scholarly journals The SPA arrangement of the branches of the upper trunk of the brachial plexus: a correction of a longstanding misconception and a new diagram of the brachial plexus

2016 ◽  
Vol 125 (2) ◽  
pp. 350-354 ◽  
Author(s):  
Amgad Hanna
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Operating Room ◽  
Patient Outcomes ◽  
Surgical Planning ◽  
Posterior Approach ◽  
Suprascapular Nerve ◽  
Branching Pattern ◽  
Posterior Division ◽  
Anterior Division

OBJECT Brachial plexus (BP) diagrams in most textbooks and papers represent the branches and divisions of the upper trunk (UT) in the following sequence from cranial to caudal: suprascapular nerve, anterior division, and then posterior division. This concept contradicts what is seen in the operating room and is noticed by most peripheral nerve surgeons. This cadaveric study was conducted to look specifically at the exact pattern of branching of the upper trunk of the BP. METHODS Ten cadavers (20 BPs) were dissected. Both supra- and infraclavicular exposures were performed. The clavicle was retracted or resected to identify the divisions of the BP. A posterior approach was used in 2 cases. RESULTS In all dissections the origin of the posterior division was in a more cranial and dorsal plane in relation to the anterior division. In most dissections the supra scapular nerve branched off distally from the UT, giving it the appearance of a trifurcation, taking off just cranial and dorsal to the posterior division. The branching pattern of the UT consistently had the following sequential arrangement from cranial and posterior to caudal and anterior: suprascapular nerve (S), posterior division (P), and anterior division (A), hence the acronym SPA. CONCLUSIONS Supraclavicular exposure of the BP exposes only the trunks and divisions. Recognizing the “SPA” arrangement of the branches helps in identifying the correct targets for neurotization, especially given that these 3 branches are the most common targets for BP repair. Understanding the anatomy means better surgical planning and better patient outcomes.

Brachial Plexus Reconstruction Following Resection of a Malignant Peripheral Nerve Sheath Tumor: Case Report

Neurosurgery ◽  
2011 ◽  
Vol 69 (1) ◽  
pp. E245-E250 ◽  
Author(s):  
Konstantinos Spiliopoulos ◽  
Ziv Williams
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Nerve Repair ◽  
Suprascapular Nerve ◽  
Neck Mass ◽  
Axillary Nerve ◽  
Nerve Sheath Tumor ◽  
Peripheral Nerve Sheath Tumors ◽  
Nerve Sheath ◽  
Anterior Division

Abstract BACKGROUND AND IMPORTANCE: The main therapeutic approach for malignant peripheral nerve sheath tumors (MPNSTs) of the brachial plexus is wide local excision. Sacrifice of some—occasionally all—elements of the brachial plexus often is required to obtain complete resection, and therefore can be associated with significant morbidity. While peripheral nerve repair is commonly used in the setting of traumatic nerve injury, little is known about its potential use in the treatment of MPNST. CLINICAL PRESENTATION: We present a patient with an enlarging right neck mass who was diagnosed with MPNST of the brachial plexus. The patient underwent gross total resection of the tumor, requiring sectioning of the upper trunk of the brachial plexus, as well as associated divisions. Following resection, sural nerve grafts were used to connect the C5 nerve root to the anterior division of the upper trunk and the spinal accessory nerve to the suprascapular nerve, whereas a triceps branch of the radial nerve was coapted directly to the anterior division of the axillary nerve. CONCLUSION: By 20 months after surgery, the patient had regained significant strength in her upper trunk distribution and demonstrated no evidence of tumor recurrence. Brachial plexus reconstruction offers a potentially valuable surgical adjunct to MPNST treatment.

