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Functional outcome after microsurgical reconstruction of the nerve trunks of plexus brachialis.
Muradov M., Sadykov T.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Republic of Kazakhstan. Reconstructive, plastic and aesthetic microsurgery department.
Introduction
Growing traumatism of the plexus brachialis (PB), leading in a consequence to disability of affected, determines the urgency of this problem (1,2,3). Absence of a single tactic in the diagnosis and treatment of this pathology leads to unsatisfactory outcomes of recovery of extremity function (5,7).
Materials and Methods
In Reconstructive, plastic and aesthetic microsurgery department of National Scientific Center of Surgery named after A.N. Syzganov examined and operated 241 patients with the consequences of traumatic injury of plexus brachialis. Of them 152 (63.4%) patients - face of young, working-age. Children up to 14 years - 21 (8.7%). In 215 (89%) patients the cause of plexus brachialis injuries were closed damages. In the period from 1 to 6 months from the time of the injury the main number of patients were hospitalized - 71.6%, in 6-12 months - 22.7%, in 1.5 -2 years - 5.6%.
Upper paralysis of Duchenne-Erb was detected in 116 patients. Lower paralysis of Dejerine Klumpke's - in 28. Total paralysis - 97 patients. At 96 affected took place pain syndrome.
Combined damage of the nerve trunks of plexus and vessels in subclavian, axillary region and upper third of the arm detected in 78 patients.
Cervical myeloradiculography performed to 195 patients. Of them 82 patients revealed traumatic meningocele at the level of different segments of the cervical spinal cord.
Computer tomography of the plexus brachialis performed to 17 patients, Magnetic Resonance Imaging - 2 patients. At 9 cases detected avulsion of roots from the spinal cord, forming the plexus brachialis, at 3 - avulsion of the primary trunks in supraclavicular region.
Angiography was performed to patients with combined injuries of the nerve trunks and subclavian vessels in cervicothoracic region.
Analysis of clinical and neurological symptoms and data of special research methods allowed us to determine, that 93 patients had spinal cord injury, forming the plexus brachialis; in 114 patients - primary trunks damage and 34 - secondary trunks of the plexus brachialis. The data allowed to choose the optimum access to the trunks of the plexus brachialis and volume of surgery.
During the revision, all patients was found conglomerate of cicatricial adhesions splices. Density and prevalence of conglomerate depended on the timing of the injury and its mechanism.
Allocation of spinal nerves, primary trunks of the plexus brachialis and vessels of neck and subclavian area from conglomerate of cicatricial adhesions splices produced under optical magnification. During operation was detected
incompliance of the clinical and neurological symptoms to anatomical damage of plexus trunks, due to involvement in cicatricial adhesions of all nerve trunks.
In 115 patients performed exo-, endonevrolysis of primary and secondary plexus trunks. In 62 patients performed heterotopic or heterogeneous neurotization of the trunks using the phrenic nerve, branches of the cervical plexus, intercostal nerves as well as their combination. 12 patients underwent neyroraphia type "end to end". 10 patients underwent interfascicular autonerve plastic of trunks of the plexus brachialis using graft from the sural nerve.
Reconstructive surgery on the arteries and veins performed to 78 patients. Excision of the subclavian artery aneurysm with subsequent plastic produced in 4 cases, autovenous bypass surgery or alloprosthetics of subclavian artery - in 15 cases, scalenotomy and angiolysis of subclavian, vertebral and transversal neck artery - in 59 cases.
In 17 cases detected avulsion of all roots from the spinal cord with a shift in clavicular region with rude scar degeneration of nerve trunks at a considerable distance. In 8 of these cases trunks were tightly soldered to the capsule of the shoulder joint. Due to the absence of conditions for reconstructive surgery, intervention in these patients ended by revision.
Case Report
Patient O. 27 years old, entered routinely with a diagnosis: Long-term consequences of traumatic injury of the left primary trunks of the plexus brachialis.
With complaints of violation of the sensitivity and movements, feeling of "coldness" in the left upper extremity.
From the Anamnesis, knife wound to the neck from left was
Pic.1: Examination of the patient before surgery.
