Brachial Plexus Injury ROH FRCS Revision Course September 2007 2003 fo

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Traumatic Brachial Plexus Injury:Assessment and Management : 

Traumatic Brachial Plexus Injury:Assessment and Management V Rajaratnam Consultant Hand Surgeon Birmingham Hand Centre www.handsurgerymanual.com www.wiziq.com/vaikunthan

Objectives : 

Objectives Anatomy Pathomechanics Pathoanatomy Pathophysiology Common clinical patterns BPI Classification Key examination points BPI investigation Early management Timing of surgery Reconstruction priorities Reconstruction ladder Evolution of modern techniques Reconstruction algorithm Additional procedures Results Prognosis in BPI Research areas Clinical cases

Brachial Plexus Anatomy : 

Brachial Plexus Anatomy Anterior primary rami of C5-T1 Phrenic nerve C3/4/5 3 important nerves originate above the clavicle C5 root-dorsal scapular C5/6/7 roots-long thoracic nerve (Bell) C5/6 upper trunk-suprascapular nerve T1 contributes preganglionic sympathetic fibres to stellate ganglion

Pathomechanics of BPI : 

Pathomechanics of BPI

Pathoanatomy : 

Pathoanatomy

Pathophysiology : 

Pathophysiology Seddon 1943 Neuropraxia Focal demyelination Axonal continuity Axonotomesis Axonal loss Wallerian degeneration Neurotmesis Transection of a nerve Complex spectrum with several patho-physiological processes co-existing: Focal ischaemia and oedema Demyelination Intraneural bleeding Axonal loss Nerve avulsions (post-ganglionic) Root avulsions (pre-ganglionic) Spinal cord oedema and haemorrhage Intra- and peri-neural fibrosis Anterior horn cell death

Common Clinical Patterns : 

Common Clinical Patterns Supraclavicular lesions Preganglionic or postganglionic Myotome / dermatome distribution Infraclavicular lesions Postganglionic Proximal peripheral nerve distribution Upper, Intermediate, Lower or TBPI Upper roots injured most frequently 80% patients are likely to have at least some complete injury Upper roots (C5/C6) often postganglionic Branches and interscalene ligaments protect roots from avulsion 60% ruptures 40% avulsions Lower roots (C8/T1) usually preganglionic Direct line of pull to spinal cord 85% avulsions 15% ruptures

Upper Plexus - C5/6 : 

Upper Plexus - C5/6 “Bad shoulder, good hand” Affects shoulder girdle muscles “Waiters tip” Erb’s palsy Adducted and internally rotated shoulder Root lesion Serratus anterior, Rhomboids, Suprapsinatus, Infraspinatus, Deltoid, Biceps brachii, Brachialis, Brachioradialis More distal lesion Rhomboids spared (dorsal scapular nerve) Serratus anterior spared (long thoracic nerve)

Intermediate Plexus - C7 : 

Intermediate Plexus - C7 Rare in isolation Tumour Iatrogenic injury Co-exists with upper and lower plexus injuries C5/6/7 C7/8/T1 Minor impact Weakness of wrist extensors Can be used as ipsilateral intraplexal donor or contralateral donor for reconstruction

Lower Plexus – C8/T1 : 

Lower Plexus – C8/T1 “Good shoulder, bad hand” Klumpke’s palsy Weakness FCU, FDP to ulnar digits Loss of hand intrinsics Loss of EIP Loss of EPL Medial forearm and hand sensory loss Horner’s syndrome (loss of sympathetic outflow)

Classification of Brachial Plexus Palsy : 

Classification of Brachial Plexus Palsy Age Pathological Anatomical Combination

Classification of Brachial Plexus Palsy : 

Classification of Brachial Plexus Palsy Age Pathological Anatomical Combination Obstetric Adult

Classification of Brachial Plexus Palsy : 

Classification of Brachial Plexus Palsy Age Pathological Anatomical Combination Traumatic Traction, avulsion, penetrating wounds Infective Cervical amyotrophy Parsonage-Turner (viral brachial neuritis) Radiation induced Malignant Pancoast tumour of the lung Primary nerve tumours Iatrogenic CVLs Invasive angiography Neck dissection

Classification of Brachial Plexus Palsy : 