The 2-Dimensional and 3-Dimensional Anatomy of the Adult Brachial Plexus Divisions and Cords

Hand ◽  
2020 ◽  
pp. 155894472090651
Author(s):  
Junot H. S. Neto ◽  
Bernardo C. Neto ◽  
Andre B. D. Eiras ◽  
Renato H. S. Botelho ◽  
Jose M. de M. Carmo ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Critical Review ◽  
Suprascapular Nerve ◽  
3 Dimensional ◽  
Lateral Cord ◽  
Posterior Division ◽  
Anterior Division

Background: The objective of this work was to perform a critical review of the 2-dimensional and 3-dimensional anatomy of the adult brachial plexus divisions and cords. Methods: Twelve adult brachial plexuses from fresh cadavers were dissected. All were male and aged between 30 and 50 years. Only corpses without brachial plexus injuries were selected. The purpose of the dissections was to identify the origin of the anterior and posterior divisions of the adult brachial plexus in their respective trunks, as well as the positioning of the posterior, lateral, and medial cords. Results: The posterior division of all trunks had a cranial and dorsal origin, while the anterior division of all trunks had a caudal and ventral origin. The posterior cord was the most cranial of all, the lateral cord was central, and the medial cord was the most caudal of all cords. The posterior division of the superior trunk was always between the suprascapular nerve and the anterior division. Conclusions: Brachial plexus diagrams in most textbooks and papers are different from what was found in our dissections. Contrary to the known diagram, the posterior divisions always had a cranial origin in the superior, middle, and inferior trunks.

Upper trunk block for shoulder analgesia with potential phrenic nerve sparing: a preliminary anatomical report

2019 ◽  
Vol 44 (9) ◽  
pp. 872-874 ◽  
Author(s):  
José Cros Campoy ◽  
Oscar Domingo Bosch ◽  
Jaume Pomés ◽  
Jing Lee ◽  
Ben Fox ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Phrenic Nerve ◽  
Suprascapular Nerve ◽  
Nerve Sparing ◽  
Phrenic Nerve Palsy ◽  
Scalene Muscle ◽  
Lower Trunk ◽  
Anatomical Basis ◽  
Dye Staining ◽  
Posterior Division

Background and objectivesIpsilateral phrenic nerve palsy (PNP) is an undesirable side of conventional approaches to interscalene brachial plexus blocks. The purpose of this study was to demonstrate whether or not the phrenic nerve can be spared by dye when injected at the division of the upper trunk of the brachial plexus.MethodsUnder ultrasound guidance, 5 mL of radiolabeled dye was injected between the anterior and posterior division of the upper trunk in two fresh, cryopreserved cadavers. CT scan analysis, cadaveric dissection, and cryosectioning were performed to examine the spread of the injectate.ResultsWe found staining of the injectate over the entire upper trunk with its anterior and posterior divisions, the suprascapular nerve under the omohyoid muscle and the lateral pectoralis nerve, and the C5 and C6 roots. The middle trunk was partially stained. There was no evidence of dye staining of the lower trunk, anterior aspect of the anterior scalene muscle, or the phrenic nerve.ConclusionsOur study offers an anatomical basis for the possibility of providing shoulder analgesia and avoiding a PNP.

scholarly journals Outcome of double nerve transfer close to target muscle both for shoulder abduction and elbow flexion in early C5 –C6 Brachial Plexus injury.

2020 ◽  
Vol 27 (07) ◽  
pp. 1442-1447
Author(s):  
Husnain Khan ◽  
Muhammad Shafique ◽  
Zahid Iqbal Bhatti ◽  
Tehseen Ahmad Cheema
Keyword(s):  
Brachial Plexus ◽  
Posterior Approach ◽  
Brachial Plexus Injury ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Suprascapular Nerve ◽  
Axillary Nerve ◽  
Shoulder Abduction ◽  
Motor Branch ◽  
Nerve Transfers

