Management of Brachial Plexus Missile Injuries

Rasulić, Lukas; Simic, Vesna; Savić, Andrija; Lepić, Milan; Kovačević, Vojin; Puzović, Vladimir; Vitošević, Filip; Novaković, Nenad; Samardžić, Miroslav; Rotim, Krešimir

doi:10.20471/acc.2018.57.03.12

Cited by 7 publications

(6 citation statements)

References 29 publications

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“…Although the role of external neurolysis was previously thought to be limited to pain relief, more recent evidence indicates that it has a sizeable impact on sensory and motor function recovery. 26,32,[57][58][59][60][61] Moreover, simple decompression and external neurolysis for nerve-in-continuity lesions have demonstrated much greater outcomes than any operative technique employed for other lesions of the brachial plexus. 58 In a study on nerve repair outcomes in traumatic brachial plexus injuries, Rasulić et al found useful functional recovery after neurolysis in 89.7% of all cases; including the axillary nerve (100%), median nerve (100%), radial nerve (84%), and ulnar nerve (69.2%) terminal branches.…”

Section: Discussionmentioning

confidence: 99%

Pain Relief after Surgical Decompression of the Distal Brachial Plexus

Morgan

Elliot

Banala

et al. 2020

J Brachial Plex Peripher Nerve Inj

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Background Brachial plexopathy causes pain and loss of function in the affected extremity. Entrapment of the brachial plexus terminal branches within the surrounding connective tissue, or medial brachial fascial compartment, may manifest in debilitating symptoms. Open fasciotomy and external neurolysis of the neurovascular bundle in the medial brachial fascial compartment were performed as a surgical treatment for pain and functional decline in the upper extremity. The aim of this study was to evaluate pain outcomes after surgery in patients diagnosed with brachial plexopathy. Methods We identified 21 patients who met inclusion criteria. Documents dated between 2005 and 2019 were reviewed from electronic medical records. Chart review was conducted to collect data on visual analog scale (VAS) for pain, Semmes-Weinstein monofilament test (SWMT), and Medical Research Council (MRC) scale for muscle strength. Pre- and postoperative data was obtained. A paired sample t-test was used to determine statistical significance of pain outcomes. Results Pain severity in the affected arm was significantly reduced after surgery (pre: 6.4 ± 2.5; post: 2.0 ± 2.5; p < 0.01). Additionally, there was an increased response to SWMT after the procedure. More patients achieved an MRC rating score ≥3 and ≥4 in elbow flexion after surgery. This may be indicative of improved sensory and motor function. Conclusion Open fasciotomy and external neurolysis at the medial brachial fascial compartment is an effective treatment for pain when nerve continuity is preserved. These benefits were evident in patients with a prolonged duration elapsed since injury onset.

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Section: Discussionmentioning

confidence: 99%

Pain Relief after Surgical Decompression of the Distal Brachial Plexus

Morgan

Elliot

Banala

et al. 2020

J Brachial Plex Peripher Nerve Inj

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“…Brachial plexus trauma is a type of peripheral nerve trauma that is most difficult to treat due to its complex surgical procedures. GSWs are the second most common cause of brachial plexus trauma [4]. The brachial plexus runs within the interscalene triangle bounded by the anterior scalene muscle anteriorly, the middle scalene muscle posteriorly, and the superior border of the first rib inferiorly.…”

Section: Discussionmentioning

confidence: 99%

Nerves Transfer Procedure in Patients with Left Upper Extremities Weakness Following Gunshot Wounds: A Case Report