Classification of Brachial Plexus Palsy Age Pathological Anatomical Combination Supraclavicular Infraclavicular

Classification of Brachial Plexus Palsy : 

Classification of Brachial Plexus Palsy Age Pathological Anatomical Combination Preganglionic Postganglionic

Classification of Brachial Plexus Palsy : 

Classification of Brachial Plexus Palsy Age Pathological Anatomical Combination Upper plexus C5/6 C5/6/7 Lower plexus C8/T1 Panplexus C5-T1

Classification of Brachial Plexus Palsy : 

Classification of Brachial Plexus Palsy Age Pathological Anatomical Combination Leffert I open II closed IIA Supra-clavicular Pre-, Post-ganglionic IIB Infra-clavicular III radiation IV obstetric IVA Erb’s IVB Klumpke’s IVC Mixed

Key Examination Points : 

Key Examination Points ATLS Serial clinical examination Flaccid paralysis of involved limb Associated fractures and dislocations First rib, clavicle, cervical transverse processes, ipselateral limb fractures Shoulder, ACJ , SCJ and scapulo-thoracic dislocations De-afferentiation pain Long tract signs in lower limbs Asymmetry of reflexes, clonus, up-going plantar Horner’s syndrome Miosis, ptosis, anhydrosis, enopthalmos Phrenic nerve palsy Loss of dorsal scapular nerve Cervical plexus involvement Sensory loss proximal to clavicles Paralysis of strap muscles Cervical scoliosis

BPI Investigation : 

BPI Investigation Imaging CXR, C spine, shoulder radiographs MRI Myelography + CT Neurophysiology tests Somatosensory Evoked Potentials NCS 6/52 neuropraxia resolution Normal SNCVs and absent MNCVs in preganglionic lesions Absent SNCVs and MNVCs in postganglionic lesions EMG Fibrillation potentials Spontaneous muscle depolarisations due to ACh receptor upregulation in target muscles Histamine Test Is it pre-ganglionic? Historical interest only

CXR: Phrenic Nerve Palsy : 

CXR: Phrenic Nerve Palsy

MRI: C5/6 root avulsions and pseudomeningocoeles : 

MRI: C5/6 root avulsions and pseudomeningocoeles

CT Myelogram: C5/6 root avulsions : 

CT Myelogram: C5/6 root avulsions

Early Management of BPI : 

Early Management of BPI Open injury: Early exploration Debridement Nerve repair, graft and transfers Closed injury: Physiotherapy Shoulder abduction Shoulder external rotation Elbow ROM ROM fingers Occupational therapy Wrist splints Resting intrinsic plus splints Skin care for trophic areas Education Regular clinical reassessment Advancing Tinel test for regeneration in zones of axonotmesis Deep muscle pain for early sign of reinnervation

Early Management of BPI : 

Early Management of BPI Open injury: Early exploration Debridement Nerve repair, graft and transfers Closed injury: Physiotherapy Shoulder abduction Shoulder external rotation Elbow ROM ROM fingers Occupational therapy Wrist splints Resting intrinsic plus splints Skin care for trophic areas Education Regular clinical reassessment Advancing Tinel test for regeneration in zones of axonotmesis Deep muscle pain for early sign of reinnervation

Case 1: Open root avulsions : 

Case 1: Open root avulsions

Case 1: Open root avulsions : 

Case 1: Open root avulsions

Case 2: Stab injury C5/C6 : 

Case 2: Stab injury C5/C6

Case 2: Stab injury C5/C6 : 

Case 2: Stab injury C5/C6

Case 2: Stab injury C5/C6 : 

Case 2: Stab injury C5/C6

Case 2: Stab injury C5/C6 : 

Case 2: Stab injury C5/C6

Early Management of BPI : 

Early Management of BPI Open injury: Early exploration Debridement Nerve repair, graft and transfers Closed injury: Physiotherapy Shoulder abduction Shoulder external rotation Elbow ROM ROM fingers Occupational therapy Wrist splints Resting intrinsic plus splints Skin care for trophic areas Education Regular clinical reassessment Advancing Tinel test for regeneration in zones of axonotmesis Deep muscle pain for early sign of reinnervation

Early Management of BPI : 

