Adult Plexus Injuries Research Articles

Traumatic Bilateral Brachial Plexus Injuries in an Adult: A Conservative Approach

Background and Aims: Traumatic bilateral brachial plexus injuries in adults are rare and present unique challenges in management. We report a case of a 21-year-old veterinary student who sustained bilateral brachial plexus injuries following a fall from a moving two-wheeler. Case Presentation: The patient suffered a C5,6 brachial plexus injury on the right side and a C5–7 injury on the left side. Remarkably, the right-sided injury showed signs of recovery after four months, while the left-sided injury took seven months to resolve completely. Despite the severity of the injuries, the patient underwent a conservative approach and did not undergo any surgical intervention. Results: Following months of dedicated rehabilitation, the patient achieved significant recovery and was able to return to her veterinary studies. This case highlights the potential for recovery in traumatic bilateral brachial plexus injuries with conservative management, emphasising the importance of patient-specific treatment strategies and rehabilitation protocols. Conclusion: Conservative management can lead to significant recovery in traumatic bilateral brachial plexus injuries. Patient-specific treatment strategies and dedicated rehabilitation are crucial components of successful outcomes in such cases.

457 Timing of Surgery as an Outcome Predictor in Brachial Plexus Injury: A Systematic Review and Meta-Analysis

INTRODUCTION: Injuries that affect the brachial plexus are considered to have a high impact on the quality of life of patients. Brachial plexus injuries in adults require reconstruction using microsurgical techniques. At least, there is still controversy about the impact of the timing of surgical reconstruction and its effect on outcome. METHODS: We searched PubMed, EMBASE, Cochrane Library, SCOPUS, and MEDLINE, up to March 2023, for published studies on evidence of timing of surgery in Brachial plexus injury and neurological outcome. Primary outcome Good motor functional Recovery (MRC). RESULTS: In this meta-analysis, it was found that early surgical treatment before 6 months post-injury increases motor recovery (MRC) three times more than late intervention (after 6 months) with adequate statistical significance and good homogeneity (OR 3,115 [95% CI 2,248–4,317] p = <0.0001; I2 = <0.00001%). CONCLUSIONS: The available evidence suggests that performing brachial plexus surgery in less than 6 months can be associated with a better outcome. Further research is needed to characterize various subgroups of BPI patients. It is necessary to improve the quality of the evidence, so we suggest the creation of a multicenter database in the United States that allows us to obtain better conclusions.

Restoration of Grasp after Single-Stage Free Functioning Gracilis Muscle Transfer in Traumatic Adult Pan-Brachial Plexus Injury.

A variety of approaches have been described to obtain rudimentary grasp after traumatic pan-brachial plexus injury in adults. The aim of this study is to evaluate hand prehension after a gracilis single-stage free functioning muscle transfer. Twenty-seven patients who underwent gracilis single-stage free functioning muscle transfer for elbow flexion and hand prehension after a pan-plexus injury were included. All patients presented with a minimum of 2 years of follow-up. Postoperative finger flexion, elbow flexion strength, preoperative and postoperative Disability of the Arm, Shoulder, and Hand questionnaire scores, secondary hand procedures, complications, and demographic characteristics were analyzed. Twenty patients (74%) demonstrated active finger pull-through. Only six patients (25%) considered their hand function useful for daily activities. Disability of the Arm, Shoulder, and Hand score improved by 13.1 ± 13.7 ( P < 0.005). All patients were expected to require one secondary procedure (wrist fusion, thumb carpometacarpal fusion, and/or thumb interphalangeal fusion) because no extensor reconstruction was performed. These were performed in 89%, 78%, and 74% of patients, respectively. Four postoperative complications (hematoma, seroma, wound dehiscence, and skin paddle loss) occurred. No flap loss occurred. In pan-plexus injuries, the use of a gracilis single-stage free functioning muscle transfer is an alternative to the double free functioning muscle transfer procedure and contralateral C7 transfer, especially for patients who are unable to undergo two to three important operations in a short period of time. Further research and studies are required to improve hand function in these patients. Therapeutic, IV.

