Brachial Plexus Surgery

October 2008 1Brachial Plexus Injury Mr V Rajaratnam

CoverageCoverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 2Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 3Brachial Plexus Injury Mr V Rajaratnam

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Supraclavicular Region• Ventral Rami• ventral rami C5-T1 and the branches:

– dorsal scapular nn – long thoracic nerve – C5 contribution to the phrenic nerve

• exit between scalenus anterior and scalenus medius• • • Trunks• superior

– nerve to subclavius (C5) – suprascapular nn – C5-C6 join to form the upper trunk

• middle – C7 forms the middle trunk

• lower – C8-T1 join to form the lower trunk

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Clavicular Region

• Divisions• anterior supply flexors

• posterior supply extensors

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Infraclavicular Region• Cords• posterior

– upper subscapular nn – thoracodorsal nn – lower subscapular nn – axillary nn – radial nn

• lateral – lateral pectoral nn – musculocutaneous nn – lateral root of median nn

• medial – medial pectoral nn – medial brachial cutaneous nn – medial antebrachial cutaneous nn – ulnar nn – medial root of median nn

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Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 8Brachial Plexus Injury Mr V Rajaratnam

History

• Closed injury• Usually motorbikes (52%)• Cars (12%), falls, sports• Open• Lacerations• Gunshots• Iatrogenic• Chainsaws

History

• Other causes – tumour – usually direct extension, primary tumours, radiation, congenital

• Immediate severe pain –suggestive of preganglionic lesion

• Associated spinal cord injury

Examination

• General ATLS protocol• Associated injuries common• Supraclavicular lesions – 10% subclavian

artery rupture• Infra clavicular - 30% axillary artery rupture

Examination

• System for examining the the plexus• Look – wounds, muscle wasting, surgical scars,

deformity• Feel – muscle bulk, sensation• Normal sensation – flail limb – think polio• Move – check tone, full rom (MRC grading

depends on a full range of movt)

Examination

• Test each muscle in a systematic manner• From behind• Trapezius – c3,4• Serratus anterior – c567 – winging scapula• Rhomboids – c5• Supraspinatous – c5,6• Deltoid – c5,6 (axillary)• Latissimus dorsi – c678

examination

• From the front• Biceps – c5,6• Brachioradialis c5,6• Supinator – c6,7• Ext digitorum c7,8• Epl c7,8• Apb c8,t1• Fcu c7,8,t1• Froments c8,t1

Classification of brachial plexus injuries (leffert)

• Supra clavicular – often traction injuries, often severe pain in limb

• C5,6 (upper trunk lesions) – shoulder control and elbow flexion lost

• C5,6,7 – plus loss of active extension of fingers and elbow

• C8,t1 – horners syndrome plus median and ulnar palsy affecting hand

• Whole plexus injury – other associated injuries, flail arm

Leffert classification (according to Miller)

• 1 – open• 2 – closed• 2a – supraclavicular• Preganglionic – non repairable• Postganglionic• 2b infraclavicular• 3 - radiation• 4 – obstetric – a- erbs, b – klumpkes, c- mixed

Classification

• Neuropraxia – good prognosis• Rupture –post ganglionic can recover• Lesion in continuity – poor prognosis• Avulsion – poor prognosis

Infraclavicular injuries

• Better prognosis – shoulder dislocation more likely method of injury

Investigations

• Plain x-ray – c spine (avulsion # TPs), shoulder trauma, cxr – raised hemidiaphragm

• Thin section CT has been replaced by MRI scanning• MRI allows multiplanar analysis – different parts of

the plexus are best viewed in different planes• Differentiate vascular from non vascular structures

• Nerve root avulsion with pseudomeningocele traditionally diagnosed by myelography

• Nerve roots usually visualised in foramen• Non visualisation suggestive of avulsion• Pseudomeningoceles can be visualised directly• Visualisation of the rest of the plexus using

various different sequences gives superior results to CT

neurophysiology

• Distinguish between different patterns of injury• Neuropraxia –compound muscle action potentials

decreased in size, conduction velocity slowed, reduced normal motor recruitment

• Axonetmesis – CMAP reduced, spontaneous motor activity

• Neurotmesis – CMAP unrecordable, fibrillations profuse, voluntary motor activity absent

Surgical Indications

• Neuropraxic lesions – non operative• May be difficult to define• Patchy sparing of sensation• Limited numbers of nerve roots• Signs of early recovery within 7-10 days• No sign of recovery – investigate with a view

to early surgery

Operative treatment

• Primary operative treatment – restore nerve function

• Secondary operative treatment – – muscle transfers and bone operations

Primary operative treatment

• Surgical approach – supraclavicular approach for proximal lesions

• Extended to deltopectoral approach for distal lesions

Direct suture

• Rarely used• Early repair of clean lacerations• Grafting is more often recommended• Good results in suitable cases

Conventional nerve grafts

• Standard nerve grafting technique• Med cut arm and forearm, sural, • Placed without tension• Fixed with sutures and fibrin glue• Arm immobilised for 6/52

Vascularised Nerve grafts

• Used where severe scarring present• For long defects• Contra lateral C7 transfers as pedicle• Results little better than standard grafts• Technically difficult when used as free graft

Nerve Transfers

• Accessory to suprascapular – improved shoulder control

• Intercostal to lat cord – grade III/IV elbow flexion• Require relearning• Improve motor function• Increase sensory input to distal nerves – pain relief

particularly in pre ganglionic lesions

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results

• Proximal muscles recover best• Distal muscles are finer – significant end organ

failure prior to reinervation• Better results if nerve grafting within 3/12• Repair c5/6 with conventional graft – functional

flexion of elbow and some shoulder control in 60%• Nerve transfer – functional gain in 60% if carried out

within 3/12• Not effective for c8/t1, less effective for c7

Reconstructive Surgery

• Muscle Transfers• Arthrodesis• Amputations

Shoulder

• Injuries to c5/6 alone have good hand function

• Shoulder function v important• Lat dorsi to external rotators• External rotation osteotomy• Flail shoulder - arthrodesis

elbow

• Elbow flexion more important the extension (gravity)

• Triceps to biceps• Steindler flexorplasty (advance

brachioradialis)

forearm

• Rotation difficult to establish• Treatment aimed at improving position with

rotational osteotomy

hand

• Loss of finger/wrist extension – extensors more proximal root value than flexors

• Tendon transfers

Epidemiology•80% supraclavicular type avulsion in type and need surgery•50% of these are pan plexal (C5 – T1)•60% of are C5/6 rupture with C7/T1 avulsion•30% of these are complete avulsion•35% of supraclavicular injury are C5/6 •20% associated with major artery injury

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Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 46Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 47Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 48Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 49Brachial Plexus Injury Mr V Rajaratnam

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Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 51Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 52Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 53Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 54Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 55Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 56Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 57Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 58Brachial Plexus Injury Mr V Rajaratnam

Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent Advances

October 2008 59Brachial Plexus Injury Mr V Rajaratnam