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Traumatic brachial plexus injury

Terms in this set (63)

• Spinal accessory: Jugular foramen. Two branches, internal goes with the X and external (spinal) -> motor innervation of SCM and, after descending in the posterior triangle between superficial and deep layers of cervical fascia next to lymph nodes, goes to trapezius. Most often injured nerve during lymph node biopsy. Harvest during exploration of supraclavicular plexus and electrical stimulation. Taken from its posterior border of the SCM and trace it down to its bifurcation. CAVE proximal branches to the trapezius must be preserved and same direction of superficial cervical plexus which should not be harmed (smaller size). If needed preoperative EMG to assess spinal accessory function.
o -> suprascapular: 2-3cm above the clavicle arises from upper trunk. Lateral and posterior to the suprascapular fossa through the notch (below the suprascapular transverse ligament). Location of vulnerability. Even with a more proximal lesion, ensure its continuity to discard a second level lesion. Other surgical approach is possible through a dorsal incision to allow a more distal transfer passed the notch. However, a reduced number of myelinated axons. Outcomes less favorable in C5C7 or panplexal and > 6Mo injuries. Serratus anterior function frankly improve functional result due to stability. Grading of muscular function difficult to assess results.
o -> musculocutaneous: Often interposition graft (10cm) is needed which may degrade the results. That is why ulnar fascicle to biceps (in C5C6) or intercostal nerves (panplexal) are often preferred. Sectioned just after its branches to the coracobrachialis and connected to the spinal accessory through a nerve graft.
Intercostal nerve transfer for neurotization.
What can it be used for?
What do you need to be careful of in your preoperative planning?

applications are FFMT, hand sensation, triceps, serratus, deltoid and MC (mostly in cases of panplexus).
CAVEAT: rib fractures (10% are non-usable), thoracotomy, chest tube.
Both motor and sensory reinnervation is possible, the master goal being motor reinnervation.
Adequate length 3-6th to reach the MC(musculocutaneous). 2nd also possible often used to be transferred to the thoracic long nerve. 7th another possibility if needed.
Incision from proximal arm to expose MC following inframammary fold caudally. CAVE do not injure intercostobrachial nerve arising from second intercostal nerve (can be used to hand sensation restoration).
o Can be transferred to MC or directly to biceps motor branch. Ideally is to separate the motor and sensory branches as far as possible distally.
Early sign of reinnervation is the squeeze test: chest pain when biceps is squeezed (4-5Mo). Later develops proximal biceps contraction with deep inspirations (6-8Mo). Eventually when Tinel sign appears, it elicits thoracic pain when biceps is percussed (12Mo). Elbow flexion against gravity (M3) after 12-18Mo. Then after voluntary recovery, a relation between inspiration and motor control which disappears (32Mo).
Phrenic nerve paralysis, rib fracture, prior chest trauma are not contraindications.
Very low pulmonary respiratory functions (rare) is the almost the unique contraindication.
Outcomes without interposition graft 75% min M3 or better, with interposition graft 45%.
Controversial option. Debate about safety, whether results are good enough to justify the risk, learning curve.
Used as donor for shoulder, elbow and hand targets. Sometimes for FFMT. Most of the time to median nerve or suprascapular nerve.
Works because C7-innervated muscles are cross innervated (as other muscles, none are innervated by a single root) by other C6 and C8.
C7 section does not result in significant loss of muscle function.
During exploration, contralateral C7 is identified and electric stimulation is done to assess whether it provokes any wrist or finger extensors. If it does not then C7 can be used. Any muscular contraction of extensors with C7 electrical stimulation is a contraindication to harvest. If contralateral C7 is used to do nerve transfer on median nerve, then ipsilateral (injury side) ulnar nerve vascularized graft can be harvested in case of pan-plexal injury. O
ther alternative in case of C5C8 is vascularized SBRN graft. Activation of the transfer can be done through adduction, external rotation and extension of the elbow.
Complications are transient motor deficit in shoulder extension, adduction, elbow extension, pronation, wrist extension, and hand movement. LD weakness is frequent. But no long-term deficits have been reported in the literature. Sensory abnormalities in C7 distribution are expected in all patient. Some persist and other disappear. In Europe, several authors have reported neuropathic pain in the C7 territory. Less problematic in Asian patients. CAVE anatomical variations: prefixed plexus with significant C4 contribution or post-fixed plexus with a substantial T2 contribution (and a C5 diminished component) considerable deficits can occur after C7 transfers.
When caused by BPI, and if feasible has to be repaired into the 6-9Mo (repair, graft or transfer). Nerve reconstruction fails > 12 Mo. If early intervention is not possible because of extension soft tissue damage for example, then alternative is tendon transfer (Steindler, PM/Pm, SCM, LD, triceps) and FFMT. The first are usually only possible in partial BPI. It aims a M4 recovery.

