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Adult Brachia l Plexus InjuryEvaluation and ManagementRoongsak Limthongthang, MDa ,*, Abdo Bachoura, MDb ,Panupan Songcharoen, MDa , A. Lee Osterman, MDb

INTRODUCTION

Traumatic brachial plexus injury (BPI) is regardedas one of the most devastating injuries of the up-per extremity. Patients typically lose sensation,motor power, and may experience disablingneuropathic pain. Several decades ago, combinedarm amputation, shoulder arthrodesis, and pros-thetic replacement was a viable treatment optionfor patients with a flail arm, because this protocolresulted in superior functional results comparedwith other reconstructive procedures at that time,

which included tenodesis, bone block, andarthrodesis. 1 However, advances in peripheralnerve surgery over the last few decades havesignificantly changed the image and outcomes of brachial plexus treatment. Today, one can expectgood to excellent f unctional results in patients withupper arm deficits. 2 Although there remains muchroom for optimizing the functional results in

patients with a flail arm, today’s outcomesfollowing reconstructive surgery have improvedto a degree that renders amputation as an anti-quated treatment option.

The treatment of BPI is based on a combinationof evidence-based principles, practical feasibility,and the personal philosophy of the surgeon. Inmany instances, dogmatic practices flourish be-cause of differences in the surgeon’s approach,the patient’s injuries and expectations, and thecultural environment. Over the past few decades,there has been a fair amount of trial and error in

BPI surgery and some techniques have developeda reputation for consistent and encouraging re-sults, whereas others have become of historical in-terest. This article provides an overview of theanatomy, diagnosis, and treatment of posttrau-matic adult BPI. In addition, some of the contro-versial topics surrounding the management of this complex injury are addressed.

a Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok

Road, Bangkoknoi District, Bangkok 10700, Thailand; b

The Philadelphia Hand Center, Thomas JeffersonUniversity Hospital, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107, USA* Corresponding author.E-mail addresses: [email protected] ; [email protected]

KEYWORDS

Adult brachial plexus injury Pattern of injury Preoperative evaluation Intraoperative study Nerve transfer Functioning free muscle transfer

KEY POINTS

Brachial plexus injury involves damage to the C5-T1 spinal nerves. Common injury patterns include“upper arm type” (C5-6 C7) and “total arm type” (C5-T1).

Preganglionic avulsion injury is suspected when the following observations are noted: Horner syn-drome, winged scapula, absence of Tinel sign over the neck, hemidiaphragm paralysis, and pseu-domeningocele. This type of injury infers poor potential for spontaneous recovery.

The treatment of upper arm type injury involves the restoration of elbow flexion and shoulder con-trol. Good results can be achieved by using nerve transfer surgery.

The treatment of total arm type injury involves the re-establishment of shoulder, elbow, and handfunction. The use of functioning free muscle transfers or nerve transfers may restore hand function.

Orthop Clin N Am 44 (2013) 591–603http://dx.doi.org/10.1016/j.ocl.2013.06.0110030-5898/13/$ – see front matter 2013 Elsevier Inc. All rights reserved. o

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ANATOMY, FUNCTION, AND LOCALIZATIONOF LESIONS

The brachial plexus is usually formed by the ventralrami of five spinal nerves (C5-T1), although somevariations exist, which involve contributions from

the C4 (prefixed) or T2 levels (postfixed). The smalldorsal rami, which are not part of the plexus, supplythe paraspinal muscles and skin of the posteriorneck. After once the spinal nerves pass throughthe spinal foramina, they form the brachial plexusbetween the scalenus anterior and the scalenusmedius muscles. The anatomy of the brachialplexus is normally divided into five segments: (1)spinal nerves or roots, (2) trunks, (3) divisions, (4)cords, and (5) terminal branches ( Figs. 1 and 2 ).3,4

Spinal NervesTwo terminal nerves emerge at the level of the spi-nal roots: the dorsal scapular nerve (C4-5), whichsupplies the levator scapulae and rhomboid mus-cles; and the long thoracic nerve (C5-7), whichsupplies the serratus anterior muscle. Injury tothis nerve results in scapular winging.

