Adult traumatic brachial plexus palsy Management

1. Adult Traumatic
brachial plexus Palsy
: management

3. CLASSIFICATION OF LESIONS
• David Chuang has classified brachial plexus lesions into four
levels –
1. Preganglionic root
2. Postganglionic spinal nerve
3. Preclavicular & Retroclavicular (trunks & divisions
4. Infraclavicular (cord and terminal branches)

4. CLASSIFICATION

5. TERMS
• Rupture :- A break in continuity of a spinal nerve with two
disrupted ends (proximal and distal).
• Avulsion :- tearing of nerve rootlets from the surface of the
cord ( proximal avulsion ) or of branches from the muscle
(distal avulsion).

7. PREGANGLIONIC ROOT INJURY
• Comprises majority of closed brachial plexus injury in adults.
• Nerves may be ruptured at the pre- ganglionic root zone or
avulsed from the spinal cord.
• There may be single or multiple root injuries
• The dorsal root ganglion may be undisplaced, mildly displaced
or displaced into the neck.

8. PREGANGLIONIC ROOT INJURY
• Preganglionic nerve injury is commonly seen with different
type or different level of injury to other spinal nerves.
• These may be root avulsion of C7-T1 with rupture of C5-C6
spinal nerves or the upper trunk.
• However double injury (different level of injury) in the same
spinal nerve is a rare phenomenon

9. PREGANGLIONIC ROOT INJURY
• The C5 spinal nerve is of greater length and curves upwards
into the intervertebral foramen.
• It has a tendency to suffer rupture rather than root avulsion if
the traction force is not too intense.
• The C7 spinal nerve runs parallel to the limb axis and more
readily suffers root avulsion

10. • There are 10 scenarios suggestive of Preganglionic nerve
injury.
1) Motor paralysis extending to proximal shoulder girdle and
neck muscles such as levator scapulae, rhomboid, serratus
anterior and deep posterior paravertebral muscles.
2) Sensory disturbance extending above the glenohumeral
joint ( C4-3 sensory zone)

11. 3) Intolerable pain( root “shooting” pain)
4) Horner syndrome
5) No or weak tinel’s sign in response to percussion in the neck
6) Cervical spine fracture
7) Elevation of hemidiaphragm

12. 8) Pseudomeningocele on standard cervical myelography or
computed tomographic myelography
9) Recording of sensory nerve action potential in an anaesthetic
limb (with absent motor nerve action potential)
10) Negative intraoperative somatosensory evoked potential.

13. POSTGANGLIONIC SPINAL NERVE
INJURY
• It is defined as injury occurring distal to the dorsal root
ganglion (or outside the intervertebral foramen) but between
scalene muscles.
• Differentiating between preganglionic nerve injury and
postganglionic nerve injury is important with respect to all
surgical procedures and predicting prognosis.

14. • This differentiation can be made using the above mentioned
features on clinical examination and interpretation of
investigation results .

15. Preclavicular and Retroclavicular
injury
• This means that the injury involves the trunks and their
divisions distal to the scalene muscles but before the divisions
join to form cords.
• In these injuries rupture with neuroma formation was the
most common finding.

16. Infraclavicular Injury
• This means lesions involving the cords and their terminal
branches.
• In a few patients these injuries extended to the supraclavicular
area usually in traction avulsion amputation in the upper arm
associated with brachial plexus injury.
• Such injuries are commonly associated with ruptured lateral
cord and C7 – T1 root avulsion.

17. • Broadly the injuries of the brachial plexus can be classified into
• Supraclavicular which includes first three categories and
• Infraclavicular
• Broad distinctions of the two categories are as follows :-

18. Supraclavicular Infraclavicular
Location Preganglionic root
,postganglionic nerve or
preclavicular and
retroclavicular injuries
Cord and terminal
branches
Inspection Drop Shoulder , Winged
scapula, flail arm, Neck
shifts to unaffected side
Flail arm
Associated #s
(common)
Cervical spine
vertebrae, first rib or
clavicle
Scapula(glenoid ) or
humerus.
Associated vascular
injury
Subclavian Artery (low
incidence)
Subclavian or axillary
artery high incidence
about 30%

19. Supraclavicular Infraclavicular
Type of Nerve Injury Root avulsion > Rupture
with Neuroma
Rupture > Avulsion
Tinel’s sign Variable Dominant Below
Coracoid Process.
Surgical procedures More nerve transfers More nerve grafts and
vessel repair
Surgical Results Unpredictable ; more
aberrant reinnervation
Better results , less
aberrant reinnervation

20. Classification of nerve injuries
• Seddons :-
• Neuropraxia- Local conduction block with segmental
demyelination, no axonal abnormalities
• Axonotmesis – Axonal injury but endoneurium and
perineurium are intact.
• Neurotmesis Complete transection of the nerve

21. • Sunderland :-
• First degree = Neuropraxia
• Second degree = Axonotmesis
• Third Degree = Axonal damage with varying degree of
scarring of the endoneurial tube, the perineurium remains
intact
• Fourth degree = Severe damage to nerve fibers but the
nerve is physically intact , No functional recovery
• Fifth degree = Neurotmesis
• Sixth degree = Neuroma in continuity ,added later

22. • Seddon’s axonotmesis or Sunderlands’s second degree
injury is associated with Wallerian degeneration at both
proximal and distal stumps .
• Seddon’s neurotmesis or Sunderlands’s third to fifth
degree injury is associated with the potential for aberrant
reinnervation after nerve regeneration.
• In Sunderlands’s fourth & fifth degree injuries only nerve
repair can successfully establish continuity, but in first to
third degree spontaneous recovery may occur.

