Brachial plexus lesions

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1 Brachial plexus lesions SGH Course Esther Vögelin and Team Handchirurgie und Chirurgie der peripheren Nerven, Universitätsspital Bern

Surgical anatomy of the brachial plexus 5-3-6-3-5 5 Roots: C5,C6,C7,C8,TH1 3 Trunks: upper, middle, lower 6 Divisions: 2 upper,

2 Surgical anatomy of the brachial plexus Roots: C5,C6,C7,C8,TH1 3 Trunks: upper, middle, lower 6 Divisions: 2 upper, 2 middle, 2 lower 3 Cords: lateral, posterior, medial C5 C6 C7 C8 TH1 5 Nerves (musculocutaneus axillary, radial, median, ulnar)

3 Surgical anatomy Supraclavicular 3 Trunks Supraclavicular 5 Roots C5 upper trunk (C5, C6) middle trunk (C7) lower trunk (C8, TH1) C6 C7 C8 TH1

4 Surgical anatomy Retroclavicular 6 Divisions Upper (C5, C6) Middle (C7) Lower (C8, TH1)

$Infraclavicular 3 Cords$ Lateral (C5, C6, C7)

5 Surgical anatomy Infraclavicular 3 Cords Lateral (C5, C6, C7) Posterior (C5, C6, C7 C8, TH1) Medial (C8, TH1)

$Surgical anatomy Infraclavicular 5 Nerves Musculocutaenous nerve (C5, C6,) Axillary nerve (C5,$

6 Surgical anatomy Infraclavicular 5 Nerves Musculocutaenous nerve (C5, C6,) Axillary nerve (C5, C6,) Radial nerve (C5, C6, C7,C8,TH1) Median nerve (C5, C6, C7,C8,TH1) Ulnar nerve (C7,C8,TH1)

7 Nerves and their muscles Plexus Nerves (n) Muscles (m) Roots C3-C5 Phrenic diaphragma Roots C5-C7 Root C5 Upper trunc C5,C6 Lateral cord C5,C6,C7 Posterior cord C5,C6,C7,C8,TH1 Medial cord C7,C8,TH1 C5/C6 C5/C6 C5/C6/C7/C8/TH1 C5/C6/C7/C8/TH1 C7/C8/TH1 Long thoracic n Dorsal scapular n Suprascapular n Lateral pectoral n Subscapular n Thoracodorsal n Medial pectoral n Medial brachial and antebrachial cutan. n Musculocutaneous n Axillary n Radial n Median n Ulnar n Serratus anterior m Levator scapulae m, Rhomboids Supra-/infraspinatus m Clavicular portion of pectoral m Teres major m Latissimus dorsi m Sternal portion of pectoral m Pectoral minor m Coracobrachial, Biceps, Brachial m Deltoid, Teres minor m Triceps, Brachioradial m, Extensors Pronators, radial wrist-,finger-, thumb flexors Intrinsic hand m, ulnar wrist-,finger flexors

8 Examination Search for associated injury in high energy trauma Closed head injury Chest wall: proximal rib fx, hematopneumothorax Spinal cord injury Vascular injury (6 P s: pain, pallor, pulselessness, poikilothermia{cool skin}, paresthesia, paralysis) Musculoskeletal injury (shoulder girdle fx, dissociation, upper limb fx)

9 Examination History Severe pain in anesthetic extremity root avulsion Paraesthesia, weakness in other extremities (Para-/Tetraplegia) Improvement/changes over 3 months: yes/no Traction Most injuries due to stretch Point of application, direction of force and relationship of arm to neck determines nerves involved

10 Upper/middle trunk mechanism Forcible widening of shoulder-neck angle

11 Lower trunk mechanism Separation of scapulohumeral angle

12 Pre- and postganglionic lesion

13 Type of pre- and postganglionic lesion

$Adult brachial plexus injury Extensive longitudinal injury common Combination of supraand infraclavicular injury Mixture of avulsion, stretch and$

14 Adult brachial plexus injury Extensive longitudinal injury common Combination of supraand infraclavicular injury Mixture of avulsion, stretch and rupture Variable injury results in uneven recovery of plexal elements C6 root injury, upper + lower trunk rupture, posterior cord rupture Prof. A. Narakas, 1989

15 Examination Establish the location of the injury Pre-ganglionic (avulsion) vs post-ganglionic (rupture) Post-ganglionic levels: root/trunk/division/cord/terminal branches Complete vs incomplete lesion Sensory exam: Tinel s sign: location and distribution Sensory loss: dermotomal and peripheral nerve pattern

16 Sensory examination Tinel s sign: Present at site of nerve rupture Advances with nerve regeneration Absence in neck may imply root avulsion Absence of sweating, loss of sympathetic innervation

17 Motor examination Knowledge of pathway from roots to individual muscles, contributions from multiple roots important to localize pathology and plan treatment

