Brachial Plexus Surgery

Brachial Plexus Injury

October 2008 1
Mr V Rajaratnam
 Coverage
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 2
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 3
Mr V Rajaratnam
 Brachial Plexus Injury
October 2008 4
Mr V Rajaratnam
 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

Brachial Plexus Injury

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Mr V Rajaratnam
 Clavicular Region
• Divisions
• anterior supply flexors

• posterior supply extensors

Brachial Plexus Injury

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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

Brachial Plexus Injury

October 2008 7
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 8
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
 Brachial Plexus Injury
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Mr V Rajaratnam
 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
Brachial Plexus Injury
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Mr V Rajaratnam
 Brachial Plexus Injury
October 2008 40
Mr V Rajaratnam
 Brachial Plexus Injury
October 2008 41
Mr V Rajaratnam
 Brachial Plexus Injury
October 2008 42
Mr V Rajaratnam
 Brachial Plexus Injury
October 2008 43
Mr V Rajaratnam
 Brachial Plexus Injury
October 2008 44
Mr V Rajaratnam
 Brachial Plexus Injury
October 2008 45
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 46
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 47
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 48
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 49
Mr V Rajaratnam
 Brachial Plexus Injury
October 2008 50
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 51
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 52
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 53
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 54
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 55
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 56
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 57
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 58
Mr V Rajaratnam
Coverage

Anatomy

Incidence

Classification

Evaluation

Surgery

Rehabilitation

Outcomes

Recent
Advances

Brachial Plexus Injury

October 2008 59
Mr V Rajaratnam