The phrenic nerve (C3-5), considered an extrap-lexal nerve, lies on the scalenus anterior muscle.Therefore, plexus injury at the root level may cause

paralysis and subsequent elevation of thediaphragm.

The sympathetic ganglion lies in close proximityto the brachial plexus at the T1 root level. There-fore, injury to the lower root may be associatedwith Horner syndrome, which consists of miosis,

enophthalmos, ptosis, and anhydrosis ( Fig. 3 ).

Trunks

Two terminal nerves emerge at the level of thetrunks: the suprascapular (SSC) nerve (C5-6),which supplies the supraspinatus and infraspina-tus muscles, arises from the superolateral aspectof the upper trunk, at a location referred to asErb’s point; and the nerve to the subclavius mus-cle (C5-6), which is smaller than its aforemen-tioned counterpart and arises from the medialside of the upper trunk.

Divisions

The division level could be conceptualized as theequator of the brachial plexus. The all roots formthe trunks that travel posterior to the clavicle andthen split into anterior and posterior divisions thatsupply the flexor and extensor muscles respec-tively (see Fig. 2 ).

Fig. 1. The anatomy of the brachial plexus. The supraclavicular component includes the spinal nerves and trunks.The divisions form cords at a level approximately posterior to the clavicle. The infraclavicular component includesthe cords and terminal nerve branches. These cords are named in reference to their anatomic relationship to theaxillary artery, which is located posterior to the pectoralis minor muscle. ( From Standring S. Gray’s anatomy: theanatomic basis of clinical practice. 40th edition. Philadelphia: Elsevier; 2008.)

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Fig. 2. Structures of the brachial plexus. Five spinal nerve roots form three trunks and travel posterior to the clav-icle, and then split into anterior and posterior divisions, which primarily supply the flexor and extensor muscles,respectively. The anterior divisions of the upper and middle trunks form the lateral cord, while the lower trunkbecomes the medial cord. The posterior divisions of every trunk form the posterior cord by contributing variousproportions of spinal nerve roots. , indicates a terminal nerve branch; MABC, medial antebrachial cutaneousnerve; MBC, medial brachial cutaneous nerve; MCN, musculocutaneous nerve; upper and lower SS, upper andlower subscapular nerves. ( Reproduced from Songcharoen P, Shin AY. Brachial plexus injury: acute diagnosisand treatment. In: Berger RA, Weiss AP, editors. Hand surgery. Philadelphia: Lippincott Williams & Wilkins;2003. p. 1005–25.)

Fig. 3. Common findings in total root avulsion BPI. ( A) Flail left arm, significant atrophy of the arm, forearm, andhand muscles are noted. ( B) Lateral view demonstrating marked shoulder subluxation. ( C ) Atrophy of the supraspi-natus, infraspinatus, andparascapularmuscles on the left side. ( D) Ptosisandenophthalmos areobserved in this pa-tientwith Horner syndrome. ( E ) Transverse processfractureof thecervicalspine anda widelygapped claviclefracture(arrows ). (F ) Myelography demonstrates a pseudomeningocele at C8 and the absence of a nerve root sleeve at C7.

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Cords

After the brachial plexus has traveled distal to theclavicle, or has become infraclavicular, it becomesinvested by the axillary sheath. The anterior divi-sions of the upper and middle trunks form lateral

cord, and lower trunk becomes medial cord. Theposterior divisions of every trunk form the poste-rior cord by contributing various proportions of spinal nerve roots. These cords are named in refer-ence to their anatomic relationship to the secondpart of the axillary artery, which is located poste-rior to the pectoralis minor muscle.