Early Management of BPI Open injury: Early exploration Debridement Nerve repair, graft and transfers Closed injury: Physiotherapy Shoulder abduction Shoulder external rotation Elbow ROM ROM fingers Occupational therapy Wrist splints Resting intrinsic plus splints Skin care for trophic areas Education Regular clinical reassessment Advancing Tinel test for regeneration in zones of axonotmesis Deep muscle pain for early sign of reinnervation

Timing of Surgery : 

Timing of Surgery Acute closed BPI <6/52 CT myelography 3-6/52 post injury Pseudomeningocoeles, myelomalacia and root avulsions Unequivocal total BPI (C5-T1 avulsion) Explore 1-2/12 All others repeated clinical assessment Consider EMG and NCS at 6-8/52 Planned exploration at 3/12 for grafting and nerve transfers Delayed presentation <6/12 Consider NCS /EMG / CT myelography Explore for neurolysis, grafting and nerve transfers Delayed presentation >6/12 Consider NCS /EMG / CT myelography Consider selective distal neurotisations , arthrodeses, tendon transfers and functioning free muscle transfers

Reconstruction Priorities : 

Reconstruction Priorities Shoulder and elbow control to enable positioning of a sensate hand for prehension Shoulder abduction SSN (AxN) Elbow flexion MCN Sensate hand (MN / lateral cord) Finger flexion (MN) Elbow extension (RN) Release (RN / PIN) (Intrinsic function)

Reconstruction Priorities : 

Reconstruction Priorities Shoulder and elbow control to enable positioning of a sensate hand for prehension Shoulder abduction SSN (AxN) Elbow flexion MCN Sensate hand (MN / lateral cord) Finger flexion (MN) Elbow extension (RN) Release (RN / PIN) (Intrinsic function)

Reconstruction Ladder in BPI : 

Reconstruction Ladder in BPI Neurolysis External / internal Nerve grafts Sural, LCNF, MCNF Plexo-plexal (anatomic) Neurotisation Reinnervation of a denervated motor or sensory end organ Extraplexal donors for specific functions Nerve transfers Ipselateral C7 or contralateral hemi C7 transfer to median nerve using a vascularised ulnar nerve graft (in cases of preganglionic C8/T1 lesions) based on superior ulnar collateral vessels Arthrodeses Osteotomies Tendon transfers Amputations Functioning Free Muscle Transfers

Evolution of modern techniques 1 : 

Evolution of modern techniques 1 Early exploration <6/52 Haemorrhage is often problematic Potential for early recovery of neuropraxic injury Unreliable intra-operative nerve stimulation Poor historical results of late exploration (>6/12) Distal reinnervation is unsatisfactory Long grafts End plate response diminishes with time Move towards earlier exploration in closed injuries (6/52-3/12) Referrals are often delayed Associated injuries (eg IPPV for HI) BPI is frequently missed Trauma surgeon education Supra-regional referrals

Evolution of modern techniques 2 : 

Evolution of modern techniques 2 Neurotise rather than plexo-plexal grafting “One nerve, one function” Uncertain condition of root (SSEPs poor predictors) Co-contraction of reinnervated antagonists Importance of reinnervation of the deltoid Leechavenvongs: Long Head Triceps to anterior axillary nerve Distally based transfers more rapid and reliable recovery Oberlin 1 and Oberlin 2 transfers for elbow flexion FCR, PL, redundant FDS branches to ECRB, PIN and PT Avoid grafts Longer reinnervation times and less predictable outcomes End to side techniques (“Something for nothing”) FFM transfer when >6/12 since injury Muscle reinnervation MRC 3+ not possible after 12/12 Contralateral C7 to provide sensation Hemi C7 transfer minimises donor morbidity Poor motor reinnervation, reasonable sensory to median nerve Selective use of osteotomies, arthrodeses, tendon and muscle transfers

Selective neurotisation: Phrenic to SSN : 

Selective neurotisation: Phrenic to SSN

Selective neurotisation: XI to SSN : 

Selective neurotisation: XI to SSN

Selective neurotisation: XI to MCN : 

Selective neurotisation: XI to MCN

Selective neurotisation: ICNs to MCN : 

