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.

Accessory Nerve to Suprascapular Nerve Transfer to Restore Shoulder Exorotation in Otherwise Spontaneously Recovered Obstetric Brachial Plexus Lesions

Neurosurgery ◽  
2006 ◽  
Vol 59 (4) ◽  
pp. 858-869 ◽  
Author(s):  
Willem J.R. van Ouwerkerk ◽  
Bernard M.J. Uitdehaag ◽  
Rob L.M. Strijers ◽  
Frans Nollet ◽  
Kurt Holl ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Brachial Plexus ◽  
Spontaneous Recovery ◽  
Nerve Transfer ◽  
Suprascapular Nerve ◽  
Resonance Imaging ◽  
Obstetric Brachial Plexus ◽  
Plexus Lesion

Abstract OBJECTIVE: A systematic follow-up of infants with an obstetric brachial plexus lesion of C5 and C6 or the superior trunk showing satisfactory spontaneous recovery of shoulder and arm function except for voluntary shoulder exorotation, who underwent an accessory to suprascapular nerve transfer to improve active shoulder exorotation, to evaluate for functional recovery, and to understand why other superior trunk functions spontaneously recover in contrast with exorotation. METHODS: In 54 children, an accessory to suprascapular nerve transfer was performed as a separate procedure at a mean age of 21.7 months. Follow-up examinations were conducted before and at 4, 8, 12, 24, and 36 months after operation and included scoring of shoulder exorotation and abduction. Intraoperative reactivity of spinatus muscles and additional needle electromyographic responses were registered after electrostimulation of suprascapular nerves. Histological examination of suprascapular nerves was performed. Trophy of spinatus muscles was followed by magnetic resonance imaging scanning. The influence of perinatal variables and results of ancillary investigations on outcome were evaluated. RESULTS: Exorotation improved from 70 degrees to functional levels exceeding 0 degrees, except in two patients. Abduction improved in 27 patients, with results of 90 degrees or more in 49 patients. Electromyography at 4 months did not show signs of denervation in 39 out of 40 patients. Intraoperative electrostimulation of suprascapular nerves elicited spinatus muscle reaction in 44 out of 48 patients. Histology of suprascapular nerves was normal. Preoperative magnetic resonance imaging scans showed only minor wasting of spinatus muscles in contrast with major wasting after successful operations. CONCLUSION: An accessory to suprascapular nerve transfer is effective to restore active exorotation when performed as the primary or a separate secondary procedure in children older than 10 months of age. Contradictory spontaneous recovery of other superior trunk functions and integrity of suprascapular nerves, as well as absence of spinatus muscle wasting direct to central nervous changes are possible main causes for the lack of exorotation.

TRAUMATIC LESIONS OF THE BRACHIAL PLEXUS

Neurosurgery ◽  
2008 ◽  
Vol 62 (4) ◽  
pp. 873-886 ◽  
Author(s):  
Kartik G. Krishnan ◽  
K. Daniel Martin ◽  
Gabriele Schackert
Keyword(s):  
Brachial Plexus ◽  
Muscle Flap ◽  
Multiple Root ◽  
Outcome Evaluation ◽  
Favorable Effect ◽  
Reconstructive Procedures ◽  
Traumatic Lesion ◽  
Flap Transfer ◽  
Nerve Transfers