It should be noted that the aforementionedanatomic description characterizes an uninjuredbrachial plexus. During surgical exploration of BPI, however, the anatomy becomes more dis-torted and complicated because there is usuallynerve retraction and associated fibrotic scar for-mation. Often, the chronically avulsed plexus isfound to be retracted distally and located posteriorto the clavicle. In addition, anatomic variationswithin the brachial plexus are not uncommon,and serve to further complicate anatomicexploration.

CLASSIFICATION, MECHANISM, ANDPATTERNS OF THE INJURY

Previous reports have classified BPI according toa combination of injury mechanism, degree of nerve injury, location, and level of injury. 4–6

Mechanism of Injury

An understanding of the mechanism of injury mayhelp predict the type of brachial plexus lesion.Closed BPIs are usually associated with a tractionmechanism where the arm and shoulder are force-fully distracted away from the neck or trunk. Thismechanism mostly results in root avulsion lesions

and 70% to 80% of these injuries have been foundto occur in motorcycle accidents. 4,5 In thesecases, spontaneous recovery rarely occurs. Otherless common mechanisms include crush orcompression caused by various mechanisms,such as compression of the clavicle against therib cage secondary to seatbelt restraint, anteriorshoulder dislocation, or iatrogenic surgical posi-tioning. Crush or compression injury mechanismstend to involve the infraclavicular part of theplexus, such as the cords or terminal braches,which may have some recovery potential.

Open BPI is usually a result of stab wounds,gunshot wounds, and sometimes open fracturesof the shoulder girdle. In patients with gunshotwounds, the initial neurologic deficit is oftenextensive; however, one report showed that only

12% to 15% of patients sustained transectednerve lesions. 7 Open fractures of the shoulder gir-dle usually occur after high-energy injuries, inwhich the combination of nerve root avulsionand major vessel injury should be suspected( Fig. 4 ).

Degree of the Nerve Injury

The classification systems of peripheral nerve injuryinto neurapraxia, axonotmesis, and neurotmesis bySeddon 8 and first- to fifth-degree injury by Sunder-land 9 are generally used to describe BPI. Neurap-raxia, or Sunderland’s first-degree injury, refers tolocalized myelin damage and conduction defi-ciencies. Complete recovery could be expected in4 to 12 weeks. Axonotmesis or second-degreeinjury refers to a disruption of the nerve cell’s

axon, followed by walleriandegeneration. Completeaxonal regeneration could be expected to occurat arate of approximately 1 to 3 mm/day from the injurysite to the target muscle. 9 During third-degreeinjury, internal derangement of the endoneuriumand intrafascicular fibrosis precludes completeregeneration and results in partial recovery. Infourth-degree injury, owing to perineurial andfascicular disruption, neuroma in-continuity formsand spontaneous recovery is not expected. Neuro-tmesis, or fifth-degree injury, refers to completenerve transection and the need for surgicalintervention. MacKinnon and Dellon 10 added asixth-degree injury as a combination of first- tofifth-degree fascicular injuries within the samenerve. This injury results in variable recovery andprognosis.

Location and Level of the Injury

Several terms and classification systems havebeen used to categorize the location and level of BPI. 5,6 In our experience, sometimes it is difficult

to define the exact location of injury. Therefore,we prefer to use a simple and practical classifica-tion scheme that divides injury location into twogroups: supraclavicular or infraclavicular lesions.Supraclavicular lesions imply injury at the spinalnerve and trunks levels. Similar to other authors,we have found that further subdivision into pre-ganglionic and postganglionic lesions is beneficialduring treatment planning and is of prognosticvalue. The signs that suggest a preganglionicinjury are presented in Table 1 . Infraclavicular le-sions mostly occur at the cord and terminal branchlevels (see Fig. 4 ). In Narakas’ series, approxi-mately 10% of patients had com bined supracla-vicular and infraclavicular lesions. 5 The commonneurologic deficit patterns according to the levelof the injury are presented in Table 2 .