23. Preoperative Evaluation and
Diagnosis
• The Brachial Plexus Chart
• This Chart must be completed at the time of primary
evaluation of a patient of brachial plexus injury.
• This Chart is different for Right and Left Upper limb.
• It Contains all the relevant clinical details along with
information obtained from radiological investigations such as
x-ray or CT scan

24. chart

25. Present illness and past history
• Etiology :- Traumatic vs Spontaneous
Static Vs Progressive
• Conscious level at the time of trauma
• Associated injuries
• Previous surgical intervention
• Characteristic of pain
• This information aids in classifying the degree and extent of
injury and in determining the need for surgery and procedure

26. • A history of shoulder dislocation or glenoid fracture is
associated with high incidence of infraclavicular brachial
plexus injury whereas with a history of cervical spine injury
root injuries are more common.
• Extreme Causalgia is often seen in patients with root avulsion
because of injury to the spinal cord and is more commonly
seen in lower root (C8-T1) avulsion because they are richest in
sympathetic fibers.

27. • The pain typically has no precise distribution and is described
as an electric shooting pain that continues for a short duration
(seconds) and Resolves spontaneously.
• The pain is recurring , can be induced by cold temperature and
can sometimes be relieved by psychological measures such as
concentrating on other tasks or in some by posture or
massage.
• This pain is called DEAFFERENTATION PAIN

28. • Also known as root shooting pain it is poorly tolerated and
may persist for ever but usually reduces in intensity 6 months
after the accident.
• This pain is more intolerable in elderly patients and is not
amenable to reconstructive treatment due to inability of these
patients to undergo proper rehabilitation.

29. • The patient may present with the following symptoms:
• Pain, especially of the neck and shoulder. Pain over a nerve is
common with rupture, as opposed to lack of percussion
tenderness with avulsion
• Paresthesias and dysesthesias
• Weakness or heaviness in the extremity
• Diminished pulses, as vascular injury may accompany traction
injury

30. MoTOR Examination-Medical
Research Council (MRC) Scale for
Muscle Strength• Grade 5: Muscle contracts normally against full resistance.
• Grade 4: Muscle strength is reduced but muscle contraction
can still move joint against resistance.
• Grade 3: Muscle strength is further reduced such that the joint
can be moved only against gravity with the examiner's
resistance completely removed. (As an example, the elbow
can be moved from full extension to full flexion starting with
the arm hanging down at the side )

31. MoTOR Examination
• Grade 2: Muscle can move only if the resistance of gravity is
removed. As an example, the elbow can be fully flexed only if
the arm is maintained in a horizontal plane.
• Grade 1: Only a trace or flicker of movement is seen or felt in
the muscle or fasciculations are observed in the muscle.
• Grade 0: No movement is observed

32. • This system is clinically modified to provide additional
information ie
• M5 – Strength against four finger resistance (by the examiner)
• M4 – Strength against one finger resistance of the examiner
longer than 30 seconds
• M3+ - Strength against one finger resistance of the examiner
shorter than 30 seconds
• M3 – strength against gravity
• M4 is recognized as the useful muscle strength

34. Brachial Plexus - Neurologic levels
C5 – T1
Neurologic Level C5
• The muscles found within this myotomal pattern are the
deltoid and the biceps brachii. Because the latter is also
innervated by C6, the deltoid is the most "pure" C5 muscle.
The deltoid’s most powerful motion is abduction. One of the
most commonly used tests for shoulder abduction is to
instruct the patient to flex the elbow at 90 degrees, then offer
gradual resistance to abduction until determining the extent
of resistance he/she can overcome

35. Neurologic Level C6
• The biceps brachii is innervated by C5 and C6. C6 also
innervates the most powerful wrist extensors, carpi radialis
longus and brevis, which do radial extension. The ulnar
extensor, extensor carpi ulnaris, is innervated by C7.

36. Neurologic Level C6
• To test for wrist extension, stabilize the patient’s forearm with
the palm of your hand on the anterior aspect of the wrist.
With the patient’s wrist in full extension, place the palm of
your free hand over the posterior aspect of the patient’s hand
and try to force it out of extension. If no damage is present,
the patient will be able to resist movement. If C6 is damaged,
ulnar deviation will occur.

37. Neurologic Level C7:
• The muscles found within this myotomal pattern are the
triceps, wrist flexors and finger extensors. The triceps muscle
primarily does elbow extension. A common test for this action
is to ask the patient to fully flex the arm. Stabilize the patient’s
arm just above the elbow and ask him/her to slowly extend it.
Before the arm reaches a 90 degree angle, begin to offer firm,
constant resistance until discerning the maximum resistance
he/she can overcome

38. Neurologic Level C8
• The muscles found within this myotomal pattern are finger
flexors—flexor digitorum superficialis, flexor digitorum
profundis, and the lumbricals. To test for finger flexion, the
patient fully flexes his/her fingers at all joints while you curl
your fingers into them. Ask the patient to resist your attempt
to pull his/her fingers out of flexion. A normal response is for
all joints to remain flexed

39. Neurologic level T1
• The muscles found within this myotomal pattern are those
involved in finger abduction—dorsal interossei and abductor
digiti quinti (5th finger)—and adduction—palmar interossei. To
test for abduction, instruct the patient to abduct his/her
fingers. Then pinch each set of fingers to try to force them
together (index to the middle, ring, and little finger, the
middle to the ring and little finger, and the ring to the little
finger.)