Abstract OBJECTIVE To analyze retrospectively the outcomes of primary as well as secondary functional reconstructions in 49 patients with traumatic brachial plexus lesions from a single service. Guidelines for treatment might be extracted from this analysis. METHODS Among 152 cases of traumatic lesion of the brachial plexus presented to our clinic, 58 underwent primary brachial plexus reconstructive surgery. On exploration, all patients showed stretching and scarring of plexus elements; root avulsions were found in 28 patients (48%). Outcome evaluation was carried out in 49 of these patients with a follow-up period of 1 year or longer (mean follow-up, 27.9 mo; range, 12–72 mo). A total of 43 secondary reconstructive procedures to improve functionality of the involved arm were performed at a later stage in 25 of 58 patients. Outcomes of the secondary functional restorative procedures were evaluated (mean follow-up, 11.5 mo; range, 3–60 mo in 43 procedures). RESULTS Patients with neurolysis as a stand-alone procedure (11 patients) showed an outcome grade of 4 or 5. The average outcome of the 19 patients with C5, C6, and C7 grafting was Grade 3, the same as in patients with nerve transfers to the upper plexus elements (C5–C6 root avulsions, 13 patients). Patients with multiple root avulsions (five cases) showed an overall poor outcome (Grades 0–2). Secondary functional restorative surgery was performed in 43% of the patients and helped improve individual outcomes, providing a favorable effect on the general functionality of the arm. Among the restorative operations performed, the Steindler procedure, wrist extension restoration, claw hand correction, and free functional muscle flap transfer to the arm and forearm were the most rewarding. CONCLUSION A combination of primary brachial plexus reconstruction and carefully evaluated, selected, and planned function-restorative secondary procedures might offer favorable outcomes in patients with partial or total brachial plexus lesions.

Management strategies for shoulder reconstruction in obstetric brachial plexus injury with special reference to loss of internal rotation after surgery

2012 ◽  
Vol 37 (8) ◽  
pp. 772-779 ◽  
Author(s):  
M. Sibinski ◽  
T. E. J. Hems ◽  
D. A. Sherlock
Keyword(s):  
Soft Tissue ◽  
Brachial Plexus ◽  
Internal Rotation ◽  
External Rotation ◽  
Management Strategies ◽  
Shoulder Function ◽  
Obstetric Brachial Plexus ◽  
Teres Major ◽  
Shoulder Reconstruction

We assessed the outcomes in 24 of 25 children (mean age 3 years) who had soft-tissue shoulder reconstruction procedures for obstetric brachial plexus injuries. All had latissimus dorsi and teres major transfers to strengthen external rotation combined with subscapularis lengthening, reduction of posterior dislocation or subluxation, and humeral osteotomy, if necessary. At a mean follow-up of 3.8 years, the mean Mallet score improved from 12.3 preoperatively to 17.4 postoperatively, active external rotation improved from 21° to 32°, and passive external rotation improved from 26° to 67°. The shoulder remained in joint in all patients. Active internal rotation deteriorated in nine shoulders, two requiring secondary internal rotation osteotomy. Combined soft tissue rebalancing and bony procedures gives reliable shoulder function improvement. Care is required regarding the effect on internal rotation.

Functional Scoring System for Obstetric Brachial Plexus Palsy

2000 ◽  
Vol 25 (1) ◽  
pp. 41-45 ◽  
Author(s):  
H. BASHEER ◽  
V. ZELIC ◽  
F. RABIA
Keyword(s):  
Brachial Plexus ◽  
Scoring System ◽  
Good Recovery ◽  
Brachial Plexus Palsy ◽  
Obstetric Brachial Plexus Palsy ◽  
Upper Limb Function ◽  
Obstetric Brachial Plexus ◽  
Good Score ◽  
New Scoring

We suggest a new scoring system that measures the upper limb function both as a unit and in separate parts. Our system was designed to study the recovery in patients with obstetric brachial plexus palsy (OBPP). It measures active limb movements and compares them with the normal side to obtain a ratio, which is then converted to a score. Fifty-two patients with OBPP were studied with a follow-up of 2 years. The progress of the patients was monitored using the system. Thirty-seven patients (71%) achieved very good recovery, eight patients (15%) achieved a good score, and five patients (10%) achieved a poor score. Most of the recovery occurred before the age of 6 months.

Measuring secondary deformities of the shoulder in children with obstetric brachial plexus lesion: reliability of three methods

2003 ◽  
Vol 12 (3) ◽  
pp. 211-214
Author(s):  
Johannes A. van der Sluijs ◽  
Marieke van der Meij ◽  
Jonathan Verbeke ◽  
Radu A. Manoliu ◽  
Paul I.J.M. Wuisman
Keyword(s):  
Brachial Plexus ◽  
Brachial Plexus Lesion ◽  
Obstetric Brachial Plexus ◽  
Plexus Lesion ◽  
Obstetric Brachial Plexus Lesion

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.

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