Brachial plexus surgery: the role of the surgical technique for improvement of the functional outcome

Abstract

Objective:The study aims to demonstrate the techniques employed in surgery of the brachial plexus that are associated to evidence-based improvement of the functional outcome of these patients. Method: A retrospective study of one hundred cases of traumatic brachial plexus injuries. Comparison between the postoperative outcomes associated to some different surgical techniques was demonstrated. Results: The technique of proximal nerve roots grafting was associated to good results in about 70% of the cases. Significantly better outcomes were associated to the Oberlin's procedure and the Sansak's procedure, while the improvement of outcomes associated to phrenic to musculocutaneous nerve and the accessory to suprascapular nerve transfer did not reach statistical significance. Reinnervation of the hand was observed in less than 30% of the cases. Conclusion: Brachial plexus surgery renders satisfactory results for reinnervation of the proximal musculature of the upper limb, however the same good outcomes are not usually associated to the reinnervation of the hand. Key words: brachial plexus surgery, nerve grafting, nerve transfer, palsy.Cirurgia do plexo braquial: o papel da técnica cirúrgica para a obtenção de melhores resultados funcionais RESUMO Objetivo: Análise de resultados das técnicas que comprovadamente melhoraram o prognóstico funcional de pacientes com lesões traumáticas do plexo braquial. Método: Estudo retrospectivo de cem casos de lesões traumáticas do plexo braquial. Foi realizada comparação dos resultados pós-operatórios obtidos com as diferentes técnicas utilizadas. Resultados: A técnica de enxertia a partir de raízes proximais resultou em bons graus de reinervação em 70% dos casos. Bons resultados (p<0,05) também foram relacionados à técnica de Oberlin e de Sansak, enquanto que a transferência frênico-musculocutâneo e acessório-suprascapular não resultaram em melhora que atingisse significância estatística. Reinervação motora da mão foi observada em menos de 30% dos casos. Conclusão: A cirurgia de reinervação do plexo braquial em geral resulta em boa recuperação da função proximal do membro, porém esses mesmos bons resultados não são observados em termos de reinervação da mão. Palavras-chave: cirurgia de plexo braquial, enxertos nervosos, transferência de nervos, paralisia.

Surgical anatomy of the radial nerve branches to triceps muscle

“…Zong‐yuan et al (2003) studied the anatomical features of the radial nerve branches innervating the triceps brachii muscle in the upper arm and found that the nerve to the long head had a constant origination point, the proximity of which can be anastomosed with the axillary nerve directly on the same side and had the largest diameter similar to the axillary nerve. The studies of Leechavengvong et al (2003,2006), Witoonchart et al (2003), and Flores (2011) concluded that double innervations using the nerve to the long head of the triceps provided good function of the shoulder and using it was the most reasonable option for double nerve transfers to restore shoulder function.…”

“…A simultaneous transfer of the suprascapular nerve and the axillary nerve yields better results when adequate donors are available (Chuang et al,1995; El‐Gammal and Fathi, 2002; Merrell et al,2001). Recent studies show better outcomes in restoration of deltoid function by combining the transfer of the nerve to the long head of the triceps to the axillary nerve (Leechavengvongs et al,2003,2006; Witoonchart et al,2003; Flores,2011; Lu et al,2012). This new technique has been widely accepted in patients with strong triceps power in order to provide dual muscular reinnervation of the shoulder.…”

Comparison of objective muscle strength in c5‐c6 and c5‐c7 brachial plexus injury patients after double nerve transfer

“…Instead of examining the strength in specific muscles, a previous study calculated the average BMRC score of muscle groups in the shoulder, elbow, and wrist to represent the functional outcome after surgery . Evaluation of the motor recovery of multiple muscles would have a better integrated profile and assist surgeons or therapists when making decisions for rehabilitation.…”

Results of surgical techniques for re-innervation of the triceps as additional procedures for patients with upper root injuries

“…Restoration of the elbow flexion remains the most important objective in treating brachial plexus injuries affecting the upper roots (Flores, 2011b). However, elbow flexion is only fully effective if the patient is able to stabilize the movement, which cannot be accomplished if the antagonist muscle cannot be co-activated (Doi et al, 1997;Goubier and Teboul, 2007).…”