Recent Modalities in Management of Brachial Plexus Injuries
Islam Abd El-samad Abd El-razik;
Abstract
Brachial plexus palsy in neonates may be the result of maternal uterine malformations, congenital aplasia of the brachial plexus roots, superior head of the humerus osteomyelitis, neoplasms, exostosis of the first rib, hemangiomas , trauma during labor and delivery (obstetrical brachial plexus palsy) , postnatal trauma, or idiopathic (intrauterine maladaptation palsy). Compression of the brachial plexus by the umbilical cord or amniotic bands.
Incidence of obstetrical brachial plexus palsy is one to two out of 1,000 live births. The mechanism of injury is usually traction. Affected infants are usually one half to one kilogram heavier than unaffected infants. The risk factors for brachial plexus palsies may be divided into three categories: neonatal, maternal, and labor-related factors. Fetal position is also very important. Brachial injury occurs more frequently with breech deliveries.
Causes of traumatic peripheral nerve injury include penetrating injury, crush, traction, ischemia, and less common mechanisms such as thermal, electric shock, radiation, percussion, and vibration .
The diagnosis of brachial plexus injuries generally can be made after a thorough history and physical examination. Imaging studies and electrodiagnostic studies are valuable and occasionally essential tools for accurate diagnosis and operative planning.
A careful prenatal, natal and postnatal history should be obtained and should include information on a number of factors; Parents are questioned about previous pregnancies and deliveries, the history of this pregnancy, including diabetes and toxemia.
Shoulder deformities are known to be the most frequent sequelae of birth palsy.Shoulder function evaluated using a modified Gilbert system. Most centers measure pronation and supination of the forearm in actual degrees of motion or as a percentage of the normal range of motion.
Neurophysiology is used to record the electrical activity of motor fibers and to detect signs of reinnervation. Neurophysiology can confirm the diagnosis of a brachial plexus injury. It can localise the site of the lesion, attempt to quantify the degree of axonal loss. Neurophysiology can also diagnose a variety of injury patterns to the C5, C6 and sometimes C7 spinal nerve roots or spinal nerves.Neurophysiology has a very important role in the evaluation of brachial plexus injuries preoperative, intraoperative and postoperative.
The main role of imaging in traumatic brachial plexus injuries is to differentiate root avulsions from more distal injuries.Plain films of the clavicle and cervical spine may identify bony injuries and raise the clinical suspicion for a brachial plexus injury C.T. Myelography is the gold standard for diagnosis of lesions in brachial plexus. MRI is an excellent tool in the evaluation of brachial plexus pathology.
Reconstruction of the brachial plexus will never fully restore the function of the upper limb to normal.The current plexus management aims to regain, as soon as possible, important functions of the upper extremity, i.e., shoulder stability, elbow flexion, elbow extension, protective sensation in the hand and, if feasible, hand reanimation.
In post-traumatic brachial plexus lesions in adults, early repair will necessitate a variety of nerve grafting and nerve transfer procedures. Neurolysis has little benefit in brachial plexus palsy . Nerve grafting and nerve transfers are the mainstay of treatment. Lesions with external compression or scarring, can be treated with neurolysis.
Trauma-induced adult brachial plexus injuries can be broadly divided into two groups – penetrating and traction injuries. In the absence of any open wounds and life-threatening injuries surgery is not traditionally the first line of treatment. The initial management is observation, pain control and physiotherapy. Patients who have complete loss of C5, C6 and C7 root functions have the most to gain from nerve transfer. Lack of elbow flexion against gravity is the primary indication for microsurgery.
Neurotizations are routinely performed to reanimate denervated muscles for elbow flexion and shoulder abduction.
Injury to the brachial plexus almost invariably involves the upper roots (C5, C6) and, therefore, elbow function is compromised in all cases. Primary restoration of elbow flexion via neurotisation of musculocutaneous nerve is of paramount importance and must always be pursued as a first priority in brachial plexus reconstruction.
Donor nerves can be classified as either intraplexal (within the brachial plexus) or extraplexal (outside the brachial plexus). Intercostal nerve transfer did not result in significant reductions in pulmonary functions. Intercostal nerves are contra-indicated when sufficient anterior chest trauma and resultant rib fractures render the nerve unusable.Operative results of nerve transfer with the spinal accessory nerve have been favorable.The transfer of the spinal accessory nerve into the suprascapular nerve has been well described for adult brachial plexus injuries, there is little available information on the use of this technique for infants with brachial plexus birth injuries.
