Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases

2005 ◽  
Vol 103 (4) ◽  
pp. 614-621 ◽  
Author(s):  
Julia A. Kandenwein ◽  
Thomas Kretschmer ◽  
Martin Engelhardt ◽  
Hans-Peter Richter ◽  
Gregor Antoniadis
Keyword(s):  
Brachial Plexus ◽  
Surgical Techniques ◽  
Functional Results ◽  
Content Type ◽  
Surgical Interventions ◽  
Louisiana State University ◽  
Surgical Measures ◽  
Grade 3 ◽  
Nerve Surgery ◽  
Fine Print

Object. Surgical therapy for traumatic brachial plexus lesions is still a great challenge in the field of peripheral nerve surgery. The aim of this study was to present the results of different surgical interventions in patients with this lesion type. Methods. One hundred thirty-four patients with traumatic brachial plexus lesions underwent surgery between January 1991 and September 1999. In more than 50% of the patients, injury was caused by a motorbike accident. Patients underwent surgery a mean of 6.3 months posttrauma. The following surgical techniques were applied: neurolysis for nerve lesions in continuity (27 cases), grafting for lesions in discontinuity (149 cases), and neurotization for root avulsions (67 cases). Sixty-five patients were evaluated for at least 30 months (mean follow up 42.1 months) after surgery. Function was graded using the Louisiana State University Health Sciences Center classification system. Only 2% of the patients had Grade 3 or better function preoperatively, increasing to 52% postoperatively. The effect of surgical measures on the functional results for different muscles were compared (supra- or infraspinatus, deltoid, biceps, and triceps muscles); the best results were obtained for biceps muscle function (57% of patients with Medical Research Council Grades M3–M5 function). Graft reconstruction yielded a better outcome than neurotization. Surgery within 5 months posttrauma clearly resulted in improved recovery of motor function compared with later interventions. Sural nerve grafts (monofascicular nerves) showed better results. Conclusions. The results of neurosurgical interventions for brachial plexus lesions are satisfactory, especially when the operation is performed between 3 and 6 months after trauma.

A series of 397 peripheral neural sheath tumors: 30-year experience at Louisiana State University Health Sciences Center

2005 ◽  
Vol 102 (2) ◽  
pp. 246-255 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert L. Tiel ◽  
Gregory Moes ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Surgical Techniques ◽  
Neurofibromatosis Type ◽  
Health Sciences ◽  
High Morbidity ◽  
State University ◽  
Content Type ◽  
Louisiana State University ◽  
Neural Sheath ◽  
Fine Print

Object. This is a retrospective review of 397 benign and malignant peripheral neural sheath tumors (PNSTs) that were surgically treated between 1969 and 1999 at the Louisiana State University Health Sciences Center (LSUHSC). The surgical techniques and adjunctive treatments are presented, the tumors are classified with respect to type and prevalence at each neuroanatomical location, and the management of malignant PNSTs is reviewed. Methods. There were 361 benign PNSTs (91%). One hundred forty-one benign lesions were brachial plexus tumors: 54 schwannomas (38%) and 87 neurofibromas (62%), of which 55 (63%) were solitary neurofibromas and 32 (37%) were neurofibromatosis Type 1 (NF1)—associated neurofibromas. Among the brachial plexus lesions supraclavicular tumors predominated with 37 (69%) of 54 schwannomas; 34 (62%) of 55 solitary neurofibromas; and 19 (59%) of 32 NF1-associated neurofibromas. One hundred ten upper-extremity benign PNSTs consisted of 32 schwannomas (29%) and 78 neurofibromas (71%), of which 45 (58%) were sporadic neurofibromas and 33 (42%) were NF1-associated neurofibromas. Twenty-five benign PNSTs were removed from the pelvic plexus. Lower-extremity PNSTs included 32 schwannomas (38%) and 53 neurofibromas (62%), of which 31 were solitary neurofibromas and 22 were NF1-associated neurofibromas. There were 36 malignant PNSTs: 28 neurogenic sarcomas and eight other sarcomas (fibro-, spindle cell, synovial, and perineurial sarcomas). Conclusions. The majority of tumors were benign PNSTs from the brachial plexus region. Most of the benign PNSTs in all locations were neurofibromas, with sporadic neurofibromas predominating. Similar numbers of schwannomas were found in the upper and lower extremities, whereas neurofibromas were more prevalent in the upper extremities. Despite aggressive limb-ablation or limb-sparing surgery plus adjunctive therapy, malignant PNSTs continue to be associated with high morbidity and mortality rates.

