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Traumatic brachial plexus injury

Terms in this set (63)

Traumatic brachial plexus injury (BPI)
Mechanism?
What determines recovery abilities?
Mostly traction or stretching injuries.
Differentiate low vs high energy mechanism, it determines the recovery abilities (Sunderland stage).
What is the mechanism of C5-C6-C7 injuries?
Shoulder-neck angle widened : C5C6C7 or upper/middle trunk.
What can cause an upper/middle trunk injury?
shoulder-neck angle widened.
What can cause a C5-C6-C7 injury?
shoulder-neck angle widened.
What will cause a lesion to C8-T1 BPI?
Scapulo-humeral widened C8T1 or lower trunk.
What will cause a lower trunk lesion?§ Scapulo-humeral widened
Is a pan plexus injury possible?
Extreme all levels can occur (pan-plexus).
Which root will be more resistant to avulsion?
Which root are more susceptible to rupture?
Upper roots are more resistant to avulsion, but more prone to rupture. Lower roots is the contrary.
Do we have more often a supraclavicular or infraclavicular injury?
2/3 supraclavicular, 1/3 retro-infra.
What is the percentage of double level injury?
Double-level injury can occur in 10% (Narakas). 75% of BPI have other associated lesion (thoracic, head, fractures), 20% have associated vascular trauma.
What is the particularity of Gunshot injuries?
mostly lesions in continuity.
Two types: low-velocity creating lesion by direct impact (neurapraxia)
vs high-velocity creating lesion by shock-wave and cavitation (stretching and contusion of the nerve)
> direct impact (neurotmesis).
Which lesion has a better spontaneous recovery? High or low velocity?
High-velocity injuries are less likely to spontaneously recover compared to low-velocity.
Penetrating trauma, aneurysm or hematoma can compress the plexus.
Anamnèse and clinical evaluation of BPI?
History of traumatism (velocity, penetrating, gunshot).
Associated injuries: bone, vascular (more severe injury and less potential for spontaneous recovery).
Clinical: Vascular pulses distally and compulsory sensitive and muscular testing.
Specific signs (cf clinical examination).
Imaging in BPI?
Para-clinical
• Imaging to assess diaphragm (C3C5) paralysis (higher on X-ray)
- costal fracture (1st and 2nd rib fracture associated with BPI ; intercostal nerve sectioned in 10%),
- cervical transverse process fracture suggest BPI.
Myelography, CT-myelography or MRI (most sensitive nowadays but risk of false positive)
EMG and NCS.
What will myelography, CT-myelography or MRI show?
When can this imaging reasonably first be done?
(most sensitive nowadays but risk of false positive):
earliest 3-4weeks after trauma. It shows root avulsion, pseudomeningocele (sign of avulsion), neuroma. Some authors advocate angio-MRI/CT or angiography in case of FFMT=free functioning muscle transfer (presence of pulse distally is not reliable enough).
EMG and NCS in BPI
What will it show?
When can it reasonably first be done?
How do you interpret it?
Diagnostic, localization and characterization (complete vs incomplete) of the lesion.
First baseline 3-4weeks after trauma.
EMG will look for muscle activity at rest : for example fibrillation is a sign of denervation.
Motor unit potential (MUPs) with voluntary effort: absence = complete lesion
MUP reduced = partial lesion.
It might also be used to test muscles that are difficult to clinically assess.
Sensitive fibers have their cell bodies into the dorsal ganglion vs motor fibers have their cell body in the anterior horn of the spinal cord.
In preganglionic lesion (avulsion), sensitive cell body is intact (meaning no Wallerian degeneration) but not connected to the CNS (anesthesia of the territory).
Present sensory nerve action potentials (SNAPs) = pathognomonic of root avulsion.
In post-ganglionic lesions, there will be Wallerian degeneration and thus SNAPS are lost.
It is possible to have both a root avulsion with absent SNAPs if secondary peripheral lesion is present.