Журнал Национального научного центра хирургии им. А.Н. Сызганова
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Pic.2: Full anatomical break the upper and middle nerve Pic.3: Neuroraphia by type «end to end» of the upper,
trunk, cicatricial compression of the lower trunk of the plexus middle plexus trunks.
brachialis.
about 1 month ago by unknown persons during self-defense.
locally: in supraclavicular region on the left has a transverse scar length 4.0 cm, soldered to the underlying tissues. Deformation of contours of the left upper extremity due to the tension of the shoulder joint capsule. Left upper extremity hangs «whip» due to the plegia. Absence of active movements of the shoulder, elbow joint. Hypoesthesia exterior surface of the shoulder, forearm, back surface of I,II Angers of the left hand. Radial artery pulse weakened.
Operation is performed under magnification 4.0 multiplicity: plastic "end to end" of the upper, middle trunks of the left plexus brachialis. Histology №6844-6851 - traumatic neuroma.
Operation process: Endotracheal anesthesia. Position of the patient on the back. Processing of the surgical field with a solution of povidone thrice. In supraclavicular region on the left has a transverse scar length 4.0 cm, soldered to the underlying tissues, excised, uncovered skin and underlying tissues. During revision revealed: expressed scar-adhesive process, involving all anatomical structures in a single conglomerate, complete anatomical break of the upper, middle trunks of the plexus brachialis, there are end neuromas, size of 0.3 cm and 0.5 cm comparable, inferior trunk sleeve figurative compressed by scar tissue over 7cm. By not sharp and sharp way performed exoneurolysis of the lower trunk of plexus through. After excision of the end neuromas diastasis between the ends of trunks of plexus was 1.8 cm, eliminated by the mobilization of ends of plexus trunks. Under increasing multiplicity 4.0 produced neuroraphia by type "end to end" of the upper, middle trunks of the left plexus brachialis. Novocaine blockade of the nerve trunks
of plexus. Hemostasis during the operation. Stitches on the wound. Drainages. Aseptic bandage.
In the postoperative period underwent a course of antibiotic, anti-inflammatory therapy, physiotherapy (magnet). Postoperative wound healed by primary intention. There is a positive dynamics of neurological status as paresthesias along the left upper extremity innervation. Discharged on day 15 with an improvement.
Results and Discussion
Evaluation of treatment outcomes based on the study of long-term results (from 1 year to 10 years), according to the dynamics of clinical and neurological symptoms.
Of the 203 patients examined again in 157 (77.6%) the result of the treatment is regarded as a good and satisfactory. These patients were operated on early after injury (up to 6 months). Most of them had no anatomical break of plexus trunks.
In 46 (22.4%) cases, treatment outcome is regarded as unsatisfactory (no pain syndrome relief, expressed violations of the upper extremity).
Conclusions:
In deciding on the surgical treatment of open injuries of the plexus brachialis must be observed differentiated approach to the choice of the method of surgical intervention with regard to the nature and timing of damage after trauma, data of preoperative clinical and paraclinical examinations and intraoperative revision of structures of the plexus brachialis.
Pic.4,5,6: Long-term outcome at 1 year after surgery.
Most effective in open injuries of the plexus brachialis with full conduction disturbance is surgery imposing epineural suture, conducted in early terms after trauma.
Inability to fulfill epineural suture (bring central and peripheral ends of the injured nerve without tension) operations are performed of autoneuroplastic or neurotisation (depending on the length of the defect of the nerve trunks).
In compression of structures of the plexus brachialis with partial violation of their conduction, dentified during the preoperative clinical and paraclinical examination as well as the safety of their anatomical integrity, determined during surgery, performs exo- and endoneural microneurolysis.
In case of impossibility of the operation on the structures of the plexus brachialis as well as during later periods after injury effective method of recovery of extremity function is the transposition of the tendons and muscles.
Thus, analysis of performed reconstructions of the consequences of brachial plexus injury depending on the mechanism of injury showed, that the best results were obtained after the exo-, endoneurolysis of brachial plexus trunks and microsurgical plastic of nerves trunks. Worse outcomes in avulsion and traction injuries. An increasing number of unsatisfactory results in injuries associated with avulsion of roots from the spinal cord.
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