A series of 146 peripheral non—neural sheath nerve tumors: 30-year experience at Louisiana State University Health Sciences Center

2005 ◽  
Vol 102 (2) ◽  
pp. 256-266 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert L. Tiel ◽  
Gregory Moes ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Surgical Techniques ◽  
Health Sciences ◽  
Benign Tumors ◽  
State University ◽  
Pelvic Plexus ◽  
Content Type ◽  
Louisiana State University ◽  
Neural Sheath ◽  
Fine Print

Object. This is a retrospective review of 146 surgically treated benign and malignant peripheral non—neural sheath tumors (PNNSTs). Tumor classifications with patient numbers, locations of benign PNNSTs, and surgical techniques and adjunctive treatments are presented. The results of a literature review regarding tumor frequencies are presented. Methods. One hundred forty-six patients with 111 benign and 35 malignant PNNSTs were treated between 1969 and 1999 at the Louisiana State University Health Sciences Center (LSUHSC). The benign tumors included 33 ganglion cysts, 16 cases of localized hypertrophic neuropathy, 12 lipomas, 12 tumors of vascular origin, and 11 desmoid tumors. There were four each of lipofibrohamartomas, myositis ossificans, osteochondromas, and ganglioneuromas; two each of meningiomas, cystic hygromas, myoblastoma or granular cell tumors, triton tumors, and lymphangiomas; and one epidermoid cyst. The locations of benign PNNSTs were the following: 33 in the brachial plexus region, 39 in an upper extremity, one in the pelvic plexus, and 38 in a lower extremity. The malignant PNNSTs included 35 surgically treated carcinomas, 15 of which originated in the breast and nine in the lung. There were two melanomas metastatic to nerve and one tumor each that had metastasized from the bladder, rectum, skin, head and neck, and thyroid, and from a primary Ewing sarcoma. There was a single lymphoma that had metastasized to the radial nerve and one chordoma and one osteosarcoma, each of which had metastasized to the brachial plexus. Conclusions. There were more benign PNNSTs than malignant ones. Benign tumors were relatively equally distributed in the brachial plexus region and upper and lower extremities, with the exception of the pelvic plexus, which had only one tumor.

Surgical management and outcome in patients with radial nerve lesions

2001 ◽  
Vol 95 (4) ◽  
pp. 573-583 ◽  
Author(s):  
Daniel H. Kim ◽  
Andrew C. Kam ◽  
Padmavathi Chandika ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Surgical Management ◽  
Radial Nerve ◽  
Gunshot Wounds ◽  
Suture Repair ◽  
Content Type ◽  
Louisiana State University ◽  
Internal Neurolysis ◽  
End To End ◽  
Grade 3 ◽  
Fine Print

Object. The goal of this paper was to review surgical management and outcomes in patients treated for radial nerve (RN) lesions at Louisiana State University Health Sciences over a period of 30 years. Methods. Two hundred sixty patients with RN injuries were evaluated. The most common mechanisms of injuries involving the RN included fracture of the humerus, laceration, blunt contusions, and gunshot wounds. One hundred and eighty patients (69%) underwent surgery. Lesions not in continuity required primary or secondary end-to-end suture repairs or graft repairs. With the use of direct intraoperative nerve action potential recording, RN injuries in which the lesion was in continuity required external or internal neurolysis or resection of the lesion followed by end-to-end suture or graft repair. A minimum of 1.5 years follow-up review was available in 90% of the patients who underwent surgery. Motor function recovery to Grade 3 or better was observed in 10 (91%) of 11 patients who underwent primary suture repair, 25 (83%) of 30 who underwent secondary suture repair, 43 (80%) of 54 who received graft repair, and 63 (98%) of 64 in whom neurolysis was performed. Sixteen (71%) of 21 patients with superficial sensory RN injury achieved satisfactory pain relief after complete resection of a neuroma or neurolysis. Conclusions. This study clearly demonstrates that excellent functional recovery can be achieved with proper surgical management of RN injuries.