40. • Note any significant weaknesses between pairs. Test both
hand in order to compare the strength of each, and evaluate
them according to the standardized grading scale for muscle
strength. To test for finger adduction, ask the patient to
extend his/her fingers and hold a piece of paper (or a rupee
note) between two of his/her fingers. Then you pull it out.
Test the other hand in the same manner and compare the
strength of each

41. Additional Muscle tests
• Levator scapulae Muscle :-
• It lies anterior to the trapezius and can be palpated more
easily than the rhomboid muscle.
• Both these muscles are innervated by the same nerve the
Dorsal Scapular Nerve C4-C5

42. • Clavicular And Sternal heads of the Pectoralis Major :-
• The Upper and middle trunk or its divisions innervate the
clavicular head whereas the sternal head is innervated by the
lower trunk

43. • Winging of sacpula :-
• Seen mainly with weakness of serratus anterior but may also
be seen in weakness or atrophy of the rhomboid

44. Sensory Examination
• This includes standard sensory tests and localization of the
Tinel’s sign
• This examination is based on Medical research council scale (
S0 To S4) which has been modified for clinical application

45. Tinel’s sign
• Tinel’s sign is an important clinical sign to determine the
location of a neuroma or to judge the regeneration of injured
nerves.
• If the tinel’s sign remains fixed at a a point over a period of
time this implies retardation of progressive regeneration and
warrants surgical exploration
• If the same advances from supra to infraclavicular region and
then to the arm and the forearm, a wait and see attitude is
recommended

46. • A weak or absent Tinel’s sign in the neck region in the
circumstance of total palsy usually indicates a total root
avulsion.
• Percussion of the Erb’s Point ( a point just lateral to the
clavicular insertion of the clavicular head of the
Sternocleidomastoid) that is perceived as pain over the
shoulder or ear is usually a false positive sign .
• It may reflect a neuroma of the cervical plexus or brachial
plexus neurotization by cervical plexus sensory fibers

47. • Pain radiating down to or below the elbow on percussion over
the Erb point in the neck is significant ( ie., positive Tinel’s
Sign)

48. • During successive weeks
• If Tinel’s sign becomes consistently positive but does not
move, a grade iv or v infraganglionic lesion is suspected and
surgery is indicated.
• If Tinel’s sign becomes strongly positive and moves in a distal
direction , a grade ii or iii lesion may be suspected with
chances of at least partial spontaneous recovery

49. • If the tinel’s sign progresses without recovery ,there is grade iii
lesion with internal or external compression and surgery is
warranted.

50. Deep pressure sensation
• Deep pressure sensation may be the only clue to continuity in
a nerve with no motor function or other sensation. Apply full
pinch to the nail base and pull the patient's finger outward.
Any burning suggests continuity of the tested nerve. When no
burning is elicited, these examination findings are less helpful
because a neuropraxia can persist for more than 6 months.

51. Location of Deep
Pressure Test
Affected Spinal Nerve Nerve Affected Cord
Thumb C6 Median nerve Lateral cord
Middle finger C7 Median nerve Lateral cord
Little finger C8 Ulnar nerve Medial cord

52. Horner Syndrome
• Components :- Miosis, Ptosis , Anhidrosis and enopthalmos
• Sign of sympathetic nervous system disturbance
• Indirectly implies avulsion of T1 and C8 roots because the
sympathetic fibers from the T1-T2 Sympathetic ganglion are
close to the preganglionic fibers of T1 and C8.

53. Vascular injury
• Subclavian artery occlusion might indicate a supraclavicular
lesion whereas involvement of axillary artery may indicate
involvement of the infraclavicular part.

54. • Briefly Horner’s sign , winging scapula, muscular atrophy of
parascapular muscles and causalgia indicate preganglionic
injury whereas Tinel’s sign in supraclavicular region, sweating
in the palm and minimal movements of the joints may be
evidence of the post ganglionic or more distal injury

57. Investigations – plain radiographs
• Plain films of the cervical spine, clavicle, scapula, chest, and
upper extremity.
• Fractures of these areas, when present, provide rough
estimates of the forces imparted to the neck, shoulder, arm,
and brachial plexus.
• However, they do not necessarily localize or quantify the
extent of damage.

58. • The presence of cervical spine fractures implies a high-energy
injury.
• Both burst fractures and transverse process fractures are
associated with proximal plexus injuries.
• The C4, C5, C6, and at times, C7 nerve roots are tethered to
the cervical spine's transverse processes.
• Accordingly, transverse process avulsion fractures at these
levels are strong evidence of preganglionic root injuries

59. • Inspiration and expiration AP views can be used to evaluate
diaphragm activity. Elevation of a hemidiaphragm and its
failure to move indicate phrenic injury and suggest proximal
C5 injury.

60. • In anteroposterior (AP) chest radiography, specific attention
should be directed to the distance between the spinous
processes of the thoracic spine and the scapula. If the
radiograph is not malrotated, an increase in this distance
compared with the contralateral side may indicate
scapulothoracic dissociation

61. Myelography
• The most reliable indicator of root avulsion is an absent root
shadow on plain myelography
• A common sign of a root avulsion is a meningocele at the
affected level; hence, myelography may best be delayed for 4
weeks so that any blood clot will not be dislodged by the
study and the meningocele can be allowed to form

62. • A meningocele usually means that either a root is avulsed, or ,
if it is in gross continuity, it has intraneural injury that extends
to a proximal level.
• The presence of a meningocele does suggest a force great
enough to cause an arachnoidal tear; if this root is
nonfunctional, then damage has usually extended proximally
• Therefore presence of a meningocele favors proximal injury
while absence is a point against it

63. • Other significant myelographic findings include extravasation
of dye into the subdural or epidural compartments, evidence
of cord swelling acutely, or after some time, evidence of cord
atrophy.

64. meningoceles at C6-7 (7th root) and C7-T1 (8th root)- arrows

65. • Based on Nagano’s classification myelographic findings are
classified into six categories :-
• N :- Normal root sleeve shadow
• A1 :-slightly abnormal root sleeve shadow with distinct root
and rootlet shadow but different from the opposite side
• A2 :- shows an obliteration of the tip of the root sleeve with
visible root or rootlet shadow

66. • A3 :- Obliteration of the tip of the root with no root shadow
visible
• D :- Defect instead of root sleeve shadow
• M :- Traumatic Meningocele

67. Computed tomography (CT)
scanning
• Plain CT scanning is very helpful in evaluating any cervical
fractures, and should be obtained if fractures are suspected
based on plain radiographic findings.
• CT scanning of the chest may reveal subclavian vessel injuries,
scapular fractures, humeral fractures, and thoracic spine
fractures

68. CT myelography (CTM)
• Lower concentrations of contrast medium can be detected by
CTM than by standard myelography.
• CTM may be better able to reveal small meningoceles, but
artifact from surrounding soft tissues may be problematic at
the lower cervical levels
• The CAT scan slices should be fine enough to cover the course
of a nerve root (2 mm)

69. • Diagnosis of root avulsion by CTM is based on absence of
either one root (P : Partial avulsion) or both dorsal and ventral
roots (A: complete avulsion)or presence of a meningocele (M)

70. Magnetic resonance imaging (MRI)
• MRI is the only technique that can be used to visualize the
postganglionic brachial plexus.
• MRI is the current criterion standard for visualizing spinal cord
injuries
• But MRI may not show all the detail on all the roots to
preclude the need for a subsequent myelogram.

