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|NI FEATURE: THE QUEST - COMMENTARY
|Year : 2016 | Volume
| Issue : 2 | Page : 289-296
Adult brachial plexus injuries: Surgical strategies and approaches
Sumit Sinha1, Mehdi Khani2, Nasim Mansoori1, Rajiv Midha3
1 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Neurosurgery, Kowsar Hospital, Shiraz, Iran
3 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
|Date of Web Publication||3-Mar-2016|
Department of Neurosurgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Traumatic brachial plexus injuries are devastating injuries commonly affecting the young population and leading to significant socioeconomic losses to the society. The results of brachial plexus surgery have been severely disappointing in the past. However, several technological advancements and newer surgical techniques, especially the advent of distal nerve transfers over recent years, have led to a paradigm shift in the outcome of patients with these injuries. The best time window for surgery is the first 3 months after injury, and the next best time is the next 3 months. The timing is a crucial factor as the neuromuscular junctions degenerate in 20–24 months. The presence of spontaneous fibrillations in a muscle on electromyography is an indication of denervated yet vital muscle. The restoration of elbow flexion is a priority followed closely by restoration of shoulder abduction and stabilization. The various surgical strategies in brachial plexus injuries should be directed toward accomplishing this goal. The global avulsion injuries have a poor outcome because of very limited source of donors in such types of injury whereas the partial injuries have a remarkable outcome in a majority of cases. This article presents the reader with the guidelines and management algorithms of repair strategy and various surgical approaches utilized in the surgical treatment of brachial plexus injuries.
Keywords: Brachial plexus; injury; nerve; outcome; repair
|How to cite this article:|
Sinha S, Khani M, Mansoori N, Midha R. Adult brachial plexus injuries: Surgical strategies and approaches. Neurol India 2016;64:289-96
| » Introduction|| |
Traumatic brachial plexus lesions are devastating injuries in adults and result in significant socioeconomic loss to the affected individual. The results of brachial plexus surgery have been so disappointing during the initial decades of the 20th century that many authors including Sir Herbert Seddon were in favour of conservative treatment or amputation of the affected extremity for them. This therapeutic nihilism was echoed in the International Society for Orthopedic Surgery and Traumatology Congress held in Paris in 1966. The surgery for brachial plexus reconstruction was popularized in the 1970s by Millesi (Vienna) and Narakas (Laussane) and since then, numerous technological advancements have been made with the development of operating microscope, intraoperative electrophysiology, suture materials, biological tissue glues, etc., and presently the efficacy of surgery has been proven beyond any doubt.
The aim of this article is to update the readers with the prevalent guidelines and management algorithms of repair strategy, as well as various surgical approaches performed in the surgical treatment of brachial plexus injuries.
| » Surgery for Brachial Plexus Injury|| |
The surgery for brachial plexus injuries was pioneered by Kennedy, Sever, and Wyeth and Sharpe in the early part of the 20th century.,,, The poor results of surgery in the initial treatment of these lesions was a setback for the development of brachial plexus surgery, till Seddon revived interest in this field during World War II and reported good results. This work laid the foundation for the subsequent important contributions by Gilbert, Tassin, and Narakas,,,,, who reported increasingly impressive results in their surgical series.
| » Indications and Timing of Surgery|| |
The best time for surgery depends on the mechanism and type of injury and has been a controversial issue with the consensus towards an early intervention. The most common clinical scenario is a patient with closed traction injuries. The patient is assessed clinically, electrophysiologically, and radiologically. If there is an unequivocal evidence of spinal nerve root avulsions (preganglionic injury), there is no rationale in waiting and surgery to perform nerve transfer is undertaken as soon as possible. However, if there is a postganglionic injury, it is prudent to wait for 3–4 months for spontaneous improvement to occur. The patient carries the best chances of improvement in the first 3 months after injury and the next best time window is within the next 3 months. The timing is a crucial factor in determining the outcome after surgery as the distal nerve and the neuromuscular junction become increasingly incapable of accepting reinnervation by 20–24 months. The patient is followed up clinically and electrophysiologically every 3–4 weeks and if the patient shows continued improvement, conservative physiotherapy is advocated [Figure 1].
|Figure 1: Flow chart showing management of closed brachial plexus injuries|
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The rationale for the treatment of acute open injuries follows a different protocol and is illustrated in [Figure 2].
|Figure 2: Flow chart showing management of open brachial plexus injuries|
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High-velocity gunshot wounds with associated vascular injuries may warrant an emergency repair. However, low-velocity gunshot wounds are usually treated 3–4 months after injury, as most of these lesions have a neuropraxic component.