Management and outcomes in 353 surgically treated sciatic nerve lesions

2004 ◽  
Vol 101 (1) ◽  
pp. 8-17 ◽  
Author(s):  
Daniel H. Kim ◽  
Judith A. Murovic ◽  
Robert Tiel ◽  
David G. Kline
Keyword(s):  
Sciatic Nerve ◽  
Functional Outcomes ◽  
Surgical Techniques ◽  
Fracture Dislocation ◽  
Suture Repair ◽  
Nerve Lesions ◽  
Content Type ◽  
Injury Mechanisms ◽  
Grade 3 ◽  
Fine Print

Object. This is a retrospective analysis of 353 surgically treated sciatic nerve lesions in which injury mechanisms, location, time to surgical repair, surgical techniques, and functional outcomes are reported. Results are presented to provide guidelines for management of these injuries. Methods. One hundred seventy-five patients with buttock-level and 178 with thigh-level sciatic nerve injury were surgically treated at the Louisiana State University Health Sciences Center between 1968 and 1999. Buttock-level injury mechanisms included injection in 64 patients, hip fracture/dislocation in 26, contusion in 22, compression in 19, gunshot wound (GSW) in 17, hip arthroplasty in 15, and laceration in 12; at the thigh level, GSW was the cause in 62 patients, femoral fracture in 34, laceration in 32, contusion in 28, compression in 12, and iatrogenic injury in 10. Patients with sciatic nerve divisions in which positive intraoperative nerve action potentials (NAPs) were found underwent neurolysis and attained at least Grade 3 functional outcomes in 108 (87%) of 124 and in 91 (96%) of 95 buttock- and thigh-level tibial divisions, respectively, compared with 84 (71%) of 119 and 75 (79%) of 95, respectively, in the peroneal divisions. For suture repair, recovery to at least Grade 3 occurred in eight (73%) of 11 buttock-level and in 27 (93%) of 29 thigh-level tibial division injuries, and in three (30%) of 10 buttock-level and 20 (69%) of 29 thigh-level peroneal division lesions. For graft repair, good recovery occurred in 21 (62%) of 34 and in 43 (80%) of 54 buttock- and thigh-level tibial divisions, respectively, even in proximal repairs requiring long grafts, and in only nine (24%) of 37 and 22 (45%) of 49 buttock- and thigh-level peroneal division lesions, respectively. Conclusions. Surgical exploration and neurolysis after positive NAP readings, or repair with sutures or grafts after negative NAP results are worthwhile in selected cases.

Initial report on the limited value of hypoglossal nerve transfer to treat brachial plexus root avulsions

1999 ◽  
Vol 91 (4) ◽  
pp. 601-604 ◽  
Author(s):  
Martijn J. A. Malessy ◽  
Carel F. E. Hoffmann ◽  
Ralph T. W. M. Thomeer
Keyword(s):  
Brachial Plexus ◽  
Cranial Nerve ◽  
Hypoglossal Nerve ◽  
Nerve Transfer ◽  
Initial Report ◽  
Content Type ◽  
Tongue Movements ◽  
Grade 3 ◽  
12Th Cranial Nerve ◽  
Fine Print

Object. Hypoglossal nerve (12th cranial nerve) transfer was performed to treat the sequelae of brachial plexus root avulsion in 12 adults and two infants, and the patients were followed to assess the effectiveness of the surgery.Methods. The 12th cranial nerve was transected at the base of the tongue, and a sural nerve graft was used to bridge the gap between the donor (12th) and recipient nerves: C-5 spinal, axillary, suprascapular, or musculocutaneous nerve. The mean graft length in adult patients was 15.75 ± 5.5 cm (± standard deviation, median 14.5 cm) and in the two infants the graft lengths were 7 and 8 cm, respectively. After a mean postoperative interval of 1138 ± 254 days, electromyographic examination of the target muscles showed tongue movement—related activity in all patients. Muscle force strength measured according to the Medical Research Council's guidelines, was Grade 3 or higher in 21% of patients. Contraction, however, could only be attained by tongue movements, and volitional control was not achieved.Conclusions. Although recovery of muscle strength was obtained by 12th cranial nerve transfer, the functional gain remained virtually nonexistent because central control was missing.

Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center

2003 ◽  
Vol 98 (5) ◽  
pp. 1005-1016 ◽  
Author(s):  
Daniel H. Kim ◽  
Yong-Jun Cho ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Gunshot Wounds ◽  
Neurological Status ◽  
Health Sciences ◽  
State University ◽  
Content Type ◽  
Lower Trunk ◽  
Louisiana State University ◽  
Fine Print

