An example of Neurolysis

fig(3)

fig(4)

fig(5)

fig(6)
Post operative result at the end of 1 year showing normal
hand function 

 

An example of Primary nerve graft

Fig 6(a) Rupture of C5, C6 roots, Inability to flex his elbow 
and raise his hand above the head
Fig (8) Intra op finding showed rupture of roots which 
was bridged by sural nerve  grafts as shown below

Fig (9) Post op result at one year follow up showing 
good flexion of elbow and full range of 
abduction of shoulder.

 

The hand is supplied by a group of nerves coming from the spinal cord at the level of the neck. This group of nerves is called Brachial plexus .It is fairly fixed at the site where they leave the spinal cord and below where they enter into the arm.  Any injury which increases the distance between the neck and the shoulder has the risk of injuring the plexus of nerves. This commonly happens when people fall off the motor cycles. Sudden deceleration with high kinetic energy  can  cause  severe  brachial plexus injuries.  Total plexus lesions tear  off  all roots from the spinal cord (Fig). THE RESULT COULD BE DEVASTATING- the whole of the upper limb may become flail with no sensation or a group of muscles may not work, thereby resulting in permanent paralysis to that side of the limb .

 The diagnosis of brachial plexus  is based on clinical and special  investigations to know  the exact level of the lesion.  Microsurgical techniques, have improved  the prognosis of nerve injuries  dramatically. It  has brought about a more aggressive attitude in brachial plexus management.

 what are the types of injuries?

The injury could be stretch of the nerves or total rupture. If the level of injury is outside the bony spinal canal it is called Nerve Rupture, repair of the nerves may be possible in such patients. If the injury happens inside the  bony spinal canal, it is called Nerve Avulsion, direct repair of the nerves is not possible. Even in such cases salvage of function by rerouting of nerves (neurotisation),microsurgical Free Functioning muscle transfer (FFMT) or tendon transfers may be done.  The field of Brachial plexus injuries is one of the newer  frontiers of Hand Surgery.  The advent of microsurgery has dramatically improved the results in many patients.  From a situation of uniform gloom, we have now reached the stage of guarded optimism. The Hand unit of Ganga Hospital is actively involved in managing such problems.

When should the patient be first seen?

It is better to be under the care of the expert team from the beginning.  If it could be confirmed that the injury is inside the bony spinal canal, rehabilitative surgery could be done early.  Good clinical examination and investigations like CT myelogram and nerve conduction studies are usually done.  Otherwise a waiting period of 3 to 4 months is appropriate. Then a detailed clinical examination is done followed if necessary by a fresh set of investigations.  Better results are obtained if  nerve surgery is done within 6 months from injury. If the patient is seen later, tendon transfers or free muscle transfers after nerve grafts can be done. 

Are operations worthwhile?

    In most cases yes. As a general rule, one can recommend the repair of nerve lesions as early as possible, as this ensures better outcome.  There is a saying, ‘For those who have nothing, a little is a lot’.  Results of Brachial Plexus surgery must be evaluated on those lines.  In most cases it is possible to stabilize the shoulder, restore elbow flexion, to establish protective sensation. It is  a marked improvement for the patient and beyond any expectation even a few years ago. Nerve recovery may proceed for many  months.  It is important to have regular physiotherapy  till recovery , which is around 9 months to one year in most cases.

What are the types of Surgery ?

1.  Direct Nerve Surgery
2.  Microvascular free functioning Muscle transfer
3. Tendon Transfers

1.  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 : 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 (fig.1 - 6 ) This is done when there is no anatomical breach in the nerve but there is no recovery of function
c. Primary Nerve Grafts : When the gap is more the cut ends can be joined by nerve grafts (fig.7 to 9) . In this situation we have good nerve roots available proximally which could be used to neurotise the muscles distally .
d. Neurotisation : 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. When only upper roots are damaged and there is good function in the hand. we could 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 and Spinal Accessory to Suprascapular Nerve . This form of nerve transfer gives extremely good results if done early from the time of injury (6Weeks from injury is ideal(Fig 10 - ).

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.

   
 

25 year male with right sided upper brachial plexus paralysis (C5&C6)and femur fracture

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

fvbvbvbvbvcbvcbvcbvbcvbbvvvvvvvvvvvvvvvvPost operative Pictures at 18 months follow up

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