Daily Life Impact of Brachial Plexus Reconstruction in Adults: 10 Years Follow-Up

Reconstructive surgery of brachial plexus injury in adults remains a challenge. Short- and midterm follow-up results have been described in terms of impairments, such as muscle strength grading. However, psychologic management has been shown to be a major contributor in long-term results. A new, specific brachial plexus injury scale, including functional and psychologic components, was described. Objectives of this study were: (1) to assess functional long-term brachial plexus reconstruction outcomes; and (2) to validate the Mancuso scale at 10 years of follow-up. Twenty patients with at least 10 years of follow-up were included in the study. Four patients had C5-C6 palsy and 16 had a C5-T1 injury. Shoulder abduction and elbow flexion were assessed with Medical Research Council grades. Shoulder function was evaluated with a Constant score. The 36-item short-form survey (SF36) was used to assess quality of life, and the quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) was used for patient reports of disability. The Mancuso scale was assessed and correlated to the different scores used. At the last follow-up, the Medical Research Council grade was at least grade 3 in 10 cases (50%) of shoulder abduction and in 12 cases (60%) of elbow flexion. The Constant score was 31.4 (SD, 15.1). The SF36 score was 67.5 (SD, 4.25) and the QuickDASH was 50 (SD, 15.9). We found a correlation between the symptom score (Mancuso score) and the different quality-of-life scores (QuickDASH: coefficient, 0.491; SF36: coefficient,-0.565; limitations score: coefficient, 0.445). This study reported results from the Mancuso scale at a minimum of 10 years of follow-up of reconstructive surgery for brachial plexus injury in adults. Correlations between this composite scale and the SF36 and QuickDASH scores suggest construct validity. Therapeutic IV.

Indications for amputation after traumatic brachial plexus injury in adults: Case report and review of new prosthetic technologies

Hand amputation can be discussed after traumatic brachial plexus injury when the patient’s hand is non-functional, painful and/or insensitive. That indication is more common in English-speaking countries than in European or Latin countries. New prostheses are now on the market and can be used after hand amputation to improve the functional prognosis in well-selected patients. A 26-year-old male was involved in a road accident in January 2016. He had a traumatic brachial plexus injury and underwent nerve surgery to restore the biceps brachii and triceps brachii. One year after nerve transfer, his hand was insensitive and non- functional. After multidisciplinary consultation, it was decided to amputate his hand to replace it with a myoelectric prosthesis. Shoulder subluxation pain and complications associated with an insensitive and heavy arm were improved after hand amputation. Functional outcomes were improved with this revolutionary myoelectric prosthesis technique. The patient was able to use his prosthesis for many daily activities. Selective amputation indications after traumatic brachial plexus injury are a heavy and stiff arm with shoulder subluxation pain and an unusable claw hand. The patient’s motivation must be high.

The influence of shoulder arthrodesis on the function of the upper limb in adult patients after a brachial plexus injury: a systematic literature review with elements of meta-analysis.

Based on the literature, 294 shoulder arthrodeses after brachial plexus injury in adults were assessed, mostly male; the mean age of the patients was 33 years, and the mean follow-up time was 5.5 years. The most common cause of injury was a traffic accident, especially on a motorcycle.Arthrodesis position ranged from 15 to 40 degrees of flexion, 15 to 60 degrees of abduction, and 0 to 50 degrees of internal rotation with the predominance of position by the 30-30-30 rule. Plates, screws, and external fixation were used for stabilization. The complication rate was at the level of 28%, the most common complication being delayed union or nonunion.Active movements of flexion and abduction averaged 61 and 56 degrees, respectively, while reaching the hand to the mouth, front pocket, and buttock was feasible for 69%, 71%, and 38%, respectively, after surgery. Shoulder pain was present in 77% of patients, and 28% experienced no relevant pain reduction after surgery. The subjective satisfaction rate was 82% based on significant improvement and satisfaction reported by patients after arthrodesis.Arthrodesis of the shoulder, in adult patients after brachial plexus palsy, can reduce shoulder pain, increase stability, and result in a range of motion that increases the possibility of carrying out everyday activities. This affects the high level of subjective patient satisfaction after surgery. Cite this article: EFORT Open Rev 2021;6:797-807. DOI: 10.1302/2058-5241.6.200114

Surgical procedure to restore shoulder external rotation in post-traumatic brachial plexus lesions in adults

The lack of active external rotation following a brachial plexus injury in adults is very disabling and very challenging to solve. If direct nerve surgery or nerve transfer fails or if the patient is seen too late, palliative surgery is the last resort. Shoulder fusion can stabilize the joint to increase strength at the elbow, but the patient loses all external rotation. A metaphyseal humeral osteotomy shifts the sector of mobility to push out the arm from the chest but does not restore any active external rotation. Latissimus dorsi and teres major transfers are not indicated in traumatic brachial plexus injuries. Lower trapezius (inferior fibers of the trapezius) transfer detached from the medial angle of the scapula and fixed to the infraspinatus tendon is the main option in paralyzed shoulders. It can restore 90° external rotation on average. This tendon transfer is an agonist, with the same direction but with less excursion and strength. If this muscle is paralyzed (nerve lesion), one can harvest and transfer the contralateral lower trapezius instead. The goals of this paper are to describe the surgical technique for these two tendons transfer, their indications and results.