Object. Outcomes of 1019 brachial plexus lesions in patients who underwent surgery at Louisiana State University Health Sciences Center during a 30-year period are reviewed in this paper to provide management guidelines. Methods. Causes of brachial plexus lesions included 509 stretches/contusions (50%), 161 plexus tumors (16%), 160 thoracic outlet syndromes (TOSs, 16%), 118 gunshot wounds (12%), and 71 lacerations (7%). Many features of clinical presentation, including prior treatment, patient's neurological status, results of electrophysiological studies, intraoperative findings, and postoperative level of function, were studied. The minimum follow-up period was 18 months and the mean follow-up period was 42 months. Repairs were best for injuries located at the C-5, C-6, and C-7 levels, the upper and middle trunk, the lateral cord to the musculocutaneous nerve, and the median and posterior cords to the axillary and radial nerves. Conversely, results were poor for injuries at the C-8 and T-1 levels, and for lower trunk and medial cord lesions, with the exception of injuries of the medial cord to the median nerve. Outcomes were most favorable when patients were carefully evaluated and selected for surgery, although variables such as lesion type, location, and severity, as well as time since injury also affected outcome. This was true also of TOSs and tumors arising from the plexus, especially if they had not been surgically treated previously. Conclusions. Surgical exploration and repair of brachial plexus lesions is technically feasible and favorable outcomes can be achieved if patients are thoroughly evaluated and appropriately selected.

Civilian gunshot wounds to the brachial plexus

1989 ◽  
Vol 70 (2) ◽  
pp. 166-174 ◽  
Author(s):  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Gunshot Wounds ◽  
Suture Repair ◽  
Loss Of Function ◽  
Content Type ◽  
Lower Trunk ◽  
Operative Indications ◽  
Grade 3 ◽  
Early Regeneration ◽  
Fine Print

✓ Many gunshot wounds (GSW's) to the brachial plexus do not improve spontaneously with time and are therefore candidates for surgery. Over an 18-year period, 141 patients with GSW's were evaluated, 90 of whom were operated on; 75 of the surgical cases were followed for 2 years or more. Thirty operative patients had initial vascular repair, while eight required thoracotomies. Total plexus palsy was present in 19 of those selected for operation. The average interval between injury and operation was 17 weeks. Six patients required early operation for an expanding aneurysm with progressive neural loss. Persistent complete loss of function in the distribution of one or more elements and/or noncausalgic pain not managed by medications provided the major operative indications. Four patients required sympathectomies for causalgia. Of 166 lesions in continuity believed to be complete, based on clinical examination and electromyography, 48 with preserved intraoperative nerve action potentials (NAP's) were spared resection or were treated with a split repair with excellent eventual results on a weighted grading system. By comparison, only seven of 55 elements believed to have incomplete loss or to be recovering did not have NAP's and required repair. Fifty-three of 98 lesions repaired by grafts and 18 of 26 wounds with suture repair recovered to a Grade 3 level or better. Most elements were in continuity but 14 were found “blown apart” and required repair, usually by grafting. The best outcome was achieved with upper trunk and lateral and posterior cord lesions, but recovery occurred with some C-7 to middle trunk and medial cord to median repairs. Results with lower trunk and most medial cord lesions were poor unless early regeneration was proved by operative NAP's, in which case either neurolysis or split repair could be performed. Surgery is warranted for selected GSW's to the plexus.

Evaluation of suprascapular nerve neurotization after nerve graft or transfer in the treatment of brachial plexus traction lesions

2004 ◽  
Vol 101 (3) ◽  
pp. 377-389 ◽  
Author(s):  
Martijn J. A. Malessy ◽  
Godard C. W. de Ruiter ◽  
Kees S. de Boer ◽  
Ralph T. W. M. Thomeer
Keyword(s):  
Brachial Plexus ◽  
Muscle Power ◽  
Nerve Transfer ◽  
Deltoid Muscle ◽  
Suprascapular Nerve ◽  
Shoulder Function ◽  
Axillary Nerve ◽  
Content Type ◽  
Grade 3 ◽  
Fine Print

Object. The aim of this retrospective study was to evaluate the restoration of shoulder function by means of suprascapular nerve neurotization in adult patients with proximal C-5 and C-6 lesions due to a severe brachial plexus traction injury. The primary goal of brachial plexus reconstructive surgery was to restore biceps muscle function and, secondarily, to reanimate shoulder function. Methods. Suprascapular nerve neurotization was performed by grafting the C-5 nerve in 24 patients and by accessory or hypoglossal nerve transfer in 29 patients. Additional neurotization involving the axillary nerve was performed in 18 patients. Postoperative needle electromyography studies of the supraspinatus, infraspinatus, and deltoid muscles showed signs of reinnervation in most patients; however, active glenohumeral shoulder function recovery was poor. In nine (17%) of 53 patients supraspinatus muscle strength was Medical Research Council (MRC) Grade 3 or 4 and in four patients (8%) infraspinatus muscle power was MRC Grade 3 or 4. In 18 patients in whom deltoid muscle reinnervation was attempted, MRC Grade 3 or 4 function was demonstrated in two (11%). In the overall group, eight patients (15%) exhibited glenohumeral abduction with a mean of 44 ± 17° (standard deviation [SD]; median 45°) and four patients (8%) exhibited glenohumeral exorotation with a mean of 48 ± 24° (SD; median 53°). In only three patients (6%) were both functions regained. Conclusions. The reanimation of shoulder function in patients with proximal C-5 and C-6 brachial plexus traction injuries following suprascapular nerve neurotization is disappointingly low.