The indications for immediate/early repair (within 3–4 weeks postinjury) are (i) sharp, open injury, (ii) associated vascular injuries, (iii) flail limb with severe deafferentation pain, and (iv) pseudomeningoceles on magnetic resonance myelography. The clean cut ends of the nerves are repaired if the nerves are lacerated. However, if the ends are lacerated and crushed, than they are tagged with nylon suture and fixed with tissue planes, for an easy identification during re-exploration, 2–3 weeks later.
The advantages of an early exploration are that the surgical field is clean and anatomy is better identifiable, including the normal fascicles; and, after surgery, rehabilitation can be started early. However, sometimes, a neuroma with regenerating fascicles can also be mistakenly resected and grafted, as even direct perioperative recording cannot reliably exclude regeneration in the first several weeks after injury. The advantage of delayed surgery is that most of the neuropraxic injuries recover by that time and regenerating nerves can be assessed by intraoperative nerve action potential recordings.
| » Operative Approaches and Surgical Techniques|| |
The plexus is approached anteriorly in most of the cases. The approach may be supraclavicular, infraclavicular, and depending on the extent of injury, in a majority of cases, a combined approach is preferred. There are four major surgical techniques commonly performed in brachial plexus injuries:
- Direct end-to-end repair is performed in clean nerve transactions when the cut ends of two nerves can be brought together without any undue tension
- Neurolysis may be the only operative procedure required when low-amplitude regenerative nerve action potentials are conducted across a neuroma on intraoperative electrical stimulation. The nerve is dissected from the constricting circumferential scar tissue by sharp dissection (external neurolysis) over a varying length proximally and distally. In select cases, fibrous scar tissue is dissected off from between the fascicles (internal neurolysis)
- Nerve grafting is required in cases after resection of a nonconducting neuroma, or in postganglionic injury with available proximal and distal nerve stumps, separated by a considerable distance so that they cannot be sutured together without undue tension. The most commonly utilized nerve for this purpose is the sural nerve, which can yield a total length of as much as 40 cm from one side. Nerve grafting is not possible when there is a spinal nerve root avulsion, where the roots are not visualized or when there are no visible fascicles in the proximal stump scar. A length of the graft of 6–8 cm is acceptable for obtaining satisfactory results, as results are poorer for more extensive lesions requiring longer graft lengths 
- Nerve transfer (neurotization) refers to the transfer of a functional but less important nerve to a distal but more important denervated nerve. The concept of neurotization was first proposed by Harrys and Low (1903), followed by Tuttle (1913), who proposed the use of spinal accessory nerve (SAN). The indications for this kind of procedure are when there is a very proximal lesion (including root avulsions), when a long segment of the nerve is lost or damaged, or when the patient has been referred late. The aim of this kind of a procedure is to recover an important nerve function, which is otherwise not possible, and to convert a high-level injury into a low-level one, thereby placing regenerating axons closer to the denervated motor endplates.
Principles of nerve transfer (neurotization)
The prerequisite for this procedure is to have a functioning muscle recipient whose nerve is denervated due to a more proximal injury. The functionality of a denervated muscle is, however, not as easy to determine. The presence of spontaneous fibrillations in a muscle on electromyography, is an acceptable indication of a denervated yet vital muscle. Another important factor is the number of nerve fibers in the donor nerve as compared to the recipient nerve. Many of the secondary and terminal branches of the plexus have numerous fibers [Table 1] whereas the recipients closer to the muscle have very limited number of fibers. This has led to the concept of using at least two donor nerves for a useful restoration of some critical functions, for example, double fascicular transfer for elbow flexion (discussed later in the following sections).
|Table 1: Average number of nerve fibers in the nerves used in neurotization|
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Various intraplexal (medial pectoral nerve [MPN], ulnar nerve, median nerve, triceps branch of radial nerve, and contralateral C7 root), and extraplexal (deep cervical plexus, SAN, phrenic nerve, intercostal nerve [ICN], and hypoglossal nerve) donors can be used to neurotize important nerves, as the case may be. Obviously, the intraplexal donors can be used only in partial plexus injuries and strictly speaking their usage connotes plexal reconstruction and not neurotization. However, if feasible, intraplexal and agonist donors are always preferred. This minimizes the cortical adaptation and the problems of co-contraction.