18 Examination Pattern Upper trunc plexus palsy: Erb-Duchenne Upper and middle trunc plexus palsy Lower trunc plexus palsy: Déjérine- Klumpke Involved roots C5/C6 C5/C6/C7 C8/TH1 Total plexus paralysis C5/C6/C7/C8 /TH1 Loss of function No shoulder abduction, external rotation, elbow flexion No shoulder function/elbow flexion/extension + no wrist-, finger- extension No intrinsic muscle function, ulnar wrist-, finger flexion flail arm

19 Signs for preganglionic lesion Denervation of rhomboids, levator scapulae, anterior serratus m (Roots C5/C6/C7) Horner sign (Root C8/TH1) No tinel sign (no conduction between spinal cord and ganglion Asensitive neck (but intact sensible action potentials) Hemidiaphragma paralysis (phrenic nerve) Pseudomeningomyeloceles: avulsion and lesion of dura mater and arachnoid Fractures of transverse process

20 Signs for root avulsion Absence of Tinel s sign or percussion, tenderness in supraclavicular fossa Parascapular muscle atrophy Shift of the head away from the injured side

rotation of inferiar angle, subtle Motor branches arising from

21 Examination for root avulsion Motor branches arising from roots Dorsal scapular (C5)- rhomboids: lateral translation and rotation of inferiar angle, subtle Motor branches arising from roots Long thoracic (C5-C7) serratus anterior: winging at medial border

22 Examination for root avulsion Examination of serratus anterior function: shoulder protraction

23 Examination for root avulsion Paralyzed diaphragm: Diaphragm C3-C5 Implies C5 avulsion Exam: chest percussion (excursion) X-ray inspiration/exspiration views

24 Examination for root avulsion: Horner s syndrome Features Ptosis Miosis Enophtalmus Implies C8/TH1 avulsion Caused by interruption of sympathetic pathway Descends in spinal cord exiting via C8-TH2 spinal nerves

25 Postganglionic examination features Tinel s sign in one or more plexus dermatome (advancing =stretch with recovery) Percussion tenderness supra- or infraclavicular Preserved movement Sweating in palm Muscle force testing BMRC (M1-M5) grade With referral to spinal level and pathway to each muscle Repeated (if immediate surgery deferred) to follow recovery Careful and complete documentation

26 Documentation Initial examination 2 years after surgery

27 Conclusion of physical exam History and physical exam = surgeon s most powerful tool Must be complete, methodical Life before limb injuries Identify possible root avulsion (phrenic nerve, rhomboid, serratus ant palsy, horner sign, absent tinel s sign) Systematic repeated exams: Identify common patterns of injury Determine complete vs incomplete lesion Follow recovery Plan surgical reconstruction 3-6 months (postganglionic, preganglionic lesions as early as possible)

28 Examination Findings in C5/C6* lesion Denervation of the following muscles: o Supra-/infraspinate muscles [no abduction (>90 ), no external rotation] o Deltoid m [no flexion, abduction(0-90 ), extension] o Pectoralis major: no adduction against resistance o Latissimus dorsi m: asymmetry when coughing, no muscle palpation with both hands against the hips No elbow flexion/no shoulder abduction/er o Upper trunc (C5/C6) o Lateral cord (C5/C6) * 15% of adult injury Kim DH, Neurosurg focus 16(5), 2004 o Musculocutaneous nerve, axillary nerve (C5/C6)

29 Examination Findings in C5, C6, C7 injury Absent shoulder abduction, external rotation (no deltoid, no supra/infraspinati) No elbow flexion No elbow extension (triceps, Brachioradialis m) o Root C7, middle trunc, o Posterior cord (C7) o Radial nerve Stretch, rupture or avulsion Erb s palsy + variable triceps, wrist extensor weakness

30 Examination Findings in C8/TH1 injury Good shoulder and elbow function No wrist and finger flexion, no intrinsic muscle activity

31 Diagnostics Myelo CT MRI Electrophysiologic tests (SSEP s) Intra-operative options Acetylcholintransferase activity (CAT measurement), SSEP s (somatosensory evoked potential s) Direct nerve stimulation (C5)

32 Pattern of plexus lesions (all roots intact, distal lesion) Rupture of C5-C7, avulsion of C8,TH1 Rupture of C5,C6, avulsion of C8,TH1 Rupture of C5, avulsion of C6-TH1 Flail arm : < 20% avulsion of all roots Supraclavicular injuries 70% Infraclavicular injuries 30% Hentz et al. In Green, Operative Hand Surgery, 2005

33 Timing of surgery Immediate: open lesions, ischemia of major blood vessels to the arm > 3-6 months after primary accident: closed lesions depending of simultaneous injuries In case of documented root avulsion preferred early reconstruction Surgical options: < 12 months: - direct nerve repair (rare) - grafting - nerve transfer > 12 months: - tendon transfers - free neurotized muscle transfers, - joint fusions

34 Priorities of surgery Elbow flexion Shoulder stabilization and motion Abduction and external rotation Serratus ant/scapular stabilization Median nerve sensibility Ihara K et al. J Hand Surg 1996;21(3):381 Elhassan B et al. J Hand Surg 2010;35(7):1211 Yamada T et al. J Hand Surg 2010;35(9):1427 Radial motor function (Triceps, Wrist/digit extension) Useful median/ulnar motor function generally no realistic goal

