Complete Brachial Plexus Lesion Research Articles

Amputation transhumérale pour séquelle de plexopathie brachiale. Une série multicentrique

BackgroundA flail limb can be the result of a traumatic complete brachial plexus lesion. Some patients prefer retaining the flail limb; however, some patients feel that a flail limb negatively affects daily life. In these circumstances, an elective amputation is sometimes elected; however, long-term follow-up, with respect to satisfaction and function, is unknown. The aim of this study is to evaluate the long-term outcome of this rare and life changing operation. Materials and methodsEight patients with a transhumeral amputation performed in 2 specialized medical centers were included. Postoperatively, the functional and psychological outcome and the quality of life were evaluated with standardized patients reported outcome measures (PROMs; DASH, SIP-68, EQ-5D-5L and HADS). ResultsAfter a median of 9.4 (range 7.5–12.8) years follow-up, 7 patients (88 %) stated that they would undergo the operation again and were satisfied with the results. At latest follow-up, the median DASH score was 37.3 (range 8.3–61.7), the median SIP-68 score was 6.5 (range 0–43) and the median HADS score was 3.0 (range 0–14) for anxiety and 3.0 (range 1–19) for depression. In the EQ-5D-5L, patients had most difficulties in self-care, usual activities and pain/discomfort. The median overall health status was 69 (range 20–95). DiscussionWith the right indication, a transhumeral amputation is a reasonable option for traumatic complete brachial plexus lesion with satisfying long-term results. Level of evidenceIV, multicenter case series.

Transhumeral amputation in brachial plexus lesion patients: A multicenter case series

BackgroundA flail limb can be the result of a traumatic complete brachial plexus lesion. Some patients prefer retaining the flail limb, however some patients feel that a flail limb negatively affects daily life. In these circumstances an elective amputation is sometimes elected, however long-term follow-up, with respect to satisfaction and function is unknown. The aim of this study is to evaluate the long-term outcome of this rare and life changing operation. Materials and methods8 patients with a transhumeral amputation performed in 2 specialized medical centers were included. Postoperatively, the functional- and psychological outcome and the quality of life were evaluated with standardized patient reported outcome measures (PROMs; DASH, SIP-68, EQ-5D-5L and HADS). ResultsAfter a median of 9.4 (range 7.5 – 12.8) years follow-up, 7 patients (88%) stated that they would undergo the operation again and were satisfied with the results. At latest follow-up the median DASH score was 37.3 (range 8.3-61.7), the median SIP-68 score was 6.5 (range 0-43) and the median HADS score was 3.0 (range 0-14) for anxiety and 3.0 (range 1-19) for depression. In the EQ-5D-5L patients had most difficulties in self-care, usual activities and pain/discomfort. The median overall health status was 69 (range 20-95). DiscussionWith the right indication a transhumeral amputation is a reasonable option for traumatic complete brachial plexus lesion with satisfying long-term results. Level of evidenceIV, multicenter case series.

Structural Changes in Muscle and Glenohumeral Joint Deformity in Neonatal Brachial Plexus Palsy

Internal rotation contracture of the shoulder is common in children with neonatal brachial plexus palsy. A long-standing contracture may cause osseous deformities in the developing shoulder. The purpose of the study was to evaluate the relationship between osseous deformities of the glenohumeral joint and structural differences due to muscle denervation in the rotator cuff muscles. One hundred and two children with residual neonatal brachial plexus palsy underwent magnetic resonance imaging of both shoulders. The glenoid version and posterior, medial, and superior subluxation of the humeral head were measured. The shapes of the glenoid and the humeral head were categorized, and the infraspinatus, supraspinatus, subscapularis, and deltoid muscles were scored as being normal, atrophic, or atrophic with fatty degeneration. Muscle degeneration was most prominent in the subscapularis muscle. Glenoid version correlated with the structural differences in the subscapularis muscle. Posterior subluxation of the humeral head and the shape of the glenoid correlated with all abnormal rotator cuff muscles. Superior humeral subluxation correlated only with changes in the supraspinatus muscle. Medialization and the shape of the humeral head were not associated with atrophic changes of the rotator cuff. Regeneration of the rotator cuff muscles was not significantly different in patients with a C5-C6 (C7) or a complete brachial plexus lesion. However, the changes in glenoid version, the degree of posterior humeral subluxation, and the degree of medial humeral subluxation were significantly more severe in patients with a C5-C6 (C7) lesion compared with those in patients with a complete lesion of the brachial plexus. Structural differences in the rotator cuff muscles alter the direction of the humeral head forces on the developing glenoid fossa and can lead to osseous deformities. Glenohumeral deformities are significantly greater with a C5-C6 (C7) lesion than with a complete brachial plexus lesion in which the large internal rotators are also affected. Reducing the muscular imbalance that occurs with a C5-C6 (C7) lesion could diminish glenohumeral joint incongruency and may improve the outcome of subsequent soft-tissue release or tendon transfer surgery.

