Traumatic Brachial Plexus Injury: Preoperative Evaluation and Treatment Principles

Jae-Sung Yoo; Sung-Bae Park; Jong-Phil Kim

doi:10.12790/jkssh.2017.22.3.137

Journal List > J Korean Soc Surg Hand > v.22(3) > 1106564

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Yoo, Park, and Kim: Traumatic Brachial Plexus Injury: Preoperative Evaluation and Treatment Principles

Review Article

J Korean Soc Surg Hand 2017;22(3):137-146.

Published online: 10 September 2017

DOI: https://doi.org/10.12790/jkssh.2017.22.3.137

Traumatic Brachial Plexus Injury: Preoperative Evaluation and Treatment Principles

Jae-Sung Yoo, Sung-Bae Park, Jong-Phil Kim

Department of Orthopedic Surgery, Dankook University College of Medicine, Cheonan, Korea

Correspondence to: Jong-Phil Kim Department of Orthopaedic Surgery, Dankook University College of Medicine, 119 Dandae-ro, Dongnam-gu, Cheonan 31116, Korea TEL: +82-41-550-3919 FAX: +82-41-556-3238 E-mail: kimjp@dankook.ac.kr

Received 25 August 201710 September 2017 Accepted 11 September 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Brachial plexus injury is regarded as one of the most devastating injuries of the upper extremity. Accurate diagnosis is important to obtain the successful results. Basic preoperative evaluation includes simple radiography, cervical myelography. Magnetic resonance imaging, angiography, electrophysiologic studies and intraoperative studies. Furthermore, proper timing of surgery, surgical indication, plan and sufficient understanding of patients about the prognosis are the key for the satisfactory outcomes. This article provides an overview of the evaluation, diagnosis, intraoperative monitoring, and proper surgical planning for the treatment of posttraumatic brachial plexus injuries.

Keywords: Brachial plexus injury, Evaluation, Diagnosis, Treatment

References

1. Bonney G. Prognosis in traction lesions of the brachial plexus. J Bone Joint Surg Br. 1959; 41:4–35.

2. Brunelli G. Direct neurotization of severely damaged muscles. J Hand Surg Am. 1982; 7:572–9.

3. Hentz VR, Narakas A. The results of microneurosurgical reconstruction in complete brachial plexus palsy: assessing outcome and predicting results. Orthop Clin North Am. 1988; 19:107–14.

4. Kawai H, Kawabata H, Masada K, et al. Nerve repairs for traumatic brachial plexus palsy with root avulsion. Clin Orthop Relat Res. 1988; (237):75–86.

5. Songcharoen P, Shin AY. Brachial plexus injury: acute diagnosis and treatment. Berger RA, Weiss AP, editors. Hand surgery. Philadelphia: Lippincott Williams & Wilkins;2004; 1005–25.

6. Limthongthang R, Bachoura A, Songcharoen P, Osterman AL. Adult brachial plexus injury: evaluation and management. Orthop Clin North Am. 2013; 44:591–603.

7. Robert EG, Happel LT, Kline DG. Intraoperative nerve action potential recordings: technical considerations, problems, and pitfalls. Neurosurgery. 2009; 65(4 Suppl):A97–104.

8. Kline DG. Timing for brachial plexus injury: a personal experience. Neurosurg Clin N Am. 2009; 20:24–6.

9. Narakas AO. The treatment of brachial plexus injuries. Int Orthop. 1985; 9:29–36.

10. Hentz VR, Doi K. Traumatic brachial plexus injury. Wolfe S, Pederson W, Hotchkiss R, Kozin S, editors. Green’s operative hand surgery. Philadelphia: Elsevier;2010; 1235–94.

11. Mansat M. Surgical topographic anatomy of the brachial plexus. Rev Chir Orthop Reparatrice Appar Mot. 1977; 63:20–6.

12. Nagano A, Ochiai N, Sugioka H, Hara T, Tsuyama N. Usefulness of myelography in brachial plexus injuries. J Hand Surg Br. 1989; 14:59–64.

13. Doi K. Management of total paralysis of the brachial plexus by the double free-muscle transfer technique. J Hand Surg Eur Vol. 2008; 33:240–51.

14. Amrami KK, Port JD. Imaging the brachial plexus. Hand Clin. 2005; 21:25–37.

15. Harper CM. Preoperative and intraoperative electrophysiologic assessment of brachial plexus injuries. Hand Clin. 2005; 21:39–46.

16. Kobayashi J, Mackinnon SE, Watanabe O, et al. The effect of duration of muscle denervation on functional recovery in the rat model. Muscle Nerve. 1997; 20:858–66.

17. Songcharoen P, Mahaisavariya B, Chotigavanich C. Spinal accessory neurotization for restoration of elbow flexion in avulsion injuries of the brachial plexus. J Hand Surg Am. 1996; 21:387–90.

18. Coulet B, Boretto JG, Lazerges C, Chammas M. A comparison of intercostal and partial ulnar nerve transfers in restoring elbow flexion following upper brachial plexus injury (C5-C6+/-C7). J Hand Surg Am. 2010; 35:1297–303.

19. Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg Am. 2005; 30:978–85.

20. Liverneaux PA, Diaz LC, Beaulieu JY, Durand S, Oberlin C. Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies. Plast Reconstr Surg. 2006; 117:915–9.

21. Chuang ML, Chuang DC, Lin IF, Vintch JR, Ker JJ, Tsao TC. Ventilation and exercise performance after phrenic nerve and multiple intercostal nerve transfers for avulsed brachial plexus injury. Chest. 2005; 128:3434–9.

22. Bertelli JA, Ghizoni MF. Reconstruction of complete palsies of the adult brachial plexus by root grafting using long grafts and nerve transfers to target nerves. J Hand Surg Am. 2010; 35:1640–6.

23. Malungpaishrope K, Leechavengvongs S, Witoonchart K, Uerpairojkit C, Boonyalapa A, Janesaksrisakul D. Simultaneous intercostal nerve transfers to deltoid and triceps muscle through the posterior approach. J Hand Surg Am. 2012; 37:677–82.

Fig. 1.

The anatomy of the brachial plexus. USS, upper subscapular; TD, thoracodorsal; LSS, lowere subscapular; MBC, medial brachial cutaneous; MABC, medial antebrachial cutaneus.

Fig. 2.

Traction injury of the brachial plexus. (A) Preganglionic injury cannot be repaired, (B) postganglionic stretch injury shows different magnitudes, and (C) extraforaminal rupture can be repaired with surgery

Fig. 3.

Double approach of brachial plexus injury (superior clavicular and deltopectoral approach).

Fig. 4.

Electrophysiological evaluation during the surgery. (A) Intraoperative electro-physiologic monitoring of 55-year-old male with C8–T1 brachial plexus injury. (B) These lines means the preoperative and intraoperative base amplitude of C8-T1. SNS, sypathetic nerve stimultation.

Fig. 5.

Nerve transfer of a 19 years-old male with right C5–6 brachial plexus injury after motorcycle accident. (A) The patient showed complete motor deficit in active elbow flexion and shoulder abduction. (B) Magnetic resonance image showed C5–6 nerve injury. (C) The 3–4 Intercostal nerves transfer to the musculocutaneous nerveand spinal accessory nerve transfer to the suprascapular nerve were performed at 7 months after injury. (D) Muscle strengths of elbow flexion and shoulder abduction were recovered at 16 months after surgery. SA, spinal accessory nerve; SSC, superior subscapular nerve; IC, intercostal nerve; MC, musculocutaneous nerve.

Fig. 6.

Functioning muscle transfer of a 64-year-old male who had crushing injury to his right arm at 1 year before the surgery. (A) The patient showed complete loss of active elbow flexion and shoulder abduction. (B) Gracilis muscle with monitoring flap was harvested from his right thigh. (C) Flap indicated well survival of free muscle transfer. (D) The patients showed excellent recovery of elbow flexion at 6 months after surgery.

Table 1.

Clinical signs of preganglionic injury and its implications

Signs	Implications
Horner syndrome	Sympathetic ganglion injury (T1 level)
Winged scapula	Long thoracic nerve injury (C5–7)
Atrophy of parascapular muscle	Dorsal scapular nerve injury (C4–5)
Cervical paraspinal muscle weakness and loss of posterior neck sensation	Dorsal rami of cervical spinal nerve roots injury
Hemidiaphragm paralysis	Phrenic nerve injury (C3–5)
Absence of Tinel sign in neck area	Absence of proximal spinal nerve stump
Pseudomeningocele on myelogram	Development of meningeal diverticulum after healing of torn nerve root sleeve
Intact sensory nerve action potentials in the area of sensory deficit	Imply no wallerian degeneration of the sensory axons because the attached nerve cells reside in the dorsal root ganglion

Adapted from Limthongthang et al.⁶, Orthop Clin North Am. 2013;44:591-603, with permission of Elsevier.

Table 2.

Root innervation and motor functions in the upper extremity (from Robert et al.⁷)

	C6			C8
	C5		C7		T1
	Serratus anterior		Flexor	Flexor	Opponence pollicis	Abductor
Deltoid	Biceps	Pronator	Digitorum	Digitorum		Pollicis
			Superficialis	Superficialis		Brevis
		Flexor	Palmaris
		Carpi	Longus
		Radialis
			Triceps	Flexor	Flexor	Adductor
				Pollicis	Pollicis	Pollicis
				Longus	Brevis
	Brachialis	Extensor	Extensor		Abductor
		Carpi	Carpi		Digit
		Radialis	Ulnaris		Minimi
Supra-spinatus	Brachioradialis	Extensor	Abductor	Flexor	Palm
		Digitorum	Pollicis	Digitorum	Interossei
		Communis	Longus	Profundus
			Extensor
			Pollicis
			Brevis
			Extensor		Dorsal
			Pollicis		Interossei
			Longus
Infra-spinatus	Supinator		Flexor
			Carpi
			Ulnaris
	Teres major		Latissimus dorsi
			Pectoralis major

TOOLS

Similar articles