Adult brachial plexus injury is a now a common problem due to high incidence of motorbike accidents. Among all types, C 5 and C6 (upper brachial plexus injury) is the most common. If the patient present within 6 months then nerve transfer is the preferred treatment. However, there are different options for nerve transfer and different approaches for surgery. Objectives: The objective of the study was to share our experience of nerve transfer close to target muscles in upper brachial plexus injury. Study Design: Quaisi experimental study. Setting: National Orthopaedic Hospital, Bahawalpur. Period: January 2015 to June 2018. Material & Methods: Total 32 patients were operated with isolated C5 and C6 injury. In all patients four nerve transfers were done. For shoulder abduction posterior approach was used and accessory to suprascapular nerve and one of motor branch of radial to axillary nerve were transferred. Modified Oberlin transfer was done for elbow flexion. Both shoulder abduction and elbow flexion was graded according to medical research council grading system. Results: After one year follow up more than 75% of the patients showed good to normal shoulder abduction and 87.50% showed good to normal elbow flexion. Residual Median nerve damage was noted only in two patients (6.25%). Conclusion: If there is no evidence of recovery up to three months early nerve transfer should be considered, ideal time is 3-6 months. Nerve transfer close to target muscle yields superior results. The shoulder stabilizers and abductors should ideally be innervated by double nerve transfer through posterior approach. Similarly double fascicular transfer (modified Oberlin) should be done for elbow flexion.

scholarly journals Abnormal formation of medial cord of brachial plexus - a case report

2016 ◽  
Vol 05 (02) ◽  
pp. 100-102
Author(s):  
Rupak Jyoti Baishya ◽  
Rubi Saikia ◽  
Shobhana Medhi
Keyword(s):  
Case Report ◽  
Brachial Plexus ◽  
Upper Limb ◽  
Invasive Procedures ◽  
Medical College ◽  
Lower Trunk ◽  
Lateral Cord ◽  
Posterior Division ◽  
Anterior Division ◽  
Ethical Clearance

AbstractBrachial plexus is the plexus of nerves that supplies the upper limb. The anterior divisions of upper and middle trunks form lateral cord and that of the lower trunk form medial cord. Posterior divisions of all the three trunks form the posterior cord. Here we report a case of unilateral variation in the formation of medial cord of brachial plexus during dissection of a female perinatal cadaver of 34 weeks of gestation which was dissected as a part of Congenital Malformation Survey conducted in the Department of Anatomy, Assam Medical College, Dibrugarh with necessary ethical clearance. Medial cord was formed by the anterior division of lower trunk and this cord had a communication from the posterior division of middle trunk. It is very important to be aware of the variations of the cords of the brachial plexus during different invasive procedures in that region.

scholarly journals VARIATIONS IN THE BRANCHING PATTERN OF THE INTERNAL ILIAC ARTERY IN AN ADULT MALE – A CASE REPORT. Variaciones en el patrón de ramificación de la arteria ilíaca interna en un varón adulto: informe de un caso

2016 ◽  
Vol 4 (1) ◽  
pp. 25-28
Author(s):  
Satheesha Nayak B ◽  
Srinivasa Rao Sirasanagandla ◽  
Narendra Pamidi ◽  
Raghu Jetti
Keyword(s):  
Iliac Artery ◽  
Internal Iliac Artery ◽  
Clinical Importance ◽  
Branching Pattern ◽  
Obturator Artery ◽  
Cadaveric Specimen ◽  
Internal Iliac ◽  
Posterior Division ◽  
Anterior Division ◽  
The Right

Variaciones en el patrón de ramificación de la arteria ilíaca interna son ocasionalmente encontradas en las disecciones cadavéricas y las cirugías. Algunas de las variaciones son de importancia quirúrgica y clínica e ignorarlas podría derivar en alarmantes sangrados durante las prácticas quirúrgicas. Evaluamos las variantes en el patrón de la arteria ilíaca interna en un cadáver masculino. La división de la arteria ilíaca interna dio origen a las arterias rectal media y obturatriz. La arteria vesical superior tenía su origen en la arteria obturatriz. La división posterior de la arteria ilíaca interna dio lugar a las arterias iliolumbar, sacra lateral, glútea superior y pudenda interna. La arteria glútea inferior estaba ausente. Variations in the branching pattern of the internal iliac artery are occasionally encountered during cadaveric dissections and surgeries. Some of the variations are of surgical and clinical importance and ignoring them might result in alarming bleeding during surgical procedures. We report variant branching pattern of the right internal iliac artery in a male cadaveric specimen. The anterior division of the internal iliac artery gave origin to obturator and middle rectal arteries. Superior vesical artery took its origin from the obturator artery. The posterior division of the internal iliac artery gave iliolumbar, lateral sacral, superior gluteal and internal pudendal arteries. The inferior gluteal artery was absent.

