a plexus injury carries a risk of permanent nerve injury. Patients should be referred for specialist nerve assessment leading to rehabilitation and timely early nerve reconstruction, if indicated. Level of evidence: IV

Flexor to Extensor Tendon Transfers in the Hand

1995 ◽  
Vol 20 (1) ◽  
pp. 26-28 ◽  
Author(s):  
W. J. DUNNET ◽  
P. L. HOUSDEN ◽  
R. BIRCH
Keyword(s):  
Brachial Plexus ◽  
Radial Nerve ◽  
Tendon Transfer ◽  
Extensor Tendon ◽  
Contralateral Side ◽  
Vascular Injuries ◽  
Wrist Extension ◽  
Power Grip ◽  
Tendon Transfers

We reviewed 49 cases of flexor to extensor tendon transfer following injury to the radial nerve (22) or brachial plexus (27). Post-operative follow-up averaged 5.6 years (0.5–12.5). Function was improved in 84% (41) of patients. 16% (8) reported no improvement; of these, four (50%) had associated vascular injuries. In those with improvement, impaired coordination and dexterity were reported by 79% (15 of 19) of the plexus injuries and in 64% (14 of 22) of the radial nerve palsies. Premature fatigue was noted by 89% (17 of 19) of plexus injuries and in 82% (18 of 22) of radial nerve palsies. The power of wrist extension averaged 22% of the contralateral side (8% to 80%), power of digital extension was 31% (5% to 130%), and power grip was reduced to 40% (5% to 86%).

Glenohumeral fusion in adults with sequelae of obstetrical brachial plexus injury: a report of eight cases

2018 ◽  
Vol 44 (3) ◽  
pp. 248-255
Author(s):  
Zoubir Belkheyar ◽  
Amar Belkacem Djeffel ◽  
Adeline Cambon-Binder
Keyword(s):  
Brachial Plexus ◽  
Brachial Plexus Injury ◽  
External Rotation ◽  
Shoulder Abduction ◽  
Level Of Evidence ◽  
Flexor Muscles ◽  
Obstetric Brachial Plexus ◽  
Brachial Plexus Paralysis ◽  
Shoulder Arthrodesis

The purpose of this study was to assess the outcomes of glenohumeral fusion performed in adulthood in patients with poor recovery after obstetric brachial plexus injury. We reviewed eight patients with obstetrical brachial plexus injury who had undergone shoulder arthrodesis. The mean age was 28 years (range 16 to 55). All of the patients had active periscapular and elbow flexor muscles. At an average follow-up of 20 months, the active range of abduction and external rotation of the affected shoulder was 67° (range 50° to 85°) and 21° (range 0° to 40°), respectively. All of the patients were satisfied with the outcome of the intervention. Fusion was obtained between 3 and 6 months, and none of the patients experienced residual pain. Shoulder fusion improved the active shoulder abduction and external rotation in adults with residual obstetrical brachial plexus paralysis. Level of evidence: IV

Isolated C5–C6 avulsion in obstetric brachial plexus palsy treated by ipsilateral C7 neurotization to the upper trunk: outcomes at a mean follow-up of 9 years

2015 ◽  
Vol 41 (2) ◽  
pp. 185-190 ◽  
Author(s):  
E. Gibon ◽  
C. Romana ◽  
R. Vialle ◽  
F. Fitoussi
Keyword(s):  
Brachial Plexus ◽  
Brachial Plexus Injury ◽  
Elbow Flexion ◽  
Root Avulsion ◽  
Pattern Of Injury ◽  
Muscle Transfers ◽  
Obstetric Brachial Plexus ◽  
Elbow Function ◽  
Nerve Root Avulsion

Cervical root avulsions are the worst pattern of injury in obstetrical brachial plexus injury (OBPI). The prognosis is poor and the treatment is mainly surgical with extraplexual neurotizations or muscle transfers. We present the outcomes of a technique performed in our institution to treat C5–C6 avulsion in obstetrical brachial plexus injury. This technique consists of a total ipsilateral C7 neurotization to the upper trunk. Ten babies with isolated C5–C6 root avulsion were operated on; we were able to review nine of them at over 12 months follow-up. The shoulder and the elbow function were assessed, as well as the Mallet Score. The mean follow-up was 9.2 years (SD 5.7). After a follow-up of 6 years, elbow flexion was restored with a range of motion ⩾130° and a motor function ⩾M3 in all patients. The average Mallet score was 18.1 (SD 1.2). This approach appears to be a viable alternative to extraplexual neurotizations for the treatment of C5–C6 nerve root avulsion.

SURGICAL TREATMENT OF TRAUMATIC PERONEAL NERVE LESIONS

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 664-673 ◽  
Author(s):  
Julia A. Seidel ◽  
Ralph Koenig ◽  
Gregor Antoniadis ◽  
Hans-Peter Richter ◽  
Thomas Kretschmer
Keyword(s):  
Functional Outcome ◽  
Peroneal Nerve ◽  
Nerve Lesions ◽  
Nerve Grafts ◽  
Internal Neurolysis ◽  
Potential Recording ◽  
External Neurolysis ◽  
Nerve Surgery ◽  
Graft Length

Abstract OBJECTIVE In this study, we compare different surgical procedures regarding the functional outcome of traumatic peroneal nerve lesions. METHODS In a retrospective study, 48 patients with traumatic lesions (17 iatrogenic) of the peroneal nerve were evaluated. Twenty-two patients presented with lesions in continuity displaying regenerative potential by nerve action potential recording. In these cases, surgery was restricted to either external (12÷) or interfascicular neurolysis (10÷). Twenty-two cases had no regenerative potential (10÷) or showed discontinuity (12÷) and thus were reconstructed with autologous sural nerve grafts. In four cases, a reconstructive procedure was intraoperatively abandoned as a result of the large extent of the lesion. RESULTS Thirty-six patients with an adequate follow-up period of at least 18 months were included in this study. Among those with external neurolysis, 73% (eight out of 11) showed a good functional outcome, obviating the need for a kick-up foot brace (M ≥ 4). In the interfascicular neurolysis group, 71% (five out of seven) exhibited a similar outcome. In the grafted group, however, only 28% (five out of 18) obtained a functionally useful result dependent on graft length. A graft length under 6 cm3 led to a functionally useful outcome in 44% of patients (four out of nine) compared with 11% (one out of nine) when the graft length was greater than or equal to 6 cm3. In six patients, muscle–tendon transfers were performed, resulting in strong, useful foot lift. CONCLUSION Peroneal nerve lesions lacking regenerative signs should be explored. A functionally useful result (M ≥4) was achieved in 72% of the patients with either external or internal neurolysis and in 28% of the patients after a nerve graft procedure. Patients in whom nerve surgery failed to reconstitute useful foot lift need to be evaluated for their suitability to undergo a tendon transfer procedure.

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