71. Angiography
• Both conventional angiography and magnetic resonance
angiography (MRA) are valuable tools in evaluating any
suspected vascular disruption

72. electrodiagnosis
1) Electromyography (EMG)
• This can be helpful in the evaluation of root avulsion, by
providing evidence of deinnervational changes in the
rhomboid and serratus anterior muscles
• Equally important is the examination of paraspinal
musculature; deinnervational changes here indicate proximal
damage because the paraspinal muscles are innervated by the
proximally located posterior spinal branches

73. • Their involvement is indicative of a preganglionic lesion
• Fibrillation potentials on EMG may suggest that the lesion is at
least axonometic.

74. Sensory nerve action potentials
(sNAP)
• These are important in the evaluation of brachial plexus
injuries, especially as regards cases of suspected root avulsion,
as the sNAP can sometimes differentiate a preganglionic from
a postganglionic injury
• Preganglionic injury, found proximal to the dorsal root
ganglion, produces a complete distal sensory loss but
preserves distal sensory conduction

75. • This occurs because the dorsal root ganglion, which is also
avulsed, is still in contact with the peripheral nerve fibers.
• If the injury is postganglionic or both pre- and postganglionic,
no sNAP will be obtained.
• Sensory studies are done by stimulating the hand in the C6
(thumb and index finger), C6-7 (index and long finger), and C8-
T1 (little and ring finger) areas and recording from median,
radial, or ulnar nerves more proximally

76. • If the stimulated area is anesthetic to touch, recording a sNAP
indicates a preganglionic injury in the particular root
• This works best for assessment of C8 and T1 and less well for
C6 and C7 due to overlap of interventional zones

77. Somatosensory evoked potentials
(SSEPs)
• Somatosensory studies, performed by stimulating over the
plexus at Erb's point and recording over the spinal cord and
contralateral cortex, can also be used in the evaluation of
plexus injuries
• Obtaining an evoked cortical response (ECR) is evidence that
posterior roots are in continuity with the spinal cord, no
guarantee is offered as to the clinical outcome

78. • Only a few hundred fibers need to be intact for a spinal
evoked potential (SEP) or ECR to be obtained
• A positive response only ensures that a minimum of sensory
spinal fibers is functioning.
• The failure to obtain an SEP or ECR may be more significant, as
it implies injury to the more resilient dorsal root

79. • Unfortunately, neither a positive nor a negative response
localizes the level of injury to the plexus
• Intraoperative SSEPs are useful in brachial plexus surgery. The
presence of SSEPs suggests continuity between the peripheral
nervous system and the CNS via the Dorsal Root Ganglion.
SSEPs are absent in postganglionic or combined pre- and
postganglionic lesions

80. • No single test can tell the surgeon whether the injured plexus
requires surgical exploration or not .
• All the information gathered must be assimilated and analyzed
within the context of presumed energy of the trauma.

81. Surgical treatment
• It is the treatment of choice for adult brachial plexus injury
either closed or open.
• Factors in the surgical treatment algorithm include
1) Timing of surgery (primary or delayed)
2) The technique of dissection (supraclavicular or
infraclavicular)
3) Selection of technique (Neurolysis, Neurorraphy, Nerve
grafting, Nerve Transfer,functioning free muscle transfer)
4) Reconstructive Strategies ( priorities of reconstruction)

82. • The possibilities and result of brachial plexus microsurgical
reconstruction differ widely according to following factors
• - Nature of lesion .Sharp lacerations carry best prognosis
traction and radiation injuries worst.
• - The extent of injury
• - The Age of lesion – The quality of results diminishes if the
interval between injury and repair exceeds two months

83. • The Nerves affected – longer peripheral nerves have
sophisticated configurations running for long distances and
wrong fiber orientation will result in poor recovery .

84. Goals of Treatment in Brachial
plexus lesions
• 1) Elbow flexion by biceps/brachialis muscle reinnervation
• 2) Shoulder stabilization ,abduction,an external rotation by
suprascapular nerve reinnervation
• 3) Brachiothoracic pinch (adduction of the arm against the
chest ) by reinnervation of the pectoralis major muscle
• 4) Sensation below the elbow in the C5-C6 area by
reinnervation of the lateral cord

85. • 5) Wrist extension and finger flexion by reinnervation of the
lateral and posterior cord
• Apart from these for patients with an injury limited to the
upper roots (C5-C6) regaining elbow flexion and shoulder
stability are priorities

86. Timing of surgery
• Primary or immediate
• Indicated in sharp penetrating injuries
• Usually done immediately or within few days after surgery
• Direct end-to-end neurorraphy is highly possible and excellent
results can be expected
• The ‘golden period’ for primary end to end repair is 1 week
after which a nerve graft is usually required

87. • Direct repair of spinal nerve lesions can result in recovery of
shoulder and arm muscles to M4, forearm muscles to
M3orM3+ and hand muscles to M2 or less.