Physical therapeutic treatment for traumatic brachial plexus injury in adults: A scoping review.

Traumatic brachial plexus injury (BPI) is one of the most disabling injuries of the upper extremity, often requiring specialized treatment and a prolonged rehabilitation period. This scoping review was carried out to identify and describe the physical therapy modalities applied in the rehabilitation of adult individuals with BPI. Electronic databases, gray literature, and reference lists were searched, and studies meeting the following eligibility criteria were included: (a) interventions including any physical therapy modality; (b) individuals age ≥18 years old; and (c) a clinical diagnosis of BPI. The literature search yielded 681 articles of which 49 met the inclusion criteria and had their outcomes, treatment parameters, and the differences between conservative and pre- and postoperative treatment phases analyzed. The most commonly used physical therapy interventions were in the subfields of kinesiotherapy (ie, involving range of motion exercises, muscle stretching, and strengthening), electrothermal and phototherapy, manual therapy, and sensory re-education strategies. Although several physical therapy modalities were identified for the treatment of BPI in this scoping review, the combination of low levels of evidence and the identified gaps regarding the treatment parameters challenge the reproducibility of such treatments in clinical practice. Therefore, future controlled clinical trials with clearer treatment protocols for individuals with BPI are needed.

Brachial Plexus Injuries in Adults with Traumatic Brain Injury : A Retrospective Study.

ObjectiveWe aimed to investigate the presence of brachial plexus injury (BPI) in traumatic brain injury (TBI) patients and to draw attention to BPI, which can be overlooked by physicians in TBI patients. MethodsThe study was designed retrospectively by examining the files of 58 patients with moderate to severe TBI to investigate coexistence of TBI and BPI. ResultsBPI was detected in six of 58 TBI patients (10.3%). BPI was detected after an average 116 days from the initial injury. Three patients had lower trunk BPI and three patients had panplexopathy. ConclusionDiagnosis of BPI in patients with TBI is delayed in the acute period of injury. The clinicians should keep in mind that BPIs may occur and remain undiagnosed in patients with TBI.

Functional outcome predictors after spinal accessory nerve to suprascapular nerve transfer for restoration of shoulder abduction in traumatic brachial plexus injuries in adults: the effect of time from injury to surgery.

Shoulder abduction is crucial for daily activities, and its restoration is one of the surgical priorities. We evaluated the predictive factors of shoulder abduction functional outcome after spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, with special emphasis on the effect of time from injury to the surgery, in the treatment of traumatic brachial plexus injuries. This cohort included adult patients who underwent SAN-to-SSN transfer with a preoperative Medical Research Council strength grade 0 and a follow-up of minimum 18months. The primary outcome was shoulder abduction function (bad, < 30°; good, 30°-60°; or excellent, > 60°). Demographics, trauma characteristics, time lapse between injury and surgery, concomitant axillary nerve reconstruction, and surgery duration were registered. Ordinal logistic regression was used to identify predictors of functional outcomes. The records of 83 patients (86.7% men, mean age 28.8 ± 9.8years) were analysed. Mean body mass index was 24.1 ± 3.7kg/m2, and 43.1% were overweight/obese. Motorcycle crashes were the most common trauma mechanism (88.0%). Excellent, good, and bad outcomes were achieved by 20.4%, 38.6%, and 41.0%, respectively. Older patients tended to have worse outcomes (p = 0.074), as well as left-sided lesions (p = 0.015) or those contralateral to manual dominance (p = 0.057). The longer the interval between injury and surgery the worse the outcome: excellent, 5.5 (4.3-7.1); good, 6.9 (5.9-8.7); and bad, 8.2 (5.7-10.1) months (p = 0.018). After multivariable analysis, longer time interval predicted lower odds of better outcomes (OR 0.823, 95% CI 0.699-0.970, p = 0.020; 17.7% lower odds of good or excellent outcome for each additional month). The odd of good or excellent outcomes was also associated with axillary nerve reconstruction (OR 2.767, 95% CI 1.016-7.536, p = 0.046), but not with age or lesion laterality. Excellent or good functional outcomes for shoulder abduction were achieved by almost sixty percent of adults who underwent SAN-to-SSN transfer for reconstruction of traumatic brachial plexus injuries, associated or not with axillary nerve reconstruction strategies. Longer delays from injury to surgery predicted worse outcomes, and the best time frame seemed to be less than 6months.