The characteristics of an ideal donor nerve are illustrated in [Table 2].
The main aim of brachial plexus surgery is to restore motor function. Hence, a pure motor nerve should ideally be used as a donor nerve directed into the recipient motor fascicles. The recipient nerve may be dissected distally into the muscle, so as to identify dedicated motor fibers and avoid donor motor fibers dropout into sensory fibers of the recipient. Whenever feasible, the anastomosis has to be performed by direct repair without the use of intervening grafts as it has been estimated that, on an average, 30% of the axons are lost while crossing one anastomotic line. The important principles of nerve transfer to maximize the outcome are shown in [Table 3].,
|Table 3: Important principles to maximize outcome in nerve transfers/neurotization|
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Priorities in repair
There is no consensus in literature about the level of importance of different functions to be restored, except the first two indications. The priorities in brachial plexus surgery are, in that order, (i) elbow flexion because it allows the limb to be placed in a better position in space and to be flexed toward the mouth for feeding, followed by, or at the same level as (ii) shoulder stabilization, abduction, and external rotation. This is followed by (iii) elbow extension, (iv) brachiothoracic pinch, (v) wrist and finger extension, (vi) wrist and finger flexion. The intrinsic function of hand is the last priority because of its greater distance from the donor nerve and poor prognosis for recovery. Sensory reanimation is also a priority in most of the repairs currently, if feasible, and many surgeons attempt to also include sensory transfers in the surgical plan to recover the protective hand sensation (median nerve area).
Strategies for C5, C6 injury
These patients have absent shoulder abduction and elbow flexion and therefore, the surgical strategies are directed toward restoration of these functions [Figure 3].
In the case of a postganglionic injury, where the viable spinal nerve root stumps are present, the following options for direct (graft) repair are available:
- C5: Lateral cord or upper trunk for achieving elbow flexion
- C6: Posterior cord for achieving shoulder abduction.
In case of a preganglionic injury (where the spinal nerve root stumps are not available), or on late presentation, or in an elderly patient, the following neurotizations can be performed to achieve shoulder abduction and elbow flexion:
- SAN to suprascapular nerve anastomosis for achieving shoulder abduction, external rotation, and stabilization.
- Nerve to long head of triceps to anterior division of axillary nerve (Somsak's procedure)Although single neurotization of suprascapular or axillary nerve can be done for shoulder abduction and stabilization, it has been shown in some studies that the double procedure is more effective in restoring shoulder abduction, external rotation, and stability ,
The axillary nerve is one of the terminal branches of posterior cord of the brachial plexus and is a strong shoulder abductor. The anterior branch is predominantly motor and supplies the bulk of the deltoid muscle. Within the main trunk of the axillary nerve, the motor fibers are topographically located superiorly, whereas the sensory fibers are typically inferior. Thus, the motor-predominant superior portion is favored for performing coaptation to the main trunk of the axillary nerve
Motor branches of the radial nerve to the triceps muscle can be used as donors to the axillary nerve either via a posterior arm approach (Somsak procedure) or by an anterior axillary approach. The triceps muscle has three heads: Medial, lateral, and long head and nerves to either of them can be transferred to neurotize the axillary nerve. The loss of the long head stands the least theoretical risk of any functional deficit. The branch to the long head, however, is short and often requires significant proximal dissection including division of the teres major in order to obtain enough length of the nerve for transfer. The branch to the medial head is longer and it is easier to obtain sufficient length of this branch. Of the three heads, the branch to the long head has the largest diameter and relatively higher number of motor axons [Figure 4]a,[Figure 4]b,[Figure 4]c,[Figure 4]d
|Figure 4: Patient in prone position for the right Somsak procedure: (a) Radial nerve as it enters the spiral groove; (b) axillary nerve exposed in the quadrangular space (recipient nerve); (c) nerve to long head of triceps (donor nerve); (d) donor and recipient nerves are ready for anastomosis|
