Youmans Neurological Surgery

1. Early Management of
Brachial Plexus Injuries
Youmans Chapter 241
Allan Belzberg
Martin J. A Malessy

2. Brachial plexus lesion
• Shoulder-neck angle is forcefully widened  entire
plexus or a part of the BP nerves is elongated
• Cause
– Motor cycle accident
– Neoplasm
– Missile injury
– Birth-related injury
• Surgical treatment
– end-to-end neurotization
– interpositional nerve grafting
– intraplexus/extraplexus nerve transfer

3. Anatomy

4. Anatomy

5. Anatomy
• Roots
– anterior divisions of spinal nerves C5-T1
– pass between the anterior and medial scalene muscles
• Trunks
– Superior trunk: A combination of C5 and C6 roots.
– Middle trunk: A continuation of C7.
– Inferior trunk: A combination of C8 and T1 roots.
– move laterally, crossing the posterior triangle of the neck
• Divisions
– Anterior division
– Posterior division

6. Anatomy
• Cords
– The lateral cord is formed by:
• The anterior division of the superior trunk
• The anterior division of the middle trunk
– The posterior cord is formed by:
• The posterior division of the superior trunk
• The posterior division of the middle trunk
• The posterior division of the inferior trunk
– The medial cord is formed by:
• The anterior division of the inferior trunk

7. Anatomy
• Branchs
– Musculocutaneous Nerve(C5,C6,C7)
– Axillary Nerve(C5,C6)
– Median Nerve(C6,C7,C8,T1)
– Radial Nerve(C5,C6,C7,C8,T1)
– Ulnar Nerve(C8,T1)

8. Pathophysiology and classification
• Traction injuries : head and neck move away from the
ipsilateral shoulder  C5,C6 spinal nerves or upper
trunk
• Arm abduct over the head : lower element of BP
• C5-6-7 have fibrous attachment at cervical transverse
process, C8-T1 absent
• T1 sympathetic component of head and neck  injury to
T1  result in sympathetic ganglion loss and Bernad-
Horner syndrome(miosis, ptosis and anhidrosis)

9. Greenberg,7th
page 802

10. Clinical
• Trauma and associate injury
• Time course
• Factor impede nerve regeneration : age, neuropathy,
metabolic disturbance, systemic disease
• Medical record : surgical of subclavian artery, fracture
spine

11. Clinical

12. Clinical
• Preserve dorsal scapular n.(Rhomboid m.), long thoracic
n.(serratus anterior m) but loss external rotation of the
shoulder(infraspinatus m.) first 30 degree of shoulder
abduction(supraspinatus m.) : distal to spinal nerve and
into the upper trunk
• Atrophy of Pectoralis m is innervated by medial and
lateral pectoral n (branch of medial and lateral cord)
pan-plexus injury
• Bernard-Horner sign  high indicative for avulsion of C8
and T1 : false negative more common, may not be
present in 48 hr after injury

13. Clinical
• Regeneratee nerve fiber develop mechanosensitivity
• Hoffman-Tinel or Tinel’s sign : percussion over the
course of the nerve  tingling paresthesia (distal to
lesion site)
• Tinel sign does not indicative the number or quality of
regenerating axon and does not guarantee functional
outcome
• Lack of tinel sign  poor prognosis

14. Clinical
• Plain film cervical, chest
– spinal transvere process fx : nerve root injury
– Elevate hemidiaphragm : phrenic n.  C3,C4,C5
– Clavicular Fx : traumatic BPI

15. Therapy/Management
• nonoperative care
– ROM joint, muscle, tendon
– Neuropathic pain : anticonvulsant with narcotic
• appropriate selection of surgical candidates
– Avulsion of nerve root  severe pain  surgical
manage at DREZ
• timing of surgery
– Sunder land gr.V by Sharp laceration and
transection : immediate exploration and repair
– Sunder land gr.V by Stretch mechanism : 2-3 wk after
injury
– Strecth : observe for 3-4 mo for regeneration

16. Therapy/Management
• priorities of the surgical targets
– Elbow flexion
– Shoudler abduction
– Sensation of hand
– Wrist extension, finger flexion, wrist flexion,finger
extension
• method of nerve repair
– Differentiate Sunderland grade III from IV : need for
surgical resection and nerve repair

17. Therapy/Management
• Timing of and Selection for Surgery in Patients with
Birth-Related Brachial Plexus Injuries
• Surgical Exposure
• Nerve Transfer Surgery
• Outcomes after Treatment of Brachial Plexus Birth Injury

18. Timing of and Selection for Surgery in Patients
with Birth-Related Brachial Plexus Injuries(BRBPI)
• Neurapraxia, axonotmesis : complete or nearly complete
recovery
• Neurotmesis and root avulsion : permanent loss of arm
function
• 2- 3 month of age, before 7 mo
• Paralysis of the bicep m at 3 mo : wrist drop

19. Surgical Exposure
• Supraclavicular exposure
• Infraclavicular exposure
• Posterior exposure

20. Supraclavicular exposure
• 2 cm above and parallel to clavicle
• Omohyoid m. : upper border
• Anterior scalene m. : phrenic n. coursing,C5 nerve root
• Upper trunk : lateral border of Anterior scalene m.
• Middle and lower trunk
• Protect long thoracic n.

21. Infraclavicular exposure
• Incision at deltoid-pectoral groove
• Pectoralis major : blunt
• Pectoralis minor : retract upward or downward
• Infraclavicular BP : lateral cord seen first, then posterior
cord
• Subclavian a.
• Median n., MCN m. : retract lateral cord

22. Posterior exposure
• Prone position, Parascapular incision
• Trapezius and rhomboid m. resection
• Paraspinal m. retract
• Proximal spinal n.

23. Nerve transfer surgery
• Spinal accessory transfer
• Intercostal transfer
• Contralateral C7 transfer

24. Spinal accessory transfer
• Often used to Innervate SSN, MCN
• End-to-end transfer
• Exit under sternocleidomastoid and cross the posterior
triangle

25. Intercostal transfer
• Often T3,T4,T5 because to mobilized to end-to-end
transfer to MCN

26. A : incision at inferior
border of major pectoralis
m
B.identify MCN
C.ICN transect from
sternum c sensory branch,
MCN cut from lateral cord
D.ICN was tunnel to MCN

27. Outcome of function
• Shoulder function : fairy good recovery
• Elbow flexion : good recovery
• Recovery of Hand function : maximal function to use
affect limb as hook