simple introduction of the main steps in the brachial plexus surgery

1. Principles of
The Brachial Plexus
surgery
Simple anatomy
Mohamed Elsayed Elsebaey, MD
Associate consultant Neurosurgery
Ministry of Health, Egypt
5/2020

2. Content
• Neck triangles
• General anatomy
• Modes and causes of injury
• Protocol of management
• Surgical landmarks
Approaches
• Infraclavicular surgical steps
• Supraclavicular surgical steps

3. Triangles of the neck

4. Neck triangles

6. General Anatomy

10. Spinal nerve
Each one originates as multiple sensory
rootlets from dorsal root entry zone of the
postrolateral zone of the spinal cord.
Dorsal rootlets combine to form one dorsal
root per spinal segment before entry the
foramen.

11. Dorsal root ganglion
The course of the roots varies between 10 mm to 16
mm
Dorsal root ganglion located at infraforaminal level
at the midpoint just shortly distal to the foramen.
Anterior and posterior roots blends together and
form------- Spinal Nerve ( mixed )
Then Posterior primary brs go to paraspinal muscles
& much anterior ramus go to br. Plx.

13. Modes of injury

15. Peripheral Mechanism of Avulsion

16. Central Mechanism of AvulsionCentral mechanism of Avulsion

17. Causes of Injury

18. Upper brachial plexus injuries

19. Lower brachial plexus injuries

23. Protocol of management

24. Clinical Picture
Upper Br Plx Palsy
Lower Br Plx Palsy
Complete Br Plx Palsy ( Flail Limb)
Pre Ganglionic Post Ganglionic

25. Diagnosis
Clinical Examination
Electrophysiological studies
NCV, SSEP
Imaging
• Plain radiography
• Angiography
• Myelography & CT myelography
• MRI with contrast
• Ultrasound
• MR myelogaphy

26. Protocol of management

28. Surgical landmarks

29. Transverse process forms a gutter supporting the spinal nerve

30. Transverse process
Anterior tubercle which attached to the scalenus anterior
Posterior tubercle which attached to the scalenus medius

31. Scapula
The transverse scapular ligament should be located, why?
- Point of attachment of the inferior belly of omohyoid muscle
- The Suprascapular nerve (SSN) passes below it

32. Point of attachment of Scalenus Ant. On the 1st rib
Subclavian vein is anterior to it
Subclavian artery is posterior to it

33. Neck fascia
• Superficial cervical fascia
• Deep cervical fascia
1. Investing fascia  splits to enclose the SCM then covers the post triangle then investing
the trapezius M.
2. Pretracheal fascia
3. Prevertebral fascia  Covers the scalenus Ant., subclavian A. & brachial plexus
elements.
4. Carotid sheaths
The familial pathway
to the cervical spine in
cases of CDP

34. The target region in surgery

35. Spinal Accessory N

36. Omohyoid muscle
Consists of two bellies joined by intermediate tendon
Inferior belly (origin) runs parallel to the SSN to the suprascapular notch
Tendon overlies the internal jugular vein (Surgical landmark)
Superior belly (insertion) runs vertically to the hyoid bone
Innervated by the ansa cervecalis

37. Omohyoid divides the neck triangles
Anterior triangle is divided by the
superior belly into
• Upper (carotid) triangle
• Lower (muscular) triangle
Posterior triangle is divided by the inferior
belly into
• Upper (occipital) triangle
• Lower (subclavian) triangle

38. Coracoid process is important landmark, why?
• Insertion of the biceps (short head)
• Insertion of the pectoralis minor muscle
• Insertion of the coracobrachialis muscle

39. Position - Skin incision
Lazy line
Formal line
Compensating with the
gap

40. Formal skin incision (blue marking)

41. .
• Skin incision
• Platysma incision
• Incise along the post. Border of SCM
• Supraclavicular bed of fat is mobilized
• External jagular V.
• Omohyoid M. is divided

42. .
Retrograde dissection
1) Phrenic nerve
2) C5
3) C5 & C6
4) Upper trunk
5) SSN
6) Middle trunk

43. Clavicle retracted upwards or divided
C8 & T1 can be viewed
Incise the Clavipectoral fascia

44. Extend the wound downwards cross the deltopectoral groove

45. Across the deltopectoral vein
Protecting the lateral pectoral nerve

46. Cutting the pectoralis minor tendon leaving cuff for reapproximation

48. Lateral cord is the first structure to be visualized after cutting the pectoralis minor
tendon

49. Lateral cord
Anterograde dissection
Musculocuatous nerve
Leteral contribution of Median nerve
Median nerve
Medial contribution of median nerve
Medial cord
Ulnar nerve
Axillary artery
Posterior cord
Steps

50. After appropriate dissection
Structural and functional anatomy,
diagnosis of the neuronal elements is done
Neurolysis – Nerve grafting – Nerve
transfer
Repair of the clavicle if it was divded
Repair of pectoralis minor muscle
Meticulous closure of the wound

51. Neurolysis was done as the elements were intact

52. Nerve grafting

53. Nerve transfer