Multi-level Nerve Injury of the Upper Extremity Management and Review of Brachial Plexus Literature: A Case Report

Monica Pecache,Rahul Patil,Tsu Min Tsai,Raya Abughanmi

doi:10.11648/j.ijcems.20200606.17

Abstract

Backround: Brachial plexus injuries are complex cases requiring a thorough understanding of nerve physiology and upper extremity anatomy. Standard approaches and management have been developed but certain situations still arise where these are not feasible options. Objectives: A case of brachial plexus injury is discussed in this report. The patient was a young male who was referred to our center with weakness of the left upper extremity, C5-C7 distribution. Certain components of his injury, such as extensive soft tissue scarring and identification of a long neuroma at the injury site, obliged the surgeons to use unconventional nerve transfers during his surgery. In this paper, we discuss these alternative options in order to support their potential use in complex brachial plexus cases. Other concepts such as single fascicular harvest for nerve transfers and nerve graft augmented nerve transfers are discussed as they were successfully used in this report. Methodology and Results: The patient underwent a total of five surgeries which were a combination of nerve and tendon transfers. Some nerve transfers were augmented with long autologous nerve grafts reaching up to fifteen centimeters in length. Throughout the patients sequence of surgeries, certain nerves, such as the ulnar nerve branch to the flexor carpi ulnaris, successfully served as a donor nerve in more than one occasion. Muscle groups where single nerve fascicles were previously used as a donor nerves also yielded adequate muscle strength and were successfully subsequently used in tendon transfers. Ultimately, the patient was able to achieve good muscle strength, range of motion and outcome scores on his left upper extremity after two years from his final surgery. Conclusion: This report offers multiple alternative options in managing complex brachial plexus cases as well as challenges some concepts in nerve grafting. Alternative donor nerves are offered for transfers, some of which are not previously used in literature. Aside from this, the use of long autologous nerve grafts, single fascicular nerve transfers and repeated use of certain nerves as donor were performed successfully. We hope these procedures and techniques can be added to each hand specialist arsenal for managing complex brachial plexus injuries, specifically when the standard techniques are not feasible.

Highlights

Brachial plexus injuries (BPI) are one of the most devastating injuries to the upper extremity and pose long term impact on a patient’s physical, social, and psychological wellbeing. [1, 2] Extensive research has been done for BPI’s in order to search for effective means of offering these patients a predictable and efficient way to regain upper extremity function
The choice to continue to use autologous nerve grafts over other options such as vein grafts and conduits, inspite of donor site morbidity, largely lie in the fact that outcomes following the use of nerve grafts in lengths such as in this case, are still best. [9, 10] functional muscle transfers and various sets of tendon transfers are useful procedures that continue to have a role in management of brachial plexus and peripheral nerve injuries
A set of recommended nerve transfers have been established in literature through the years, which have yielded good results

Summary

Introduction

Brachial plexus injuries (BPI) are one of the most devastating injuries to the upper extremity and pose long term impact on a patient’s physical, social, and psychological wellbeing. [1, 2] Extensive research has been done for BPI’s in order to search for effective means of offering these patients a predictable and efficient way to regain upper extremity function. [2, 3] Recommended transfers have since been established for each type of BPI. In spite of this surgeons must stay prudent and keep in mind that each BPI is different. Instances still arise when conventional nerve transfers are not viable options for a patients case. Monica Pecache et al.: Multi-level Nerve Injury of the Upper Extremity Management and Review of Brachial Plexus Literature: A Case Report aims to provide readers with alternative options and combinations for performing nerve transfers by presenting a case of brachial plexus and peripheral nerve injury where conventional transfers were not performed. Due to the extensive scarring and other intra-operative findings, the surgeons in this case explored alternate options which proved effective in restoring upper extremity function

Objectives

Discussion

Conclusion