Brachial Plexus Repair Research Articles

Functional and morphological evaluation of the trapezius muscle after spinal accessory nerve transfer to brachial plexus nerves.

The main innervation of the trapezius muscle is provided by the spinal accessory nerve. Several studies describe the contributions of cervical plexus roots to the trapezius muscle innervation, either directly or through connections with the spinal accessory nerve. There is no adequate understanding of how the trapezius muscle is affected after using the spinal accessory nerve in nerve transfer procedures with the usual technique, preserving at least 1 branch for the upper trapezius. We evaluated 20 patients with sequelae of traumatic brachial plexus injury who underwent surgical procedures for brachial plexus repair or free muscle transfer, which included the spinal accessory nerve transfer technique and were followed for a minimum of 1 year. The three portions trapezius muscle were evaluated by physical examination, magnetic resonance imaging (analysis of fatty degeneration) and electromyography. In all evaluation methods, the middle and lower portions of the trapezius muscle showed more significant morphological and/or functional impairment than the upper portion, in most cases. There was a statistically significant difference in all the complementary exams results, between the affected side (with sacrifice of the nerve) versus the normal side, in the middle and lower portions of the trapezius muscle. Physical examination alone is not sufficient to determine the residual functionality of the trapezius muscle. Magnetic resonance imaging and electromyography are useful tools to assess both morphological involvement of the trapezius muscle and nerve conduction impairment of the trapezius muscle, respectively. The results suggest that the middle and lower portions of the trapezius muscle are affected by previous SAN transfer and should be considered with caution for further muscle transfer procedures.

Is it possible to follow the risk of rupture after end-to-end nerve repairs in brachial plexus surgery? Technical note.

In traumatic and obstetric brachial plexus injuries, removal of the damaged nerve, repair with the nerve grafts, and nerve transfers are mostly preferred techniques. Success is directly proportional to surgical technique as it is known that end-to-end repair of the peripheral nerves gives better results. The greatest risk in end-to-end repair is the nerve rupture at the brachial plexus repair region and this cannot be detected by conventional radiological techniques. Brachial plexus injuries of obstetrical and traumatic patients were operated. If possible and at least one nerve was repaired end to end, follow-up of nerve continuity was done by titanium hemopclip insertion to both sides of the nerve repair area. A new technique nerve repair site marking was developed and end-to-end nerve repair continuity was followed simply by x-ray. This technique was used for end-to-end nerve coaptions of 38 obstetric and 40 traumatic brachial plexus injuries. Follow-up was done for 6 weeks. Every week patients sent the x-ray of the repair site. Only 3 patients had nerve repair site rupture, and revision surgery was done immediately. Nerve repair site marking technique and follow-up with only x-ray is a simple reliable, safe, and cheap method that can be applied to any end-to-end nerve repair. This technique has no morbidity or side effects. The aim of the study is to summarize or explain the nerve repair site marking technique used in the brachial plexus region.

Total Intravenous Anaesthesia with Propofol and Dexmedetomidine for Brachial Plexus Repair with Intraoperative Neuromuscular Monitoring: A Case Series

Background: Brachial plexus surgery requires neural repair with the use of intraoperative peripheral nerve stimulation without muscle relaxants.
 Methods: Twelve cases were conducted under total intravenous anaesthesia, receiving intravenous propofol, fentanyl and dexmedetomidine infusion. Intraoperative hemodynamic conditions and postoperative functional recovery were assessed.
 Results: 9 out of 12 cases were stable while one was in a lighter plane requiring 20 mg propofol and increased dexmedetomidine, two had bradycardia requiring reduced dexmedetomidine infusion. At three months, five cases showed improvement.
 Conclusion: Satisfactory conditions were achieved including hemodynamic stability, and muscle-sparing improving prognoses of brachial plexus surgeries.

Two clinical tests assessing long thoracic nerve function to determine C5 and C6 root graft eligibility in patients with brachial plexus injury.