On the contrary, motor conduction will be absent in both pre and post-ganglionic lesions because of Wallerian degeneration. If possible a second electrodiagnostic study is performed 6-12w after trauma.
Indications for immediate surgical exploration in traumatic brachial plexus injury = TBPI?
o All open injuries (laceration = plaies, be it sharp or blunt) or with associated vascular lesion
o Clear identification of complete root or nerve rupture
After a period of observation if there is no clinical or electrophysiologic evidence of recovery:
o Gunshot (only 12-15% of transected nerves)
o traction injuries
o Low-velocity: period of observation for recovery (neurapraxia)
o High-velocity: exploration (neurotmesis)
o After a period of observation with clearly no objective signs (clinical, electrophysiological) of recovery, or recovery has reached a plateau
Contraindications for surgery in TBPI?
main absolute contraindication is:
o Unrealistic goals/expectations or unwillingness
Relative contraindications are:
- stiffness and contractures
- age
- comorbidities
- associated traumatic brain injury
- associated spinal cord injury
- Ongoing recovery
o C8T1 roots low success (because too far from the hand, might be better to do forearm nerve transfers or tendon transfers).
o > 12 months from trauma (young patients excepted) / distal nerve transfers may be considered up to 18months after injury.
Timing of surgery in TBPI?
Adequate identification of the candidate. Once it's been done, the earliest the better is the outcome. However too early jeopardize the chance of spontaneous recover. The answer is in between.
For Primary reconstruction, best timing?
a) Immediate: sharp open injuries with plexus deficit or when vascular repair is done.
Blunt laceration, timing is subject to debate, maybe better within 3-4w to define the zone of injury (lesions might be marked).
If sharply sectioned, direct repair can be done.
If avulsed or bluntly transected or divided, they can be tagged and repair can be done 3-4months later to better identify the type of lesion.
b) Delayed. Allow time to recovery or for injuries that require time to be better defined.
Typically gunshot or traction, if no evidence of spontaneous recovery.
3-4months is an acceptable delay to wait for signs of recovery if there is evidence of root lesion and maybe a little bit longer (up to 6-9 months) for these with a higher chance of recovery.
No universal guidelines, some authors advocate early surgery while others wait for a delay.
Timing for secondary reconstruction after TBPI?§
Secondary reconstruction
o >12Mo after trauma, primary nerve repair shows significantly poorer results (muscle reinnervation).
Secondary distal nerve transfers can be considered up to 18Mo later, FFMT/tendon transfer at any time.
Surgical exposure in TBPI?
Some authors recommend routine exploration of the plexus, except for patients seen late who have a better distal transfer option. For example in pan-plexus injuries, <20% have all five roots avulsion, therefore grafting material can be found. Previously, long zigzag incision was done from posterior jaw the anterior pillar of axilla. Nowadays, transverse scar 2-3 fingers breadth over and parallel to clavicle. If needed, longitudinal scar from clavicle to axilla along the delto-pectoral septum.
Intraoperative aspects - how do you define the quality of the nerve intra-operative?
Which methods exist to assess the nerve/root quality?
Direct inspection and palpation not reliable enough to assess pre vs postganglionic or presence of neuroma.
Perioperative electrodiagnostic is mandatory (SSEPs, spinal evoked potentials replace SSEPs, MEPs, NAPs).
Some groups even use biochemical activity with ChAT.
Even histologic assessment of a nerve section before transfer can be realized perioperative to assess scaring.
• Evoked potentials (S for sensory and M for motor)
o SSEPs: on the scalp over the parietal cortex to record very low amplitude potentials after simulation of a contralateral peripheral nerve.
o MEPs: motor potential recorded from surgically exposed nerves after central stimulation.
• NAPs (nerve action potentials): functioning axons both sensory and motor. Ideal to assess post-ganglionic neuroma in continuity. If a good potential is present through a neuroma-in-continuity, the is a likelihood of significant recovery and the lesion should undergo neurolysis instead of resection graft.
