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Current status of Brachial Plexus Surgery

Brachial Plexus Surgery has dramatically changed throughout the world over the last twenty years. In 1968, in a major meeting in Paris, it was decided that surgery in the Brachial Plexus for the repair of ruptured roots was not worthwhile as the results were so poor. At that time various people in the world were starting to do Brachial Plexus Surgery and were experimenting with nerve grafting and nerve grafting techniques, namely, surgeons such as Professor Narakas of Lausanne, Switzerland and Professor Millesi of Vienna, Austria. and over the years the techniques have become established. Nerve grafting for the repair of Brachial Plexus injuries is now successful to the point that we can expect over 80% of recovery for simple muscle movements, although the recovery for fine hand movements such as the intrinsic muscles. is still poor.

The policy now does vary for the various types of injuries and the common injuries are one of a traction injury such as in a motor vehicle accident or birth injury, stab injuries of the Brachial Plexus; bullet injuries of the Brachial Plexus and a miscellaneous group of Brachial Plexus injuries such as radiation injuries from X-Ray therapy. injection injuries, tumour involvement of the Plexus and others.

A big difference between adults and children with nerve injuries is that the regeneration potential of the nerve in children is much greater than in adults, and the delay between injury and surgical repair of the damaged nerves in children. can be much longer than in adults. In children operations done even two to three years after the injury, still recover although perhaps not as well. whereas an adult's operation done six months after injury, certainly has a reduced potential to recover compared to earlier, and if they are done at a year, the recovery can be as low as 50% of what one would expect.

This means that in children with birth or motor vehicle accident injuries, the delay to surgery is usually related to the waiting period as the nerves recover from the traction injuries, so that in a new born child the waiting period for upper trunk injuries would be about three and a half months. If the shoulder and the elbow muscles. namely Deltoid. External Rotators and Elbow Flexion have not recovered by three and a half months. then it means that those nerves have been significantly ruptured and warrant a nerve graft. If these muscles have recovered prior to three and a half months, the potential for the child to recover well, with minimal deficits in the long-term, are good and therefore nerve surgery would not be performed. The child would be reassessed after eighteen months to two years of age for tendon transfers if some muscle group had not recovered sufficiently.

On the other hand, in adults with traction injuries or motor vehicle accident injuries, many surgeons in Europe operate much earlier. certainly before two months, although if there is a fair amount of function in the limb after the injury, waiting up to three or four months is not unreasonable as the muscles continue to recover and the examiner can assess more accurately the nerve root which have been ruptured and those which have been partially damaged only. Thus the method of surgery can be more accurately predicted.

In stab injuries, of course. the Plexus should be repaired immediately and often if there are vessels involved, they would be repaired simultaneously.

Bullet injuries are treated slightly more conservatively. provided there are no vessel problems. and would initially be debrided but nerve repairs would not be done primarily. They would be observed for two to three months and. in fact, the commonest indication for early surgery is the pain pattern that they experience with bullet injuries. as the bullets cause an unique type of shock wave damage to the nerve which produces a pain syndrome. The release of the scarring in the nerve or a Neurolysis is very beneficial in resolving the pain syndrome and may be the strongest indication to operate earlier than two to three months. Many of the patients with bullet injuries have a major loss of function initially, but recover remarkably well, and only the nerves that have actually been directly hit by the bullet, are permanently damaged and may need repair.

Brachial Plexus Surgery invariably involves nerve grafting techniques as once the Brachial Plexus roots and trunks have been damaged, it is not possible to approximate them without leaving tension across the repair site and these repairs rupture in the immediate post-operative period when the patient sneezes or coughs and so nerve grafts have to be inserted. These nerve grafts are generally obtained from the Sural Nerve at the posterior calf in both legs.



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Current status of Brachial Plexus S...
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