88. • In case of open gunshot injuries, the brachial plexus palsy is
usually caused by peripheral heat or by cavitation shock with
Sunderland First to Third degree usually predominating
• The majority of these palsies will improve within 6 months .
• Immediate exploration for neural surgery is not indicated in
these cases

89. • In case of open traction injuries like the ones caused by conveyor
belt or rolling machine, the brachial plexus injuries are rupture or
avulsion type and the open wounds are seen usually in the axilla.
• Immediate primary repair of associated vascular lesions is the
priority
• If the nature of brachial plexus injury is diagnosed at the time of
initial exploration the recommended time for delayed repair of the
plexus is 2-3 weeks after the first surgery to avoid the troublesome
scars during dissection

90. Delayed repair
• This is classified into 3 phases :-
• Intentionally Early Delayed Repair :- within 3 weeks after
injury
• Early Delayed Repair :- Within 1 month for established
diagnosis in case of open injuries or within 5 months for
closed injury
• Late Delayed Repair :- after six months of injury

91. Intentionally early Delayed Repair
• The peak metabolic response of the cell body after trauma is
seen at 2 to 3 weeks during the subacute phase.
• An intentional delay of this period is therefore done to allow
maximal effect of central regeneration power at the time of
repair.
• This concept though is more pertinent for peripheral nerves as
in brachial plexus this delay may make primary repair
impossible

92. Early Delayed Repair
• Indicated in open injuries with established diagnosis also in
closed injuries where the level of injury is not ascertained and
requires workup.
• Closed traction injuries are the most common brachial plexus
injuries in traumatized adult patients.
• The management of these patients can be considered in six
stages :-

93. • Stage1 :- Stabilization Stage (first Month)
• This includes stabilization of vital signs, bone # or joint dislocation
• Stage 2 :- Diagnostic Stage ( Second month )
• Clinical examination and investigation to establish the diagnosis
of the lesion including the level. Physiotherapy is started to
prevent soft tissue swelling , joint stiffness. Electric stimulation is
started to slow down muscle atrophy. Psychological education is
initiated before the surgery

94. • Stage 3 :- Surgery (3rd to 5th month)
• Stage 4 :- Rehabilitation stage requiring at least two years
• Stage 5 :- Late reconstructive stage :- usually during third and
fourth year post operatively.
• Usual time for assessment of residual deformity and planning of
tendon transfer procedures.
• Tendon transfers done too early (within two years ) after injury
will end with failed or useless results
• Stage 6 :- Destination stage (fifth year postoperatively)

95. Late Delayed Repair
• It is unwise to perform brachial plexus repair more than 6
months after injury
• In chronic cases (1 year or more after injury) the muscles have
undergone a long time of denervation and atrophy and the
muscle fiber has been replaced by connective tissue and fat.
• Nerve repair in such delayed cases is no more effective and
represents at best an adjuvant procedure.

96. • If there is clean transection , a primary repair with neuroraphy
is indicated
• If there is open injury with blunt trauma to the nerves and
complicating factors such as vascular injury or fracture , it is
advisable to deal primarily with the other injuries and to
perform reconstruction of the brachial plexus as a secondary
procedure

97. • If there is a closed injury in a brachial plexus lesion, an elective
reconstruction of the brachial plexus may be planned after
clarifying the diagnosis and excluding the possibility of
spontaneous recovery

98. Technique For REPAIR
• 1) NEUROLYSIS
• 2) DIRECT NERVE REPAIR( Neurorraphy)
• 3) NERVE REPAIR WITH NERVE GRAFT (free or Vascularized)
• 4) NERVE TRANSFER
• 5) FUNCTIONING FREE MUSCLE TRANSPLANTATION

99. NEUROLYSIS• Indicated only in lesions in continuity and with preserved
intraoperative nerve action potential (Sunderland First to
Third degree lesions )
• It is used to free the lesioned nerve from scar and facilitate
nutrition and scar growth
• Neurolysis may be
A) External :- Epifascial epineurotomy or epineurectomy
B) Internal :- Interfascicular Epineurectomy

100. NEUROLYSIS
• A split repair leaving the normal portion of the elements and
resecting the nonconductive portion with nerve graft is
sometimes required.

101. DIRECT NERVe REPAIR
(Neurorraphy)
• This is possible only in sharply divided nerves.
• It is essential that end to end anastamosis be performed
without tension
• The golden time for end to end repair is is within 1 week for
supraclavicular lesions and 2 weeks for infraclavicular lesions.
• The techniques for direct coaptation without tension include
• A) Sufficient mobilization of respective nerve ends.

102. • B) Traction suture with 6-0 nylon from the epineurium of both
stumps to the firm soft tissue on opposing sides or to fibrotic
muscle fascia
• C) Internal group fascicular suture with 10-0 nylon and
external trunk epineural sutures with 8-0 nylon.
• D) Post operative immobilization for at least 3 weeks.

103. Nerve grafting
• It is the predominant technique employed in brachial plexus
Repair.
• There are two types of nerve grafts
• A) Free nerve Grafts
• B) Vascularized nerve grafts.
• The sural nerve is the source of free nerve graft in most cases.
• Other nerves used are :-
• Medial cutaneous nerve of arm and forearm
• Lateral cutaneous nerve of arm

104. • Superficial Radial nerve
• Lateral femoral cutaneous nerve
• Superficial peroneal nerve
• Saphenous nerve and
• Split Ulnar nerve
• The Out come of nerve grafting is influenced by the length of
the graft used, scar tissue at wound site, no of grafts used and
presence of healthy appearing proximal stump available for
grafting.

