[Surgery of post-traumatic brachial plexus lesions (personal approach in 2003)]

H Millesi
Handchirurgie, Mikrochirurgie, Plastische Chirurgie 2004, 36 (1): 29-36
The surgery of traumatic brachial plexus lesions has developed extensively. At present (in the year 2003), five different approaches are utilised: A simple nerve transfer to restore elbow flexion without exploration of the brachial plexus is still recommended. In contrast to this technique, in many centres an extensive exploration of the brachial plexus is performed, to clarify an exact anatomical diagnosis. The treatment depends on the findings and consists of neurolysis, interfascicular nerve grafting, or nerve transfers in case of root avulsions. The surgery of the brachial plexus is followed by an intensive physiotherapy and, when the result of the plexus surgery can be evaluated, by a series of reconstructive procedures to maximise the functional result. The dorsal approach by David Kline is is indicated in special situations. The re-implantation of avulsed roots according to Carlstedt is still in an experimental phase. Doi recommended primary free functional muscle transplantation without exploration of the brachial plexus, which is a waste of muscles which have the potential of regeneration. The free muscle transplantation should be limited to inveterated cases. In the past ten years, the nerve fibre transfer from contralateral C7 according to Gu (1991) has opened a new source for axon sprouts. With this technique very good results can be achieved in elected cases, especially in young patients with a short interval between accident and surgery. The termino-lateral coaptation according to Fausto Viterbo provides axon sprouts from other nerves, without the necessity to sacrifice the function of the donor nerve. Excellent results can be achieved if the donor nerve is a small pure motor nerve, and the recipient nerve as well, in order to avoid a dilution of axon sprouts. Knowledge of the different fascial systems around the brachial plexus helps to facilitate the exploration. This is especially important in the area of the cuppula pleurae (membrana suprapleuralis Sibson). A detailed description of this system is provided. Pathology of the root-nerve complex is more complicated and cannot be reduced to the simple alternative "either root avulsion or rupture". Inspite of improvement of diagnostic means, cases are seen frequently in which--under the diagnosis "complete root avulsion"--non-avulsed roots have not been recognized and have not been used as donors for axons. MR-imaging has a failure rate and cannot be relied upon for surgical decision making. If the continuity of a root is proven, it is not sure that this root is really conducting and that there is a sufficient potential for regeneration. The only way to gain knowledge about the conductivity of roots in continuity is the "Central stimulation according to Turkof". This technique should be improved and one should get a quantitative answer. A surgical exploration of the brachial plexus, even if root avulsions are suspected, is mandatory. The most important point, as far as the brachial plexus lesion is concerned, is a combined approach: The brachial plexus lesion should be attacked directly, and as much reconstruction should be performed at the level of the brachial plexus as is possible. In elected cases, a C7 transfer might be indicated in a second stage. Surgery on the brachial plexus is followed by a period of intensive physiotherapy. When the result of the surgery on the brachial plexus can be evaluated, all possibilities of reconstructive surgery have to be applied to maximise the result.

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