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DIAGNOSISHistory Taking and Physical Examination

A detailed history of the mechanism of injury,associated injuries, and previous treatment ismandatory to guide lesion localization and treat-ment planning. The character and severity of

pain should be documented. In addition to the mo-tor and sensory examination of the injured limb, aglobal neurologic examination should be conduct-ed, because associated cervical spine and spinalcord injury are not uncommon. A focused exami-nation of the injured limb should be performed,including an assessment of the functional deficitssecondary to BPI, and an evaluation of potentialdonor muscles and nerves, to ensure they meetthe prerequisites required for subsequent transfer.The motor power of every muscle that is suppliedby the brachial plexus should be documented ac-cording to the Medical Research Council system,between grades 0 and 5. Normal power of thetrapezius muscle, innervated by cranial nerve(CN) XI (spinal accessory nerve), is required toallow CN XI transfer. Examination of the peripheral

vasculature is necessary especially during theplanning of functioning free muscle transfers.Concomitant fractures and dislocations of theinsensate paralytic limb are often missed or ne-glected, and if not addressed early, could lead tononunion, malunion, or joint contracture. In thisevent, regardless of the reinnervation procedure,

poor functional results develop because it ismore difficult to rehabilitate weak, newly reinner-vated muscles with stiff and deformed joints.

Plain Film

Chest radiographs may reveal hemidiaphragmelevation, which would indicate phrenic nervepalsy and raise suspicion about nerve root avul-sion. First or second rib fractures may be associ-ated with BPI. Knowledge of the presence orabsence of additional rib fractures is important if intercostal nerve transfer is being considered. A transverse process fracture of the cervical spinemay imply root avulsion injury, whereas a widelygapped clavicle fracture may indicate a tractionmechanism of injury (see Fig. 3 E).

Fig. 4. This 6-year-old girl presented 4 months following open fracture of the proximal shaft of the humerus andinfraclavicular BPI. ( A) The patient lost all elbow, wrist, and hand function, and Horner syndrome was observed.(B) She could abduct her right shoulder to 30 degrees. ( C ) The x-ray showed union of the proximal shaft of thehumerus. ( D) The CT angiography revealed absence of right subclavian-axillary artery perfusion ( arrowheads ). (E ,

F ) Adhesions were found extending all the way from the cord level to the area of the initial open wound scar. ( G)An in-continuity lesion was found at the medial cord.

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Cervical Myelography or Computed Tomography Myelography

Cervical myelography has been used to demon-strate spinal nerve root lesions in BP I for morethan 50 years and remains a useful tool. 11 Findings

that suggest nerve root injury include the absenceof a nerve root sleeve, a defect of the root sleeveshadow, and formation of a pseudomeningocele(see Fig. 3 F).4,12 Myelographic studies should beperformed approximately 3 weeks or more afterthe injury to allow sufficient time for pseudomenin-gocele formation.

Current computed tomography (CT) myelogra-phy methods provide better resolution and moreaccurate categorization of nerve root statuscompared to plain film myelography, with a re-ported accuracy greater than 90%, especiallywhen combined with the clinical examination. 13,14The disadvantages of these techniques includetheir invasive nature and their inability to demon-strate lesions beyond the level of the intervertebralforamina.

Magnetic Resonance Imaging

Novel magnetic resonance imaging (MRI) tech-niques are increasing in popularity secondary totheir noninvasive nature and the details theyprovide. Many evolving techniques, such as fastimaging using steady-state acquisition, MR neu-rography, and high-field 3-T MRI, are able to visu-alize spin al nerve root lesions with relatively highaccuracy. 6,13 Doi and colleagues 14 reported asensitivity and specificity of 92.9% and 81.3%,respectively, for overlapping coronal-oblique

Table 1Signs and physical findings that suggest apreganglionic injury

Signs and Findings Implications

Horner syndrome Sympathetic ganglioninjury (T1 level)

Winged scapula Long thoracic nerveinjury (C5-7)

Atrophy ofparascapular muscle

Dorsal scapular nerveinjury (C4-5)

Cervical paraspinalmuscle weaknessand loss of posteriorneck sensation

Dorsal rami of cervicalspinal nerve rootsinjury

Hemidiaphragmparalysis

Phrenic nerve injury(C3-5)