• ChAT (choline acetyltransferase activity): helps differentiate motor and sensory fascicles during surgery. Its activity is higher in motor vs sensitive fascicles.
Repair
Do you repair every lesion?
What guides your choices?
...
Based on functional priorities.
When only some elements are injured, it is reasonable to reestablish continuity with all donor available.
When all plexus elements are ruptured, this approach is no longer possible and priorities have to be made.
Priorities of reconstruction are based on 3 factors:
1. Functional significance
2. Likelihood of recovery
3. Technical difficulty.
...
In which pattern of TBI injury is there a problem of the shoulder and forearm?
C5-C6 pattern or Erb-Duchenne palsy
TBI, C5-C6 pattern
a) What is the name of that palsy?
b) Which function is impaired?
c) What are the most important functions to give back?
a) Erb or Erb-Duchenne palsy
b) Functions impaired are: shoulder stability, abduction, IR/ER, elbow flexion (musculocutané), forearm supination (main supinator biceps)
c) Priorities for repair:
- Elbow flexion
- Shoulder stability, ER/IR, abduction --> to place the hand in an adequate position for use...
TBI, C5-C6 pattern,
How can you restore elbow flexion?
Muscle to reinnervate: biceps, brachialis.
Either by reparation of anterior division of upper trunk, musculocutaneous nerve or directly muscular branches.
o C6 grafting -> anterior division of upper trunk
o Ulnar nerve fascicle to biceps +/- median nerve fascicle to brachialis
TBI, C5-C6 pattern,
How can you restore shoulder functions (stability, abduction, ER/IR)?
a) deltoid: reparation of posterior division of upper trunk or axillary nerve anterior division
If post ganglionic and C5 functional:
- C5 + graft to posterior division of upper trunk and suprascapularis
- C5 + graft to posterior division of upper trunk + spinal accessoire to suprascapularis.
If preganglionic or C5 non functional or late exploration:
- spinal accessory to suprascapularis
TBI, C5-C7 pattern
How does it differ from a C5-C6 lesion?
problems for shoulder functions, elbow flexion + elbow and wrist extension (sometimes also fingers extension).
TBI, C5-C7 pattern
Which functions need to be repaired?
How do you proceed?
same as for C5-C6: upper trunk: deltoid through n. axillaire and supra-infra-épineux through n. suprascapularis.
+ if wrist and fingers extension severely impaired, needs to be addressed.
Usually, combination of verge grafts and transfers (spinal accessory, intercostal, pectoral, thoracodorsal and median/ulnar fascicles)
What are the available grafts for TBI?
Sural nerve or ulnar nerve (in certain circumstances)
Which nerves can be used for neurotization?
Spinal accessory nerve
Intercostal nerves (D3-D4-D5 on musculocutaneous for example)
cervical plexus
More rarely: hypoglossus nerve and contralateral C7 root.
C5-C7 pattern
What is the clinical presentation?
What are the problems to address?
C5-C6 + weakness in elbow triceps and wrist extension (sometimes according the anatomical variations, fingers extension).
The priorities are the same as for C5C6 and, if wrist and fingers extension is severely impaired (uncommon), has to be addressed.
Usually combination of nerve grafts and transfers (spinal accessory, intercostal, pectoral, thoracodorsal and median/ulnar fascicles)
Results are not as good as for C5-C6 alone.
...
C8T1 pattern
What are the symptoms?
What are the problems to be addressed?
How?
Sympathetic symptoms such as Claude-Bernard-Horner.
Weakness in hand intrinsics and extrinsics muscles, in a more variable way on wrist extrinsics depending on C7 contribution.
Timing of surgery is debated.
Nerve grafting is not adequate for these injuries, because of the long distance until muscle target (takes 2 years for reinnervation).
Some authors do distal nerve transfers in C8T1 plexus.
Early tendon transfer is also a possibility.
