journal club - article published by Dr. Mukund Thatte sir and Split Weld Technique Published by Prem Singh Bandari sir

1. JOURNAL CLUB – BRACHIAL
PLEXUS
DR G AVINASH RAO
Fellow In Hand And Micro
Surgery
SKIMS
MODERATOR – DR MIR MOHSIN.

5. Journals – For Today
A. Management of Birth Brachial Plexus Injury Including Use of
Distal Nerve Transfers - Mukund R. Thatte et al.
B. A Novel Technique in Fibrin Gluing of Intercostal Nerves:
Splint and Weld - Prem Singh Bhandari.

6. Management of Birth Brachial Plexus Injury
Including Use of Distal Nerve Transfers - Mukund
R. Thatte, Nayana S. Nayak, Amita S. Hiremath.
 INTRODUCTION
Kennedy (1903)- published the first known report of surgical
repair.
The standard of care then was intraplexal repair bridging the
ruptured root stumps to the distal nerves using nerve grafts.
Nerve transfers were introduced later and now form an
important part of treatment protocol in several centres.

7. ETIOPATHOGENESIS
FETAL CAUSES –
Macrosomia
Breech
Shoulder Dystosia
MATERNAL CAUSES –
Gestational Diabetis
Short stature /CPD
Primi / Multiparaous
Prolonged Second stage of Labour

8.  Traction to the neck caused by a pull by the obstetrician’s hand or
instruments in shoulder dystocia is the most accepted cause of BBPI.
 The left occipito anterior (LAO) is the most common presentation of the fetus
at delivery, and the anterior shoulder is involved - higher incidence of left-
sided injuries.
 Intrauterine injury, intrauterine maladaptation has been proposed as another
cause for BBPI. And denervation potentials have been recorded on day 1
after delivery, suggesting that the BBPI can occur in the intrauterine period.
 It has been shown that the posterior shoulder can get stuck on the sacral
promontory and cause injury through a stretch on that side while the baby is
in early stages of labour before the issue of shoulder dystocia and traction
can occur.

9.  A bicornuate uterus has also been described to be associated with BBPI with
phrenic palsy.
 Preventing BPPI by performing elective caesarean deliveries is not an
effective option.
 Gilbert found that 92% deliveries of high-risk patients (diabetic women
delivered by operative vaginal delivery with infants of 4.5 kg birth weight) did
not have BBPI.
 Elective caesarean delivery has not been shown to be beneficial in women
with estimated foetal weights of 4.5 kg, unless they were also diabetic.

10. CLINICAL ASSESSMENT
 Typically, a child is brought with or without a history of difficult labour
and the narrative is either that the parents or relatives noticed one
upper limb not moving well or were informed about it by the
neonatologist.
 Clinical examination is key to diagnosis.
 Motor examination is easier than sensory in the infant.
 Start by observing hand function to assess the function of C8/T1
roots. If these roots are intact, the fingers can be either observed to
be moving, either spontaneously or via a response by stroking the
hand.

11.  Next is the elbow - By holding the upper arm down to the bed, we can test
for antigravity elbow flexion (important in making decisions for Group I and II
cases.)
 Similarly, by lifting the arm and allowing the elbow to flex by gravity we can
then test for antigravity elbow extension.
 Finally, by lifting the whole limb and dropping it we can trigger reflexes that
demonstrate shoulder antepulsion and abduction.
 If an infant is not moving, then covering the eyes and restricting the
normal limb elicits all possible movements of the affected limb in various
combinations. It is better to ask the mother/ parent to cover the eyes.
 Stroking the limb in various areas and watching for a response gives a very

12. AMS (active movement scale)SCALE – 15 movements are
assessed score from 0-7.
Score > 3.5 – NON
Sx

13.  Many muscles have two roots innervation and foetal innervation
further complicates the issue. However, it is a useful guide
towards making a clinical diagnosis.

14. NCS
 The role of electrodiagnosis in preoperative assessment of OBPP is to
discriminate between a nerve conduction block and a root avulsion or to
predict the severity of axonal injury or degeneration.
 There is no role for motor-evoked potentials in OBPP yet.
 For imaging of the brachial plexus in infants, magnetic resonance imaging
has surpassed computed tomography–myelography as modality of choice.

