brachial plexus surgery
DESCRIPTION
A overview of the latest advancements in brachial plexus surgeryTRANSCRIPT
![Page 1: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/1.jpg)
Brachial Plexus Surgery
October 2008 1Brachial Plexus Injury Mr V Rajaratnam
![Page 2: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/2.jpg)
CoverageCoverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 2Brachial Plexus Injury Mr V Rajaratnam
![Page 3: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/3.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 3Brachial Plexus Injury Mr V Rajaratnam
![Page 4: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/4.jpg)
October 2008 Brachial Plexus Injury Mr V Rajaratnam 4
![Page 5: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/5.jpg)
Supraclavicular Region• Ventral Rami• ventral rami C5-T1 and the branches:
– dorsal scapular nn – long thoracic nerve – C5 contribution to the phrenic nerve
• exit between scalenus anterior and scalenus medius• • • Trunks• superior
– nerve to subclavius (C5) – suprascapular nn – C5-C6 join to form the upper trunk
• middle – C7 forms the middle trunk
• lower – C8-T1 join to form the lower trunk
October 2008 Brachial Plexus Injury Mr V Rajaratnam 5
![Page 6: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/6.jpg)
Clavicular Region
• Divisions• anterior supply flexors
• posterior supply extensors
October 2008 Brachial Plexus Injury Mr V Rajaratnam 6
![Page 7: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/7.jpg)
Infraclavicular Region• Cords• posterior
– upper subscapular nn – thoracodorsal nn – lower subscapular nn – axillary nn – radial nn
• lateral – lateral pectoral nn – musculocutaneous nn – lateral root of median nn
• medial – medial pectoral nn – medial brachial cutaneous nn – medial antebrachial cutaneous nn – ulnar nn – medial root of median nn
October 2008 Brachial Plexus Injury Mr V Rajaratnam 7
![Page 8: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/8.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 8Brachial Plexus Injury Mr V Rajaratnam
![Page 9: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/9.jpg)
History
• Closed injury• Usually motorbikes (52%)• Cars (12%), falls, sports• Open• Lacerations• Gunshots• Iatrogenic• Chainsaws
![Page 10: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/10.jpg)
History
• Other causes – tumour – usually direct extension, primary tumours, radiation, congenital
• Immediate severe pain –suggestive of preganglionic lesion
• Associated spinal cord injury
![Page 11: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/11.jpg)
Examination
• General ATLS protocol• Associated injuries common• Supraclavicular lesions – 10% subclavian
artery rupture• Infra clavicular - 30% axillary artery rupture
![Page 12: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/12.jpg)
Examination
• System for examining the the plexus• Look – wounds, muscle wasting, surgical scars,
deformity• Feel – muscle bulk, sensation• Normal sensation – flail limb – think polio• Move – check tone, full rom (MRC grading
depends on a full range of movt)
![Page 13: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/13.jpg)
Examination
• Test each muscle in a systematic manner• From behind• Trapezius – c3,4• Serratus anterior – c567 – winging scapula• Rhomboids – c5• Supraspinatous – c5,6• Deltoid – c5,6 (axillary)• Latissimus dorsi – c678
![Page 14: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/14.jpg)
examination
• From the front• Biceps – c5,6• Brachioradialis c5,6• Supinator – c6,7• Ext digitorum c7,8• Epl c7,8• Apb c8,t1• Fcu c7,8,t1• Froments c8,t1
![Page 15: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/15.jpg)
Classification of brachial plexus injuries (leffert)
• Supra clavicular – often traction injuries, often severe pain in limb
• C5,6 (upper trunk lesions) – shoulder control and elbow flexion lost
• C5,6,7 – plus loss of active extension of fingers and elbow
• C8,t1 – horners syndrome plus median and ulnar palsy affecting hand
• Whole plexus injury – other associated injuries, flail arm
![Page 16: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/16.jpg)
Leffert classification (according to Miller)
• 1 – open• 2 – closed• 2a – supraclavicular• Preganglionic – non repairable• Postganglionic• 2b infraclavicular• 3 - radiation• 4 – obstetric – a- erbs, b – klumpkes, c- mixed
![Page 17: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/17.jpg)
Classification
• Neuropraxia – good prognosis• Rupture –post ganglionic can recover• Lesion in continuity – poor prognosis• Avulsion – poor prognosis
![Page 18: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/18.jpg)
Infraclavicular injuries
• Better prognosis – shoulder dislocation more likely method of injury
![Page 19: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/19.jpg)
Investigations
• Plain x-ray – c spine (avulsion # TPs), shoulder trauma, cxr – raised hemidiaphragm
• Thin section CT has been replaced by MRI scanning• MRI allows multiplanar analysis – different parts of
the plexus are best viewed in different planes• Differentiate vascular from non vascular structures
![Page 20: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/20.jpg)
• Nerve root avulsion with pseudomeningocele traditionally diagnosed by myelography
![Page 21: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/21.jpg)
• Nerve roots usually visualised in foramen• Non visualisation suggestive of avulsion• Pseudomeningoceles can be visualised directly• Visualisation of the rest of the plexus using
various different sequences gives superior results to CT
![Page 22: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/22.jpg)
neurophysiology
• Distinguish between different patterns of injury• Neuropraxia –compound muscle action potentials
decreased in size, conduction velocity slowed, reduced normal motor recruitment
• Axonetmesis – CMAP reduced, spontaneous motor activity
• Neurotmesis – CMAP unrecordable, fibrillations profuse, voluntary motor activity absent
![Page 23: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/23.jpg)
Surgical Indications
• Neuropraxic lesions – non operative• May be difficult to define• Patchy sparing of sensation• Limited numbers of nerve roots• Signs of early recovery within 7-10 days• No sign of recovery – investigate with a view
to early surgery
![Page 24: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/24.jpg)
Operative treatment
• Primary operative treatment – restore nerve function
• Secondary operative treatment – – muscle transfers and bone operations
