Adult brachial plexus injuries: Surgical strategies and approaches

Abstract

Traumatic brachial plexus injuries are devastating injuries commonly affecting the young population and leading to significant socioeconomic losses to the society. The results of brachial plexus surgery have been severely disappointing in the past. However, several technological advancements and newer surgical techniques, especially the advent of distal nerve transfers over recent years, have led to a paradigm shift in the outcome of patients with these injuries. The best time window for surgery is the first 3 months after injury, and the next best time is the next 3 months. The timing is a crucial factor as the neuromuscular junctions degenerate in 20-24 months. The presence of spontaneous fibrillations in a muscle on electromyography is an indication of denervated yet vital muscle. The restoration of elbow flexion is a priority followed closely by restoration of shoulder abduction and stabilization. The various surgical strategies in brachial plexus injuries should be directed toward accomplishing this goal. The global avulsion injuries have a poor outcome because of very limited source of donors in such types of injury whereas the partial injuries have a remarkable outcome in a majority of cases. This article presents the reader with the guidelines and management algorithms of repair strategy and various surgical approaches utilized in the surgical treatment of brachial plexus injuries.

Introductory Chapter: Brachial Plexus Injuries - Past, Present, and Future

“…Waiting for spontaneous recovery will entail an inexcusable waste of time that will lead to an unsatisfactory recovery [50,53]. Thus, once the diagnosis of the nerve root avulsion is confirmed, the repair will have to be done as soon as the patient is able to tolerate the surgical procedure needed to be done [54,55]. The "urgent" repair, a few days after injury, has been reported by some in cases of confirmed avulsion and in clean nerve sections (i.e., glass) [56].…”

Multiple uses of fibrin sealant for nervous system treatment following injury and disease

“…A similar technique was applied to humans; however, with limited success [57, 84]. Further experimental ventral root implant approaches were carried out using 9/0 non-absorbable sutures (EthilonH®), lithium chloride, tissue glue (TisseelH®), fibrin sealant (TissueCol®; Baxter BVUtrecht, the Netherlands), nerve grafting, biodegradable scaffolds and nerve transfer [79, 85–91]. For dorsal root repair, some promising results towards regeneration were obtained by using inhibitors of chondroitin sulfate proteoglycans, myelin associated proteins, and by knocking down neurotrophin receptors [92–103].…”

A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report

“…In such emergency situations, immediate surgical exploration is necessary and there is consensus for simultaneous vascular and nerve repair [4, 8, 9]. Immediate nerve repair also minimizes the need for nerve grafts, flaps, or nerve reconstruction conduits [5].…”

“…In these circumstances, clinical evaluation might be the only diagnostic tool and therefore plays a pivotal role in early diagnosis and surgical planning [4, 8, 9]. In fact, a summary medical history and a directed physical examination are in most cases sufficient to identify the level of injury, the nerves involved, and the severity of injury [8, 9]. However, it should be noted that in many cases of open wounds associated with major vascular bleeding, patients are too unstable for even a summary neurological examination to be made prior to transport to the operating room [10].…”

“…However, it should be noted that in many cases of open wounds associated with major vascular bleeding, patients are too unstable for even a summary neurological examination to be made prior to transport to the operating room [10]. In fact, frequently patients are carried to the emergency room already under sedation and ventilated [8–10]. Depending on the severity and degree of vascular involvement, the urgency of these situations may even preclude the use of any ancillary diagnostic methods and force a rapid clinical assessment based on a sound knowledge of BP anatomy [10].…”