Repair Of Brachial Plexus Injury Research Articles

Surgical Approach to Brachial Plexus Root Repair: A Case Study with Literature Review

This article presents a clinical case study of a 32-year-old patient with brachial plexus trauma following a motorcycle accident, as well as a review of the relevant literature on surgical approaches to brachial plexus root repair. The case study highlights the patient's symptoms, initial assessments, further investigations, surgical management, and post-operative results. The literature review synthesizes the main surgical approaches used in the repair of brachial plexus injuries, highlighting direct root repair techniques, nerve grafts, nerve transfers, as well as their results and complications. This study contributes to the body of knowledge on surgical options for brachial plexus injuries, highlighting the importance of post-operative rehabilitation and long- term follow-up in improving patients' functional recovery.

The Brachial Plexus: More and More Variations

The brachial plexus is so variable that most of dissected cases will show some form of anatomical variations. In the same person, the right and left sides are not the same. This study was done to identify the variations of the brachial plexus and highlight their clinical significance. The materials of this study included 10 cadavers dissected on both sides to find out the variations of the different parts of the plexus. Variations were found in 85% of cases. Variations included all stages of the plexus. Phrenic nerve took origin from the upper trunk in 10%, while the lateral pectoral nerve took origin by 2 roots from the upper and middle trunks or from the lateral and medial cords in 40%. Abnormal communications were found between the trunks, cords, or branches. Abnormal relations were found between the trunks, cords, or branches and the subclavian or axillary arteries. It is essential to know the exact anatomy of the brachial plexus prior to surgical repair of brachial plexus injuries or prior to supra or infraclavicular plexus block. Variations of brachial plexus are so common. Researchers have been trying for so long to assign specific patternsfor brachial plexus. Their efforts were inutile and now is the time to acknowledge anatomical variations of brachial plexus as the rule.

Retracted: Overexpression of Neuregulin-1 (NRG-1) Gene Contributes to Surgical Repair of Brachial Plexus Injury After Contralateral C7 Nerve Root Transfer in Rats

Retracted on the author's request: "We would like to withdraw our manuscript. We restarted the project for further study last year, we found that the results in this study are not solid enough and need to be further explored." Reference: Zong-Qiang Wang, Dian-Hui Xiu, Gui-Feng Liu, Jin-Lan Jiang. Overexpression of Neuregulin-1 (NRG-1) Gene Contributes to Surgical Repair of Brachial Plexus Injury After Contralateral C7 Nerve Root Transfer in Rats.Med Sci Monit 2018; 24: 5779-5787; DOI: 10.12659/MSM.908144.

Effect of Stellate Ganglion Block on Intraoperative Propofol and Fentanyl Consumption in Patients with Complex Regional Pain Syndrome Undergoing Surgical Repair of Brachial Plexus Injury: A Randomized, Double-blind, Placebo-controlled Trial.

Stellate ganglion block (SGB) is commonly performed to treat chronic painful conditions, such as complex regional pain syndrome (CRPS) and postherpetic neuralgia. However, whether it is effective in reducing anesthesia and analgesia requirement during surgery (acute pain) is not known. Sixty American Society of Anesthesiologists (ASA) physical status I and II patients with CRPS type II undergoing surgery for repair of brachial plexus injury were randomized (1:1) to receive SGB with either 10 mL of 0.5% bupivacaine (Group B) or a matching placebo (Group S) before induction of anesthesia. There was a significant reduction in the requirement of total intraoperative propofol (1659.7 ± 787.5 vs. 2500.7 ± 740.9 mg, P = 0.0003) and fentanyl (190.0 ± 82.5 vs. 327.3 ± 139.3, P = 0.0001) in Group B compared with Group S. Similarly, in Group B, the time to first analgesic was much longer (328 ± 219 vs. 64 ± 116 min, P = 0.000) and postoperative fentanyl requirement for 24 h was lesser compared to Group S (0.6 ± 1.1 vs. 2.1 ± 1.3 μg/kg, P = 0.000). SGB is effective in reducing the requirement of intraoperative propofol and fentanyl as well as decreasing opioid requirement in the postoperative period in patients with CRPS type II undergoing surgery.