Absence of Tinelsign in neck area

Absence of proximalspinal nerve stump

Pseudomeningoceleon myelogram

Developmentof meningealdiverticulum afterhealing of tornnerve root sleeve

Intact sensory nerveaction potentials inthe area of sensorydeficit

Imply no walleriandegeneration ofthe sensory axonsbecause theattached nerve

cells reside inthe dorsal rootganglion

Reproduced from Songcharoen P, Shin AY. Brachial plexusinjury: acute diagnosis and treatment. In: Berger RA,Weiss AP, editors. Hand surgery. Philadelphia: LippincottWilliams & Wilkins; 2003. p. 1005–25.

Table 2Common neurologic deficit patterns according to the level of the injury

Level Patterns of Injury Motor Deficits

Supraclavicular Upper arm type (C5-6 nerve roots) Shoulder abductionElbow flexion

Extended upper arm type (C5-7 nerve roots) Shoulder abductionElbow flexion and extensionWrist extension

Total arm type (C5-T1 nerve roots) Shoulder abductionElbow flexion and extensionGlobal hand function

Infraclavicular Lateral cord (musculocutaneous nerve) Elbow flexionMedial cord (medial and ulnar nerves) Finger flexion

Intrinsic hand functionPosterior cord (axillary and radial nerves) Shoulder abduction (supraspinatus

and infraspinatus muscles intact)Elbow and wrist extension

Reproduced from Spinner RJ, Shin AY, He´bert-Blouin M, et al. Traumatic brachial plexus injury. In: Wolfe SW, Hotchkiss RN,Pederson WC, editors. Green’s operative hand surgery. 6th edition. Philadelphia: Churchill Livingstone Elsevier; 2010.p. 1235–92.



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slices for detecting the presence of root avulsions.Moreover, MRI is capable of providing useful im-ages of the entire brachial plexus. The disadvan-tages of MRI include false-positive interpretations.

Angiography

Major vessel injury associated with BPI has beenreported to be as high as 23%. 5 The vesselsmost often damaged include the subclavian artery,subclavian vein, and the axillary artery in associa-tion with infraclavicular lesions. Conventional angi-ography, CT angiography (see Fig. 4 D), or MRangiography should be considered in cases of suspected arterial damage, and cases that involveoperative planning with consideration of functionalfree muscle transfer in order to demonstrate thestatus of the thoracoacromial trunk as a source

of the arterial pedicle.

Electrodiagnostic Studies

Electrodiagnostic studies are useful during preop-erative evaluation and intraoperative manage-ment. Preoperative evaluation usually consists of nerve conduction studies and needle electromy-ography. For nerve conduction studies, the pres-ervation of the sensory nerve action potentials inthe area of sensory deficit may indicate pregangli-onic nerve root avulsion injury at that given level.

Electromyography may demonstrate the develop-ment of signs of muscle denervation (polyphasic,fibrillation, positive sharp wave) approximately 10to 21 days after the injury has occurred. 15

Intraoperative Studies

Intraoperative electrodiagnostic studies are veryuseful and could help guide operative decision-making, especially in cases of incomplete lesions,neuromas in-continuity, and the presence of nerve

root stumps. During the treatment of partial injuries, intraoperative nerve action potential record-ings across the lesion may help determine whichfascicles should be resected and grafted, or whichfascicles are intact or recovering. 16

Various additional intraoperative techniqueshave been described to assess the functional con-dition and usefulness of spinal nerve stumps asdonor tissue for nerve reconstruction. The tech-niques and their respective results are displayedin Table 3 .

MANAGEMENT

Return to the preinjury functional status would bean ideal goal; however, the reconstructive optionsfor the regain of C5-T1 function is limited second-ary to the small number of available donor nerves.Sensate prehensile hand function may be the mostrequired function for patients. However, whereaselbow flexion and shoulder abduction take priorityas they have a higher likelihood of success.