Incidence of obstetrical brachial plexus palsy is one to two out of 1,000 live births. The mechanism of injury is usually traction. Affected infants are usually one half to one kilogram heavier than unaffected infants. The risk factors for brachial plexus palsies may be divided into three categories: neonatal, maternal, and labor-related factors. Fetal position is also very important. Brachial injury occurs more frequently with breech deliveries.
Causes of traumatic peripheral nerve injury include penetrating injury, crush, traction, ischemia, and less common mechanisms such as thermal, electric shock, radiation, percussion, and vibration .
The diagnosis of brachial plexus injuries generally can be made after a thorough history and physical examination. Imaging studies and electrodiagnostic studies are valuable and occasionally essential tools for accurate diagnosis and operative planning.
A careful prenatal, natal and postnatal history should be obtained and should include information on a number of factors; Parents are questioned about previous pregnancies and deliveries, the history of this pregnancy, including diabetes and toxemia.
Shoulder deformities are known to be the most frequent sequelae of birth palsy.Shoulder function evaluated using a modified Gilbert system. Most centers measure pronation and supination of the forearm in actual degrees of motion or as a percentage of the normal range of motion.
Neurophysiology is used to record the electrical activity of motor fibers and to detect signs of reinnervation. Neurophysiology can confirm the diagnosis of a brachial plexus injury. It can localise the site of the lesion, attempt to quantify the degree of axonal loss. Neurophysiology can also diagnose a variety of injury patterns to the C5, C6 and sometimes C7 spinal nerve roots or spinal nerves.Neurophysiology has a very important role in the evaluation of brachial plexus injuries preoperative, intraoperative and postoperative.
The main role of imaging in traumatic brachial plexus injuries is to differentiate root avulsions from more distal injuries.Plain films of the clavicle and cervical spine may identify bony injuries and raise the clinical suspicion for a brachial plexus injury C.T. Myelography is the gold standard for diagnosis of lesions in brachial plexus. MRI is an excellent tool in the evaluation of brachial plexus pathology.
Reconstruction of the brachial plexus will never fully restore the function of the upper limb to normal.The current plexus management aims to regain, as soon as possible, important functions of the upper extremity, i.e., shoulder stability, elbow flexion, elbow extension, protective sensation in the hand and, if feasible, hand reanimation.
In post-traumatic brachial plexus lesions in adults, early repair will necessitate a variety of nerve grafting and nerve transfer procedures. Neurolysis has little benefit in brachial plexus palsy . Nerve grafting and nerve transfers are the mainstay of treatment. Lesions with external compression or scarring, can be treated with neurolysis.
Trauma-induced adult brachial plexus injuries can be broadly divided into two groups – penetrating and traction injuries. In the absence of any open wounds and life-threatening injuries surgery is not traditionally the first line of treatment. The initial management is observation, pain control and physiotherapy. Patients who have complete loss of C5, C6 and C7 root functions have the most to gain from nerve transfer. Lack of elbow flexion against gravity is the primary indication for microsurgery.
Neurotizations are routinely performed to reanimate denervated muscles for elbow flexion and shoulder abduction.
Injury to the brachial plexus almost invariably involves the upper roots (C5, C6) and, therefore, elbow function is compromised in all cases. Primary restoration of elbow flexion via neurotisation of musculocutaneous nerve is of paramount importance and must always be pursued as a first priority in brachial plexus reconstruction.
Donor nerves can be classified as either intraplexal (within the brachial plexus) or extraplexal (outside the brachial plexus). Intercostal nerve transfer did not result in significant reductions in pulmonary functions. Intercostal nerves are contra-indicated when sufficient anterior chest trauma and resultant rib fractures render the nerve unusable.Operative results of nerve transfer with the spinal accessory nerve have been favorable.The transfer of the spinal accessory nerve into the suprascapular nerve has been well described for adult brachial plexus injuries, there is little available information on the use of this technique for infants with brachial plexus birth injuries.
Other data
| Title | Recent Modalities in Management of Brachial Plexus Injuries | Other Titles | لطرق المستحدثة لعلاج إصابات الضفيرة العصبية العضدية | Authors | Islam Abd El-samad Abd El-razik | Issue Date | 2014 |
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