15. MRI
 High-strength magnetic resonance scanners, applying different
techniques in a noninvasive way, allow imaging of plexus structures
with great detail.
 Detection of different nerve lesion types is possible, such as root
avulsions or nerve ruptures, formation of pseudomeningoceles,
neuromas, or scarring as well as deformities of the shoulder joints.
 Magnetic resonance imaging is becoming a great aid as a
preoperative investigation in determining treatment strategy in infants
with severe OBPP

16. The Narakas classification
proposed in 1987 – widely used
Grade 1 = C5,6 • Upper trunk
Grade 2 = C5,6,7 • Upper Trunk Extended
Grade 3 = C5,6,7,8,T1 • Total palsy / No Horner’s.
Grade 4 = C5,6,7,8,T1 • Total Palsy / Horner’s

19. INITIAL TREATMENT
 After clinical assessment, the diagnosis is discussed with the parents and a
treatment plan was discussed.
 This is based on the Narakas classification and the return of antigravity
elbow flexion
 They teach parents the following 4 exercises and ask them to perform it on
the infant 10–15 times with every breastfeed:
1. Circumduction to get full range of shoulder motion and also to relax co
contracting adductors
2. External Rotation of shoulder with arm adducted and elbow flexed
3. Hand to mouth and elbow extension
4. Pronosupination with elbow flexed

20.  These exercises aim to
1) prevent a shoulder internal rotation contracture.
2) They also give feedback to the brain about various possible
movements in an attempt to cortically re-integrate the limb.
 The child is then seen every month until a decision is made for
surgery.
 Electrodiagnostic study (Edx) to be done at 4 weeks. This has
prognostic value, especially in Group I. (Pondaag)

21. Spontaneous recovery of biceps: If spontaneous recovery of
the biceps is noted, then the aim of treatment is to prevent and
treat shoulder issues caused by co-contraction of adductors
and internal rotators.
Typically, it is easy to palpate the Teres Major and Latissimus
Dorsi co contracting as a child is attempting to abduct.
For the rotators it is harder to detect by palpation. If it is
suspected clinically, we order an Edx to document co-
contraction

22. CO-CONTRACTIONS
 Agonist and Antagonist – act at same time
 Normally it helps in improving Joint stability and to perform
skillful activities.
 But in Brachial plexus injury – Recovering Naturally /
Reconstructed with Nerve Grafts – Tendency of mixup of
growing axons to the target muscle.
 Detected by EDxS.

23. B) Internal rotation contracture: Between 3–6 months it is usually
clear if an internal rotation contracture is developing.
In patients with an internal rotation contracture where passive
External rotation is stuck at 90 degrees, but MRI is showing
reasonable congruence, the issue is still restricted to muscle
misbehaviour without any adverse joint changes.
In such situations, botulinum toxin can be injected directly into the
internal rotators, namely the Teres major and the Subscapularis. This
is usually followed by application of a shoulder spica cast to maintain
the correction.

24. If the external rotation is restricted beyond 120 degrees then we
try gradual stretching of the subscapularis and teres followed by
splinting.
If splinting and/or botulinum injections do not result in useful
shoulder function, one must consider surgery for the shoulder.

25. C) Congruence of gleno-humeral joint: It is important to assess
the relationship of the head of humerus in the glenoid fossa in
patients with an internal rotation contracture.
This is best assessed by an MRI of the shoulder.
In an infant, MRI will need some form of anaesthesia.
Botulinum injection is only considered if the head of the
humerus is still in the glenoid. It is given under General
Anaesthesia; typical dose is 25 units in Teres Major and 25

26. Shoulder surgery should also be considered in children
where the head of the humerus is not within the glenoid.
If MRI scan demonstrating poor congruence between the
glenoid and humeral head and increased glenoid
retroversion. This infant will benefit from direct shoulder
surgery.

27. Botox injection

28. Surgical correction

29. Indication and timing for primary nerve
surgery
 The indications and timing for surgery in BBPI is controversial.
 If there is no recovery in Group III or IV by 3 months, there is
agreement that surgery is indicated.
 The controversy exists in Group I and II, particularly in Group I.
 Gilbert and Tassin recommended that absence of antigravity
biceps at 3 months was indication for surgery. This
recommendation is still widely followed.