Management of Birth Brachial Plexus Injury Including Use of Distal Nerve Transfers

Birth Brachial plexus injury continues to remain a problem despite significant care from obstetricians to prevent it. Many children show spontaneous recovery but a significant proportion do not have adequate recovery. This review article discusses, etiology, assessment, investigations and overall strategy to treat the condition. Surgical strategy consists of primary intraplexal repair as the standard of care but of late the distal nerve transfers used in adult plexus injuries are increasingly being used in infants too. We discuss the history, current usage and pros and cons of distal nerve transfers, the usage of Botulinum Toxin and finally given an overall algorithm for the management.

Diagnosis and management of adult BPI: Results of first 50 cases

IntroductionCommonest cause of brachial plexus injury in adults is traction injury sustained in motorcycle accidents. This article reports the results of first 50 cases done in a tertiary referral center with a brief review of literature. Material and methodsFirst 50 patients (46 male; 4 female, age from 12 to 45 years) with post traumatic brachial plexus palsy were included. There were 30 upper plexus and 20 pan plexus injuries, 27 had preganglionic and 23 postganglionic injury. Neurolysis was done in 19 patients and various combination of nerve transfer in 31. Mean follow-up period was 13.98 months. Results– Over all shoulder abduction was good in 10 patients, fair in 32 and poor in 8. Elbow flexion was good in 19 patients, fair in 18 and poor in 13 patients. ConclusionThe upper plexus and partial injuries have a good outcome in a majority of cases, while the results in global palsy are far from satisfactory.

Feasibility of the Oberlin Procedure in Late Presentation Cases of C5-C6 and C5-C7 Brachial Plexus Injuries in Adults.

Background: Oberlin et al presented a new technique for nerve transfer that completely changed the prognosis of patients with brachial plexus injury. Currently, most of the literature addresses cases submitted to early surgical intervention, before 12 months from injury, showing consistent good results. The aim of this study was to evaluate the feasibility of the Oberlin procedure in late presentation cases (≥12 months), comparing the elbow flexion strength with patients operated earlier. Methods: We retrospectively reviewed 49 patients with partial brachial plexus injuries submitted to the Oberlin procedure. They were divided into 2 groups. Group A included 39 patients operated with <12 months of injury. The mean postoperative follow-up was 22.53 months. The interval from injury to surgery varied from 4 to 11 months (±8.45 months). Group B included 10 patients with surgery ≥12 months after injury. The mean postoperative follow-up was 32 months. The interval from injury to surgery ranged from 12 to 19 months (±15.4 months). Patients were evaluated monthly after surgery and the elbow flexion strength was measured using the British Medical Research Council scale. Results: In Group A, 24 patients presented with either good (M3) or excellent (M4) elbow flexion strength. In Group B, 9 patients presented with either good (M3) or excellent (M4) elbow flexion strength. A significant difference was not seen in the postoperative elbow flexion strength among the 2 groups. Conclusion: Biceps reinnervation with the Oberlin procedure is still feasible and should be attempted after more than 12 months of injury in partial brachial plexus injuries.

GRACILIS MUSCLE TRANSFER TO ELBOW FLEXION IN BRACHIAL PLEXUS INJURIES.

ABSTRACTObjective: Brachial plexus injury can lead to significant functional deficit for the patient. Elbow flexion restoration is a priority in surgical treatment. Free functional muscle transfer is an option for early or late treatment failure. This study evaluated patient characteristics and elbow flexion muscle strength after gracilis functioning muscle transfer.Methods: Medical records of 95 patients operated from 2003 to 2019 were analyzed and the following variables recorded: age, gender, nerve transfer used to motorize the gracilis muscle, time between trauma and surgery, age at surgery and elbow flexion strength after a minimum of 12 months following functioning muscle transfer.Results: 87 patients were included, averaging 30 years of age (17 to 57 years). Fifty-five achieved elbow flexion muscle strength ≥ M3 (55/87, 65%), with a mean follow-up of 37 months. The nerves used for activation of the transferred gracilis were: 45 spinal accessory, 10 intercostal, 8 median n. fascicles, 22 ulnar n. fascicles and 2 phrenic nerves.Conclusion: Functional muscle transfer is a viable surgical procedure for elbow flexion in chronic traumatic brachial plexus injuries in adults. Level of Evidence II, Retrospective study.

