Vikram Kumar, R (2010) Evaluation of functional outcome of reanimation procedures in traumatic brachial plexus injuries. Masters thesis, Madras Medical College, Chennai.
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Abstract
INTRODUCTION: One of the earliest descriptions of injuries to the brachial plexus can be found in Homer’s Iliad, but it was not until this past century that attempts at reconstruction were reported. Thorburn was the first to publish an article describing direct repair of brachial plexus elements in 1900, and the first neurotizations were reported in 1903 by Harris and Low. In 1920, Vulpius and Stoffel rerouted some of the available fascicles of the pectoral nerves onto the musculocutaneous and the axillary nerves. In 1947, Seddon published his proposed method of surgical correction of traction injuries with application of long interposition nerve grafts. The introduction of microsurgical techniques allowed inspired surgeons such as Narakas, Millesi, Allieu, Brunelli, Terzis, Doi, Gu, and others to transform these initial unsuccessful trials to a more reasonable approach of the brachial plexus injury and reconstruction. The use of extraplexus donors as motor donors such as the intercostal nerves, the ipsilateral cervical plexus, the spinal accessory nerve, the contralateral lateral pectoral nerve, the phrenic nerve, the contralateral C7 root, the selective contralateral C7 technique and more recently the ulnar nerve to musculocutaneous nerve transfer reveals a progression in brachial plexus treatment. Despite an apparent increase in brachial plexus reconstructive techniques, there has been an increase in the frequency of brachial plexus injuries caused by high-velocity trauma (motor vehicle and motorcycle accidents). The incidence of brachial plexus injury from motorcycle injuries corresponds to 5 percent of the victims and is responsible for the majority of the cases (84 percent in some series). The principles guiding brachial plexus reconstruction continue to evolve and the modern management of brachial plexus injuries should focus on early aggressive microsurgical reconstruction. The patient should be informed that the return of function to his or her upper extremity depends on the severity of the injury and that the reconstruction may require multiple stages, from simple neurolysis to nerve repairs, nerve transfers, nerve grafting, nerve banking, tendon transfers, muscle transplantations, osteotomies and bone fusions. AIM AND OBJECTIVES 1. To study the pattern of brachial plexus injuries in our trauma care setup. 2. To study about the various surgical procedures used to reanimate the upper extremity following injury which includes both dynamic procedures such as nerve transfers, muscle transfers and static procedures such as arthrodesis so as to gain useful function in the upper limb. 3. To develop a protocol for the management of traumatic brachial plexus injuries. MATERIALS AND METHODS: The study was conducted in the Department of Plastic and Reconstructive surgery, Madras Medical College for a period of 31 months from September 2007 to March 2010. All cases of traumatic brachial plexus injury were included in the study. Proforma for collection of data was made. Acute open injuries with or without vascular compromise were explored directly to look for feasibility of primary repair in the case of rupture of the roots of brachial plexus. Other cases were investigated thoroughly by clinical examination, radiological investigations and electrophysiological studies to arrive at a conclusion about the level of injury and nature of injury. Based on the information obtained appropriate surgical procedure was planned and executed. Proper informed consent was obtained from all patients explaining about the nature of the problem, surgical procedure, postoperative follow up and prognosis. All the relevant details of the patient during preoperative, surgical, postoperative and follow up periods were collected and analyzed. Inclusion criteria: 1. All traumatic brachial plexus injury patients presenting to our trauma ward in an acute setting. 2. All traumatic brachial plexus injury patients presenting to our outpatient department at a later date. Exclusion criteria: 1. Obstetric brachial plexus injury. 2. Other brachial plexopathies with thoracic outlet syndrome and compression. 3. Cases which were operated from September 2007 to March 2009 were only taken for the study, though the department continued to operate other cases. In view of having a minimum follow up period of 1 year, cases operated after March 2009 were excluded. OBSERVATIONS AND RESULTS The study period was from September 2007 to March 2010. To have a minimum follow up period of 1 year for all cases, no new cases were included after March 2009. The total number of patients in this study were 26. There were 24 male patients and 2 female patients. The average age of injury was 33.5 years and age range was 15-65 years. The most common cause of injury was road traffic accident in 23 patients followed by direct assault in 3 patients. The average interval between injury and surgery was 4.6months. The earliest interval between injury and surgery was 1 month and the largest interval between injury and surgery was 1 year. The number of pan brachial plexus injuries (C5-T1) was 22 and the number of partial brachial plexus injuries (C5±C6±C7) was 4. CONCLUSION: Based on the study, the following conclusions can be made: • Pseudomeningocoele is not a hallmark of avulsion type of injury as it can occur in rupture of the roots and paradoxically avulsion can occur without pseudomeningocoele. • Extraforaminal rupture is common in C5-C6 roots whereas avulsion injury is common in C8-T1 roots due to ligament attachments. • Squeeze test is almost always corroborative. • Early surgery, irrespective of unequivocal results of imaging and electrophysiological studies gives a superior result. • Retrograde dissection of the suprascapular nerve is ideal in delayed cases. • In delayed cases with pseudoanerysm of subclavian artery with dense fibrous adhesions, functional trapezius transfer gives good results. • For access of the intercostal nerve, muscle-splitting approach is better. • Dissection of the intercostal nerve from midclavicular line to posterior axillary line is needed for tensionless anastomosis to the musculocutaneous nerve. • Antebrachial nerve neurotisation hastens the recovery of the biceps muscle after intercostal to musculocutaneous nerve transfer. Antebrachial nerve can also be used to neurotise supinator muscle. • For identification of the musculocutaneous nerve, the M configuration is very useful. • Anastomosis should be done as close as possible to the neuromuscular junction of the muscle to be neurotised. • Oberlin I and Somsack procedure gives good results in partial brachial plexus injuries. • Fascicle for the flexor carpi ulnaris is located in the anteromedial aspect of the ulnar nerve in the upper arm. • In free functional muscle transfer, post traumatic vascular disease plays a key role in the anastomosis. Therefore anastomotic site should be well away from the diseased segment. • Our modified MRC grading is very useful. 90 % of the patients developed pain in the muscle that has been neurotised and this can be taken as M1 rather than the M1 of the original MRC grading because it is difficult to identify flicker in the paralysed muscle. • Deafferentation pain usually disappears after 6 months of nerve transfer. • On an average, M1 power is obtained in 1.5 months, M3 in 3.5 months and M4 in 6 months from M3 power.
| Item Type: | Thesis (Masters) |
|---|---|
| Uncontrolled Keywords: | functional outcome, reanimation procedures, traumatic brachial plexus injuries. |
| Subjects: | MEDICAL > Plastic and Reconstructive Surgery |
| Depositing User: | Subramani R |
| Date Deposited: | 31 Jul 2020 16:51 |
| Last Modified: | 31 Jul 2020 16:51 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/12676 |
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