![Page 25: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/25.jpg)
Primary operative treatment
• Surgical approach – supraclavicular approach for proximal lesions
• Extended to deltopectoral approach for distal lesions
![Page 26: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/26.jpg)
![Page 27: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/27.jpg)
![Page 28: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/28.jpg)
Direct suture
• Rarely used• Early repair of clean lacerations• Grafting is more often recommended• Good results in suitable cases
![Page 29: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/29.jpg)
Conventional nerve grafts
• Standard nerve grafting technique• Med cut arm and forearm, sural, • Placed without tension• Fixed with sutures and fibrin glue• Arm immobilised for 6/52
![Page 30: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/30.jpg)
Vascularised Nerve grafts
• Used where severe scarring present• For long defects• Contra lateral C7 transfers as pedicle• Results little better than standard grafts• Technically difficult when used as free graft
![Page 31: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/31.jpg)
Nerve Transfers
• Accessory to suprascapular – improved shoulder control
• Intercostal to lat cord – grade III/IV elbow flexion• Require relearning• Improve motor function• Increase sensory input to distal nerves – pain relief
particularly in pre ganglionic lesions
![Page 32: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/32.jpg)
October 2008 Brachial Plexus Injury Mr V Rajaratnam 32
![Page 33: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/33.jpg)
results
• Proximal muscles recover best• Distal muscles are finer – significant end organ
failure prior to reinervation• Better results if nerve grafting within 3/12• Repair c5/6 with conventional graft – functional
flexion of elbow and some shoulder control in 60%• Nerve transfer – functional gain in 60% if carried out
within 3/12• Not effective for c8/t1, less effective for c7
![Page 34: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/34.jpg)
Reconstructive Surgery
• Muscle Transfers• Arthrodesis• Amputations
![Page 35: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/35.jpg)
Shoulder
• Injuries to c5/6 alone have good hand function
• Shoulder function v important• Lat dorsi to external rotators• External rotation osteotomy• Flail shoulder - arthrodesis
![Page 36: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/36.jpg)
elbow
• Elbow flexion more important the extension (gravity)
• Triceps to biceps• Steindler flexorplasty (advance
brachioradialis)
![Page 37: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/37.jpg)
forearm
• Rotation difficult to establish• Treatment aimed at improving position with
rotational osteotomy
![Page 38: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/38.jpg)
hand
• Loss of finger/wrist extension – extensors more proximal root value than flexors
• Tendon transfers
![Page 39: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/39.jpg)
Epidemiology•80% supraclavicular type avulsion in type and need surgery•50% of these are pan plexal (C5 – T1)•60% of are C5/6 rupture with C7/T1 avulsion•30% of these are complete avulsion•35% of supraclavicular injury are C5/6 •20% associated with major artery injury
October 2008 Brachial Plexus Injury Mr V Rajaratnam 39
![Page 40: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/40.jpg)
October 2008 Brachial Plexus Injury Mr V Rajaratnam 40
![Page 41: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/41.jpg)
October 2008 Brachial Plexus Injury Mr V Rajaratnam 41
![Page 42: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/42.jpg)
October 2008 Brachial Plexus Injury Mr V Rajaratnam 42
![Page 43: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/43.jpg)
October 2008 Brachial Plexus Injury Mr V Rajaratnam 43
![Page 44: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/44.jpg)
October 2008 Brachial Plexus Injury Mr V Rajaratnam 44
![Page 45: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/45.jpg)
October 2008 Brachial Plexus Injury Mr V Rajaratnam 45
![Page 46: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/46.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 46Brachial Plexus Injury Mr V Rajaratnam
![Page 47: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/47.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 47Brachial Plexus Injury Mr V Rajaratnam
![Page 48: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/48.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 48Brachial Plexus Injury Mr V Rajaratnam
![Page 49: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/49.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 49Brachial Plexus Injury Mr V Rajaratnam
![Page 50: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/50.jpg)
October 2008 Brachial Plexus Injury Mr V Rajaratnam 50
![Page 51: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/51.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 51Brachial Plexus Injury Mr V Rajaratnam
![Page 52: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/52.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 52Brachial Plexus Injury Mr V Rajaratnam
![Page 53: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/53.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 53Brachial Plexus Injury Mr V Rajaratnam
![Page 54: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/54.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 54Brachial Plexus Injury Mr V Rajaratnam
![Page 55: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/55.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 55Brachial Plexus Injury Mr V Rajaratnam
![Page 56: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/56.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 56Brachial Plexus Injury Mr V Rajaratnam
![Page 57: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/57.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 57Brachial Plexus Injury Mr V Rajaratnam
![Page 58: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/58.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 58Brachial Plexus Injury Mr V Rajaratnam
![Page 59: Brachial Plexus Surgery](https://reader033.vdocuments.net/reader033/viewer/2022051111/552853934a795967508b46a8/html5/thumbnails/59.jpg)
Coverage
Anatomy
Incidence
Classification
Evaluation
Surgery
Rehabilitation
Outcomes
Recent Advances
October 2008 59Brachial Plexus Injury Mr V Rajaratnam