30.  Clarke uses a more comprehensive scoring of all movements
using the Toronto Active Movement Scale (AMS). Above a
certain threshold, they will wait until 9 months to see if the child
can take his/her hand to the mouth, the so called COOKIE
TEST.
 Malessy and Pondaag - showed consensus about evaluation at
1/3/6/9 months which should include external rotation
(measured in adduction), abduction, elbow flexion, wrist
extension, finger flexion, and finger extension. 86% agreed the

31.  THE CURRENT CONSENSUS is that antigravity elbow flexion is
important as an overall indicator of C5/C6 recovery including that of
the shoulder.
 Earlier surgery gives better overall outcomes including shoulder.
 Most surgeons including the author will operate on Group I and II
between 3–6 months depending on presence or absence of
recovery, especially of antigravity elbow flexion.
 There are instances where a child recovers good shoulder abduction
but does not recover good elbow flexion; rarely it is good elbow
flexion but poor shoulder function. (phenomenon of dissociative

32. Surgical Incision - Showing incision used
for supra and infraclavicular exploration of the
plexus

33. SURGICAL TREATMENT OPTIONS
 Nerve grafting
The most common injury is a post-ganglionic rupture. Over the
last few decades the standard of care has been resection of
neuroma and intra-plexal reconstruction using nerve grafts.
In babies with no recovery or poor recovery, Author performed a
supraclavicular and if needed infraclavicular exploration and
intraplexal nerve reconstruction, using nerve grafts, from roots
to trunks or cords depending on the extent of lesion.

34. Usually he will perform a spinal accessory nerve (cranial nerve XIth)
to suprascapular nerve transfer in addition to the intra-plexal nerve
grafting.
He feel this prevents co-contraction caused by nerve crossing in the
Intraplexal repair from hampering shoulder external rotation
In a pure intra-plexal repair only, Author have often found co-
contraction of the Teres major and Latissimus dorsi with the Deltoid
and Infraspinatus.
He avoid this cocontraction bought on by initiation of shoulder
abduction and external rotation by innervating the Supra and
Infraspinatus by the cranial nerve XIth.

35.  Nerve grafts are usually harvested from the sural nerve and in
global cases with involvement of multiple roots, he harvested
medial cutaneous nerves of arm and forearm (MCNA and
MCNF) taking them off the medial cord for a substantial length
as well as the superficial radial nerve (SRN).
 If avulsions are present and the proximal roots are no longer
available, nerve transfer options come into play depending on
availability.

36. Nerve transfers
 The concept of a distal transfer without a full formal intra-plexal
reconstruction with nerve grafts is a very attractive since the resultant
loss of any minimal preexisting movement (typically some shoulder
antepulsion and abduction) which is entailed in cutting the neuroma is
absent.
 At present there is no consensus whether this is an acceptable option
in post ganglionic injuries. (as the current standard of care is intra-
plexal reconstruction with nerve grafts)
 There is no controversy about the role of nerve transfers in avulsion
type injuries, but fortunately these are rare.

37.  Advantages of nerve transfers in BPBI are
1. Using a known functioning nerve and therefore a viable fascicle
2. Being close to the hilum of the target muscle
3. The target nerve distally is typically healthy and not involved in the
proximal scar
4. Timing is advantageous, even in late cases
5. Conceptually less chances of co-contraction
 Disadvantage of nerve transfers in BPBI are
1. Only those muscles which are targeted are innervated for e.g.
Supra/Infra Spinatus and Biceps with Deltoid
2. The neuroma may not be conducting and therefore recovery of other
muscles may not happen.
3. If the transfer fails, it may be too late to go back for an intra-plexal

38.  Distal nerve transfers use a functioning intra, or extra plexal nerve as a donor nerve to
reinnervate the target muscles.
 The principle involved is to either take a few fascicles to avoid a significant distal deficit,
as in case of a Oberlin transfer or sacrifice relatively unimportant target muscles, as in
case of intercostal nerves, to provide reinnervation to the desired recipient nerve and
muscle.
 Distal nerve transfers allow for an undisturbed neuroma in continuity.
 A triple transfer of spinal accessory to suprascapular nerve, Somsak transfer of a triceps
nerve branch to axillary nerve and Oberlin transfer of ulnar nerve fascicle to biceps motor
branch to restore shoulder abduction, external rotation and elbow flexion can be done for
a Narakas Group I child.
 Various nerves, such as the ulnar nerve fascicle, median nerve fascicle, 3rd–6th
intercostal nerves, spinal accessory nerve, medial pectoral nerve, thoracodorsal nerve
and nerve to subscapularis have been used as donors in nerve transfers.

