Surgical treatment of adult traumatic brachial plexus injuries: an overview

Abstract

Traumatic injuries to the brachial plexus in adults are severely debilitating. They generally affect young individuals. A thorough understanding of the anatomy, clinical evaluation, imaging and electrodiagnostic assessments, treatment options and proper timing of surgical interventions will enable nerve surgeons to offer optimal care to patients. Advances in microsurgical technique have improved the outcome for many of these patients. The treatment options offer patients with brachial plexus injuries the possibility of achieving elbow flexion, shoulder stability with limited abduction and the hope of limited but potentially useful hand function. Key words: brachial plexus injury, surgical treatment, nerve repair.Tratamento cirúrgico das lesões traumáticas do plexo braquial em adultos: uma visão geral RESUMO As lesões traumáticas do plexo braquial em adultos são severamente debilitantes e, em geral, afetam indivíduos jovens. Uma ampla compreensão da anatomia, da avaliação clínica, dos estudos eletrodiagnósticos e por imagem, das opções de tratamento e do momento apropriado para o tratamento cirúrgico irá permitir que o cirurgião de nervos ofereça o tratamento ideal ao paciente. Os avanços na técnica microcirúrgica melhoraram os resultados para muitos desses pacientes. As opções de tratamento oferecem aos pacientes com lesões do plexo braquial a possibilidade de obter flexão do cotovelo, estabilidade do ombro com abdução limitada e a esperança de função limitada mas potencialmente útil da mão. Palavras-chave: lesão do plexo braquial, tratamento cirúrgico, reparo de nervos. Traumatic brachial plexus lesions in adults are devastating injuries. The typical patient is a young man who was injured in a motorcycle accident. These lesions are of great social significance since most of the patients have to face severe residual morbidity after their injuries. The exact number of lesions occurring each year is difficult to ascertain, but it is certainly growing, in parallel with the increasing number of high-speed motor vehicle accidents, especially involving motorcycles.Based on experience with 1,068 patients with brachial plexus injuries, Narakas 1 developed a rule of "seven seventies" that gives an approximate idea of the statistics involved in brachial plexus lesions: approximately 70% of traumatic brachial plexus injuries are secondary to motor vehicle accidents; of these, approximately 70% involve motorcycles or bicycles. Of the cycle riders, approximately 70% have multiple injuries. Overall, 70% have supraclavicular lesions; of these, 70% have at least one root avulsion. At least 70% of patients with a root avulsion also have avulsions of the lower roots (C7, C8 or T1). Finally, of patients with lower root avulsion, nearly 70% will experience persistent pain.

Correlation between motor function recovery and daily living activity outcomes after brachial plexus surgery

“…The LSUHSC score is directly correlated with the time elapsed between injury and surgery (r = 0.554 and p = 0.001), and these results were in accordance with most studies published on this subject 4,18 . A similar correlation, albeit weaker, was observed between the time elapsed before surgery and the DASH Brazil questionnaire responses.…”

“…According to previous publications, the timing of the surgery depends on the mechanism and type of injury. However, spontaneous recovery for a period of up to three months has been observed in the year after injury 4 . The time elapsed between injury and surgery is one of the primary influences on the prognosis of patients who underwent brachial plexus surgery.…”

“…Restoring active forearm flexion is the primary goal of surgical treatment of upper trunk brachial plexus injuries 3,4 . This injury affects motor function and can impair the ability of patients to do physical work as well as engage in their activities of daily living.…”

Different cerebral plasticity of intrinsic and extrinsic hand muscles after peripheral neurotization in a patient with brachial plexus injury: A TMS and fMRI study

“…For BPI patients, it is crucial but difficult to restore the function of hand, especially the fine motor functions controlled by the intrinsic muscles [3,4]. The flexor digitorum (FD) and abductor pollicis brevis (APB) represent gross and fine motor functions of hand, respectively.…”

A cadaveric microanatomical study of the fascicular topography of the brachial plexus

“…Even then, the results of surgery may not be favorable. 25 Various modalities have been used in the surgical treatment of these devastating injuries, depending on the type of injury. These modalities consist of either neurolysis, or intra/extraplexal nerve transfer (neurotization), with or without a nerve graft.…”