Outcomes in a consecutive series of 111 surgically treated plexal tumors: a review of the experience at the Louisiana State University Health Sciences Center

2001 ◽  
Vol 95 (1) ◽  
pp. 51-60 ◽  
Author(s):  
Aruna Ganju ◽  
Norbert Roosen ◽  
David G. Kline ◽  
Robert L. Tiel
Keyword(s):  
Brachial Plexus ◽  
Health Sciences ◽  
Consecutive Series ◽  
State University ◽  
Palpable Mass ◽  
Content Type ◽  
Presenting Symptoms ◽  
Louisiana State University ◽  
Neural Sheath ◽  
Fine Print

Object. The authors conducted a retrospective study of 107 consecutive patients with 111 brachial plexus tumors surgically treated at the Louisiana State University Health Sciences Center (LSUHSC). Methods. During a 12-year period, from 1986 to 1998, 371 patients with lesions of the brachial plexus underwent surgery at LSUHSC. Among this group, 107 patients harbored 111 tumors of the brachial plexus. Neural sheath tumors were the most commonly found and included 33 neurofibromas (20 of which were associated with von Recklinghausen disease), 36 schwannomas, and 12 malignant neural sheath tumors. Of the non—neural sheath tumors, 13 were benign and 17 were malignant. Presenting symptoms included pain (59%), palpable mass (52%), paresthesias (30%), and paresis (29%). Anterior supraclavicular (82%) or posterior subscapular (18%) approaches were used to achieve gross-total (79%) or subtotal (21%) resection of tumor. The average follow-up period was 38.3 months or 3.2 years. Seventy percent of patients with benign neural sheath tumors became free from pain postoperatively or reported improvement in their preoperative pain status. Function remained intact or improved in 50% and remained stable postoperatively in another 20% of cases. Preservation of function was more likely in patients who presented intact and in those who had not undergone a previous attempted biopsy procedure or resection than in those in whom such manipulation had occurred. Conclusions. Resection of most plexal tumors is technically feasible and associated with acceptable morbidity and mortality rates.

Surgical management and outcomes in patients with median nerve lesions

2001 ◽  
Vol 95 (4) ◽  
pp. 584-594 ◽  
Author(s):  
Daniel H. Kim ◽  
Andrew C. Kam ◽  
Padmavathi Chandika ◽  
Robert L. Tiel ◽  
David G. Kline
Keyword(s):  
Median Nerve ◽  
Suture Repair ◽  
State University ◽  
Content Type ◽  
Louisiana State University ◽  
Internal Neurolysis ◽  
Common Causes ◽  
End To End ◽  
Grade 3 ◽  
Fine Print

Object. One hundred sixty-seven of 250 patients with median nerve (MN) lesions, excluding carpal tunnel syndrome and nerve sheath tumors, at the levels of the arm, elbow, forearm, and wrist, underwent surgical treatment at Louisiana State University Health Sciences over a 30-year period. The most common causes of MN injuries were laceration, fracture-associated stretch and contusion, gunshot wound, compression, and injection injuries. In this study, surgically treated patients were followed and evaluated retrospectively for favorable functional outcomes. Methods. Lesions not in continuity required primary or secondary end-to-end suture or graft repairs. With the aid of direct intraoperative recording of nerve action potentials (NAPs), MN injuries in which the lesion was in continuity underwent external or internal neurolysis, or resection of the lesion, followed by end-to-end suture or graft repair. A minimum of 12 months follow-up review (mean 18 months) was available in 85% of the surgically treated patients. For lesions in continuity, a functional recovery of Grade 3 or better was seen in 72 (95%) of 76 patients who underwent neurolysis, 18 (86%) of 21 who received suture repair, and 21 (75%) of 28 who received graft repair. In lesions not in continuity, favorable results (Grade ≥ 3) were seen in 10 (91%) of 11 patients who received primary suture repair, seven (78%) of nine who received secondary suture repair, and 15 (68%) of 22 who received graft repair. Conclusions. Surgical intervention for MN injuries with complete or severe deficits achieved favorable outcomes.

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