Identifying roots available for grafting is of paramount importance prior to reconstructing complex injuries involving the brachial plexus. This is traditionally achieved by combining input from both clinical examinations and imaging studies. In this paper, the authors describe and evaluate two new clinical tests to study long thoracic nerve function and, consequently, to predict the status of the C5 and C6 roots after global brachial plexus injuries. From March 2020 to December 2020, in 41 patients undergoing brachial plexus repair, preoperative clinical assessments were performed using modified C5 and C6 protraction tests, C5 and C6 Tinel's signs, and MRI findings to predict whether graft-eligible C5 and C6 roots would be identified intraoperatively. Findings from these three assessments were then combined in a logistic regression model to predict graft eligibility, with overall predictive accuracies calculated as areas under receiver operating characteristic curves. In the 41 patients, the pretest probability of C5 root availability for grafting was 85% but increased to 92% with a positive C5 protraction test and to 100% when that finding was combined with a positive C5 Tinel's sign and favorable MRI findings. The pretest probability of C6 root availability was 40%, which increased to 84% after a positive C6 protraction test and to 93% when the protraction test result concurred with Tinel's test and MRI findings. Combining observations of the protraction tests with Tinel's sign and MRI findings accurately predicts C5 and C6 root graft eligibility.

Axillary Artery Pseudoaneurysm due to Bullet Injury: Open Surgery of Lesion

A 27-year-old male patient with a wound due to a gunshot in right upper thoracic area who was diagnosed as a pseudoaneurysm of right axillary artery underwent open resection and bypass graft with saphenous vein. Today, most vascular surgeons tend to treat these complications with endovascular procedure, but because of this patient’s young age and his occupation and the necessity for brachial plexus repair, we decided the open procedure method.

Evidence that nerve surgery improves functional outcome for obstetric brachial plexus injury.

The majority of children with obstetric brachial plexus injury show some degree of spontaneous recovery. This review explores the available evidence for the use surgical brachial plexus repair to improve outcome. So far, no randomized trial has been performed to evaluate the usefulness of nerve repair. The evidence level of studies comparing surgical treatment with non-surgical treatment is Level IV at best. The studies on natural history that are used for comparison with surgical series are also, unfortunately, of too low quality. Among experts, however, the general agreement is that nerve reconstruction is indicated when spontaneous recovery is absent or severely delayed at specific time points. A major obstacle in comparing or pooling obstetric brachial plexus injury patient series, either surgical or non-surgical, is the use of many different outcome measures. A requirement for multicentre studies is consensus on how to assess and report outcome, both concerning motor performance and functional evaluation.

Traumatic partial posterior cord brachial plexus injury in a patient with aberrant innervation of the long head of the triceps by the axillary nerve: Implications in nerve transfer surgery

Brachial plexus repair forms an unmet need in terms of posttraumatic rehabilitation, especially the young population, wherein the incidence of accidents is high. This leads to decrease in the number of functionally active years after the accident. We encountered an interesting case of posttraumatic posterior cord injury predominantly affecting the shoulder abduction beyond 15°. An electrodiagnostic study showed a complete lack of conduction within the axillary nerve with reduced conduction velocity in the radial nerve. We took the patient up for the long head of the triceps transfer to the anterior division of the axillary nerve transfer. Intraoperatively, we found that the long head branch was originating from the axillary nerve at the point of division. As it could not be used for neurotization, we transferred the medial head branch of the radial nerve to the axillary nerve. The patient started to show electroclinical improvement after 3 months of the surgery. A few similar cases have been published, as a cadaveric finding. We report this case to highlight the possibility and need for a high clinical suspicion and also to provide a possible treatment option, in such aberrant anatomy.