106. Topographic orientation
• The following inferences have been drawn regarding the
topography of the nerves for aid of the brachial plexus
surgeon :-
• The anterior (ventral) segments of the spinal nerves carry
fibers that mostly go to the lateral and medial cords.
• The posterior (dorsal) half of the spinal nerve give fibers
that will be innervating structures depending on the
posterior cord
• Nerve fibers of the suprascapular nerve are located in the
region of 12 ‘o’ clock in C5

107. • Nerve fibers for the axillary nerve are located near 9 ‘o’
clock in C5 and C6, while those for the pectorals are at the
anterior opposite side at 3 ‘o’ clock in C5-C8
• Those for musculocutaneous nerve are located at 1 to 2 ‘o’
clock to those of the pectorals
• The fibers of radial nerve are located at around 7 ‘o’ clock
• Those for the median and ulnar nerve are located between
3 and 6 ‘o’ clock ,median nerve fibers lying above those of
ulnar nerve

108. • In case of total root avulsion or lower plexus root avulsion (C8-
T1+/-C7) ,the entire ulnar nerve from axilla to the wrist may
be used as a vascularized nerve graft either pedicle or free.
• A pedicled vascularized ulnar nerve graft is based on the
superior ulnar collateral vessels.
• It is usually harvested from the wrist , including the deep
motor branch , the superficial volar digital branches & dorsal
digital branches

109. • A free vascularized ulnar nerve graft can be harvested
segmentally and transferred passing through a subcutaneous
tunnel or through the prevertebral space.
• These grafts are frequently used in contralateral C7 elongation
and transfer.

110. Nerve transfers
• These provide an extraplexal source of axons to reinnervate
the distal part of the avulsed or irreparable brachial plexus
damage.
• Care must be taken not to cause significant motor or sensory
deficit at the donor sites while doing nerve transfers.
• Usual nerves used are :-
• Phrenic, Spinal Accessory, intercostal, motor branches
of the cervical plexus, hypoglossal and contralateral C7

111. • Viterbo in 1994 noted good neurotization in a degenerated
nerve after end to side coaptation to an innervated nerve.
• Apparently a denervated nerve posses such a stimulus to
the axons that they start to sprout even if undamaged and
even across intact perineurium
• The problem however is that there is no control
whatsoever over which fibers shall start sprouting sensory
or motor and if motor which function. This led to failure of
this procedure.

112. Shoulder Abduction
• Simultaneous transfer of two nerves phrenic and spinal
accessory either both to the distal C5 spinal nerve or both
separately to axillary and suprascapular nerves
• If Phrenic nerve is injured or not available hypoglossal nerve is
used instead .
• Cervical motor branches are used as an adjuvant and are
usually transferred to the distal stump of the C5 spinal
segment coupled with any of these techniques.

113. Elbow Flexion
• Transfer of three intercostal nerves to musculocutaneous
nerve is preferred
• A part of Ulnar nerve transferred to musculocutaneous nerve
in the upper is another preferred procedure.
• It is quick and easy and has no significant sensory or motor
deficit associated.

114. Hand flexion and Sensation
• Neurotization of the median nerve from either ipsilateral
spinal nerve (C5-C6) if available or contralateral C7 is preferred
• A vascularized ulnar nerve graft is always required in both
these scenarios

115. Functioning free muscle transfer
• Mostly applied for elbow flexion and finger flexion and
extension

116. Reconstructive strategies for
different levels
• PREGANGLIONIC ROOT INJURY
• 1) Total root avulsion
• Most common root injury encountered in adults
• A single stage procedure is now preferred for total
reconstruction in early stage.
• Contralateral C7 transfer to median nerve with use of
vascularized ulnar nerve graft for some hand function(finger
sensation & finger flexion ) to be regained

117. • Intercoastal nerve transfer to the musculocutaneous nerve for
elbow flexion and forearm back sensation and
• Phrenic nerve and spinal accessory nerve transfer for shoulder
elevation
• After the patient has obtained hand function wrist and thumb
fusion is performed to improve stability of the hand.
• Other procedures such as Fusion of shoulder may be required
for final outcome .

118. • At the end of surgical and rehabilitation period hand
prehension (grasp and sensation) shall become possible

119. • Four root Avulsion
• C5-T1 root avulsion is usually associated with rupture of C5
• If the proximal C5 fibers are grossly healthy it is preferable to
perform a transfer to anterior division of the upper trunk for
elbow flexion or to the median nerve for hand function.
• If the integrity of the fibers is doubtful it is transferred to the
posterior division of the upper trunk

120. • The spinal accessory nerve is also simultaneously transferred
to the suprascapular nerve for more confident shoulder
function
• Contralateral C7 transfer to median nerve can also be done in
the same sitting to achieve hand function and obtain a total
reconstruction by a single stage procedure.

121. • Three root avulsion
• Combined C5-7 three root avulsions with intact C8-T1 is the
second most common type of root injury encountered.
• The recommended procedures in these type of injuries are :-
• Phrenic and spinal accessory nerve transfer for shoulder
abduction and
• Intercostal nerve or part of ulnar nerve transfer for elbow
flexion

122. • Combined C7-T1 root avulsion is usually associated with
rupture of upper trunks.
• By use of nerve grafts C5 fibers are transferred to the
suprascapular and posterior division of the upper trunk for
shoulder elevation
• The proximal c6 stump is transferred to the distal C8 spinal
nerve or median nerve intentionally for hand function.

123. • Two root Avulsion
• Combined C5-C6 :- multiple nerve transfers are recommended
ie ; for shoulder elevation transfer of spinal accessory to the
suprascapular nerve combined with phrenic nerve transfer to
the posterior division of the upper trunk.
• For elbow flexion transfer of three intercostal nerves to
muculocutaneous nerve is routinely done.

124. • In combined C6-C7 root avulsions :- C5 root is usually
ruptured.
• The proximal stump if healthy is transferred to the anterior
division of the upper trunk for elbow flexion.
• Shoulder function is obtained as for C5-C6
• If the proximal stump is of doubtful health it is transferred to
the posterior division of the upper trunk in addition to the
Spinal accessory to suprascapular transfer for more
predictable shoulder elevation

125. • Elbow flexion in case of doubtful C5 stump is obtained by
intercostal nerve transfer to musculocutaneous nerve.

