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2012 CRN - Brachial Plexus Lesions

Comprehensive Review of Neurosurgery; 7/8/2012
by Andrew Yee on 26 October 2012

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Transcript of 2012 CRN - Brachial Plexus Lesions

Reconstructive Options Open Nerve Injury Brachial Plexus
Closed Nerve Injury Gun-shot Wound Parsonage-Turner Syndrome Nerve in-continuity Nerve not in-continuity Sharp injury "Messy" crush injury Approximate nerve
ends (if possible) Nerve Reconstruction Nerve Reconstruction
3 weeks - 3 months after injury Manage as Clinical Examination Surgery Closed Nerve Injury EMG / NCS
4-6 weeks No recovery EMG / NCS
end of 3rd month No recovery Motor unit potentials Monthly clinical and
electrical assessments Failure to recovery Nerve Reconstruction Observe recovery Transection Injury Trajectory Crush Injury Wake Surgical Exploration - Delayed 4 months occasionally involve transecting nerve
initial injury is often secondary to to heat/stretch from projectile Severe pain Surgery Conservative
Management Recovery No recovery
after 6-9 months Reconstructive Surgery
Nerve Reconstruction Management of Nerve Injures Surgical Management Exposure of the Brachial Plexus Infraclavicular Exposure - Pectoral Take-down Brachial Plexus Horner's Syndrome Long Thoracic Nerve Deficit Dorsal Scapular Nerve Deficit Stretch Transection Avulsion Rhomboid Major/Minor Shoulder Deficit Elbow Flexion Deficit C5, C6, C7 Injury C8, T1 Injury C5, C6 Injury High Brachial Plexus Avulsion Elbow Extension Deficit Transverse Ganglion Anatomy Supra (Pre) - ganglionic Injury Infra (Post) - ganglionic Injury Dorsal Root Ganglion - Sensory Cell Body
Ventral Horn - Motor Cell Body Peripherial Nerve Surgery Education
nervesurgery.wustl.edu

Surgical Video Library
https://vimeo.com/user6062882

Prezi Presentation
http://prezi.com/user/yeeandrew/ Credits Andrew Yee, BS Classification of Nerve Injuries Supercharge
Nerve Transfers (+) (+) Nerve Transfers Recipient Nerve Distal Results of Nerve Grafting Results of Nerve Transfers Medial Pectoral to Musculocutaneous
Nerve Transfer Thoracodorsal to Axillary
Nerve Transfer Muscle Neuron Cell Body (Gateway Arch) Anchorage, AK St. Louis, MO Muscle Neuron Cell Body (Gateway Arch) Anchorage, AK St. Louis, MO Fairbanks, AK Adjacent Neuron Fibers Nerve Injury and Recovery Nerve Transfers II Degree III Degree donor nerve near target muscle
expendable donor nerve
donor nerve with "pure" motor fibers
donor nerve with large number of motor axons
donor muscle is synergistic to target muscle Indications need to direct a large number of motor axons quickly to denervated muscle

Nerve Transfer provides:
source of nerve in close proximity to the denervated muscle
faster and superior muscle reinnervation Susan E. Mackinnon, MD

Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO Brachial Plexus Lesions I, Susan E. Mackinnon, MD, am the co-inventor of the PGA Neurotube and have received research funding from AxoGen Inc. NIH - 5R01 NS 033406-17
Nerve Allotransplantation for Traumatic Nerve Injury Comprehensive Review of Neurosurgery Types of Ganglionic Nerve Injuries Musculocutaneous Nerve Axillary and Suprascapular Nerves Triceps Brachii Nerve Nerve Reconstruction Tendon Transfers Free Muscle Transfers Phrenic Nerve Lateral Cord Injury Root Injuries Cord Injuries Serratus Anterior Diaphragm C5, C6 Sensory Deficit C5, C6, C7 Sensory Deficit C8, T1 Sensory Deficit Medial Cord Injury Posterior Cord Injury Lateral antebrachial cutaneous nerve
Median nerve sensation within C6,C7 territory Lateral Cord Injury Medial brachial cutaneous nerve
Medial antebrachial cutaneous nerve
Median/ulnar nerve sensation within C8 territory
Dorsal cutaneous branch of ulnar nerve Medial Cord Injury Posterior brachial cutaneous nerve
Posterior antebrachial cutaneous nerve
Radial nerve sensation Posterior Cord Injury Elbow Flexion Deficit Musculocutaneous Nerve Lateral Cord (C5, C6, C7) Sensory Deficit Medial Cord (C8, T1) Sensory Deficit Posterior Cord (C6, C7, C8) Sensory Deficit Axillary Nerve Deficit Elbow Extension Deficit Wrist / Fingers Extension Deficit Triceps Brachii Nerve Radial Nerve Shoulder Function
Musculocutaneous Nerve
Median Nerve