Timing

The timing of surgery is one of the most importantaspects of treatment. With too long of a delay,denervated muscles will undergo the process of

Table 3Intraoperative diagnostic tests used to assess the condition of the nerve root stump

Authors Techniques Results

Oberle et al, 34 2002 Evoked MEP and SSEP Absence of MEP demonstrated a100% sensitivity for anterior root

lesionsAbsence of SSEP from the scalpdemonstrated a 100% sensitivity forposterior root lesions

Flores, 33 2008 Electrical stimulation of the longthoracic nerve, used for the C5 rootstump grafted to the suprascapularnerve

Transfer of C5 root with positiveelectrical stimulation can achieveM3 (37%) and M4 (62%) of shoulderabduction

Malessy et al, 35 1999 Frozen section of the C5-6 rootstumps, used for the restoration ofbiceps muscle function

Prefer myelinated axons >50%Significant relation between biceps

muscle strength and percentage ofmyelinated axons ( P 5 .02)

Hattori et al,36

2001 Measurement of CAT activity of donornerve for FFMT All donors with CAT activity >2000cpm provided all muscles withfunctional recovery by 3.2 mo

Abbreviations: CAT, choline acetyltransferase; cpm, counts per minute; FFMT, functioning free muscle transfer; MEP,muscle evoked action potentials; SSEP, somatosensory evoked potentials.



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denervation atrophy, rendering them refractory toreinnervation. Furthermore, animal studies havedemonstrated that recovered muscle force de-creases by at least 30% to 50% if the nerve repairis delayed for a month or longer. 17 However, earlyor immediate nerve reconstruction may preclude

the chance for spontaneous recovery, especiallyfor hand function, which usually requires a lengthytime period.

Immediate or early (3–4 weeks postinjury)brachial plexus exploration and repair is generallyaccepted for sharp, open injuries. If the nervesare found to be ruptured or crushed and divided,tagging and re-exploration in 3 to 4 weeksis planned, because this time period allows forbetter identification of the nerve injury zone. 18

Nerve reconstruction surgery within 6 to9 months of injury is generally an acceptable time-frame for intervention. 7,19 This allows sufficienttime for axonal regeneration to reach the targetmuscle before irreversible motor end plate degen-eration occurs. In light of advanced neuroimagingtechniques and more precise diagnoses, earlynerve reconstruction is an attractive treatment op-tion. Birch encouraged early plexus exploration forclosed traction injuries within 3 months of injury,and recommend ed repair or reconstruction within14 days of injury. 20 He pointed out that the benefitof early intervention allows identification and full

assessment of the lesion and the usefulness of the nerve root stumps as a donor before the onsetof fibrotic scar tissue, which are likely to distort theanatomy further. Kline found that 40% of C5-6 injuries spontaneously recovered in 3 to 4 months,whereas 15% of C5-7 injuries recovered in 3 to4 months, and only 5% of flail arms (C5-T1) hadfunctional recovery. 7 Thus, preganglionic totalarm BPI seems to be the type of injury that maybenefit most from earlier nerve reconstruction pro-cedures, especially for hand function reconstruc-

tion, which is obstinate to treatment.

C5-6 Injury

The functional deficits of C5-6 injury include theloss of elbow flexion and shoulder control (stabil-ity, flexion, abduction, and external rotation). Theterminal nerve branches that usually need tohave their function restored are (1) the musculocu-taneous nerve to re-establish elbow flexion, (2)SSC nerve, and (3) the axillary nerve to re-establish shoulder control.