39. Common nerve transfers in BBPI
1. Intercostal nerves (ICN) to musculocutaneous nerve (MCN) for elbow
flexion: This transfer was first done by Yeoman and Seddon in 1961 and
published by Seddon in 1963.
They used the ulnar nerve as a graft connecting the 3rd and 4th ICNs to
MCN.
El Gammal also reported that all children developed basal pulmonary
atelectasis postoperatively, but in a recent personal communication to
Author, El Gammal believed that there were no long-term implications to
the respiratory physiology.
In a recent review in 2013, Pondaag and Malessy mention approximately

40. 2. Oberlin type transfer: We call this Oberlin ‘type’ because Oberlin
initially described the use of an ulnar nerve fascicle to biceps in adult
patients. Subsequently the use of both ulnar and median nerve
fascicles have been described.
In general, it produces good results, with power of up to 4+ without a
clinically obvious distal defect, even in cases of late transfers either
due to late referral of the child or as a salvage procedure after a failed
initial repair in cases where good hand function existed.
The transfer is technically more difficult in children, and use of a
microscope is preferable.

41. 3. Spinal accessory nerve (SAN) to suprascapular nerve (SSN): This transfer
reinnervates the supra- and infra-spinatus muscles for initiation of shoulder
abduction as well as external rotation.
It is one of the triad of the now classic ‘triple nerve transfer’ done in adults
with upper plexus injury.
Kotani described it for adults, and Kawabata applied it to BPPI.
This transfer is performed both with intraplexal repair as well as part of pure
nerve transfers without neuroma resection.
SAN to SSN is an essential part of reconstruction in BBPI irrespective of
whether the reconstructive plan is nerve grafting or nerve transfers.

42.  4. Medial pectoral nerve (MPN) transfer: The pectoralis major muscle
is innervated by the medial and lateral pectoral nerves. The medial
pectoral nerve has been used for reinnervation of both deltoid and
biceps.
Samrdzic et al. described its use in BBPI in 2002 followed by Blauww
et al, who described it for biceps function in BBPI in 2003. A study
comparing the results of ICN vs MPN - found similar good results in
elbow flexion.

43. 5. Contralateral C7 (CC7) root transfer: The use of CC7 in BBPI is
limited to the rare case of root avulsion or where the available root
stump is of questionable quality, it is reasonable to use a CC7
especially targeted at C8T1 for restoring hand function.
In these circumstances, the strategy consists of:
a. Cervical motors to SSN
b. b. SAN to MCN
c. c. CC7 to Lower Trunk (C8T1)
d. d. Additionally, ICN’s can be used for other targets
.

44.  Although there are only a few reports with a large series that use
CC7,
 Author experience with the above strategy has been good. The
debate over the correct strategy for nerve reconstruction particularly
in Group I and II cases is unresolved.
 An IFSSH report concluded that the comparative merits of the two
different strategies are untested in a prospective trial anywhere

45. Summary
 Children with inadequate recovery due to a BBPI injury need surgery
of the nerves.
 The debate is on the indication, timing and appropriate treatment
modality.
 Intraplexal reconstruction using nerve grafts can be considered as the
standard of care.
 Primary intra-plexal reconstruction using nerve grafts has the
theoretical advantage of targeting all muscle supplied by the
concerned root, if all trunks/cords are coapted to them. This raises
the possibility of a better overall outcome in the long term.