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- Thoracodorsal nerve (TDN) to axillary nerve anastomosis for achieving shoulder abduction
- MPN to musculocutaneous nerve (MCN) anastomosis for elbow flexion
- The MPN to MCN transfer is a good option for upper plexus injuries restoring Medical Research Council (MRC) Grade 3 or better elbow flexion in 68–84% of patients., The MPN originates from C8 to T1 and contains nearly 1500 motor axons. There is no profound weakness of the pectoralis major muscle following this transfer, as it is doubly innervated by medial and lateral pectoral nerves, and also because the surgeon can select the larger fascicle of the MPN as donor, preserving some innervation to the muscle. Over the last 20 years, several authors have reproduced positive results with MPN to MCN reinnervation ,
- Oberlin procedure for achieving elbow flexionThis procedure was first performed by Prof. Oberlin in mid-1990s  and is the Copernican revolution for brachial plexus surgery, which has changed the philosophy of treatment of these devastating injuries. It utilizes an ulnar fascicle to reinnervate the biceps branch of the MCN. The advantages of the Oberlin procedure are (1) a short distance to the denervated motor end-plates, (2) a single suture line, and (3) a good size match between donor and recipient nerves
The nerve to biceps takes origin from the MCN near the mid-portion of arm and nerve to brachialis arises nearly 3 cm distally. The typical donor fascicle from the ulnar nerve is the fascicle mostly innervating the flexor carpi ulnaris (FCU) muscle and is located within the superolateral portion of the ulnar nerve., Optimal results were obtained in younger patients with late injuries as well. Leechavengvongs et al., later reported >90% patients achieving MRC grade >4 elbow flexion using the Oberlin technique [Figure 5] and [Figure 6]
he original Oberlin procedure can be fortified by another nerve transfer to brachialis branch of MCN using a motor fascicle from the median nerve (double fascicular transfer). The ideal median nerve donor fascicle contains nerves to the flexor digitorum superficialis (FDS) and flexor carpi radialis, without the anterior interosseous nerve (AIN) supply [Figure 7]
- SAN to MCN for elbow flexion
Accessory nerve comprises nearly 1500 motor axons and has been used as a donor since a long time. Recent series evaluating elbow flexion after SAN to MCN transfers have established MRC Grade 3 function or better in 65–83% of patients ,
- Phrenic to MCN for elbow flexionPhrenic nerve contains nearly 800 motor axons. It can be used to neurotize the MCN with nearly 65% chance of functional recovery to MRC Grade 3–4. The use of phrenic nerve entails the risk of respiratory compromise, especially in children, hence it should be used cautiously and as a secondary option
- TDN to MCN for elbow flexion
TDN gets fibers from C6 to C8 and contains approximately 2000 motor axons. TDN is a strong neurotizer and in a few case series, the TDN transfer has restored elbow flexion with over 90% of patients having a favorable outcome., The use of TDN requires appropriate planning as muscle transfers using latissimus dorsi cannot be done thereafter.
Strategies for C5, C6, and C7 injury
In a combined upper and middle trunk or C5–C7 injury, in addition to the shoulder abduction and elbow flexion, the restoration of elbow extension is an additional priority [Figure 8]. The shoulder abduction and elbow flexion can be achieved by transfers described previously. Obviously, Somsak procedure cannot be performed due to nonfunctioning of radial nerve outflow to triceps in this type of injury.
Elbow extension has generally been given a lower priority in plexal reconstruction but is considered whenever it is feasible. A number of activities require an active triceps function.,,, The donor nerves can be ICN, TDN, MPN, phrenic nerve, axillary nerve, or ulnar nerve fascicles. Less success was seen using ICNs or contralateral C7 as donors, with the series of Terzis and Barmpitsioti reporting that only 16 of 55 adult patients achieved MRC ≥ 3 strength using these donors. Utilizing a nerve branch to triceps, rather than the radial nerve itself, as the recipient leads to better outcomes. Most published transfers utilize the MPN and ICNs as donors, with MPN showing promising results. The average success for ICN transfer in the published literature is approximately 40%., The current best evidence supports the use of the MPN as the donor nerve and should be utilized when feasible.
