Search

Seventy-eight patients who had a complete brachial plexus palsy caused by a stretching injury were operated on by the same surgeon between January 1980 and December 1991. The aim of the operative intervention was to obtain the best functional result, including at the level of the hand, that was possible in view of the initial lesions and the intraoperative findings. Therefore, the treatment strategy included not only nerve repair with grafting (124 grafts) or nerve transfer (twenty-seven transfers) but also palliative procedures, the latter of which sometimes were performed several years later. Sixty-three patients were evaluated by an independent observer at least three years postoperatively. The results associated with each type of lesion and each type of nerve repair were assessed according to the function of the muscles that were innervated by the recipient nerve. Six patients had a neurolysis only. The remaining fifty-seven patients had grafts or nerve transfers to repair the biceps. Thirty-six of the fifty-seven received a rating of 3+ or more (meaning that the patient was able to flex the elbow repeatedly); the remaining twenty-one received a rating of 3 or less (meaning that the patient was able to flex the elbow only once or not at all), which we considered unsatisfactory. The function of the triceps recovered after eleven of thirty-one procedures that were performed to restore that nerve; that of the extensor carpi radialis, after five of thirty-one procedures; that of the flexor carpi radialis, after six of thirty-one procedures; and that of the flexor digitorum, after four of thirty-one procedures. A statistical analysis revealed that an operative delay of less than six months was a significant factor with respect to recovery of the function of the biceps (p = 0.003). The thirty-nine grafts that were sutured onto the lateral or posterior cord produced better results than did the thirty-six that were sutured onto the distal branches (the musculocutaneous and radial nerves); however, with the numbers available, this difference was not found to be significant (p = 0.08). Eleven patients had a successful result (a rating of 3+ or more) and eight, a fair or poor result, with respect to recovery of biceps function after transfer of the spinal accessory nerve to the musculocutaneous nerve. Overall, twenty-nine patients had relief of pain postoperatively. Sixteen patients had grade-3 pain preoperatively compared with only three after the operation. According to a self-rating scale, twenty-five patients were satisfied with the overall result, sixteen were fairly satisfied, and twenty-two were dissatisfied.

Twenty-three shoulder arthrodeses after brachial plexus injuries have been performed. Average time between injury and arthrodesis was 3.4 years. 18 patients had palliative procedures or direct approach of the brachial plexus to improve shoulder and hand function. Average follow-up was 5 years and 11 months. An analysis based on pain, function, and fusion occurrence gave 15 good, 2 fair and 4 poor results. The authors conclude that the shoulder arthrodesis is indicated when elbow and hand functions are sufficient and deafferentation pain has not occurred.

Since 1972, the author has performed 259 brachial plexus repairs and various associated secondary procedures. The best results were obtained with surgery delayed four to five weeks, because the preoperative assessment of the lesion is more accurate after wallerian degeneration has occurred. In addition, formation of a proximal neuroma allows definition of the exact limits for resection. In cases with associated vascular damage, the vessels should be repaired at the same time as the nerve grafts unless there is severe ischemia. Intraspinal exploration with cervical laminectomy is not justified because intraspinal avulsion is always due to rootlet avulsion. Division of the clavicle to facilitate exploration of the anatomy of the plexus where it is the most complex is advocated. In general, distal grafting allows the recovery of a single function, which is preferable to an attempt at total anatomic repair. The adverse effects of contractions must be avoided. The priority of restoration of functions is an important consideration. Elbow flexion should be the first priority, followed by wrist extension, finger flexion, and shoulder abduction, in that order. The results of grafting may be improved by ancillary operations such as shoulder fusion, flexor tendon tenodesis, humeral derotation, and other procedures that provide limited function for patients with various incomplete and complete avulsions. Microsurgical repairs of brachial plexus lesions currently offer the best results for patients with this type of injury.

