Brachial plexus root avulsions

The majority of adult brachial plexus palsies are posttraumatic injuries caused by high-energy forces, usually involving motor vehicles. In infants, brachial plexus palsies commonly represent obstetrical injuries following excessive traction on the plexus during complex or difficult delivery. Most adult injuries, and occasionally those in infants, represent brachial plexus root avulsion injuries that carry serious ramifications from the standpoint of permanent disability of a paralyzed extremity, prolonged recuperation, and significant socioeconomic impact. Modern-day management of root avulsions should focus on early, aggressive microsurgical reconstruction of the brachial plexus, combining various neurotizations with intraplexus and extraplexus ipsilateral and contralateral nerve donors, utilization of vascularized nerve grafts, and finally the use of free vascularized and neurotized muscles. When these multistage microsurgical management techniques are applied early (with complete avulsions) they may often result in significant return of neurologic function, especially in young patients. Amputation should be looked upon as an option only when these newer microsurgery techniques have failed.     

臂丛神经根性撕脱伤的治疗

神经移位术是治疗臂丛根性撕脱伤的主要方法。臂丛丛外移位神经包括肋间神经(Tsuyama1969)、副神经(Kotani1970)、颈丛运动支(Brunelli1977)、膈神经(顾玉东1970)、健侧颈7神经根(顾玉东1986)等。其中，健侧颈7根移位神经纤维数量最多，安全有效，已被国内外广泛应用。近年来，胸腔镜下超长切取膈神经，有效缩短了神经再生时间。对颈5、6根性撕脱伤，改良的Oberlin术式——臂丛丛内部分尺神经或正中神经移位修复肌皮神经肱二头肌支，手术简单，屈肘功能疗效肯定；同侧颈7根移位术有效且能恢复多组肌肉功能。对颈8胸1根性撕脱伤，肌皮神经肱肌肌支移位修复正中神经屈指肌束或骨间前神经以恢复屈指功能。对全臂丛根性撕脱伤，改良的Doi术式——双股薄肌移位联合神经移位较好恢复了手握持功能；肢体短缩，健侧颈7移位直接修复正中、尺神经，能恢复屈拇屈指功能，但手内肌功能仍无恢复。如何重建手内肌仍需作进一步探索。     

肋间神经移位治疗全臂丛根性撕脱伤两种术式的比较

目的　比较肋间神经移位直接与肌皮神经缝合 ,和通过皮神经移植桥接肌皮、肋间神经两种术式的疗效。方法　 3 2例全臂丛根性撕脱伤 ,其中将肋间神经游离 10～ 13cm ,经电刺激证实含有运动神经束后切断 ,与肌皮神经直接缝合 2 0例。在肋间神经与肌皮神经间移植皮神经 (平均长 10 .2cm) 12例。术后平均随访 3年 ,观察肱二头肌屈肘功能及肌力的恢复。结果　肌力达 3级或 3级以上的 ,神经移位组占 75 % ,神经移植组为 2 5 %。结论　肋间神经与肌皮神经缝接后 ,屈肘功能恢复明显 ,直接缝合组优于神经移植桥接组 (P <0 .0 1)。     

椎管内外神经根移位整体化治疗臂丛神经根性撕脱伤的实验研究

目的：研究臂丛神经根性撕脱伤后,椎管内、外神经根移位治疗臂丛神经根性撕脱伤的疗效。方法随机选取SD大鼠60只,随机分为实验组及对照组。实验组采用椎管内C5,C6神经根原位修复及健侧C7神经移位修复C8,T1神经根治疗臂丛根性撕脱伤;对照组为膈神经修复肌皮神经,副神经修复肩胛上神经,健侧C7移位修复C8,T1神经根治疗臂丛根性撕脱伤。术后6个月时取材,进行电生理检测,肌肉湿重的测量,肌肉纤维横截面积的检测,HE染色检测观察肌纤维数量,电镜观察神经纤维数量及神经直径。结果实验组神经损伤修复6个月时,其肌肉湿重、肌肉纤维横截面积、肌肉运动诱发电位恢复率、神经生长情况优于对照组。结论椎管内神经根原位修复及椎管外神经根移位整体化治疗臂丛神经根性撕脱伤,无论从肌肉湿重、还是肌肉纤维横截面积比率,或者肌肉运动诱发电位及再生神经生长情况等方面,都取得了良好的效果。     

Brachial plexus traction injuries.