Radial Nerve
Ulnar Nerve Pronator Teres
FCR / PL
FDS
AIN
Intrinsics
Median Sensation +/-
+/-
+
+
+
- +
-





+
+ Shoulder Function

Musculocutaneous Nerve
Median Nerve
Radial Nerve




Ulnar Nerve

+
+
-




+ Lateral Cord Exam Findings Posterior Cord Exam Findings C6,7
C6,7,8
C7,8,T1
C(7)8,T1
C8,T1
C6,7,8 Finger Flexion Deficit Median Nerve Intrinsics Deficit
AIN - Anterior interosseous nerve Recurrent Thenar Nerve Branch Ulnar Nerve Deficit Classification of Nerve Injuries I II IV III V VI David Kline, MD Intra-operative Nerve Conduction Studies Localizing Level of Nerve Injury Intrinsic Ulnar Atrophy Deep Motor Branch Intrinsic Ulnar Atrophy
Ulnar Hand Sensory Deficit Guyon's Canal Intrinsic Ulnar Atrophy
Ulnar Sensory Deficit
Extrinsic Weakness
DCU Deficit Cubital Tunnel Intrinsic Ulnar Atrophy
Intrinsic Median Atrophy
Normal Sensation C8,T1 Root / Spinal Cord Sensory vs Motor
Intrinsic vs Extrinsic
Median vs Ulnar Examination Patient Evaluation Brachial Plexus Examination Clinical Examination Reconstructive Options Regenerative Operative Window: 0-9 months ...following injury before muscle atrophies No Time Limitation, Faster Results Complex Procedure Reconstructive Options Double Shoulder Nerve Transfers
Medial triceps / medial pectoral to axillary
Accessory to suprascapular

Double Fascicle Nerve Transfers
FCR, FDS / FCU to biceps / brachialis

3rd to 1st Webspace Sensory Nerve Transfer C6,7
C6,7,8
C7,8,T1
C(7)8,T1
C8,T1
C6,7,8 Medial Cord Exam Findings Shoulder Function
Musculocutaneous Nerve
Median Nerve




Radial Nerve
Ulnar Nerve +
+





+ Pronator Teres
FCR / PL
FDS
AIN
Intrinsics
Median Sensation FCU
FDP
Intrinsics
Ulnar Sensation C8,T1
C8,T1
C8,T1
C8 Wrist / Fingers Extension Deficit Radial Nerve Shoulder Deficit Elbow Flexion Deficit Musculocutaneous Nerve Axillary and Suprascapular Nerves Finger Flexion Deficit Median Nerve Intrinsics Deficit
AIN - Anterior interosseous nerve Recurrent Thenar Nerve Branch Ulnar Nerve Deficit Sensory - Normal
Motor - Abnormal Electrical Studies (EMG/NCS) Sensory - Abnormal
Motor - Abnormal Electrical Studies (EMG/NCS) Reconstructive Options Reconstructive Options Reconstructive Options Reconstructive Options C5, C6 Injury C5, C6, C7 Injury C8, T1 Injury Lateral Cord Injury Posterior Cord Injury Medial Cord Injury Double Shoulder Nerve Transfers
Medial pectoral to axillary
Accessory to suprascapular

Double Fascicle Nerve Transfers
FCR, FDS / FCU to biceps / brachialis

Intercostals to Medial Triceps Nerve Transfer

Median to Radial Tendon Transfers
PT to ECRB
FCR / FCU to EDC
PL / FDS to EPL

Ulnar to Median Sensory Nerve Transfers
DCU to 1st / 2nd webspace Ulnar sensory to 3rd webspace
Ulnar sensory to distal DCU End-to-side Double Fascicle Nerve Transfers
FCR,FDS / FCU to biceps / brachialis Medial Pectoral to Axillary Nerve Transfer

