Surgical management of the proximal injury to the nerves of the upper extremity: strategy at overcoming multiple critical gaps

Abstract

Aim of the study — to evaluate the outcomes of reconstruction procedures at complete injuries of brachial plexus in subclavicular region. The retrospective analysis of the reconstruction procedures in 3 men and one woman (mean age 36,4 years) with complete injury of brachial plexus in subclavicular region was conducted. Injury to musculocutaneuos, median, ulnar and radial nerves was accompanied by axillary (2 cases) or brachial (2 cases) artery injury. One patient had no injury to musculocutaneous nerve within the injury’s structure. All patients underwent surgical reconstruction of the neural structures 4,8 months (mean term) post initial vascular surgery. The autografting was the main reconstruction procedure of the long nerves of the upper extremity at their critical gap (mean gap 10,5cm) with donor-nerves of the small (sural nerve) and large (ulnar nerve) cross sectional diameter. Both motor and sensory components of recovery were evaluated with MRC Scale and Seddon Scale respectively. Each patient evaluated the recovered median nerve mediated functions with Brief Michigan Hand Questionnaire. It was revealed that one patients showed poor recovery of the entire complex of the muscles of the upper and lower arm (MRSC 2 points or lower). Two patients showed good recovery of the biceps brachii muscle (MRCS score 5 points) on 14th and 13th month respectively. Mean MRC Scale score among three patients for the muscles of the anterior compartment of the forearm was: 3,3 points for m. flexor pollicis longus, 3,6 points for mm. flexores digitorum and 4 points for m. flexor carpi radialis respectively. Mean MRC Scale score among three patients for the muscles of the posterior compartment of the forearm was: 2,6 points for m. extensor pollicis longus, 3,3 points for m. extensor digitorum sublimis and 4 points for radial wrist extensors respectively. The median nerve mediated sensation recovered to 2,3 points on Seddon scale. Only one patient showed effective recovery of the thumb opposition. Loss of ulnar nerve mediated functions was expectable among all 4 enrolled patients, thereafter we observed no recovery of key pinch and diagonal volar grip. Three patients showed recovery of transversal volar grip only. Mean Brief MHQ score was 55,55 points – unsatisfactory recovery. The reconstruction of the ulnar nerve, thereafter recovery of the “intrinsics”, should be the priority in terms of reanimation of the basic grips and pinches of the upper extremity – one should avoid harvesting of the ulnar nerve at multiple nerve injury cases; the expectable loss of functions at the utililization of the radial nerve as a donor nerve, could be easily recompensed with the tendon transfer procedures in later terms.