Surgical management of the proximal injury to the nerves of the upper extremity: strategy at overcoming multiple critical gaps
Aim of the study — to evaluate the outcomes of reconstruction procedures at complete injuries of brachial plexus in subclavicular region. The retrospective analysis of the reconstruction procedures in 3 men and one woman (mean age 36,4 years) with complete injury of brachial plexus in subclavicular region was conducted. Injury to musculocutaneuos, median, ulnar and radial nerves was accompanied by axillary (2 cases) or brachial (2 cases) artery injury. One patient had no injury to musculocutaneous nerve within the injury’s structure. All patients underwent surgical reconstruction of the neural structures 4,8 months (mean term) post initial vascular surgery. The autografting was the main reconstruction procedure of the long nerves of the upper extremity at their critical gap (mean gap 10,5cm) with donor-nerves of the small (sural nerve) and large (ulnar nerve) cross sectional diameter. Both motor and sensory components of recovery were evaluated with MRC Scale and Seddon Scale respectively. Each patient evaluated the recovered median nerve mediated functions with Brief Michigan Hand Questionnaire. It was revealed that one patients showed poor recovery of the entire complex of the muscles of the upper and lower arm (MRSC 2 points or lower). Two patients showed good recovery of the biceps brachii muscle (MRCS score 5 points) on 14th and 13th month respectively. Mean MRC Scale score among three patients for the muscles of the anterior compartment of the forearm was: 3,3 points for m. flexor pollicis longus, 3,6 points for mm. flexores digitorum and 4 points for m. flexor carpi radialis respectively. Mean MRC Scale score among three patients for the muscles of the posterior compartment of the forearm was: 2,6 points for m. extensor pollicis longus, 3,3 points for m. extensor digitorum sublimis and 4 points for radial wrist extensors respectively. The median nerve mediated sensation recovered to 2,3 points on Seddon scale. Only one patient showed effective recovery of the thumb opposition. Loss of ulnar nerve mediated functions was expectable among all 4 enrolled patients, thereafter we observed no recovery of key pinch and diagonal volar grip. Three patients showed recovery of transversal volar grip only. Mean Brief MHQ score was 55,55 points – unsatisfactory recovery. The reconstruction of the ulnar nerve, thereafter recovery of the “intrinsics”, should be the priority in terms of reanimation of the basic grips and pinches of the upper extremity – one should avoid harvesting of the ulnar nerve at multiple nerve injury cases; the expectable loss of functions at the utililization of the radial nerve as a donor nerve, could be easily recompensed with the tendon transfer procedures in later terms.
2. Assmus, H. (2017). Timing and Decision-Making in Peripheral Nerve Trauma. In Haastert-Talini, Kirsten, Assmus, Hans, Antoniadis, Gregor (Eds.) Modern Concepts of Peripheral Nerve Repair (pp. 27–39). Springer Internetional Publishing. doi:10.1007/978-3-319-52319-4_3.
3. Den Dunnen, W. (2001). Sensory nerve function and auto-mutilation after reconstruction of various gap lengths with nerve guides and autologous nerve grafts. Biomaterials, 22(10), 1171–1176. doi:10.1016/s0142-9612(00)00339-2.
4. Kamal, A. S., & Austin, R. T. (1980). Dislocation of the median nerve and brachial artery in supracondylar fractures of the humerus. Injury, 12(2), 161–164. doi:10.1016/0020-1383(80)90144-8.
5. Meyer, R., Claussen, G. C., & Oh, S. J. (1995). Modified trichrome staining technique of the nerve to determine proximal nerve viability. Microsurgery, 16(3), 129–132. doi:10.1002/micr.1920160302.
6. Midha, R., & de Villiers Alant, J. D. (2012). Nerve repair/nerve transfer strategies for adult brachial plexus palsies. Practical Management of Pediatric and Adult Brachial Plexus Palsies, 198–211. doi:10.1016/b978-1-4377-0575-1.00015-0.
7. Padayachy, V., Robbs, J. V., Mulaudzi, T. V., Pillay, B., Paruk, N., Moodley, P., & Ramnarain, A. (2010). A retrospective review of brachial artery injuries and repairs — Is it still a “training artery”? Injury, 41(9), 960–963. doi:10.1016/j.injury.2010.01.009/
8. Rasulic, L. (2017). Current Concept in Adult Peripheral Nerve and Brachial Plexus Surgery. Journal of Brachial Plexus and Peripheral Nerve Injury, 12(01), e7–e14. doi:10.1055/s-0037-1606841.
9. Sollerman, C., & Ejeskär, A. (1995). Sollerman Hand Function Test: A Standardised Method and its Use in Tetraplegic Patients. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 29(2), 167–176. doi:10.3109/02844319509034334.
10. Spinner, R. J., & Kline, D. G. (2008). Combined upper extremity nerve injuries. Kline and Hudson’s Nerve Injuries, 199–207. doi:10.1016/b978-0-7216-9537-2.50018-9.
11. Sunderland, S. (1951). A Classification Of Peripheral Nerve Injuries Producing Loss Of Function. Brain, 74(4), 491–516. doi:10.1093/brain/74.4.491.
12. Surgical disorders of the perpheral nerves. By Sir Herbert Seddon, C.M.G., F.R.C.S., London. 9¾ × 7½ in. Pp. 332 + xi. Illustrated. 1972. Edinburgh: Churchill Livingstone. £8. (1972). British Journal of Surgery, 59(9), 749–749. doi:10.1002/bjs.1800590930.
13. Waljee, J. F., Kim, H. M., Burns, P. B., & Chung, K. C. (2011). Development of a Brief, 12-Item Version of the Michigan Hand Questionnaire. Plastic and Reconstructive Surgery, 128(1), 208–220. doi:10.1097/prs.0b013e318218fc51.
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