Selective neurotisation: ICNs to MCN

Leechavengvongs: Triceps branch to axillary transfer : 

Leechavengvongs: Triceps branch to axillary transfer

Leechavengvongs: Triceps branch to axillary transfer : 

Leechavengvongs: Triceps branch to axillary transfer

Leechavengvongs: Triceps branch to axillary transfer : 

Leechavengvongs: Triceps branch to axillary transfer

Leechavengvongs: Triceps branch to axillary transfer : 

Leechavengvongs: Triceps branch to axillary transfer

Leechavengvongs: Triceps branch to axillary transfer : 

Leechavengvongs: Triceps branch to axillary transfer

Leechavengvongs: Triceps branch to axillary transfer : 

Leechavengvongs: Triceps branch to axillary transfer

Oberlin 1: Selective distal neurotisation for elbow flexion : 

Oberlin 1: Selective distal neurotisation for elbow flexion

Oberlin 1 and 2: Selective distal neurotisations for elbow flexion : 

Oberlin 1 and 2: Selective distal neurotisations for elbow flexion

Oberlin 1 and 2: Selective distal neurotisations for elbow flexion : 

Oberlin 1 and 2: Selective distal neurotisations for elbow flexion

Doi: Functioning free gracilis for elbow flexion and finger extension : 

Doi: Functioning free gracilis for elbow flexion and finger extension

Functioning Free Gracilis Transfer : 

Functioning Free Gracilis Transfer

Functioning Free Gracilis Transfer : 

Functioning Free Gracilis Transfer

Functioning Free Gracilis Transfer : 

Functioning Free Gracilis Transfer

Functioning Free Gracilis Transfer : 

Functioning Free Gracilis Transfer

Contralateral Hemi C7 Transfer : 

Contralateral Hemi C7 Transfer

Contralateral Hemi C7 Transfer : 

Contralateral Hemi C7 Transfer

Contralateral Hemi C7 Transfer : 

Contralateral Hemi C7 Transfer

Contralateral Hemi C7 Transfer : 

Contralateral Hemi C7 Transfer

Contralateral Hemi C7 Transfer : 

Contralateral Hemi C7 Transfer

Osteotomy : 

Osteotomy TBPI Some C5/6/7 recovery No wrist extension Supinated forearm Poor cosmesis and function

Osteotomy : 

Osteotomy TBPI Some C5/6/7 recovery No wrist extension Supinated forearm Poor cosmesis and function

Osteotomy : 

Osteotomy Plan Derotation osteotomy of forearm Wrist fusion Wrist flexor to digital extensor transfer

Arthrodeses : 

Arthrodeses Glenohumeral fusion Wrist fusion CMCJ fusion to thumb

Glenohumeral Arthrodesis 1 : 

Glenohumeral Arthrodesis 1 TBPI post XI to SSN and ICNs to MCN Poor shoulder recovery GHJ instability with “pistoning” with elbow flexion Shoulder internal rotation with elbow flexion

Glenohumeral Arthrodesis 2 : 

Glenohumeral Arthrodesis 2

Glenohumeral Arthrodesis 3 : 

Glenohumeral Arthrodesis 3

Glenohumeral Arthrodesis 4 : 

Glenohumeral Arthrodesis 4 GHJ plate fusion 30-30-30 positioning

Tendon and Muscle Transfers : 

Tendon and Muscle Transfers Trapezius to greater tuberosity Latissimus dorsi to infraspinatus Latissimus dorsi to Biceps Pectoralis major rotationplasty to Biceps Steindler flexorplasty for assisted elbow flexion Pedicled Latissimus dorsi to finger flexors

Pectoralis to Biceps 1 : 

Pectoralis to Biceps 1

Amputation: Scapulothoracic dissociation : 

Amputation: Scapulothoracic dissociation

Reconstruction Algorithm : 

Reconstruction Algorithm C5 avulsion C5 and C6 avulsions C5, C6 and C7 avulsions C8 and T1 avulsions C5-T1 (TBPI) avulsions

C5 root avulsion : 

C5 root avulsion No supraspinatus or deltoid “Bad shoulder, good hand” XI to suprascapular nerve (no graft needed) LHT branch to anterior division axillary nerve

C5 and C6 root avulsions : 