In any case, an individual approach based on available donors.
Goals are fingers and thumb flexion
correction of intrinsic minus and claw deformity.
FFMT (<6Mo) is an alternative in case of limited donors.
C5T1 pattern (pan-plexal)
Priorities of reconstruction?
Impossible to graft all the lesions.
Priorities of reconstruction in order of importance.
1. Elbow flexion by reinnervation biceps/brachialis (hand-to-mouth)
2. Shoulder stabilization, abduction, ER/IR by reinnervation suprascapular/axillary.
3. Hand sensation (C6-C7) by reinnervation of lateral cord.
4. Wrist and finger flexion. Consider reinnervation of triceps, when FFMT is envisaged (important antagonist).
5. Wrist and finger extension.
6. Intrinsic hand function.
Restoration of elbow flexion with a stable shoulder with or without hand sensation is the goal.
Some authors recommend exploration of the supraclavicular plexus hoping to identify viable nerve stumps for reconstruction, even in cases of multiple avulsion. Rarely more than one viable stump is found, which can be used to innervation shoulder. Elbow flexion is the priority, explaining why certain authors do double reinnervation (intercostal to biceps motor branch and FFMT branched on intercostal).
In case of panplexal injuries, what is available as donor nerve, graft or motor unit?
In cases of pan-plexal injuries, no musculotendinous unit is available for transfer, extra-plexal nerves and unit have to be harvested somewhere else (spinal accessory, intercostal, C3 and C4, contralateral C7, FFMT).
Qu'est-ce qui est fait d'ordinaire comme reconstruction pour panplexus injury?
elbow flexion is the priority: intercostal to biceps motor branch and FFMT branched on intercostal.
Then shoulder stbailization and external rotation: spinal accessory on suprascapular.
If additional nerves are available they can be transferred to serratus or latissimus dorsi.
If hand sensation is attempted then
• FFMT to restore both elbow and fingers flexion.
• Shoulder is addressed with either suprascapular or axillary by nerve grafting
• Spinal accessory to triceps.
• Intercostal sensory nerve to lateral cord for median nerve sensation.
• Secondary procedure 4-6 months later.
o Selected fusion (wrist, thumb CMC and IP) and soft tissue balancing (lasso to prevent claw deformity).
Other possibility is two-stage FFMT and contralateral C7 to median nerve.
TBI, How so you treat an Infraclavicular pattern?
Exploration through NAP (nerve action potential). Nerve grafts are often performed for example with posterior cord with axillary and triceps branch. However distal transfers for wrist/fingers/thumb extension.
Indication for simple neurolysis in TBI
Neurolysis (external)
Indication: post-ganglionic neuroma-in-continuity with present (positive) NAP. Proximal integrity can be assessed through MEP and SSEP. If clearly infraclavicular lesion evoked potentials not necessary. Rare are the indications of intrafascicular neurolysis.
Nerve grafting in TBI?
Indications?
Typical patterns?
Donors?
Indication: post-ganglionic rupture or post-ganglionic with absent (negative) NAP. Exception could be distal muscle target, long graft >10cm, late reconstruction.
Typical nerve grafting patterns
• C5 -> suprascapular, axillary and posterior division of upper trunk. SHOULDER STABILITY.
• C6 -> anterior division of upper trunk, musculocutaneous. ELBOW FLEXION.
• C7 -> posterior division of middle trunk, radial nerve. EXTENSION.
Donors: sural nerve (35-40cm) next to the saphenous vein; SBRN; MABC; MBC; DBUN (dorsal branch of ulnar nerve). Some authors advocate the use of vascularized nerve grafts in cases of large defects (ulnar nerve when nonfunctional, contralateral C7, sural nerve, radial nerve). Allograft?
Indications for neurotization?
Nerve transfers (neurotization)
Indication: irreparable preganglionic, FFMT, selected postganglionic. Advantage: only one suture, often synergistic.