Bilateral Suprascapular Nerve Injury and Novel Technique of Nerve Transfers for Restoration of External Rotation: Case Report

Complex brachial plexus and peripheral nerve injuries can be challenging to evaluate and treat, especially in the face of novel pathology. To describe the diagnosis of bilateral suprascapular nerve injury, the unique surgical anatomy, and the novel use of a distal nerve transfer to re-establish external rotation. To the best of our knowledge, bilateral suprascapular nerve injury has not previously been reported. The authors describe the physical examination and electrodiagnostic and imaging work-up for elucidating complex injury patterns and present a procedure for reinnervating the infraspinatus muscle. A 48-yr-old man presented with profound, right-sided, partial brachial plexus injury incurred 5 mo earlier in a motorcycle accident. Imaging demonstrated atrophy and severe edema within the bilateral supraspinatus and infraspinatus muscles. Needle electromyography depicted no motor units and insertional activities in bilateral infraspinatus muscles, consistent with bilateral suprascapular nerve injury. Along with brachial plexus repair, the patient underwent transfer of a distal branch of the spinal accessory nerve to the inferolateral branch of the suprascapular nerve to the infraspinatus muscle. At 16 mo, he had recovered strong restoration of shoulder external rotation. Systematic evaluation can assist in defining complex pathology, particularly with previously unreported types. In this case, predominant injury was inflicted upon the branch innervating the infraspinatus. Highly focal nerve transfers can achieve substantial restoration of external rotation.

C5-8 neonatal brachial plexus palsy. Operative findings, reconstructive strategy and outcome.

From 1998 to 2014, we performed primary brachial plexus repair in 260 children with neonatal brachial plexus palsy. Thirty-three presented with a C5-8 palsy and 24 were reviewed for this study. The surgical strategy was to focus on repairing the upper trunk. Secondary surgical procedures were performed in 21 patients, mainly for shoulder external rotation deficit or weak wrist extension. After a mean follow-up of 9.7years (range 3 to 19), the median Mallet score for the shoulder was 9.5 and the mean Raimondi score for the hand was 3.3. Median active movement scale was 5, 7 and 5.5 for the deltoid, biceps and triceps, respectively. We conclude that primary C5-8 brachial plexus reconstruction provides restoration of elbow flexion and most patients have a sensitive and functional hand. We also found that secondary surgery to improve shoulder and wrist function is often necessary, which should initially be explained to the family.Level of evidence: IV.

Anatomy of scalenovertebral triangle: A vade mecum for clinicians

The thorough anatomical knowledge of scalenovertebral triangle or Triangle of the vertebral artery and its contents is crucial in various neurosurgical procedures such as scalenotomy, stellate ganglion block, direct isolation of proximal vertebral artery and proximal brachial plexus repair. Thirty scalenovertebral triangles of known age and sex were dissected. The morphometry of the triangle and stellate ganglion was done. Various relevant distances were measured for topographical location of neurovascular structures especially stellate ganglion and vertebral artery within the triangle. The mean height and width of the scalenovertebral triangle was 21.7+5.1mm and 19.4+4.4mm respectively. Vertebral artery originated from subclavian artery within the triangle except in one case (left side) where it originated from aortic arch. The mean minimum distance of stellate ganglion from phrenic nerve, scalenus anterior and vertebral origin was 12.6+4.5mm, 12.26+4mm and 2.3+1.3mm respectively. The origin and proximal part of vertebral artery may not be present within the scalenovertebral triangle, thus topographic anatomy of the stellate ganglion is also affected and may cause complications during stellate ganglion block. Stellate ganglion is never located in the lateral or upper third of triangle. Occasionally, the phrenic nerve may cross the triangle, making it unsafe during stellate ganglion block.

Retrospective Study of Surgical Repair of Gunshot Injuries of Peripheral Nerves.