Overexpression of Neuregulin-1 (NRG-1) Gene Contributes to Surgical Repair of Brachial Plexus Injury After Contralateral C7 Nerve Root Transfer in Rats.

BackgroundSurgeons usually transfer the contralateral C7 to the median nerve on the injured side via a nerve graft to recover sensation and movement in a paralyzed hand. The purpose of our study was to determine whether NRG-1 affects the recovery of nerve function in brachial plexus injury after contralateral C7 nerve root transfer in a rat model.Material/MethodsAn injury model of left brachial plexus and contralateral C7 nerve root transfer was established. Four weeks after the operation, NRG-1 expression was examined by reverse transcription quantitative polymerase chain reaction and Western blot analysis. The diameter rate differences of the healthy limb and affected limb were estimated. The postoperative mass of the left latissimus dorsi, triceps, extensor carpi radialis brevis, and musculus extensor digitorum were examined. The number of nerve fibers and typical area of the affected side were assessed. Postoperative left motor nerve conduction velocity (MNCV) and motor nerve action potential (MNAP) were tested by use of a biological information recording and collecting system.ResultsEukaryotic expression plasmid of pcDNA4/myc/A-NRG-1 was successfully constructed, and NRG-1 was overexpressed. Compared with the model group, the NRG-1 group had a lower rate of differences of the limbs; higher mass of left latissimus dorsi, triceps, extensor carpi radialis brevis, and musculus extensor digitorum; more nerve fibers and larger typical area in the affected side, left MNCV, and MNAP; and wider CSA of the left triceps.ConclusionsThese results demonstrated that NRG-1 can promote recovery of nerve function in brachial plexus injury after contralateral C7 nerve root transfer in rats.

Upper limb nerve transfers: A review

While upper limb nerve transfers were first described and performed several years ago, they have seen expanded use in the past 20 years. Initially indicated for surgical repair of brachial plexus injuries with nerve root avulsion, the indications have been extended to post-ganglionic lesions because of the excellent results of certain intraplexus nerve transfers. The traditional nerve repair techniques – primary suture and nerve grafting – form the basis of nerve surgery. Although nerve transfer does not replace them, they are a useful supplement as they provide a targeted approach to reinnervation and recovery of key functions of the upper limb. The goal of this review is to provide an overview of the various possible transfers by the function being restored and the quality of the outcomes.

Brachial plexus injury: are we doing enogh?

Introduction and Objective: Repair of Brachial plexus injury is a neglected art in developing countries like ours. We discuss here various case scenarios managed at our centre and the challenges involved.Materials and Methods: Cases with brachial plexus injury attending our OPD were included in this study. Different neurotisation and repair techniques were used depending on the situations. Outcome in form of improvement in function and relief of pain were evaluated.Results: During last 5 year (July 2010 to September 2015), 100 patients with brachial plexus injury were evaluated in our outpatient OPD. Majority of them were too late to be offered any treatment. 20% patients had neuropraxia and were managed conservatively. 41 patients were operated. 19 were complete brachial plexus injury and underwent extraplexal neurotisation procedures. 11 were partial brachial plexus injury and had intraplexal neurotisation procedures. Neurolysis were done as required. 11 case of peripheral nerve injury was managed with direct repair and neurolysis. Almost all patients with neuropraxia had good recovery in follow up. Patients who underwent surgical intervention had good recovery in terms of recovery recovery of function and relief of pain.Conclusion: Due to lack of awareness and socioeconomic reasons, majority of nepalese people approach very late for surgical options. Benefit of the brachial plexus repair depends upon factors like type of injury, timing of intervention, surgical technique and post operative follow up. We had good outcome in our patients who came early and continued on follow up.

Phrenic nerve transfer to the musculocutaneous nerve for the repair of brachial plexus injury: electrophysiological characteristics.

Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we performed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduction function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regenerated potentials first appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering ‘excellent’ and ‘good’ muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The functional recovery of a transplanted nerve can be dynamically observed after the surgery.

Contralateral C7 transfer to lower trunk via the prespinal route in the repair of brachial plexus injury: An experimental study in rats

Contralateral C7 (cC7) root transfer to reconstruct brachial plexus injury (BPI) has been widely used. A revised technique that cC7 root was transferred to lower trunk via the prespinal route with direct neurorrhaphy has been reported clinically. The aim of this experimental study was to develop an animal model of the modified surgical approach in order to obtain quantification index of postoperative nerve regeneration and muscle morphology. Sixty adult Sprague-Dawley rats randomized into experimental and control groups of 30 each. In the experimental group, after total brachial plexus injury (BPI) the cC7 root was transferred to lower trunk via the prespinal route with direct neurorrhaphy, and in the control group the brachial plexus was only exposed without intervention. Electrophysiological study, muscle tension test, neuromorphology, muscle wet weight, and muscle fiber cross-sectional area measurements were obtained 4, 8, and 12 weeks postoperatively. Median and ulnar nerve regeneration and the forearm flexor muscles functional recovery were obtained by cC7 root transfer to lower trunk via the prespinal route when measured at 12 weeks following the operation though the parameters had not recovered to normal value. We concealed the control and experimental groups from those who did the evaluations.

Nerve transfer helps repair brachial plexus injury by increasing cerebral cortical plasticity

In the treatment of brachial plexus injury, nerves that are functionally less important are transferred onto the distal ends of damaged crucial nerves to help recover neuromuscular function in the target region. For example, intercostal nerves are transferred onto axillary nerves, and accessory nerves are transferred onto suprascapular nerves, the phrenic nerve is transferred onto the musculocutaneous nerves, and the contralateral C7 nerve is transferred onto the median or radial nerves. Nerve transfer has become a major method for reconstructing the brachial plexus after avulsion injury. Many experiments have shown that nerve transfers for treatment of brachial plexus injury can help reconstruct cerebral cortical function and increase cortical plasticity. In this review article, we summarize the recent progress in the use of diverse nerve transfer methods for the repair of brachial plexus injury, and we discuss the impact of nerve transfer on cerebral cortical plasticity after brachial plexus injury.

Restoration and protection of brachial plexus injury: hot topics in the last decade.

Brachial plexus injury is frequently induced by injuries, accidents or birth trauma. Upper limb function may be partially or totally lost after injury, or left permanently disabled. With the development of various medical technologies, different types of interventions are used, but their effectiveness is wide ranging. Many repair methods have phasic characteristics, i.e., repairs are done in different phases. This study explored research progress and hot topic methods for protection after brachial plexus injury, by analyzing 1,797 articles concerning the repair of brachial plexus injuries, published between 2004 and 2013 and indexed by the Science Citation Index database. Results revealed that there are many methods used to repair brachial plexus injury, and their effects are varied. Intervention methods include nerve transfer surgery, electrical stimulation, cell transplantation, neurotrophic factor therapy and drug treatment. Therapeutic methods in this field change according to the hot topic of research.

Transplantation of human amniotic epithelial cells repairs brachial plexus injury: pathological and biomechanical analyses.

A brachial plexus injury model was established in rabbits by stretching the C6 nerve root. Immediately after the stretching, a suspension of human amniotic epithelial cells was injected into the injured brachial plexus. The results of tensile mechanical testing of the brachial plexus showed that the tensile elastic limit strain, elastic limit stress, maximum stress, and maximum strain of the injured brachial plexuses were significantly increased at 24 weeks after the injection. The treatment clearly improved the pathological morphology of the injured brachial plexus nerve, as seen by hematoxylin eosin staining, and the functions of the rabbit forepaw were restored. These data indicate that the injection of human amniotic epithelial cells contributed to the repair of brachial plexus injury, and that this technique may transform into current clinical treatment strategies.