46.  In reality, there are confounding variables including the quality of the
proximal root (despite investigations and visual impression), the
ability of distal nerves to let the advancing axons grow strongly
towards all targets, the question of timing, status of nerve muscle end
plates, and nerve cross over causing co-contractions and loss of
effective function.
 There is a role for nerve transfers for BPPI, in late cases, dissociative
recovery, avulsed proximal roots, and failure of nerve grafting.
 However, author feel that nerve transfers without neuroma resection
should also be considered as a primary treatment modality,

47.  Nerve transfers are now routinely being done for BBPI, and
although not yet standard of care, nerve transfers can be
considered as primary treatment, especially in group I and II
cases.
 In late cases and failed cases they are a very valuable tool at
our disposal.
 It is therefore currently difficult to give firm recommendations
regarding choices to be made. Each case will have to be
treated on merits and the surgeon must make choices based on
multifactorial assessment.

48. A Novel Technique in Fibrin Gluing of
Intercostal Nerves: Splint and Weld

49. A Novel Technique in Fibrin Gluing of Intercostal
Nerves: Splint and Weld - Prem Singh Bhandari.
 Splint and weld technique allows a sound coaptation of
intercostal and musculocutaneous nerves with minimal
synthetic suture through the neural tissue.
 Traditionally, nerve coaptation has been achieved by suturing.
 Challenges - Uneven Tension,
Skewed Alignment,
Trauma To Nerve Fascicles From
Microinstruments,
Foreign Body Reaction To Synthetic Suture
Lead To Loss Of Regenerative Axons + Suboptimal Functional

50.  Recent trends of using fibrin glue in nerve repair can yield
results similar to suturing in experienced hands, and even
superior when the surgeon is less conversant with microsurgical
techniques.
 Fibrin glue creates an adhesive cylinder around the stumps of
the nerve through which regenerating axons grow by
chemotaxis.
 The new technique described here takes advantages of both
suture and glue fixation without introducing foreign material

51. GLUE – STITCH – GLUE
In the entire process, approximately 2 mL of reconstituted fibrin
glue is consumed
 Distal 2.5 cm segments of three intercostal nerves are placed parallel
on a thin plastic sheet and splinted with a layer of fibrin glue.
 Approximately 60 seconds later, on formation of a coagulum, the
glued edge of intercostal nerves is freshened with sharp
microscissors. Thereafter, three 10/0 nylon sutures are passed
through the edges of coagulum and the epineurium of the
musculocutaneous nerve at 3, 6 and 12 o’ clock positions.
 Placement of microsutures through the soft and fragile coagulum
requires a gentle and careful handling.
 A tension-free approximation is ensured without buckling of fascicles.

53.  Synthetic microsutures - foreign material sutures are known to
produce local inflammatory reaction that might hamper regeneration.
These pathologic processes cause hindrance to the sprouting axons
and impair blood supply to the fascicles.
 Suturing of thin caliber nerves, for example, intercostal nerves, may
also be difficult and technically challenging.
 Use of fibrin glue prevent suture-related problems. Fibrin glue forms
an adhesive cylinder around the nerve ends and allows axonal
migration by chemotaxis.
 Intercostal nerve to musculocutaneous nerve neurotization is a
standard procedure in restoration of elbow flexion.

54.  Intercostal nerve does not allow placement of more than a
single suture – Thin And Fragile.
 Suturing itself causes microtrauma and inflammatory reaction,
even with sutures as thin as 10/0 – and it is LESS with fibrin
glue fixation.
 The strength at coaptation site with glue fixation alone remains
the subject of concern. Suture and weld technique take
advantages of both suture and glue fixation, without introducing
foreign material through the actual neural tissue and at the

55.  This technique has been used in adult (six patients) as well as
birth-related (11 patients) brachial plexus palsy patients.
 In the adult group, three patients restored M3, two patients M2,
and a single patient M1 elbow flexion at 14 months follow-up.
 Results have been more encouraging in the birth palsy group,
with nine patients attaining M3, and two patients M2 at 10
months follow-up.
 When compared with conventional techniques, the functional
gains in attainment of active elbow flexion have been superior

56.  Conclusion
This technique has dual advantage of both suturing as well as
glue coaptation. Placement of sutures in extraneural tissue
minimizes foreign body reaction, while splinting of distal
segments of intercostal nerves ensures good approximation
without loss of axons from misdirected fascicles.