Background: Shotgun injuries of the peripheral nerves are presented frequently during the last decades at the Service of Neurosurgery of UHC “Mother Theresa” in Tirana. In such cases the surgical repair of brachial plexus and peripheral nerves constitutes a challenge with relation to difficulties related with mechanism of injury, coexistence of other vascular damage, bone, soft tissue and visceral lesions.
 Materials and methods: A retrospective study of operated cases with shotgun injuries treated in our Department from 1997 to 2012 was conducted getting information from clinical charts, surgical registries, intraoperative photos and videos of the surgical repair of peripheral nerves. We performed a thorough analysis of the most influencing factors of surgical outcome such as: age, severity of injury, site of injury with relation to the innervated muscles, type of necessary nerve repair, presence of causalgia before operation, concomitant compromise of vascularization and/or locomotor apparatus. Follow-up of the patient was conducted through out-patient visits and phone interviews going back 10 years from surgical repair.
 Results: 68 cases operated for shotgun injury of brachial plexus or peripheral nerves were revised. There were different ages and both sexes involved. The type of nerve repair went from interfascicular neurolysis to direct end-to-end microsuture and nerve grafting. Timely repair of the nerve injury proved to be yielding better result than late repair in terms of pain relief and sensory motor improvement of the preoperative neurological deficit. The degree and the quality of improvement after surgery is related to the type of repair (neurolysis improves better and faster than grafting), the distance from site of injury to the effector muscle (the longer the distance more time it takes for the function to recover). The recovery of the brachial plexus was followed up for many years and further surgery proved to be necessary and of further improvement.
 Conclusions: From our long term experience dealing with surgical repair of shotgun injury of peripheral nerves we have learnt that early surgical repair is more efficacious in treating pain and gives better results in terms of motor and sensitive recovery than six months after injury as it was usually done. Long term follow-up is necessary to help with further surgery in case of distal decompressive surgery in anatomical tunnels.

Socioeconomic Disparities in Brachial Plexus Surgery: A National Database Analysis.

Background:Brachial plexus injuries have devastating effects on upper extremity function, with significant pain, psychosocial stress, and reduced quality of life. The aim of this study is to identify socioeconomic disparities in the receipt of brachial plexus repair in the emergent versus elective setting, and in the use of supported services on discharge.Methods:Analysis of the Healthcare Cost and Utilization Project National Inpatient Sample Database was performed for the years 2009–2014. Adults with brachial plexus injury with or without nerve repair were identified; patient and hospital specific factors were analyzed.Results:Overall, 6,618 cases of emergent brachial plexus injury were retrieved. Six hundred sixty cases of brachial plexus repair were identified in the emergency and elective settings over the study period. Of the 6,618 injured, 153 (2.3%) underwent nerve surgery during the admission. Patients undergoing repair in the elective setting were more likely to be white males with private insurance. Patients treated in the emergency setting were more likely to be African American and in the lowest income quartile. Significant differences were also seen in supported discharge: more likely males (P < 0.001), >55 years of age (P < 0.001), white (P < 0.001), with government-based insurance (P < 0.001).Conclusions:There are significant disparities in the timing of brachial plexus surgery. These relate to timing rather than receipt of nerve repair; socioeconomically advantaged individuals with private insurance in the higher income quartiles are more likely to undergo surgery in the elective setting and have a supported discharge.

Résultats des réparations nerveuses tardives au-delà de 12 mois chez 16 patients

The aim of this study is to estimate the maximum delay following nerve injury at which a nerve can be reconstructed and still recover good function. This is a retrospective study of a series of 16 patients who underwent delayed nerve reconstruction at 12 months or later post-injury with the target muscle showing a fibrillatory pattern on preoperative EMG. There were 16 males and one female, ages ranging from 17 to 74 average 38 years. Thirteen patients had brachial plexus injuries (4 complete) where a nerve was transferred onto the nerve branch directly supplying the target muscle, according to the case. Two had a complete sciatic nerve injury where a graft was used in one and a secondary suture in the other, and two axillary nerve injuries were included with a secondary suture for one and a transfer in the other. Muscle power of the target muscle was assessed using the Medical Research Council grading system from 1 to 5 at a minimum of 9 months follow up. Strength of deltoid abduction and elbow flexion where measured against weights. M3 and M4 were considered good results. Sensory recovery was not measured. We began to observe positive results at 18 months. At final follow up, 2 patients had contraction against 7 kg resistance, 2 against 5 kg, 4 against less than 5 kg, 2 were M3 and 5 were M2, thus 11 good results (69%). The two sural grafts done were of 10–18 cm length, one from spinal nerve to triceps with result M2 at 18 months and the other for the sciatic nerve with result of M3 at 26 months. In the literature a maximum delay for brachial plexus repair of 12 months post injury is usually considered. Our results show that motor function can be restored at more than 12 months delay and up to 24 months. Further investigations are needed to determine the cut-off point of delay after which nerve recovery after repair is unlikely. Our study showed that excellent results of contraction can be obtained even after nerve repair at 24 months preoperative delay. It should therefore be considered as a treatment option besides nerve transfer or tendon transfers.

Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus

To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis. Twenty-four male patients were reoperated upon an average of 45 months (SD, ± 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle belly was sutured to the biceps distal tendon. Vascular repair was performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus. Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110° (95% confidence interval [95% CI], 100°-120°) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94° (95% CI, 86°-102°). There was, on average, a 10° (95% CI, 4.4°-15.6°). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in12. In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination. Therapeutic IV.

Phrenic and intercostal nerves with rhythmic discharge can promote early nerve regeneration after brachial plexus repair in rats.

Exogenous discharge can positively promote nerve repair. We, therefore, hypothesized that endogenous discharges may have similar effects. The phrenic nerve and intercostal nerve, controlled by the respiratory center, can emit regular nerve impulses; therefore these endogenous automatically discharging nerves might promote nerve regeneration. Action potential discharge patterns were examined in the diaphragm, external intercostal and latissimus dorsi muscles of rats. The phrenic and intercostal nerves showed rhythmic clusters of discharge, which were consistent with breathing frequency. From the first to the third intercostal nerves, spontaneous discharge amplitude was gradually increased. There was no obvious rhythmic discharge in the thoracodorsal nerve. Four animal groups were performed in rats as the musculocutaneous nerve cut and repaired was bland control. The other three groups were followed by a side-to-side anastomosis with the phrenic nerve, intercostal nerve and thoracodorsal nerve. Compound muscle action potentials in the biceps muscle innervated by the musculocutaneous nerve were recorded with electrodes. The tetanic forces of ipsilateral and contralateral biceps muscles were detected by a force displacement transducer. Wet muscle weight recovery rate was measured and pathological changes were observed using hematoxylin-eosin staining. The number of nerve fibers was observed using toluidine blue staining and changes in nerve ultrastructure were observed using transmission electron microscopy. The compound muscle action potential amplitude was significantly higher at 1 month after surgery in phrenic and intercostal nerve groups compared with the thoracodorsal nerve and blank control groups. The recovery rate of tetanic tension and wet weight of the right biceps were significantly lower at 2 months after surgery in the phrenic nerve, intercostal nerve, and thoracodorsal nerve groups compared with the negative control group. The number of myelinated axons distal to the coaptation site of the musculocutaneous nerve at 1 month after surgery was significantly higher in phrenic and intercostal nerve groups than in thoracodorsal nerve and negative control groups. These results indicate that endogenous autonomic discharge from phrenic and intercostal nerves can promote nerve regeneration in early stages after brachial plexus injury.

Comparison of Dexmedetomidine and Propofol on Haemodynamics, Ionic Balance and Postop Sedation in Brachial Plexus Repair Surgery: An Entropy Guided Prospective Trial

Comparison of Dexmedetomidine and Propofol on Haemodynamics, Ionic Balance and Postop Sedation in Brachial Plexus Repair Surgery: An Entropy Guided Prospective Trial

Histological effects of fibrin glue and synthetic tissue glues on the spinal cord: are they safe to use?

Introduction: Fibrin glues such as Tisseel® have been established in neurosurgery for over thirty years. They are recommended for extradural use but have intradural applications. Brachial plexus reimplantation after trauma requires intradural fibrin glue because reimplanted nerves cannot be sutured to the spinal cord. Recently synthetic glues have become popular in spinal surgery but there is limited information about their safety. Our study compared the histological effects of Tisseel®, Adherus® and BioGlue® on spinal cord using our rat brachial plexus repair model.Materials & methods: Randomised observational animal study. Forty-one Sprague-Dawley rats divided in to control (n = 9), Tisseel® (n = 8), BioGlue® (n = 10) and Adherus® (n = 14) groups. Under general anaesthesia a posterior midline cervical incision was made and hemi-laminectomies performed at C7 and T1. Dura was opened and T1 dorsal root transected and repositioned on the spinal cord. Two drops of Tisseel®, BioGlue®, Adherus® or no glue (control) were applied over the cut nerve and cord. At days 7, 14 and 28 rats were euthanized, processed and sections stained with Haematoxylin & Eosin and evaluated blind by a neuropathologist.Results: Control and Tisseel® groups showed only mild focal inflammation in the cord. Adherus® and Bioglue® groups showed evidence of spinal cord inflammation and degeneration. All BioGlue® and Adherus® rats had evidence of distortion of the cord from the glue mass at all time points. Two BioGlue®-treated and one Adherus®-treated rat developed a hemiparesis. One BioGlue® rat developed hind limb paralysis. One BioGlue® rat failed to wake up at the end of the procedure. There were no complications in control and Tisseel® groups.Conclusion: Tisseel® caused a similar inflammatory response to control and may be used on spinal cord. BioGlue® and Adherus® should be applied thinly for a watertight dural closure but intradural use and contact with spinal tissue must be avoided.