Brachial plexus traction injuries most frequently occur following acute flexion or extension of the neck. The symptomatology following this injury may be defined clearly into the anatomic patterns of upper trunk, lower trunk, posterior cord, medial cord, and lateral cord radiations. This injury is the most common cause of the neurogenic form of thoracic outlet syndrome and is frequently seen in conjunction with cervical spine disease as well as peripheral entrapment syndromes of the ulnar, radial, and medial nerves.     

Phrenic nerve transfer treating root avulsion of the brachial plexus

164 patients with injury of root avulsion of the brachial plexus was treated by way of ipsilateral phrenic nerve transfer through a time period from 1970 to 1987. The among 65 cases that had been followed up for 2-13.5 years on average, 55 cases (84.6%) regained muscular strength of 30 or more. None of the patients had any subjective feeling or objective signs of respiratory disturbance, although post- operative machinery tests and laboratory surveys had detected some impairment of pulmonary function, which gradually improved with lapse of time. In conclusion age of the patients, length of the time delayed for surgery, severity of the nerve injury and the operative choice are the determining factors of the final results.     

全臂丛神经根性撕脱伤28例治疗分析

目的　介绍全臂丛神经根性撕脱伤的手术方法及远期疗效。方法　 1 994年至 2 0 0 1年 ,对2 8例全臂丛神经根性撕脱伤患者行多组神经移位术 ,即膈神经→肌皮神经 ,肋间神经→正中神经 ,副神经→腋神经 ,健侧C7经尺神经桥接移位至桡神经。结果　术后随访 1年半～ 5年 ,平均 2年半。 2 0例的肩外展在 30°以上 ,1 9例的屈肘在 70°以上 ,1 1例的伸肘可达 1 80°,1 6例的伸腕为 40°,1 1例的伸指可达 1 80°,1 4例的屈腕为 60°,1 0例的手指屈曲能达掌纹 ,1 3例的前臂旋前功能有所恢复。其余病例的自主运动功能均未恢复。总有效率为 75%。结论　多组神经移位治疗全臂丛神经根性撕脱伤对肩、肘、腕关节的功能恢复有确切的疗效     

Nerve repairs for traumatic brachial plexus palsy with root avulsion

Thirty-six patients with traumatic brachial plexus lesions and root avulsions were treated surgically between 1972 and 1986 and were followed for more than 24 months (average, 42.6 months). Neurotization of the musculocutaneous nerve with intercostal nerves or the spinal accessory nerve resulted in satisfactory elbow flexion in 21 of the 33 cases (64%). Combined nerve repairs (i.e., intercostal and spinal accessory neurotization of the terminal branch of the brachial plexus in combination with nerve grafts from the upper spinal nerves of the brachial plexus) created a useful function in at least one functional level of the upper limb for 11 of the 15 cases so treated. Nerve repairs resulted in stability of the shoulder and elbow function controllable with a sensible hand for patients with root avulsion injury of the brachial plexus.     

Brachial plexus. Anesthesia and analgesia

This review explains the different approaches to the brachial plexus (posterior cervical, interscalene, supra- and infraclavicular, and axillary) and their advantages and disadvantages (indications, contraindications, and complications) for surgery and postoperative or chronic pain management. One of the focussed areas of this review is the use of continuous catheter techniques. Information about the most commonly used local anesthetics as well as adjuncts suggested in the literature is summarized. As essential components for the success of those techniques, organizational and documentation requirements are described. In summary, regional techniques for single shot or continuous block of the brachial plexus are an efficient and safe way of providing anesthesia and analgesia for surgery or pain in the region of the shoulder, arm, or hand.     