Free Functional Gracilis Muscle Transplantation for Reconstruction of Active Elbow Flexion in Posttraumatic Brachial Plexus Lesions

Reconstruction of powerful active elbow flexion. Reconstruction of missing muscle unit by neurovascular pedicled functional muscle transplantation. Treatment of last choice for --secondary reconstruction of active elbow flexion in case of complete lesion of the brachial plexus or musculocutaneous nerve (M0 muscle function = replacement indication), partial but incomplete lesion of the brachial plexus or musculocutaneous nerve (M1-(3) muscle function = augmentation indication); --replacement of the elbow flexor muscles in case of primary muscle loss (tumor, trauma). Concomitant lesions of the axillary artery. No adequate donor nerve. Relative: no sensibility at all at the forearm and hand. Free functional biarticular myocutaneous transplantation of gracilis muscle. A myocutaneous gracilis flap is raised at the thigh. At the upper arm the flap is fixed proximally to the coracoid process or the lateral clavicle. The distal insertion is sutured to the distal biceps tendon. Vascular anastomoses are carried out in end-to-side fashion with the brachial artery and vein. Nerval coaptation is done in end-to-end technique using the muculocutaneous nerve. Complete immobilization for 6 weeks. Dorsal upper arm splint until sufficient muscle power (M(4)). Progressive increase of active range of motion for another 6 weeks. Continuation of physiotherapy for 12-18 months. Postoperative standardized compression therapy, combined with scar therapy (silicone sheet). Functionally useful results can be expected in 60-75% of patients, especially if there is some residual function (M1 or M2) left ("augmentation indication"). Early free functional muscle transplantation shows best results in patients with direct muscle defect, because all vascular and neuronal structures are still available, and no secondary changes such as fibrosis or joint stiffness are present yet. There are inconsistent results for patients with neurologic insufficiency (i.e., total brachial plexus palsy) or mixed neuromuscular insufficiency, such as compartment syndrome. Especially in complete brachial plexus lesion, free functional muscle transfer is often the only treatment option. Provided there is a good patient selection, satisfactory results can be achieved for elbow flexion. Whether a higher number of axons, as provided by the contralateral C7 transfer, will lead to better results is the topic of an ongoing study.

Partial Contralateral C7 Transfer in Adult Brachial Plexus Lesions—Results after Five Years

Within the last decade, contralateral C7 transfer has become a new source of axon donors in complete brachial plexus lesions.

Muscle and Tendon Transfer after Nerve Lesion

Elbow flexion plays a key role in the global function of the upper extremity. In the case of unilateral complete brachial plexus lesion, restoration of elbow flexion will dramatically increase the patient's regaining of bimanual prehension. Furthermore, depending on the type of reconstruction, stability of the glenohumeral joint, as well as some supination function of the forearm, can be restored to varying degrees simultaneously. Depending on the level of brachial plexus lesion and/or reinnervation, different reconstructive procedures are available. In order to select the best treatment option for the patient, it is necessary to know the extent of the lesion of the brachial plexus and/or ventral upper arm muscles.

Secondary operation for elbow flexion reconstruction after brachial plexus lesion.

Elbow flexion plays a key role in the overall function of the upper extremity. In the case of unilateral complete brachial plexus lesion, restoration of elbow flexion will dramatically increase the patient's chances of regaining bimanual prehension. Furthermore, depending on the type of reconstruction, stability of the glenohumeral joint as well as some supination function of the forearm can be restored to a varying degree at the same time. Depending on the level of brachial plexus lesion and/or reinnervation, different reconstructive procedures are available. In order to select the best treatment option for the patient it is necessary to known the extent of the lesion of the brachial plexus and/or ventral upper arm muscles, to time the operation appropriately, to be aware of all treatment possibilities and to recall the special problems of tendon transfer for brachial plexus patients. Our concept is based on our experience with more than 1100 patients presenting a brachial plexus lesion between 1981 and 1996 and treated in our institution. There were 528 operative revisions of the brachial plexus. Some 225 patients underwent secondary muscle/tendon transfers. In 35 patients elbow flexion was reconstructed by bipolar latissimus dorsi transfer (n = 10), triceps-to-biceps transfer (n = 15), modified flexor/pronator muscle mass proximalization (n = 6) and multiple-stage free functional muscle transfer after intercostal nerve transfer (n = 4).

Functional connectivity of the transected brachial plexus after intercostal neurotization in monkeys.

Microsurgical reconstructions of brachial plexuses were performed on twelve monkeys by using ipsilateral intercostal nerves (T3-9). Reinnervation in individual nerves was evaluated monthly by observations of neuromuscular and electromyographic improvements. The electromyographic studies revealed reappearance of motor unit potentials. According to a motor scale ranging from 0 to 4, the mean muscle power 6 months after operation improved to 2.75 in the deltoid muscles, 2 in the biceps muscles, 1.22 in the triceps muscles, 1.13 in the flexor carpi radialis muscles, and 1.6 in the intrinsic muscles of the hands. Retrograde transport of horseradish peroxidase (HRP) from the neuromuscular junctions of the reconstructed musculocutaneous nerves 6 months after complete brachial plexus lesion in four animals demonstrated HRP-labeled neurons in the anterior horns, spinal ganglia and sympathetic ganglia of the thoracic spinal cords. It suggested that the regenerated afferent and efferent circuits in the thoracic cords innervating the transected brachial plexuses were able to generate the movements in the paralyzed upper limbs. However, as evidenced by the behavior patterns and the fact that retrograde-labeled neurons were all found in the thoracic cords, the novel movements observed in the reconstructed brachial plexuses were in synchrony with respiration. These results suggested that the plasticity of central neural networks is limited between two widely separated areas, such as between the midcervical and midthoracic motor cortical areas in the present studies, and therefore, the efforts to reconstruct neural networks, both centrally and peripherally, should aim at rebuilding situations as nearly to the original status as possible.