Traumatic Suprascapular Nerve Injury at the Notch—A Reason for the Posterior Approach in Brachial Plexus Reconstruction

2017 ◽  
Vol 33 (08) ◽  
pp. 592-595
Author(s):  
Marc Seifman ◽  
Scott Ferris
Keyword(s):  
Brachial Plexus ◽  
Posterior Approach ◽  
External Rotation ◽  
Nerve Transfer ◽  
Suprascapular Nerve ◽  
Shoulder Function ◽  
Senior Author ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Spinal Accessory

Background Optimal dynamic reconstruction of shoulder function requires a functional suprascapular nerve (SSN). Nerve transfer of the distal spinal accessory nerve (dSAN) to the SSN will in many cases restore very good supraspinatus and infraspinatus function. One potential cause of failure of this nerve transfer is an unrecognized more distal injury of the SSN. An anterior approach to this transfer does not allow for visualization of the nerve at the scapular notch which is a disadvantage when compared with a posterior approach to the SSN. Methods All patients of the senior author (S.F.) with traumatic brachial plexus injuries undergoing spinal accessory nerve to SSN transfer via the posterior approach were analyzed. Results Of the 58 patients, 11 (19.0%) demonstrated abnormal findings at the notch. In two of these 11 patients (18.2%), reconstruction was abandoned due to severe injury of the nerve. There was a higher rate of clavicular fractures in patients with SSN injuries at the notch, compared with no SSN injury at the notch (63.6 vs. 12.8%). Conclusion The dSAN to SSN transfer is a reliable reconstruction for restoration of shoulder external rotation and abduction. There is a high proportion of injuries to the nerve at the notch, which can be best appreciated from a posterior approach. The authors, therefore, advocate a posterior approach for this nerve transfer.

Comparison between the anterior and posterior approach for transfer of the spinal accessory nerve to the suprascapular nerve in late traumatic brachial plexus injuries

2014 ◽  
Vol 156 (12) ◽  
pp. 2345-2349 ◽  
Author(s):  
F. H. M Souza ◽  
S. N. Bernardino ◽  
H. C. Azevedo Filho ◽  
P. L. Gobbato ◽  
R. S. Martins ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Posterior Approach ◽  
Suprascapular Nerve ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Spinal Accessory

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

scholarly journals Ulnar and Median Fascicular Transfers for Elbow Flexion-Predicting Outcomes in a Heterogeneous Patient Group and Implications for Surgical Planning

2020 ◽  
Vol 7 ◽  
Author(s):  
Scott Ferris ◽  
William Alexander
Keyword(s):  
Medical Research ◽  
Brachial Plexus ◽  
Patient Outcomes ◽  
Patient Group ◽  
Surgical Planning ◽  
Research Council ◽  
Medical Research Council ◽  
Treatment Options ◽  
Elbow Flexion ◽  
Nerve Transfers

Purpose: To measure the outcomes in patients undergoing nerve transfers for elbow flexion restoration, and compare patient outcomes based on the pre-operative fascicular transfer plan.Methods: Single surgeon series of 48 consecutive patients who underwent median and/or ulnar fascicular nerve transfers for elbow flexion restoration to treat palsies of the brachial plexus or musculocutaneous nerve. Outcomes measured were Medical Research Council (MRC) power grade, strength in kilograms, and time taken to recover function.Results: Overall, 96% of patients achieved MRC M4 or greater power. The subgroup who were planned for, and particularly those who then underwent, double as opposed to single fascicular transfer, had significantly better results.Conclusions: Overall results were excellent. Double fascicular transfers were superior, with no failures in this group. If pre-operatively a single fascicle transfer alone is planned due to a paucity of expendable donors, the predicted outcomes are worse and other treatment options should be considered.

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