The restoration of elbow flexion in C5-6 injurycould be performed either by biceps reinnervation,or biceps and brachialis reinnervation. The loca-tions of recipient nerves includethe anterior divisionof the upper trunk, the musculocutaneous nerve, or

the motor branches that supply the biceps and bra-chialis muscles. 18 Reinnervation by the upper trunkor musculocutaneous nerve could restore functionto the biceps and brachialis. Most of the time, how-ever, these techniques require the interpo sition of nerve grafts and long recovery periods. 5,18,19 If

when close-targeted intraplexal donors are avail-able, transfer of an ulnar (or median) nerve fascicleto the motor branch of the biceps muscle couldachieve more reliable functional results comparedto the use of extraplexal donor nerves, such asthe intercostal and spinal accessary nerves. 21

Today, the double fascicular nerve transfer to thebiceps and brachialis’ motor branches has becomean attractive option that theoretically allows for agreater regain in elbow flexion strength. 22,23 A com-parison of elbow flexion torque strength betweensingle and double transfers, however, was notfound to result in significant differences (single16% vs double 21% of normal side). 24 In our prac-tice, we do not use double fascicular transfers asroutinely because we believe that this approachmay increase the risk of donor site morbidity, in ex-change for no additional gain in function. However,this is our own personal bias, and previous studieshave indicated that double fascicular transfer is asafe procedure. 22,23

In C5-6 injury, many combinations of nervetransfers to the SSC and axillary nerves could be

performed to restore shoulder function. In one se-ries that studied single nerve transfer of spinalaccessory nerve (CN XI) to the SSC nerve, 80%motor recovery was observed, with 70 degree of shoulder abduction, 60 degree of shoulder flexion,and 30 degree of external rotation. 25 Wheneverpossible, double transfer of CN XI to the SSCnerve, along with transfer of the motor branchesof the medial or long head of the triceps to the axil-lary nerve, is recommended because this has re-sulted in encouraging functional results ( Figs. 5

and6 ).

2

The phrenic nerve also allows direct coap-tation of SSC nerve transfer. 25 Although adverseclinical consequences are rare, the measurabledeficits in lung function 26 deter many surgeonsfrom using phrenic nerve transfer. Other alterna-tive donor nerves that have been used includethe thoracodorsal nerve, intercostal nerves, andmedial pectoral nerves.

C5-7 Injury

Patients with this type of BPI have deficits similarto patients with C5-C6 injury, in addition to lossof elbow extension and wrist extension as a resultof C7 root involvement. The principles of nervereconstruction are similar to those for patientswith C5-6 injury. Additional problems include



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Fig. 5. ( A) Restoration of shoulder function in C5-6 injury through the anterior approach. ( B, C ) The spinal acces-sory nerve has been transferred to the suprascapular nerve via the supraclavicular approach. ( D, E ) The motorbranch to the long head of the triceps was transferred to the axillary nerve via the deltopectoral approach.The ulnar fascicular transfer to the motor branch of the biceps muscle was used to restore elbow flexion inthis patient.

Fig. 6. The result of the patient with

C5-6 injury 2 years after (1) spinal ac-cessary transfer to suprascapularnerves, (2) branch of long head tri-ceps transfer to the axillary nerve viathe anterior approach, and (3) fasci-cles of ulnar transfer to the motorbranch of the biceps muscle. The pic-tures demonstrate elbow flexion andshoulder external rotation, forwardflexion, and abduction. ( Courtesy of S. Wongtrakul, MD, Department ofOrthopaedic Surgery, Faculty of Med-icine Siriraj Hospital, Thailand.)



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(1) the absence of a branch to the triceps thatcould be used for transfer to the axillary nerve;(2) loss of elbow extension, which restricts reachand the ability to position the hand in space; and(3) loss of wrist extension.

Restoration of the axillary nerve could be

accomplished by the use of alternative donors,such as the intercostal nerve, or interpositionnerve grafts from the C5-C6 nerve stump, 27 whichcould simultaneously restore radial nerve function(or the motor branch to triceps). 28 For elbowextension, Bertelli and Ghizoni 27 reported pooroutcomes after C6 root to radial nerve grafting,because only 40% of patients achieved grade 3motor strength (M3). Malungpaishrope and col-leagues 28 reported their results for simultaneousthird-fourth intercostal nerve transfer to the axillarynerve, combined with fifth-sixth intercostal nervetransfer to the triceps branch. Only 30% of pa-tients achieved M3 elbow extension. It should benoted, however, that a delicate balance of reinner-vation of elbow flexors and extensors is required. If the triceps becomes too powerful relative to theflexors, it may negate the function of elbow flexion,which is the priority.