126. • Combined C8-T1 root avulsion usually occur along with C5-C7
rupture.
• Shoulder elevation is regained with nerve graft from C5 to the
suprascapular nerve and posterior division of the upper trunk.
• C6 fibers are transferred to median nerve for motor and
sensory hand function
• Elbow flexion is achieved by intercostal nerve transfer.

127. • Pure C8 and T1 root injury with intact C5,C6,C7 is very rare.
• In these cases early exploration is not preferred and in
later stages tendon transfers are performed.
• Two separate procedures are done
• ECRL (C6) is transferred to extensor digitorum for wrist and
finger extension
• FCR (C6) is transferred to FDP for finger flexion.
• All the thumb joints are fused for it to work as a post.

128. • Single root avulsion :-
• Isolated C5 – Nerve transfers with spinal accessory ,phrenic
and cervical motor branches en mass to the C5 spinal nerve
will achieve good supraspinatus ,infraspinatus and deltoid
muscle strength and obtain powerful shoulder abduction.
• C6 root avulsion is usually associated with C5 rupture .
• Nerve grafts from proximal C5 stump are transferred to the
anterior division of the upper trunk for elbow flexion.

129. • Shoulder elevation involves transfer of phrenic nerve to
posterior division of the upper trunk and spinal accessory to
the suprascapular nerve.
• Single C7 root injury is usually associated with upper trunk
rupture in which case only repair of the upper trunk is
required.
• Isolated C8 And T1 injuries are not reported.

130. Post ganglionic
• Disruption with neuroma formation is the main finding in this
type of injury
• Rupture of C5,C5-C6,C5-C7, C5-C8 0r C5-T1 may be found.
• Nerve grafting is always necessary
• Pure post ganglionic injury is not uncommon.
• Most cases were associated with other root injuries.
• Such as rupture of C5-C6 associated with root injury of C7-T1

131. • Managed with primary repair or nerve grafts.
• Bypass from the proximal segment to the distal nerve
branches is a controversial procedure advocated by some
researchers.

132. Preclavicular and retroclavicular-
trunks &upper division
• Rupture of upper trunk with Neuroma formation is the most
common lesion.
• It is sometimes associated with the lesion of the middle trunk
• Pure lesions of this zone are most common with less
association with other root injuries.
• Selective nerve transfers are preferred instead of an upper
trunk to upper trunk mass cable graft due fear of aberrant
reinnervation.

133. • C5-to posterior division of upper trunk and the suprascapular
nerve and C6 to anterior division of the upper trunk with cable
grafts is preferred method of reconstruction.

134. Infraclavicular brachial plexus
injury
• In closed injury of infraclavicular brachial plexus the extent
of nerve damage is variable ranging from simple isolated
nerve injuries to lesions of all cords or all terminal
branches .
• The incidence of vascular injury with axillary or subclavian
artery rupture is high in these injuries.
• The nerve might be avulsed From the neuromuscular
junction called distal avulsion.

135. • This is frequently seen with axillary and radial nerves but less
commonly with other terminal branches.

136. Technique of exploration
• Supraclavicular dissection:-
• A C-shaped incision along the posterior border of the
sternocleidomastoid muscle curved laterally parallel to and
above the clavicle is the standard incision for supraclavicular
approach to the brachial plexus.
• Other Ancillary incisions may be required such as
• extended neck incision for visualization of the spinal accessory
nerve,
• a semicircular chest incision for exposure of the intercostal
nerves

137. • An inframental incision to expose the hypoglossal nerve and
• A contralateral neck incision for contralateral C7 spinal nerve
dissection and transfer

138. Key points for supraclavicular
dissection
• Brachial plexus dissection never needs to cross the line medial
to the internal jugular vein
• The transverse cervical artery or vein is preserved if possible
• Abundant adipofascial tissue is present between the
omohyoid muscle and the brachial plexus .This contains rich
lymphatic network . All the lymph ducts in this field need to
be ligated or coagulated during dissection to prevent postop
lymph leakage

139. • The fibrotic scalene muscles can be totally excised.
• Each spinal nerve can be dissected upto the intervertebral
foramen to locate the more healthy proximal stump for
diagnose true root avulsion.
• The phrenic nerve is located on the scalenus anterior muscle.
Superior dissection along the course of phrenic nerve leads to
the cervical plexus.
• The nerve beneath the transverse cervical artery is usually C5
or the upper trunk

140. • The nerve beneath the subclavian artery is C8 or the lower
trunk.
• The first main branch from the upper trunk is Suprascapular
nerve.The division beside the suprascapular nerve is the
posterior division which goes in the posterior plane , the
anterior division of the upper trunk is seen going in the
anterior plane.

141. Infraclavicular dissection
• For the Infra clavicular approach the incision is made just
along the deltopectoral groove .
• It can then be extended upward to meet the supraclavicular
incision or down wards towards the medial sulcus of the
biceps.
• Connection between the supraclavicular and infraclavicular
incisions is easily obtained with out the need to osteotomize
the clavicle.
• The clavicular head of the pectoralis major is detached

142. Infraclavicular dissection
• The clavicle and the subclavius muscle are lifted by a rolled
gauge and the connection between the supra and
infraclavicular fossae is established.

143. Infraclavicular dissection
• The Chuang triangle is formed by the main branch of the
cephalic vein on one side and the clavicle on the other side. It
is an avascular zone. From here under the subclavius muscle it
is easy to find the suprascapular nerve which goes posterior to
the scapular notch.
• The y shaped limbs from lateral and medial cords have the
subclavian artery running below and beneath them. These
limbs later become The median Nerve.