• Modified Steindler: flexor-pronator insertion on medial epicondyle relocated proximally on humerus to increase its moment arm. Preoperative function of flexor AND pronator must be M4M5. Results better in patients needing a "simple" elbow flexion augmentation. Present Steindler effect: pronation when gravity is suppressed.

• Triceps to biceps transfer: for patients with poor elbow flexion and strong co-contraction of triceps. Medial head passed from the lateral aspect to the antecubital fossa. CAVE will adversely affect transfer from bed to wheelchair and use of cane.

• Latissimus dorsi transfer: can pe partially denervated in C5C6 injuries, thorough examination is mandatory. Two possibilities, unipolar transfer which transfers the distal insertion or the bipolar transfer which moves origin and distal insertion. Bipolar preferable. Better mechanical efficiency increased by anterior placement, less risk of vascular pedicle kinking and easier tension adjustment when distal insertion (distal biceps) is settled first. If needed biceps resection is possible.

• Pectoralis major: both unipolar and bipolar transfer. Bipolar is preferred. Be certain that sternocostal portion of PM is functional. Medially fully harvested and turned 180°. Contraindicated in women because of cosmetic burden.

• FFMT: when >6Mo to the trauma. Technically difficult in children and poor functional result in patients >65yo (poor reinnervation). Be attentive to other limitations (elbow join contracture, vascular injury, poor soft tissue coverage). For late reconstruction donor of choice for reinnervation are spinal accessory or 3rd to 6th intercostal nerves. Similar results.
- modified steindler
- triceps to biceps transfer
- latissimus dorsi transfer
- pectoralis major
- FFMT
• Modified Steindler: flexor-pronator insertion on medial epicondyle relocated proximally on humerus to increase its moment arm. Preoperative function of flexor AND pronator must be M4M5. Results better in patients needing a "simple" elbow flexion augmentation. Present Steindler effect: pronation when gravity is suppressed.

• Triceps to biceps transfer: for patients with poor elbow flexion and strong co-contraction of triceps. Medial head passed from the lateral aspect to the antecubital fossa. CAVE will adversely affect transfer from bed to wheelchair and use of cane.

• Latissimus dorsi transfer: can pe partially denervated in C5C6 injuries, thorough examination is mandatory. Two possibilities, unipolar transfer which transfers the distal insertion or the bipolar transfer which moves origin and distal insertion. Bipolar preferable. Better mechanical efficiency increased by anterior placement, less risk of vascular pedicle kinking and easier tension adjustment when distal insertion (distal biceps) is settled first. If needed biceps resection is possible.

• Pectoralis major: both unipolar and bipolar transfer. Bipolar is preferred. Be certain that sternocostal portion of PM is functional. Medially fully harvested and turned 180°. Contraindicated in women because of cosmetic burden.

• FFMT: when >6Mo to the trauma. Technically difficult in children and poor functional result in patients >65yo (poor reinnervation). Be attentive to other limitations (elbow join contracture, vascular injury, poor soft tissue coverage). For late reconstruction donor of choice for reinnervation are spinal accessory or 3rd to 6th intercostal nerves. Similar results.