Direct Nerve Sutures in (Extended) Upper Obstetric Brachial Plexus Repair.

Background In rare, selected cases of severe (extended) upper obstetric brachial plexus palsy (OBPP), after supraclavicular exposure and distal mobilization of the traumatized trunks and careful neuroma excision, we decided to perform direct nerve coaptation with tolerable tension and immobilized the affected arm positioned in adduction and 90-degree elbow flexion for three weeks. Objectives We present our surgical technique and preliminary results in a prospective open patient series, including 22 patients (14 right and 8 left side affected) between 2009 and 2016, operated at a mean age of 8.4 months. Methods Analysis of functional results after a minimum of 18 months was conducted using the British Medical Research Council (BMRC) scale. Results All children reached 60–90° of elbow flexion and 75° of shoulder abduction at already six months after surgery. For those patients having already passed one year post surgery, the mean active shoulder abduction reached 92°, and for those who past the 18 months 124°. We discuss the actual knowledge about nerve coaptation under “reasonable” tension including its advantages and drawbacks. Conclusion This technique may be indicated in preoperatively selected cases of (extended) upper OBPP and may give good functional results.

Late Nerve Repairs in Brachial Plexus Lesions

Objectives: It is a common opinion that surgical repair of brachial plexus later than 1 year from the lesion cannot lead to real functional results. This is probably true for repair by means of multiple grafts which need specially in root’s lesions a long time for reinnervation: This fact and the frequent delay in repair reduce in a substantial way the possibility to obtain good results in brachial plexus surgery. The continuous development of nerve transfers allowed shortening the time of recovery by means of very distal repairs, near to the mainly motor targets. The shortening of recovery time gives today the possibility to move forward the classical limits for nerve repair. Materials and Methods: The authors present the results obtained in 93 nerve transfers in 52 patients who underwent nerve repair after more than 1 year from the lesion. The series consists of 22 children with obstetric brachial plexus palsy and 30 adults with traumatic brachial plexus lesions all of them repaired after 1 year from the lesion with a maximum delay of 7 years. The nerve repaired by means of late transfers had been the suprascapular, the musculocutaneous, and the axillary. In all the cases, a previous electromyography detected the presence of fibrillation in the muscles that are planned to be reinnervated. Fibrillation is actually considered as a prerequisite to indicate a late nerve transfer. Results: Evaluation of results has been separate between children and adult patients. In adult patients, the results for biceps have been 30% of failures, 42% of partial results (M2/M3−), and 28% of good results (M3+/M4). The results for suprascapular have been 23% of failures, 45% of partial results, and 32% of good results. In children, the results for biceps have been 15% of failures and 85% of good results (&lt;M3+). The results for suprascapular have been 25% of failures, 25% of partial results, and 50% of good results. No result can be reported for deltoid due to the too reduced number of operated cases. Conclusions: Nerve transfers allow in a considerable number of cases to obtain functional results, in some case even after several years of delay. A part for late observed cases we can offer in this way a second option in cases of lack of recovery from primary surgery. Actually nerve transfer is nowadays a new possibility placed in between primary microsurgical repair and classic palliative surgery. Undoubtedly better results have been obtained in children, but surprisingly useful results could be obtained in adults even if in a more reduced percentage of cases.

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.