Efficacy and effect of TIVA with propofol or dexmedetomidine versus sevoflurane without muscle relaxant during repair of the brachial plexus

BackgroundTotal intravenous anesthesia (TIVA) versus inhalational anesthesia was selected as the anesthetic method, in order to avoid the use of muscle relaxants during repair of brachial plexus injury. We designed this study to determine effect and efficacy of TIVA versus sevoflurane during repair of brachial plexus injury.MethodsSixty patients scheduled for repair of injured brachial plexus from January 2009 till December 2011 were enrolled in this prospective, single-blind, randomized study. They received either inhalation induction with sevoflurane and maintenance with sevoflurane and fentanyl (Group 1) or TIVA with, propofol and fentanyl (Group 2) or TIVA with dexmedetomidine and fentanyl (Group 3). Hemodynamics, intubation conditions, sedation score were assessed. Postoperative pain using visual analogue scale (VAS) was assessed. Discharge time, postoperative respiratory condition, any postoperative complications were recorded.ResultsAll groups provided a similar significant reduction in hemodynamics compared with baseline values. Respiratory rate values of dexmedetomidine–fentanyl group were significantly higher than those in other groups. Oxygen saturation values of dexmedetomidine–fentanyl group were significantly higher than those of propofol–fentanyl group. Time to reach an Aldrete score of 10 was similar in all groups. Patients in sevoflurane–fentanyl group have significantly higher visual analogue score than other groups. Sedation score was higher in the dexmedetomidine–fentanyl group.ConclusionTIVA with propofol and with dexmedetomidine was more effective and favorable anesthesia than sevoflurane anesthesia during repair of brachial plexus injury.

NERVE TRANSFER SURGERY FOR ADULT BRACHIAL PLEXUS INJURY

To review the clinical outcomes in our patients who have undergone nerve transfer operations for brachial plexus reconstruction at the Louisiana State University (LSU) over a 10-year period. A secondary objective is to compare clinical outcomes in patients who had only nerve transfer operations as compared with patients whose nerve transfers were supplemented with direct repair of brachial plexus elements. Retrospective review of the medical records, imaging, and electrodiagnostic studies (electromyographic and nerve conduction studies) of patients with brachial plexus injuries who underwent nerve transfer operations at LSU over a period of 10 years. A total of 81 patients were treated between 1995 to 2005 at the LSU Health Sciences Center; 7 of these patients were lost to follow-up, leaving 74 patients, with an average follow-up of 3.5 years, for review. We evaluated recovery of elbow flexion and shoulder abduction. Ninety percent of patients with medial pectoral to musculocutaneous nerve transfers recovered to LSU grade 2 (Medical Research Council grade 3), and 60% of those patients with intercostal to musculocutaneous nerve transfer regained similar strength in elbow flexion. Shoulder abduction recovery to LSU grade 2 (Medical Research Council grade 3) after spinal accessory to suprascapular and/or thoracodorsal to axillary nerve transfer, was 95% and 36%, respectively. There was a tendency for better motor recovery when nerve transfer operations were combined with direct repair of plexus elements. Nerve transfers for repair of brachial plexus injuries result in excellent recovery of elbow and shoulder functions. Patients who had direct repair of brachial plexus elements in addition to nerve transfers tended to do better than those who had only nerve transfer operations.

Restoration of hand function in a rat model of repair of brachial plexus injury

The incurability of spinal cord injury and subcortical strokes is due to the inability of nerve fibres to regenerate. One of the clearest clinical situations where failure of regeneration leads to a permanent functional deficit is avulsion of the brachial plexus. In current practice, surgical re-implantation of avulsed spinal roots provides a degree of motor recovery, but the patients neither recover sensation nor the use of the hand. In the present rat study, we show that transplantation of cultured adult olfactory ensheathing cells restores the sensory input needed for a complex, goal-directed fore-paw function and re-establishes synaptic transmission to the spinal grey matter and cuneate nucleus by providing a bridge for regeneration of severed dorsal root fibres into the spinal cord. Success in a first application of human olfactory ensheathing cells in clinical brachial plexus injury would open the way to the wider field of brain and spinal cord injuries.