Secondary replacement operations for reconstruction of elbow joint function after lesion of the brachial plexus

Elbow flexion plays a key role in the overall function of the upper extremity. In the case of unilateral complete brachial plexus lesion, restoration of elbow flexion will dramatically increase the patient's chances of regaining bimanual prehension. Furthermore, depending on the type of reconstruction, stability of the glenohumeral joint as well as some supination function of the forearm can be restored to a varying degree at the same time. Depending on the level of brachial plexus lesion and/or reinnervation, different reconstructive procedures are available. In order to select the best treatment option for the patient it is necessary to known the extent of the lesion of the brachial plexus and/or ventral upper arm muscles, to time the operation appropriately, to be aware of all treatment possibilities and to recall the special problems of tendon transfer for brachial plexus patients. Our concept is based on our experience with more than 1100 patients presenting a brachial plexus lesion between 1981 and 1996 and treated in our institution. There were 528 operative revisions of the brachial plexus. Some 225 patients underwent secondary muscle/tendon transfers. In 35 patients elbow flexion was reconstructed by bipolar latissimus dorsi transfer (n = 10), triceps-to-biceps transfer (n = 15), modified flexor/pronator muscle mass proximalization (n = 6) and the multiple-stage free functional muscle transfer after intercostal nerve transfer (n = 4).

Upper extremity arterial injuries: Experience at the Royal Adelaide Hospital, 1969 to 1991

Purpose: A review of upper extremity arterial injuries managed at the Royal Adelaide Hospital between 1969 and 1991 was undertaken because the optimal management of complex upper extremity trauma, particularly in proximal injuries, remains unclear.Methods: Patients were identified from the computer registry of patients treated by the vascular unit at the Royal Adelaide Hospital. They were studied in three groups: (1) subclavian and axillary artery, (2) brachial artery, and (3) radial and ulnar artery injuries. The mechanism of injury, associated injuries, treatment and outcome were reviewed.Results: There were 114 patients with upper extremity arterial injuries: 28 with subclavian and axillary, 62 with brachial, and 24 with radial and ulnar artery injuries. Good upper limb function was obtained in 32% of subclavian and axillary artery injuries, 79% of brachial artery injuries, and all radial and ulnar artery injuries. Amputation was performed in 14% of the proximal injuries and 8% of the brachial artery injuries. Three deaths occurred in this study group.Conclusion: Blunt proximal injuries were usually associated with neurologic, soft tissue, and bony damage, which was responsible for the poor functional outcome. Critical limb ischemia or severe hemorrhage rarely occurred. Complete brachial plexus lesions resulted in uniformly poor outcomes. More distal injuries were associated with fewer nerve and soft tissue injuries, resulting in a more satisfactory outcome.

The Role of Surgery in the Management of Closed Injuries to the Brachial Plexus

Complete brachial plexus lesions occur infrequently and have until recently been treated by amputation followed by fitting of a prosthesis. The results of such treatment are unsatisfactory. Recently, surgical repair of the plexus has been reintroduced; our experience with complete brachial plexus lesions treated by exploration and nerve grafts are as follows. Early surgical repair of the plexus does produce reasonable results, while late repair is unrewarding. The future of the management of brachial plexus lesions lies in early diagnosis and exploration of these lesions. In medical institutions with personnel interested in the problem of brachial plexus injury, further surgical research is bound to lead to new and improved treatment.

Complete brachial plexus lesions: a ten-year follow-up of twenty cases

Twenty patients with complete brachial plexus lesions were reviewed approximately nine and a half years after injury. Thirteen were amputees and seven had received no surgical treatment. Amputation did not alleviate pain and a prosthesis was frequently of no greater use of the patient than the useless limb it replaced: only two of the thirteen amputees were true prosthetic users and they both had dominant limb involvement, the rest adapting easily to being one-handed. Initial treatment should therefore be conservative, with intensive rehabilitation and retraining. It is recommended that amputation should not be considered until a year after injury and only if the flail limb causes repulsion, prevents sporting activities or if the patient has difficulty in converting to the non-dominant limb. In no instance should smputation be done for relief of pain.

Successful repair of a complete brachial plexus lesion

A case of a complete brachial plexus lesion and partial axillary artery division is described, which was satisfactorily treated by operation. A case of a complete brachial plexus lesion and partial axillary artery division is described, which was satisfactorily treated by operation.