35 Immediate vs early vs late surgery Time needed for nerve recovery (1mm/day) 50% muscle loss after 2-3 months of denervation Loss of motor months o Early: 0-6 months o Late: 9-12 months Intact roots, distal lesions Intraplexular nerve transplantations Avulsion of roots Nerve transfer The more extensive the plexus lesion the more modest the expecting reconstructive result

36 Priority of reconstructions Shoulder function Scapulohumeral (trapezius, rhomboids, serratus anterior muscles) Glenohumeral ABD: (Deltoid, supraspinatus muscle): Intraplexal nerve transfers: spinal accessory nerve suprascapular nerve Trapezius muscle transfer Rotation (IR: pectoral, subscapular muscles AR: infraspinate muscle) In global lesions no reconstruction Glenohumeral arthrodesis: 15 F+Abd,45 IR

37 Priority of reconstructions Elbow flexion Biceps, brachialis m o If C5,C6 present: intraplexal reconstructions with nerve grafts o if C5,C6 avulsion: Nerve transfer: ulnar/median nerve branch musculocutaneous nerve (double Oberlin) Med. pectoral nerve musculocutaneous nerve Intercostal nerves musculocutaneous nerve o If global avulsion: {pectoral muscles <M4); intercostal nerves, phrenic nerve, hypoglossus nerve, contralateral C7 (only in children) nerve transfer musculocutaneous nerve} Oberlin et al JBJS 2004;86A:1485 Merrel et al J Hand Surg 2001;26A:303 Chuang et al J Hand Surg 2012;37(2):270

38 Nerve transfers (elbow flex) MacKinnon et al J Hand Surg 2005;30A:978 lateral medial

39 Nerve transfers (shoulder abd) Pruksakorn et al Clin anat 2007;20(2):140 Spinal accessory suprascapular nerve from posterior SSN SAN SAN SSN

40 Nerve transfers (shoulder abd) Spinal accessory suprascapular nerve from anterior Leechavengvongs S et al. Hand Clin 2016;32(2): Bertelli JA. J Hand Surg 2007;32A:

41 Nerve transfers (elbow ext) Radial nerve branche axillary nerve Axillary nerve Leechavengvongs et al J Hand Surg 2003;28A:628 Radial nerve Axillary nerve Radial nerve

42 Options of nerve transfers Early: Spinal accessory nerve (1700 axons, pure motor) suprascapular nerve Intercostal nerves (1300 axons, 2-3 nerves ICN III-VI best with sensory components) musculocutaneous nerve Medial pectoral nerve radial nerve Ulnar/median nerve branches musculocutaneous nerve Radial nerve branch axillary nerve Other donors: Phrenic nerve (800 axons, hemidiaphragm paralysis, adults only), Contralateral C7 (only children), hypoglossal, cervical plexus

43 Late Reconstructions Tendon transfers line of pull straight, one tendon = one function Shoulder abduction/external rotation o Upper/lower trapezius muscle transfer Elbow flexion o Steindler transfer o Pectoralis major transfer o Latissimus dorsi bipolar transfer Grasp o If C7 or radial nerve intact: ECRL FDP; BR FPL;EIP opponensplasty

Wrist extension Finger extension Finger flexion Single or double

44 Late: free neurotized muscle Innervated proximally > power distally Can span long distance waiting for nerve recovery Elbow flexion Wrist extension Finger extension Finger flexion Single or double (elbow flex and wrist ext) Barrie KA et al. Neurosurg Focus.2004;16(5).E8

45 Late: free neurotized muscle Doi s procedure(taiwan): Double gracilis muscle transfer 1. Gracilis m, obturator n branch spinal accessory nerve elbow flexion + wrist extension C5/C6 suprascapular + axillary nerves, Phrenic n suprascapular nerve Maldonado A et al. Plast Reconstr Surg 2016;138:483-88e

46 Late: free neurotized muscle 2. Gracilis muscle, intercostal nerves obturator nerve branch Finger flexion if good elbow flexion fascia lata graft between gracilis muscle and finger flexors (Oberlin)

47 Free neurotized muscle transfer Power Intraplexal: AIN Extraplexal: Spinal accessory nerve, intercostal nerves Vascular supply Thoraco-acromial trunk

48 Late reconstructions Bony Arthrodesis o Glenohumeral o Wrist o Thumb CMC, IP

If head is rapidly forced away from shoulder the injury is generally at C5,C6. If arm is rapidly abducted the lesion is generally at C8-T1.

If head is rapidly forced away from shoulder the injury is generally at C5,C6. If arm is rapidly abducted the lesion is generally at C8-T1. BRACHIAL PLEXUS Etiology Generally caused by MVA in adults. Generally males aged 15 to 25 years old. Naracas: Rule of seven seventies. 70% occur secondary to MVA; 70% involve motorcycles or bicycles. 70%