The inability to extend the wrist and fingers weakens hand-grip power and initiating the grip around a desired object. To restore distal upper extremity extensor function, tendon transfers with wrist and finger flexor donors have been quite effective. Recently, it has been reported by various authors that neurotization from the pronator teres, flexor pollicis longus (FPL), flexor digitorum superficialis (FDS), and pronator quadratus branches of the median nerve to select posterior interosseous nerve (PIN) branches are anatomically possible, with some preliminary reports demonstrating the efficacy of the procedure.,,,
In the case of a postganglionic injury, with viable spinal nerve root stumps, the plexus can be reconstructed using nerve graft repairs with the following options:
- C5: Lateral cord or upper trunk for achieving elbow flexion
- C6: Posterior cord for achieving shoulder abduction
- C7: Middle trunk/posterior cord.
Strategies for lower plexus (C8, T1) injury
Finger flexion and grasp function are of extreme importance for patients [Figure 9]. These are mediated by median and ulnar nerves. Median nerve function is a crucial component of a pinch action. Nerve transfers for reinnervation of the median nerve (for primarily reinnervating muscles supplied by AIN) include nerve to FDS to AIN, nerve to brachialis to AIN, nerve to extensor carpi radialis brevis to AIN, nerve to FCU to AIN, nerve to supinator to AIN, and nerve to FDS to FPL.,,
The nerve transfers for reinnervation of radial nerve include nerve to brachioradialis or supinator to PIN.
In cases of a postganglionic injury, ipsilateral or contralateral C7 can be joined to the lower trunk or the medial cord directly or with interpostional nerve grafts [Figure 8].
Strategies for global palsy (C5–T1 injury)
In cases of global palsy with complete root avulsions from C5 to T1, there are limited donor nerve options and obviously, only extraplexal donors can be used [Figure 10]. The results for reanimation of the hand function are very poor.
In a (very rare) postganglionic injury and on early referral, a total intraplexal reconstruction may be possible from root, trunks, or cords.
However, the more common injury is a preganglionic root avulsion of all the roots. In these cases, a multistage approach using extraplexal donors is the only option. In the first stage, XI-SSN anastomosis is done to achieve shoulder abduction, along with contralateral C7 to lateral cord (LC) or posterior cord (PC) anastomosis to achieve either biceps and pectoralis major (PM) function (if LC is the target); or, to achieve deltoid, triceps, and extensor carpi radialis longus (ECRL) function (if PC is the target). Alternatively, elbow flexion can be achieved by performing a 2nd–4th ICN-MCN and 5th, 6th ICN-RN anastomosis to achieve elbow extension.
Approximately 3 months after the stage I, free functioning gracilis transfer using the thoracodorsal vessels and ICNs can be performed and sutured to FPD and FPL. However, if there is no ECRL recovery, then wrist fusion can be done after an year to stabilize the wrist. Finally, tendon transfers can be performed to improve hand function, and shoulder fusion to stabilize the shoulder.
| » Conclusions|| |
The surgery in brachial plexus injuries has seen a significant revolution during the past decades due to technological advancements and refined ingenious reconstructive techniques, including distal targeted nerve transfers. The partial injuries have a remarkable outcome in a majority of cases, while the results in global avulsions are not very satisfactory and are more of a salvage option even now. The timing of surgery is a crucial factor in determining the outcome of these injuries, hence, an early referral is mandatory.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3]
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| ||Marcelo José Silva de Magalhães, Mariano Socolovsky, Mariana Mendes Araújo, Mariana Oliveira Silva, Mayallu Almeida Mendes, Pedro Augusto Costa, Telma Soares Santos |
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| ||Mahadewa Tjokorda |
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||A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report
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||Multiple uses of fibrin sealant for nervous system treatment following injury and disease
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| ||Journal of Venomous Animals and Toxins including Tropical Diseases. 2017; 23(1) |
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||Microanatomy of the brachial plexus roots and its clinical significance
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