C5 and C6 root avulsions No supraspinatus, deltoid or biceps XI to suprascapular nerve (no graft needed) LHT branch to anterior division axillary nerve Oberlin 1 (+/- Oberlin 2) +/- LTN (Serratus anterior) neurotisation with TDN (C7) or 2x i/c nerves

C5, C6 and C7 root avulsions : 

C5, C6 and C7 root avulsions No supraspinatus, deltoid, biceps or triceps XI to SSN 2x i/c nerves to AxN 2x i/c nerves to triceps branch Oberlin 1 or 2 FDS fascicle to PIN

C8, T1 avulsions : 

C8, T1 avulsions Poor hand function Loss of intrinsics and flexors Pedicled Latissimus dorsi transfer to finger flexors (under PT) if contra-indication to FFM (C7 thoracodorsal nerve intact) Static anticlaw procedures CMCJ fusion or opponensplasty Consider FFM transfer (gracilis) for finger flexion

C5-T1 avulsions : 

C5-T1 avulsions No function “Bad shoulder and bad hand” XI to SSN Phrenic nerve to musculocutaneous nerve Contralateral C7 to median nerve (using vascularised ulnar nerve) Early may provide MRC 3 flexor function Late for sensation to radial side of hand 2 x FFM transfers (gracilis) Doi 1 Finger extension and elbow flexion (if poor recovery following phrenic to MCN transfer Doi 2 Finger flexion and elbow extension

Total Plexus injury at 3/12 : 

Total Plexus injury at 3/12

Additional Procedures : 

Additional Procedures Weak elbow flexion If co-contraction biceps and triceps consider triceps to biceps transfer If weak post Oberlin consider Steindler flexorplasty Supination deformity after Biceps reinnervation Derotation forearm osteotomy Weak finger extension Wrist arthrodesis and wrist flexor to finger extensor transfers

Neurotisation Results 1 : 

Neurotisation Results 1 XI to SSN Leechavengvongs 7% need graft (2-5cm) 73% >M3, ROM 30-150 (Av 50)M3 @ 9/12 Songcharoen 577 Mixed recipients MRC 3+ 80% SSN SSN (Ab 70, F 60, ER 30) Phrenic Songcharoen 9.4% reduction in VC with recovery by 24/12 No respiratory complications Retraining avoided MRC 3+ SSN 75%/MCN 60%/Axillary 66% SSN Shoulder abduction 70 and External rotation 30

Neurotisation Results 2 : 

Neurotisation Results 2 ICNs to MCN Songcharoen 22 M3+ 65% in mean 12/12 Voluntary control at 3 years but involuntary contraction with coughing persists Oberlin (UN FCU dominant fascicle to Biceps branch of MCN) Songcharoen 40 87.5% M3+ at 2 years (mean M3 7.1/12) 17% mild clawing and weakened grip donor deficit with full recovery at 13/12 3 patients ulnar parasthesia recovered by 3/12 Triceps to Ax N Leechavengvongs 7 M4 in 100%, Mean Abduction 124 No grafts needed, no elbow weakness LTN neurotisation TDN or ICNs as donor With C5-7 injury 40% have significant winging Transfer decreases fatigue

FFM Transfer Results : 

FFM Transfer Results FFMT Doi 1 EF/WE and FE (route under BR) Songcharoen 150 Leechavengvongs 40 2 revision anastomoses 80% success (MRC 3+) 18/12 to innervate using XI

Contralateral C7 Transfer Results 1 : 

Contralateral C7 Transfer Results 1 Gu 32 (described in 1986) > 2 years 2002 Chin Med J MRC 3+ MCN 80%/RN 60%/MN 50% Songcharoen 111 Hemi C7 transfers (2007 = 200+) Posteromedial Hemi C7 >3 years 30% MRC 3, 20% MRC 2 S2+ 83% (S3 50%/S2 33%) Mean 35/12 to M3/S3 Postoperatively 97% parasthesia index pulp / MN / shoulder Recovery by 7/12 (mean 3.75/12) 3 donor weakness (2 triceps M4 recovered in 2/12 and 1 EDC M2 required transfers)

Contralateral C7 Transfer Results 2 : 