Restoration of elbow flexion 16 years after brachial plexus root avulsion

To restore elbow flexion in brachial plexus lesions or cervical root avulsions, surgical nerve reconstruction can be attempted after approximately 6 months. If the reconstruction is not successful or was not performed, tendon transfer may improve the function of a paralysed limb. The selection of the muscle for transfer can be influenced by strengthening potentially available muscles by a myo-feedback method.     

Brachial plexus injuries. Nerve grafting

Brachial plexus lesions with complete or partial palsy of the dependent musculature are a severe handicap for the patient. By microsurgery of lesions in continuity and nerve grafting in cases with complete interruption, some recovery can be achieved. Comparing the present-day results with the ones of earlier years, a significant increase of the percentage of useful recoveries has been observed. The quality of the results of the two groups does not differ very much.     

健侧颈7移位治疗臂丛神经根性撕脱伤最佳时间选择的实验研究

健侧颈７移位治疗臂丛神经根性撕脱伤手术分第一阶段（健侧颈７移位到移植神经），第二阶段（移植神经另一端移植修复患侧神经），二次手术间隔多少时间才能获得最好的神经再生？选用ＳＤ大鼠及健侧颈７移位的实验模型，按二次手术间隔时间的不同（０、１、２、３、４、８、１６周）分成７组，在第二次术后１２周，进行电生理测定肌张力恢复率及组织切片的形态学观察，结果证实二次手术最佳间隔时间为４～８周．此结果可提供临床参考．     

Seventh cervical nerve root transfer from the contralateral healthy side for treatment of brachial plexus root avulsion.

Cervical root nerve transfer from the contralateral side has been used for the treatment of brachial plexus root avulsion in 49 patients. Resection of C7 root from the healthy side has produced no long-term symptoms or signs. Nine patients with ten recipient nerves have been followed up for more than two years and seven have obtained a functional recovery. This operation offers a new approach for the treatment of brachial plexus root avulsion.     

神经移位治疗臂丛上干根性撕脱伤

目的 阐明神经移位治疗臂丛上干根性撕脱伤的疗效。方法 1990年3月至1998年2月,对14例臂丛干根性撕脱伤患者,将同侧胸前外侧神经直接移位于腑神经,胸背神经直接移位于肌皮神经,以重建三角肌、肱三头肌功能。结果 术后随访1年以上,三角肌肌力8例恢复至M4,4例M3,2例为M3－;肱二头肌肌力14例均恢复至M4。结论 运用同侧胸前外侧神经、胸背神经移闰的方法治疗臂丛上干根性撕脱伤,疗效较好;对原有的臂丛中、下干神经的主要功能无明显影响。     

Brachial plexus injuries. Management and results

At the time of accident the brachial plexus can be repaired primarily if there is a clean transection. In case of a clavicular fracture and/or of a severe bleeding by rupture of the subclavian artery, the hematoma has to be evacuated to avoid compression of the brachial plexus. For the same reason, the fracture should be stabilized as soon as possible and the artery repaired. The reconstruction of the brachial plexus is performed as a secondary procedure. In case of a closed injury all efforts should be directed to clarify the diagnosis and to exclude cases with good chances of spontaneous recovery. The remaining cases are subject to direct repair. According to the amount of damage, external or internal neurolysis, neurorrhaphy, nerve grafting, or neurotization by nerve transfer is performed. Direct surgery is followed by a period of intensive physiotherapy. Social and psychologic care are extremely important. Patients should start to work as soon as possible. If they are not able to resume their original profession, they have to be prepared for another job that they can perform with one arm and one hand. The whole treatment is planned and supervised by the surgeon. After a sufficiently long period, usually one-and-a half years following direct repair, the amount of functional return is analyzed. Decisions are made to perform adequate palliative surgery, in order to make maximum use of the returned function.     

Brachial plexus injury caused by impalement.

Open injuries of the brachial plexus are rare. One such case, that of a 68-year-old impaled on a fence spike, is presented here. Certain principles to guide evaluation and treatment are discussed. Concomitant injury to the pleura or to vascular structures requires immediate attention; the extent and type of plexus damage may be determined from physical findings and the nature of injury. The results of plexus reconstruction are variable and routine exploration may be detrimental. The Brooks classification is reviewed.