Voie d'abord pour le prélèvement du spinal accessory nerve? et procédure?
• 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.
Ulnar nerve fascicles for neurotization
Prerequisites?
Often combined with what?
Technique?
Ulnar nerve fascicle (FCU) to biceps motor branch: C8T1 function must be intact.
Preferred to intercostal transfers for elbow flexion in cases of C5C6 palsy: ease and reliability.
Often combined to triceps -> axillary and spinal accessory -> suprascapular.
Some authors recommend not to use this transfer in C5C7 BPI because then not enough axons are available for distal ulnar nerve function (C7T1).
Longitudinal medial incision allowing identification of both the musculocutaneous nerve and the ulnar nerve. Posteromedial fascicles to the FCU is identified with electrostimulation and transferred (1-2fascicles in case of large MC). Preoperative weakness in the ulnar nerve is a contraindication. Complications reported are transient numbness and weakness into the ulnar nerve distribution. Outcomes report >90% of M3M4 to the biceps (better in C5C6 lesions compared to C5C7).
Median nerve fascicles for neurotization
For which function?
Indication?
Technique?
• Median nerve fascicle (FCR) to brachialis motor branch: Either for double transfer to restore elbow flexion or as single transfer in cases of preoperative ulnar nerve weakness when ulnar to biceps is envisaged.
Recent studies showed no differences in strength single vs double transfer but theoretical increase risk of morbidity of the donor site.
Same surgical access than described above. Motor fascicle to the FCR is transferred to the brachialis (CAVE ta care to differentiate from the LABC either by direct vision of its enter into the muscle or gentle traction to the LABC will tend the skin in proximal forearm). Contraindications are preoperative weakness to the median nerve and some authors advocate C5C7 BPI. Complications are the same.
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%.
...
Triceps motor branch as neurotization
What can it be used for?
Triceps motor branch -> axillary.
Ideal indication: C5C6 avulsion, and sometimes C5C7/8 avulsion if triceps function is good.
For patients with partial C7 need EMG preoperative can be useful.
Some authors do it as double reinnervation complementary to spinal accessory -> suprascapular.
Longitudinal incision on the posterior aspect of the proximal arm, from acromion to mid-arm. Axillary nerve is identified into the quadrilateral space. There is a theoretical advantage to target the main nerve which also innervates the teres min. But most of the time, anterior division is enough. Then lateral triangular space is exposed (between long and lateral head allowing exposition of the triceps motor branch to the long head). If needed fascia of the teres major can be incised to allow proximal mobilization of the motor branch. Leechavengvongs procedure. Sometimes contraindications are preoperative weakness of the triceps. Better results of C5C6 than C5C7.
Contralateral C7 as neurotization?
Used for?
What is the test to make sure that it is safe to harvest it?
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.
Other nerve transfers for neurotization?
For partial plexus lesions, other intraplexal sources are ipsilateral C7, medial pectoral and thoracodorsal. For pan-plexal lesions, other extra-plexal sources are phrenic, hypoglossal, platysma motor branch, and cervical plexus branches. Controversial again.
o Ipsilateral C7. Whole or anterior division of C7.
o Medial pectoral to MC, long thoracic, axillary. Pros are synergistic and partial fascicle harvest is possible. Cons are contribution of pectoralis major to shoulder adduction
o Thoracodorsal (C7C8+/-C6) to MC, thoracic long, axillary.
o Phrenic (C3C4C5) is often functional in cases of complete brachial avulsions. Used to suprascapular, MC and axillary. 3 possibilities: direct approach to suprascapular, + graft to MC or axillary, thoracic approach to MC or + graft direct to the median nerve. Cons are diaphragm paralysis, reduction of pulmonary function (diaphragm goes higher) said to be transient.
o Hypoglossal. Hemi or complete with graft. Disappointing results. Not an option.
o Platysma motor branch. Used to pectoralis major + graft in 1 patient.
o Cervical plexus. Reported but mostly composed of sensory nerves.