Between 1973 and 1984, 31 direct explorations of traumatic Duchenne-Erb palsy (C5 and C6) were performed in two hospitals. Simple neurolysis was performed in 12 cases, in which C5 and C6 were found to be in continuity; the operation resulted in useful motor function in nine of the 12 cases. A cause-and-effect relationship of neurolysis to the recovery of function was difficult to prove. In five cases where only one root was completely damaged, four nerve graftings produced useful motor results but the function of one graft was not demonstrable when the other root was in continuity. In 14 cases of complete lesions of both C5 and C6 treated by nerve grafting, there were seven functional motor results that were attributable to the grafts. Both the overall results and the result of elbow flexion were statistically correlated with the number of grafts used to repair the corresponding nerve structure (p less than 0.01). Favorable results were not obtained when the graft had been delayed for more than nine months. All of the patients who had nerve grafts within five months had favorable results.

The authors have observed 103 cases of brachial plexus paralysis due to trauma. There were 65 total and 38 partial paralysis. The follow-up was for more than 5 years in half of the cases. Twenty-one of the 65 total paralysis showed no recovery. Total or partial recovery occurred in other cases. Recovery was more complete when it began earlier, within a few days or weeks, but, in a number of cases, isolated muscles such as biceps recovered after two, three or even four years. The authors analyse the results of peripheral surgery. Amputation did not improve patient function. Arthrodesis of the shoulder, tendon transfers for the restoration of finger extension and Stenidler procedures at the elbow gave good results. Tendon transfers at the shoulder (Clark procedure), operations for restoration of opposition of the thumb and transfers of triceps to biceps were beneficial. Poor results were obtained after arthrodesis of the wrist, complex tendon transfers in the hand and transfers of latissimus dorsi and teres major. A direct surgical approach to the lesion is indicated when there is no recovery after two months.

Between 1972 and 1985, 256 patients with a brachial plexus injury were operated on in our institution. One hundred fifty-nine post-traumatic injuries, with a minimal follow-up of 2 years for partial palsies and 3 years for complete palsies were reviewed. Clinical examination is particularly important, and CT scan combined with myelography and more recently Magnetic Resonance Imaging ensures exact assessment of the lesions. The operative procedure is described, depending on the level and the number of injured nerve roots. Eighty-six fascicular grafts, 9 trunk grafts and 35 nerve transfers were performed. In 40 cases a neurolysis only was performed. Results were analyzed: at follow-up a motor and sensory recovery was observed in 70% of cases allowing to relieve the pain and to improve the function of the limb. The operation must therefore be performed at the appropriate time according to the most appropriate procedure depending on the number of usable roots. Secondary palliative transfers also help to improve function.

Between October 1972 and December 1980, 139 post-traumatic brachial plexus palsies were operated upon by the same surgeon. The results of 63 are reported with a follow up of at least three years for the 32 complete palsies and two years for the 31 partial palsies. The protocol for examination and surgical repair is described. Major repairs were performed in 48, including suture, interfascicular grafting and nerve transfer. The remaining 15 had a neurolysis. The results are given for each type of lesion and for each kind of repair. Two series of complete palsies, one treated operatively, the other conservatively, are compared. It is concluded that surgical repair gives good results in partial palsies and in some complete palsies. Nerve transfer or graft gives some improvement but the usefulness of the limb remains disappointing.

Abstract: Radiation therapy of the neck or axillary areas for cancer may result in delayed brachial plexus palsy. Differential diagnosis between radiation and tumor brachial plexopathy is difficult. We report the case of a 38-year-old woman, treated by radiation therapy for osteosarcoma of the humeral head 22 years before, who exhibited a rapidly progressive incomplete hand palsy. EMG study revealed a conduction block at the level of the lateral cord. In this case, MRI could not distinguish between a delayed radiation injury and tumor infiltration. The diagnosis was clarified with an ultrasonographic examination. Neurolysis and epineurotomy of the median trunk in the brachial and axillary areas were performed. Histological examination confirmed radiation-induced nerve injury. The characteristics of this uncommon form are reviewed with regard to the previously reported descriptions. [Copyright &y& Elsevier]