Pratistha

Bimantara

Putra

et al. 2021

Open Access Maced J Med Sci

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BACKGROUND: Gunshot wounds (GSWs) to the extremities can result in damage to the neurovascular structure which results in high morbidity and loss of function. According to the Centers for Disease Control report, the incidence of non-fatal GSWs has increased in the past decade. Trauma to the brachial plexus is a type of peripheral nerve trauma that is most difficult to treat due to its complex surgical procedures. Early exploration and reconstruction of peripheral nerve trauma are still being debated to this day. However, most recommend surgical exploration when the suspicion of neurovascular trauma is very high based on clinical findings. Nerve transfer is one of the recommended methods of nerve reconstruction even in pre-ganglionic lesions. We report a case of a patient with weakness of the upper limb after a gunshot wound to his left shoulder. Based on clinical considerations and investigations, nerve transfer procedure is carried out to restore patient’s shoulder function. CASE REPORT: Male, 32 years old, working as a policeman, complained difficulty on moving his shoulder for 3 months. Patients had a history of GSWs to the left shoulder which also results in a left clavicular fracture. First aid, debridement, and fracture management were performed at Bhayangkara Hospital, Palu. Physical examination revealed winging scapula positive on his left shoulder, shoulder abduction 5/1, and hypoesthesia at left C5 level. Electromyographic examination revealed lesions on the left posterior chord and left brachial plexus. Based on clinical findings and supporting examination, we performed nerve transfers procedure from the accessory nerve to suprascapular notch. In the previous study, 63% of cases GSWs associated with nerve dysfunction. About 75% of patients with nerve palsy are associated with nerve lacerations during surgical exploration. However, many surgeons continue to recommend early exploration after GSWs to the upper extremities, especially in patients who will undergo surgical treatment for other indications. Based on this, we suggest the probable cause of brachial plexus lesions in this case resulted from gunshot wound which injures the brachial plexus or as a complication from previous procedures. Surgery that is too early can interfere with the spontaneous reinnervation process, but late surgical procedures can result in failure of reinnervation. In general, optimal time is set between 3 and 6 months after trauma. Nerve transfer is one method of reconstructing peripheral nerve lesions that can be applied to pre-ganglionic or post-ganglionic lesions. CONCLUSION: This procedure has several benefits, namely, the proximity of the donor and the recipient nerve anatomy, shorter operating time and does not require grafts. Brachial plexus trauma due to trauma or non-trauma together has an impact on the patient’s quality of life. However, advances in surgical techniques and further understanding of nerve physiology have led clinicians and patients to better outcomes. The current trend of treatment strategies for brachial plexus trauma is surgical reconstruction with the nerve transfer procedure.

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“…The timing of surgical intervention after nerve transection depends on whether the transection is ragged or sharp [ 245 , 246 , 247 , 248 ]. Sharp injuries from knives or razors should be repaired within 3 days but the repair of ragged transections from blast, gunshot, fracture, or crush injuries is usually delayed for at least 3 weeks to allow the nerve ends to be demarcated [ 248 ]. Frequently, an early surgical evaluation is made of whether any of the nerve remains in continuity.…”

Section: Poor Recovery Of Function After Peripheral Nerve Injury and ...mentioning

confidence: 99%

“…ES immediately after carpal tunnel release surgery (CTRS), which released the ligament over the crushed median nerve, had a profound positive effect of promoting all the axotomized nerves to regenerate and reinnervate the muscles of the thenar eminence within 6–8 months when the small increase in the reinnervation by the corresponding unstimulated nerves in the control group of patients had not reached statistical significance ( p > 0.05) even 12 months after CTRS ( Figure 20 ; [ 416 ]). This is particularly striking considering that over a distance of 100 mm, the regenerating axons should reach the median eminence musculature within ~3–4 months at a reported rate of 1 mm/day [ 248 , 250 ] for human motor and sensory nerves, respectively. Chan and his colleagues went on to demonstrate the significant acceleration of sensory nerve regeneration in human subjects after surgical repair of transected digital nerves in the hand [ 417 ] as well as after ulnar nerve compression at the elbow [ 418 ].…”

Section: Neuronal Activity and Nerve Regenerationmentioning

confidence: 99%

Brief Electrical Stimulation Promotes Recovery after Surgical Repair of Injured Peripheral Nerves

Gordon

2024

IJMS

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Injured peripheral nerves regenerate their axons in contrast to those in the central nervous system. Yet, functional recovery after surgical repair is often disappointing. The basis for poor recovery is progressive deterioration with time and distance of the growth capacity of the neurons that lose their contact with targets (chronic axotomy) and the growth support of the chronically denervated Schwann cells (SC) in the distal nerve stumps. Nonetheless, chronically denervated atrophic muscle retains the capacity for reinnervation. Declining electrical activity of motoneurons accompanies the progressive fall in axotomized neuronal and denervated SC expression of regeneration-associated-genes and declining regenerative success. Reduced motoneuronal activity is due to the withdrawal of synaptic contacts from the soma. Exogenous neurotrophic factors that promote nerve regeneration can replace the endogenous factors whose expression declines with time. But the profuse axonal outgrowth they provoke and the difficulties in their delivery hinder their efficacy. Brief (1 h) low-frequency (20 Hz) electrical stimulation (ES) proximal to the injury site promotes the expression of endogenous growth factors and, in turn, dramatically accelerates axon outgrowth and target reinnervation. The latter ES effect has been demonstrated in both rats and humans. A conditioning ES of intact nerve days prior to nerve injury increases axonal outgrowth and regeneration rate. Thereby, this form of ES is amenable for nerve transfer surgeries and end-to-side neurorrhaphies. However, additional surgery for applying the required electrodes may be a hurdle. ES is applicable in all surgeries with excellent outcomes.

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Management of Brachial Plexus Missile Injuries

Cited by 7 publications

References 29 publications

Pain Relief after Surgical Decompression of the Distal Brachial Plexus

Pain Relief after Surgical Decompression of the Distal Brachial Plexus

Nerves Transfer Procedure in Patients with Left Upper Extremities Weakness Following Gunshot Wounds: A Case Report

Brief Electrical Stimulation Promotes Recovery after Surgical Repair of Injured Peripheral Nerves

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