Postoperative care after surgery for TBI?
Immobilization of the shoulder for 3 weeks in adduction. Then physiotherapy is started for conserve passive motion and supple joints. When early signs of muscular reinnervation is observed, active muscle exercises are started focusing on biofeedback and strengthening. Visible and palpable contraction comes 2 months later than muscle reinnervation on EMG. Regular follow-up every 2-3-5 years is advised.
Free functional muscle transfer for TBI?
What are the criterias for the muscles?
Which muscles can be harvested?
What are the nerves for neurotization?
What needs to be imperatively present to allow FFMT?
What is the contraindication for FFMT?
Muscle must be long enough and have a proximal motor point to allow early reinnervation with an extraplexal source (spinal accessory, 2-3 intercostal nerves, contralateral C7).
Basic concepts for tendon transfer applies, one tendon one function/supple joints/adequate skin coverage. So if the muscle is attached proximally between clavicle and acromion down to the fingers flexors to restore the latter, it will cross GHJ and elbow.
Antagonists must imperatively be present otherwise it will use all his strength for the first two articulations before reaching fingers.
Always address shoulder stability first (nerve graft, tendon transfer, arthrodesis). Same for elbow, triceps function must be addressed, and wrist, either arthrodesis or separate muscle transfer.
Lesion of subclavian/axillary artery is a contraindication for FFMT (most of the time vascular anastomosis is done on TD artery or TA artery). Muscles described for this application: LD, rectus femoris, adductor longus or gracilis. Most useful with good results are gracilis and LD. For elbow flexion alone, alternative is to reinnervate LD and transfer it as a pedicled flap.
FFMT What is
• Grasp transfer?
= double FFMT.
<6Mo after trauma, <40yo, no subclavian artery trauma, avulsion of 4-5 roots.
Two procedures. First surgery: exploration and proximal reconstruction of ruptured motor nerves, then transplantation of the contralateral gracilis neurotized by the spinal accessory nerve. This will restore elbow flexion and finger or wrist extension (preferred). It is anchored on the acromion and placed on the anterolateral aspect of the arm and dorsal aspect of the forearm passing below the BR and radial wrist extensors. Position if adequate for elbow flexion and fingers extension, however strength decreases when elbow is flexed.
Second surgery (2-3months later): transplantation of the ipsilateral gracilis anchored on the second rib and passed deep to the flexor pronator origin and next to the FDP in the forearm. FDP are first interconnected and then sutured to gracilis in a pulvertaft fashion. Sometimes FCR graft is necessary to improve length. Neurotized by the 5th and 6th intercostal nerves for finger flexion then use 3rd and 4th intercostal nerves to neurotize triceps for elbow extension. Eventually intercostal nerves to medial cord for hand sensation.
Secondary reconstruction procedures are often required to shoulder, thumb CMC/IP and wrist. Secondary claw deformity can occur, thus prevention is needed with lumbrical bar. However if needed, static procedure of Lasso can be done. Satisfactory results in 57% of the cases.
• Single stage FFMT.
When do it?
Technique?
<6Mo after trauma, <40yo, no subclavian artery trauma, avulsion of 4-5 roots.
Exploration of subclavicular plexus to look for postganglionic lesions. Sural grafts are prepared for suprascapular nerve and axillary. 5th and 6th intercostal nerves to biceps motor branch/MC and 3rd and 4th to FFMT. Anchored proximally on the lateral clavicle and acromion, distally woven through FDS and FDP. A pulley in the forearm must be used to avoid bowstringing (lacertus + FCU).
Spinal accessory to triceps + graft (SBRN). When function returns, thumb CMC and IP arthrodesis + lasso to prevent claw deformity.
Secondary reconstruction after TBI
Which transfers exist?