Contralateral C7 Transfer Results 2 Leechavengvongs 42 (1997-2001) Anterolateral hemi C7 24% M3, 2% M4, questionable sensation quality 2% donor deficit (1 tendon transfer) Young, motivated and <6/12 from injury only Songcharoen 2% spontaneous recovery even with +ve EMG, CT myelogram and clinical examination for C8/T1 avulsions Plus poor motor recovery reported NO LONGER TRANSFERS FOR MOTOR RECOVERY LATER TRANSFER FOR SENSATION ONLY

Prognosis in BPI : 

Prognosis in BPI Improved if young (<30 years) Distal injuries do better (“Time Distance”) Incomplete motor loss suggests a focal injury Some neuropraxia likely Partial plexus injury better than flaccid paralysis of whole arm Pre-ganglionic signs do worse Associated vascular injuries do worse

Research Areas in BPI : 

Research Areas in BPI Surgical Re-plantation of pre-ganglionic avulsions to the CNS May reduce brachialgia (Sciatic conduit to conus medullaris has been used to re-innervate glutei in paraplegics) Molecular Neural transmitters Nerve growth factors Neural tubes and neurotropism (Lundborg) Rehabilitation Sensory re-education Neural plasticity “Acoustic glove” Lundborg (Sweden)

Case1: Preganglionic C5/C6 : 

Case1: Preganglionic C5/C6 Phrenic to MCN XI to SSN

Case1: Preganglionic C5/C6 : 

Case1: Preganglionic C5/C6 Phrenic to MCN XI to SSN Shoulder abduction 70 Biceps MRC 4 Returned to work as a soldier

Case1: Preganglionic C5/C6 : 

Case1: Preganglionic C5/C6 Phrenic to MCN XI to SSN Shoulder abduction 70 Biceps MRC 4 Returned to work as a soldier But scapular winging due to long thoracic palsy

Case 2: C5-T1 Avulsions : 

Case 2: C5-T1 Avulsions Poor results of shoulder & elbow neurotisations >6/12 at presentation

Case: TBPI : 

Case: TBPI Poor results of shoulder & elbow neurotisations >6/12 at presentation No hand function and trophic changes

Case 3: TBPI Pre-operative assessment : 

Case 3: TBPI Pre-operative assessment Wasted deltoid, biceps and pectoralis major

Case 3: TBPI Pre-operative assessment : 

Case 3: TBPI Pre-operative assessment Wasted deltoid, biceps and pectoralis major Some dorsal scapular nerve function

Case 3: TBPI Pre-operative assessment : 

Case 3: TBPI Pre-operative assessment Wasted deltoid, biceps and pectoralis major Some dorsal scapular nerve function No shoulder abduction

Case 3: TBPI Pre-operative assessment : 

Case 3: TBPI Pre-operative assessment Wasted deltoid, biceps and pectoralis major Some dorsal scapular nerve function No shoulder abduction

Case 3: TBPI Pre-operative assessment : 

Case 3: TBPI Pre-operative assessment Wasted deltoid, biceps and pectoralis major Some dorsal scapular nerve function No shoulder abduction No biceps

Case 3: TBPI Pre-operative assessment : 

Case 3: TBPI Pre-operative assessment Wasted deltoid, biceps and pectoralis major Some dorsal scapular nerve function No shoulder abduction No biceps No hand function

Case 3: TBPI Pre-operative assessment : 

Case 3: TBPI Pre-operative assessment Wasted deltoid, biceps and pectoralis major Some dorsal scapular nerve function No shoulder abduction No biceps No hand function Plan?

Case 4: TBPI : 

Case 4: TBPI TBPI at presentation with flaccid paralysis of arm and open humerus

Case 4: TBPI : 

Case 4: TBPI TBPI at presentation with flaccid paralysis of arm and open humerus Poor shoulder with C5/6 avulsions

Case 4: TBPI : 

Case 4: TBPI TBPI at presentation with flaccid paralysis of arm and open humerus Poor shoulder with C5/6 avulsions Good recovery of C7-T1 at 3/12 Plan?

Case 5: C5/6/7 preganglionic : 

Case 5: C5/6/7 preganglionic Head injury and lower limb fractures ACJ dislocation Now 9/12 Plan?