AN EXPERIMENTAL MODEL OF VENTRAL ROOT REPAIR SHOWING THE BENEFICIAL EFFECT OF TRANSPLANTING OLFACTORY ENSHEATHING CELLS

A series of published cases show that repair of brachial plexus injuries by reimplantation of avulsed spinal roots can restore a degree of recovery, particularly to the more proximal shoulder and arm musculature in a proportion of patients. There remains, however, some disagreement regarding how far the benefits outweigh the risks of causing further spinal cord damage. Improving the number of motor fibers regenerating into the reimplanted ventral roots may enhance the muscular recovery, possibly extending it to the more useful distal musculature that would restore a degree of wrist and finger functions. This study was based on our previous rat model showing regeneration of severed fibers and resumption of function after transplantation of cultured adult olfactory ensheathing cells into spinal cord injuries and reimplanted dorsal roots. We now report that olfactory ensheathing cells transplanted at the spinal cord interface of reimplanted S1 ventral roots survive and migrate selectively into the ventral root where they associate intimately with regenerating ventral root fibers. Whereas only approximately 20% of the normal complement of fibers enter roots reimplanted without olfactory ensheathing cells, this increases to 80% in the presence of olfactory ensheathing cell transplants. These observations suggest that transplants of olfactory ensheathing cells could improve the outcome of ventral root repair.

Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons

Background Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering it a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear. Object The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons regarding the management of BPIs. Methods The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians of whom 49 (39%) participated in the study. The respondents represented 22 countries and multiple surgical subspecialties. They performed a mean of 34 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal compared with proximal coaptation during nerve transfer. Conclusions Experienced peripheral nerve surgeons disagreed in important respects as to the management of BPI. The decisions made by the various treating physicians underscored the many areas of disagreement regarding the treatment of BPI including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, choice of nerve transfers to achieve elbow flexion and shoulder abduction, use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.

Emergency or subemergency repair of brachial plexus injury associated with other traumas

目的 在急诊处理锁骨骨折、肩胛骨骨折、锁骨下动脉损伤及肩关节脱位、骨盆骨折等创伤的同时或 2～ 3周内进行臂丛神经离断伤或部分离断伤的手术修复,以提高其术后的优良率.方法 1993年 2月～ 2003年 1月,我们对怀疑有臂丛损伤的患者,尽快进行 MRI等检查,根据临床表现和检查结果,对其中明确为离断伤或部分离断伤的 29例患者,在伤后急诊或 2～ 3周内实施了臂丛探查,神经直接缝接,颈丛、膈神经、副神经移位,臂丛神经交叉移位及侧侧缝合等手术. 结果其中 21例患者术后得到 6个月～ 6年 (平均 3年 )的随访,按照顾玉东的臂丛损伤功能评定标准,本组患者观察总体优良率达 70.6%. 结论对有合并伤的臂丛神经离断伤或部分离断伤患者,急诊或 2～ 3周内进行手术探查和修复,可减少手术次数和难度,提高臂丛损伤修复术的优良率.

Evaluation and Surgical Repair of Brachial Plexus Injuries

Traumatic injuries of the brachial plexus may result in severe and permanent loss of motor and sensory function of the involved extremity. The neurosurgeon's ability to improve the functional outcome following a plexus injury requires an understanding of the functional anatomy of the brachial plexus, the pathophysiology of nerve injury, and the natural history of these lesions. Primary reanastomosis, neurolysis, and nerve grafting techniques are commonly used to restore normal axonal continuity. When these options are unavailable, muscle and tendon transfers or neurotization techniques have been successful in achieving functional restoration of limb movements.

752 Surgical Repair of Brachial Plexus Injury: A Multinational Survey of Experienced Peripheral Nerve Surgeons

752 Surgical Repair of Brachial Plexus Injury: A Multinational Survey of Experienced Peripheral Nerve Surgeons