- Upper trapezius transfer --> recreate abduction. needs fuctioning biceps, coracobrachialis, pectoralis major or triceps
- Latissimus dorsi transfer --> abduction and ER
- Pectoralis transfer --> abduction
- Lower trapezius transfer --> external rotation
- Contralateral lower trapezius origin transfer --> restore external rotation
What does the Mayo propose for secondary reconstruction in TBI?
Preferred at the Mayo
If complete paralytic: upper serratus or pectoralis minor -> subscapularis insertion for IR ; levator scapula -> supraspinatus and middle and upper trapezius -> deltoid for abduction ; lower trapezius -> infraspinatus for ER. If limited option, only restore ER with lower trapezius to infraspinatus (contralateral if needed).
Other options then transfers for secondary reconstruction for TBI?
- shoulder arthrodesis (for panplexus or upper plexus, contraindicated if extensive paralysis of trapezius and shoulder stabilizers
- late elbow flexion reconstruction.
Late elbow flexion reconstruction
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.
Upper trapezius transfer
Saha described upper trapezius transfer with concomitant other transfers for poliomyelitis patients! Aim to recreate abduction. Later, technique was modified. Trapezius is transferred from the spine of the scapula with the acromion and transferred to humerus, just distal to the greater tuberosity. Modified technique, deltoid is partially detached and sutured medially over the trapezium. Best results with patient with functioning biceps, coracobrachialis, pectoralis major or triceps.
Latissimus dorsi transfer
+/- teres major. Mostly used to pediatric or birth plexus palsies (C5C6, sometimes some LD function is still present) to restore abduction and ER. Some authors consider deltoid and subscapularis paralysis as contraindication and may worsen inferior subluxation and adduction/extension deformity.
Pectoralis transfer
For deltoid paralysis, aim to restore abduction. Transfer of upper portion (clavicular and sternocostal parts) and turn over 180° (deep becoming superficial). Distally inserted onto deltoid tuberosity and proximally onto clavicle and acromion.
Lower trapezius transfer
Use for patients with paralysis of deltoid, infraspinatus and teres minor. Restore external rotation. Lower trapezius is harvested through a medial incision to the scapula. It is then anchored to the infraspinatus footprint onto the humerus (lengthen with Achilles or posterior tibial) also described inserted onto the tendon of infraspinatus in cases of multiple transfers. All patients had stable shoulders, but marginal improvements of flexion and abduction.
Contralateral lower trapezius origin transfer
To restore external rotation, sometimes only option, when prolonged with lumbosacral fascia. Transferred to infraspinatus.
Shoulder arthrodesis
GH and AH fusion. Indications: upper plexus paralysis or panplexus. Some authors use GH arthrodesis to allow use of available nerve donors for elbow flexion/extension and prehension. Cons: decrease the use of a reconstructed hand; humerus fractures; difficulty with turning during sleep, high rate of nonunion (long lever arm, little surface of contact, no compression from paralyzed muscles). Contraindications: extensive paralysis of trapezius and shoulder stabilizers (pain or scapulothoracic luxation can appear) then scapulothoracic fusion might be considered. Optimum position is debated but 30-40° abduction-flexion-internal rotation. Surgical position beach-chair, posterior inverted L approach, cancellous bone graft from iliac crest in the subacromial space. Outcome at least 45°(up to 60°) abduction if serratus anterior has an preoperative adequate function.
Late elbow flexion reconstruction, what is available?
- 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.
Neuropathic pain management in TBI
Pain develops in 80% and persist in 20%. Pathogenesis may include postganglionic neuroma, central deafferentation or segmental hyperactivity of the dorsal horn (avulsion). If conservative treatment (physiotherapy with biofeedback, comportmental therapies, relaxation, pharmacotherapy) does not bring any improvement over time then surgery (neurolysis, neuroma resection or nerve grafting) might be envisaged with some improvement. Patients with roots avulsion and chronic pain might be candidate for radiofrequency destruction of the dorsal entry root. Eventually central nervous system neuromodulation therapies (deep brain, spinal cord, motor cortex stimulation) can be envisaged.
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