145. • The posterior cord lying posterior to the subclavian artery has
two terminal branches, Bigger – radial , Smaller- axillary
• In the upper arm the musculocutaneous nerve can usually be
found between the biceps and coracobrachialis muscle.
• The axillary nerve in the axilla can be found in the humeral
neck ,above the tendinous portion of Teres major,
accompanied by lateral circumflex humeral artery

146. incisions
For supraclavicular
For infraclavicular
To join the two incisions

147. Adjuncts To surgical technique
• Pre operative preparation and informed consent
• Post operative exercises to be taught
• Detailed discussion about the prolonged course of treatment and
practical outcome
• Positioning of the patient and magnification
• Supine
• Arm abducted on board and neck turned to opposite side
• Arm is prepared and draped loosely to enable visualization of
effects of nerve stimulation

148. • Both lower extremities and contralateral neck mandible and
hemithorax prepared for the possible need of nerve grafts.
• Avoidance of muscle relaxant ,prolonged surgery duration and
need for frequent change of posture to be discussed with the
anaesthesiologist
• At least 2.5 x magnification is recommended for the dissection
of the brachial plexus

149. Postoperative management and
rehabilitation
• Immediate post operative splinting for three weeks
• This is followed by retraining and rehabilitation.
• This includes Physiotherapy to avoid joint stiffness, muscle
stimulation to avoid muscle atrophy, brain cognition,
biofeedback and occupational therapy
• Patients should be examined every 3-4 months by the surgeon
and twice a month by the physical therapist

150. • Electrical stimulation is encouraged for muscles twice at
home.
• In case of intercostal nerve transfer passive shoulder elevation
remains restricted to less than 90 degrees for 6 months
• ‘Induction Exercise’ is an important exercise for the patients
with nerve transfer.

151. • For patients after intercostal or phrenic nerve transfer, as soon
as the reinnervated muscle starts to move with deep
breathing, the patients are directed to run, walk or climb hills
to encourage numerous deep breaths which can induce
further stimulation to the re innervated muscle.
• Similarly tongue to palate push up exercise in hypoglossal
nerve transfer and shoulder adduction or grasp exercises of
the contralateral or healthy limb in contralateral C7 transfer
have the same effect.

152. • Due to these factors good results are obtained by individuals
who are psychologically strong , ambitious and cooperate well
in terms of the rehabilitation program.
• A permanent external orthosis to extend the IP joints of the
fingers is often required for intrinsic palsy of the hand to
improve final surgical results.

153. Surgical treatment of functional
sequelae
• Palliative reconstruction can be considered when the
functional sequelae persist after the maximal recovery , either
by spontaneous recovery or after nerve reconstruction .
• Palliative reconstruction procedures include muscle transfer,
functioning free muscle transplantation , tenodesis and
arthrodesis

154. Muscle transfer to the Shoulder
Pectoralis major transfer Hidebrandt (1906)
Trapezius Muscle transfer Hoffa(1902), Saha (1967)
Bateman (with acromion and spine of
scapula en bloc)
Long head of triceps to acromion Sloaman
Short Head of biceps Ober , Hass, Davidson, Harmon
Latissimus Dorsi Shultze-Berge, L’Episcopo

155. Muscle transfer for elbow
• Pedicled muscle transfers
Latissimus Dorsi Zancolli and mitre1973
Pectoralis major transfer Schottstaedt et al 1955
Triceps transfer Narkas 1989
Steindler transfer- Flexor
pronator muscle transfer
Transposition of the common
head of the forearm flexors to
the humerus shaft in order to
give better lever arm for
flexion of the elbow joint.

156. • Free muscle transfer for elbow flexion
• Used in delayed cases of more than 10 months , failed cases
after nerve transfer or grafting
• In young patients.
• Commonly used muscles are
• Latissimus Dorsi
• Gracilis
• Rectus femoris
• Pectoralis major (rare)

157. Technical considerations
• Stability of the proximal joints
• Antagonist of the transferred muscle
• Selection of donor muscle
• Suitable neurovascular anatomy of the donor muscle
• Adequate strength and range of excursion of donor muscle
• Suitable gross anatomy to fit the defect (muscle length
,location of neurovascular bundle , and tendon availability)
• Minimal functional and cosmetic donor defect

158. Technical points
• Dissection and transfer of donor nerve
• Dissection and transfer of recipient vessel
• Harvest of donor muscle
• Suture of proximal attachment of the muscle
• Noeurovascular anastomoses
• Suture of distal attachment of the muscle in its correct tension

159. Double free muscle transfer for
prehensile function
• This double free gracilis transfer technique consists of five
established reconstructive procedures.
• Exploration of brachial plexus a and repair of damaged nerves
if possible
• The first free muscle transfer is for elbow flexion and finger
which is neurotized by the spinal accessory nerve
• The second free muscle transfer is for finger flexion which is
neurotized by the 5th and 6th intercostal nerves

160. • A nerve crossing procedure using the third and fourth
intercostal nerve to neurotize the motor branch of the triceps
brachii done for elbow extension simultaneously along with
second muscle transfer.
• The intercostal sensory rami coapted to the medial cord of
brachial plexus to restore sensibility of the hand.
• It is imperative to achieve proximal joint stability before
performing the procedure.

161. Humeroscapular arthrodesis
• It is done in failed or neglected cases with glenohumeral
instability , in total or upper type paralysis with or without
serratus paralysis but with patients in whom trapezius is
normal.
• This procedure provides stability to the shoulder and improves
range of shoulder motion depending on the strength of the
scapulothoracic muscles

162. Outcome of treatment
• Spontaneous recovery in adult brachial plexus injury
,especially in high energy is rare but still possible .
• This is especially true in lower plexus root injuries.
• After successful nerve grafting for infraclavicular injuries
recovery can usually be expected to M4 for deltoid biceps or
triceps ; M3+to M3 for forearm flexors or extensors (except
extensor digitorum ,abductor pollicis longus, and brevis) &

163. • M2 or less for hand intrinsic muscles
• In pure preclavicular and retroclavicular injury the results are
more unpredictable because of development of aberrant
innervation.
• In root avulsion nerve transfer can obtain an average of 55
degrees of shoulder abduction (80%) ,M4 to M3 elbow flexion
(around 80% by intercostal nerve graft) and M3+to M3 finger
flexion (nearly 50% from contralateral C7 nerve transfer)

164. Thank You