Plastic, Hand & Microsurgery>>Brachial Plexus >>Direct Nerve Surgery
..:: Brachial Plexus - Direct Nerve Surgery ::..
|
Direct Nerve Surgery
Direct Nerve Surgery consists of exploring the brachial plexus and depending
on the intraoperative finding one of the following can be carried out
a. Direct repair
b. Neurolysis
c.
Primary Nerve Grafts
d.
Neurotisation
a. Direct repair : When the ends are cleanly cut like in a stab injury
they can be directly repaired
b.Neurolysis : Consists of freeing the Nerves caught in the scar This is done when there is no anatomical breach in the nerve but there is no recovery of function
Preop Photos showing no elbow flexions and
shoulder abductions 4 months following trauma |
On Exploration there was severe fibrosis around the
upper trunk. The nerves were neurolised and all the
branches were carefully freed as
seen below |
Post operative result at the end of 1 year showing normal
hand function
c.
Primary Nerve Grafts : When the gap is more the cut ends can be joined
by nerve grafts. In this situation we have good nerve roots available proximally which could be used to neurotise the muscles distally .
Rupture of C5, C6 roots, Inability to flex his elbow
and raise his hand
above the head
|
Intra op finding showed rupture of roots which
was bridged by sural nerve grafts as shown below |
Post op result at one year follow up showing
good flexion of elbow and full range of
abduction of shoulder. |
d.
Neurotisation :
fghhghghWhen only upper roots are damaged and there is good function in the hand. We could transfer few fasicals from the intact nerve to achive elbow and shoulder function. This form of reconstruction is called Intraplexal Neurotisation.
We now routinely transfer one fascicle from Ulnar nerve for Biceps Branch, Median Nerve Fascicle for Brachialis muscle branch (Oberlin's Transfer), One branch of radial Nerve going to Long head of triceps to Axillary nerve (Somsak) and Spinal Accessory to Suprascapular Nerve . This form of nerve transfer gives extremely good results if done early from the time of injury.Surgery by 6Weeks from injury is ideal.
When all roots are avulsed, nerves such as spinal accessory,
phrenic , intercostal can be used to neurotise important nerves responsible
for specific functions in the upper limb.This form of reconstruction is called Extraplexal Neurotisation.
Surgery
and good rehabilitation programmes result in a good assisting hand to the
other hand. Whether requiring surgery or not, every patient with Brachial
plexus injury needs proper evaluation of an expert team, counseling and
rehabilitaion.
Ulnar nerve Fascicle for Biceps Branch, Median
Nerve Fascicle for Brachialis muscle branch(Oberlin's Transfer) |
Spinal Accessory to Suprascapular Nerve Transfer |
Long head of triceps branch to Axillary |
Post operative Pictures at 18 months follow up
|