Total Arm BPI

The outcomes of total plexus treatment are com-

pletely different in comparison to the encouragingresults seen in upper arm treatment. Part of thisproblem is associated with the unfavorable resultsof hand function after reconstruction. Elbowflexion, the first priority in reconstruction, could

be restored by reinnervation of the biceps musclewith the spinal accessory nerve (77% M3)19 ;multiple intercostal nerves (81% M3)29 ; andinterp os ition nerve grafts from C5 root (90%

M3). 27 Shoulder reinne rvation could be achievedby single nerve transfer. 25 Alternatively, the shoul-

der could be arthrodesed if donor nerves areinadequate.

Regain of elbow and shoulder function takes pri-ority over hand function reconstruction because of more successful reinnervation of the proximalmuscles compared to the distal muscles. How-ever, treatment planning may depend on the pri-mary method selected for hand reconstruction.Currently available methods include primary func-tioning free muscle transfers or nerve transfer 30–32

for the restoration of finger flexion. Our currenttreatment algorithm for total arm BPI is presentedin Fig. 7 . The methods selected for each patientdepend on multiple factors including the following:

1. Time period after injury and the degree of mus-cle atrophy: a long time period after the injuryworsens the outcomes of nerve transfer, espe-cially for motor function. If patients present atapproximately 6 months or later after injury, pri-mary functioning free muscle transfers arepreferred.

2. Associated vascular injury: this occurs ap-

proximately 10% of the time when total rootavulsion is present. In cases of associatedvascular injury, we prioritize and focus on thenerve transfer method regardless of the degreeof vascular injury and previous treatment.

Fig. 7. Treatment algorithm for totalarm BPI. Factors that guide thedecision-making process for treat-ment include timing, vascular injury,and the status of the C5 nerve stump.(1) With longer delays between injury

and surgery, especially 6 months afterinjury, the results of nerve transferbecome worse. (2) If vascular injuryis present, despite vascular repair,the possibility of free muscle transferfailure is very high. (3) An intact C5root stump can be transferred to themedian nerve with the expectationsof extrinsic finger flexion and protec-tive sensation. FFMTs, functioningfree muscle transfers; Hemi CC7, hem-icontralateral C7 spinal nerve; CN XI,spinal accessory.



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3. The presence or absence of a functional C5

nerve root stump: electrical stimulation of thelong thoracic or dorsal scapular n er ves isused to gauge C5 nerve root function. 33 Nervetransfer of the C5 root to the median nervewith interposition nerve grafting is expected tolead to extrinsic finger flexion and protectivesensation ( Fig. 8 ).

SUMMARY

Traumatic adult brachial plexus treatment requiresmultiple well-planned primary and secondaryreconstructive procedures. Intractable neuro-pathic pain threatens the quality of life despite mo-tor and sensory nerve reconstruction. Realisticpatient expectations should be set with the ideathat no single procedure is capable of

guaranteeing promising results or return to the

preinjury status. It is not uncommon to performsecondary functioning free muscle transfers afterunsuccessful nerve transfers, or even after failedprimary functioning free muscle transfers.

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Fig. 8. ( A, B) Rupture of the upper trunk ( arrowheads ) and avulsion of C7-T1 roots is demonstrated in a patientwith total arm BPI. ( C ) The distal part of upper trunk was located distally posterior to the clavicle. ( D) Treatmentconsists of (1) C5 grafting to the median nerve, (2) phrenic grafting to the musculocutaneous nerve (MCN), (3)spinal accessary transfer to the suprascapular nerve, and (4) C6 grafting to the posterior cord. ( E–G) At 14 monthsafter surgery, the patient had recovered shoulder abduction, elbow flexion, and extrinsic finger flexion.


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