Brachial Plexus Injuries in Adults: Guidelines and Management in our Experience

According to the data published in current medical literatures, brachial plexus injuries affect slightly more than 1 % of multi-trauma patients. Motorcycle accidents were the leading cause associated with the occurrence of these lesions that often lead to severe disability mostly in young individuals. The vast majority of these patients were young males between 15 and 35 years. After the injury, approximately 95% of these patients suffer from excruciating pain that poses an additional burden on the quality of life, already disrupted by the functional impairment of the upper limb. Despite the statistical rarity, brachial plexus injuries clearly have a remarkable impact on the community. Today with new techniques in the role of surgical procedures, the quality of life of many of these patients can be improved especially in partial lesions allowing functional recovery, rescuing these young individuals from disability and improving their lifestyle. Early diagnostic assessment with prompt referral to the surgeon is crucial to obtain a positive outcome. Physiotherapy plays a vital role in the rehabilitation process. The Author aims to illustrate guidelines in the management and surgical treatment of brachial plexus injuries as gained in over 20 years of experience in medical practice.

Early nerve repair in traumatic brachial plexus injuries in adults: treatment algorithm and first experiences.

The object of this study was to assess the advantages and disadvantages of early nerve repair within 2 weeks following adult traumatic brachial plexus injury (ATBPI). From 2009 onwards, the authors have strived to repair as early as possible extended C-5 to C-8 or T-1 lesions or complete loss of C-5 to C-6 or C-7 function in patients in whom there was clinical and radiological suspicion of root avulsion. Among a group of 36 patients surgically treated in the period between 2009 and 2011, surgical findings in those who had undergone treatment within 2 weeks after trauma were retrospectively compared with results in those who had undergone delayed treatment. The result of biceps muscle reanimation was the primary outcome measure. Five of the 36 patients were referred within 2 weeks after trauma and were eligible for early surgery. Nerve ruptures and/or avulsions were found in all early cases of surgery. The advantages of early surgery are as follows: no scar formation, easy anatomical identification, and gap length reduction. Disadvantages include less-clear demarcation of vital nerve tissue and unfamiliarity with the interpretation of frozen-section examination findings. All 5 early-treatment patients recovered a biceps force rated Medical Research Council grade 4. Preliminary results of nerve repair within 2 weeks of ATBPI are encouraging, and the benefits outweigh the drawbacks. The authors propose a decision algorithm to select patients eligible for early surgery. Referral standards for patients with ATBPI must be adapted to enable early surgery.

Brachial Plexus Injury in Adults

Brachial Plexus Injury in Adults

Surgical Options for Brachial Plexus Injury in Adults

Surgical Options for Brachial Plexus Injury in Adults

Triceps to biceps transfer for restoration of elbow flexion following upper brachial plexus injury.

Introduction:Upper brachial plexus injury in adults causes loss of elbow fl exion; when the primary nerve surgery has failed or the patient seeks treatment after 12 months of injury and pedicled muscle transfers are required. Most commonly, the latissimus dorsi or the Steindler flexorplasty is used.Material and Methods:We have transferred one of the heads of triceps muscle to restore the elbow flexion in such cases. In addition to return of elbow flexion, extension of elbow following surgery is retained. Ten patients suffering from upper brachial plexus injuries underwent transfer of one head of triceps to biceps tendon between December 2011 and August 2015.Results:The recovery of elbow flexion was Grade 5 in 1, Grade 4 in 4 and Grade 3 in 2; only three of the ten patients had no functionally useful elbow flexion. Seven of the ten patients had an adequate elbow extension following the procedure.

Brachial plexus injuries in adults

As the number of survivors of motor vehicle accidents and extreme sporting accidents increases, more people must live with brachial plexus injuries. Brachial plexus injuries also occur in multiple trauma patients and can be debilitating. Although the injured limb will never return to normal, an impr...