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Brachial Plexus Injuries

Dr. Ashok K. Gupta

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Projecting for a useful rehabilitation following Brachial Plexus Injury is one of the most demanding surgical designs. Advent of microsurgical techniques has made Brachial Plexus more accessible surgically, than it used to be a couple of decades ago. Microneural co-aptation of damaged Nerve Fascicles at Trunk, Division or Cord levels, have its limitations of time gap between the injury and repair and ultimate usefulness of the limb. Secondary Microsurgical Reconstruction in pre-ganglionic or Global Brachial Plexus Lesions, utilizing Adjoining or Distant Motor Nerves and Free Functioning Muscle Transfer (FFMT) have added a number of possibilities for a useful rehabilitation program. The person will never be able to achieve precision and original technical skills, after these secondary procedures; however, the limb can be turned into a useful supporting limb. Time interval between injury and secondary surgical repair do not influence the outcome significantly, however it is recommended to perform the neural re-distribution of the injured / damaged Brachial Plexus, utilizing available adjoining / distant donor motor nerves as early as possible.

Secondary Microsurgical Reconstructions - In Global Root Avulsion Injuries: Brachial Plexus

Over the decades, the therapeutic approach and the strategy of the management of Global Root Avulsion Injuries in Brachial Plexus lesions have changed dramatically. Secondary Neuro-muscular Microsurgical Reconstruction has replaced steps like Limb Amputations. Primary micro-neural reconstitution of Brachial Plexus Roots / Cords / Trunks is limited by factors like level of the injury, extent of the Neural / Muscular involvement and the time gap between the Surgery and the Injury. Results are greatly influenced by other factors and the Age and the Occupation of the patient.

Secondary Microsurgical Reconstruction offered plenty of options in the strategies of management of Brachial Plexus Injuries. Use of Adjoining and Sparable Motor Nerves like Accessory Spinal Nerve, Dorsal (Motor) Root of C-4, Inter-Costal Nerves (T3, T8) and Contralateral Lateral Pectoral Nerve, has been in clinical practice over 15 years. Uses of Contralateral Root of Contralateral C-7 have added a new leaf in the management of Brachial Plexus Injuries.

The ability to transfer a Live, Functioning and a Dynamic Muscle (FFMT) by Micro-neurovascular Techniques has changed the overall picture of rehabilitation in these cases. Muscles like Gracilis, Latissimus Dorsi and / or Serratus Anterior are effectively being transferred to achieve important and useful functions such as:

  1. Flexion at Elbow,
  2. Extension at Elbow,
  3. Flexion at wrist,
  4. Flexion of Fingers and Thumb and
  5. Extension at wrist.

I would like to share my experiences of Primary and Secondary Microsurgical Reconstructive procedure in over 105 Global Brachial Plexus Lesions.

Possible Nerve Donors:

Accessory Spinal Nerve

Dorsal Root of C-4 (IPSI-Lateral)

Inter-Costal: T-4 TO 9.

Dorsal Root of C-4 (Contra-Lateral)

Contra-Lateral Lateral Pectoral Nerve

Contra Lateral Accessory Spinal Nerve.

Possible Donor Muscles: (free)

Gracillis For Elbow Movements.

Gracillis + Adductor Longus for Shoulder.

Lattissimus Dorsi For Shoulder.

Gracillis for Finger Flexors.

Possible Muscle Transfer:(Island)

Trapezes for Shoulder Abduction.

Lattissimus Dorsi for Flexion of Elbow.

Lattissimus Dorsi for Extension of Elbow.

Serratus Anterior/ Pectoralis Major for Flexion of Elbow.

Teres Major + Lattissimus dorsi for External Rotation of Arm.

Zanoli Procedure for Pronation of Arm.

Brachio-Radialis Transfer for Extension of Fingers.

Extensor Indices for Opponence of thunb.

Flexor Carpi Ulnaris to extensor Carpi radialis.

Other Tendon/Muscle Transfer Based on it’s Recovery.

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