Intercostals / FCU to Medial Triceps Nerve Transfer

Median to Radial Nerve Transfers
FDS to ECRB
FCR to PIN

LABC to Radial Sensory Nerve Transfer associated with severe pain and delayed neurological motor deficit
localizes to cell body
surgical option - distal nerve transfers and release of entrapment points
serial EMG/NCS prior to surgery for recovery Surgical Interventation 7 months Brachialis to AIN Nerve Transfer

Brachioradialis to FDP Tendon Weave / FDP Tenodesis

EDQ Opponensplasty

EIP Tendon Transfer for Thumb Adduction

Median to Ulnar Sensory Nerve Transfers
3rd webspace to ulnar sensory Median sensory / PCM to DCU
Median sensory to distal 3rd webspace End-to-side Anatomy Brachialis to AIN Nerve Transfer

Brachioradialis to FDP Tendon Weave

EDQ Opponensplasty

EIP Tendon Transfer for Thumb Adduction

Median to Ulnar Sensory Nerve Transfers
3rd webspace to ulnar sensory Median sensory / PCM to DCU
Median sensory to distal 3rd webspace End-to-side Orientation Exposure Pectoralis Major Incision of Pectoralis Major Tendon Incision of Pectoralis Major Tendon Tendon Sutures for Pectoralis Major Exposure of Brachial Plexus Repair of Pectoralis Major Examination Worksheet Shoulder Nerve Transfers Restoration of Elbow Function Restoration of Shoulder Function Spinal Accessory Nerve
C7 (Pectoral) to spinal accessory transfer

Suprascapular Nerve
Spinal accessory to suprascapular transfer

Axillary Nerve
Medial triceps to axillary transfer
Medial pectoral to axillary transfer
Thoracodorsal to axillary transfer

Long Thoracic Nerve
Double-level transfer
C7 (Pectoral) to long thoracic transfer
Thoracodorsal to long thoracic transfer

Intercostal to long thoracic transfer Musculocutaneous Nerve
Double fascicular transfer
Thoracodorsal to musculocutaneous transfer
Medial pectoral to musculocutaneous transfer

Triceps Brachii Nerve
Flexor carpi ulnaris to medial triceps transfer Spinal Accessory to Suprascapular Transfer (ETE - Posterior Approach) Spinal Accessory to Suprascapular Transfer (ETS - Anterior Approach) Medial Triceps to Axillary Nerve Transfer Medial Pectoral to Axillary Nerve Transfer Double-level Transfer for Long Thoracic Nerve Double Fascicular Nerve Transfer Thoracodorsal to Musculocutaneous Nerve Transfer Medial Pectoral to Musculocutaneous Nerve Transfer Flexor Carpi Ulnaris to Triceps Brachii Nerve Transfer C7 (Pectoral) to Spinal Accessory Nerve Transfer Double Fascicular Transfer Median and Ulnar Anatomy Double Fascicular Transfer Double Fascicular Transfer Median and Ulnar Anatomy Median and Ulnar Anatomy FCU Fascicle Stimulation FCR Fascicle Stimulation Post-operative Results Double Fascicle Nerve Transfer Ulnar and Radial Anatomy Nerve Transfer Donor Recipient Donor Recipient Donor Recipient Recipient Donor Donor Donor Recipient Recipient Donor Donor Recipient Recipient Post-operative Results FCU to Medal Triceps Nerve Transfer (N) musculocutaneous Recipient (N) thoracodorsal Donor (N) C7 pectoral fascicle Donor (N) long thoracic Recipient Proximal Level Nerve Transfer (N) thoracodorsal Donor (N) long thoracic Recipient Distal Level Nerve Transfer Proximal Level Nerve Transfer C7 Pectoral Fascicle to Long Thoracic Nerve Transfer Distal Level Nerve Transfer Thoracodorsal to Long Thoracic Nerve Transfer Pre-operative Examination Post-operative Results Post-operative Results Motor Transfer Sensory Transfer Radial Sensory Component to Superior Lateral Cutaneous Nerve Transfer (N) suprascapular Recipient (N) spinal accessory Donor Acromion Medial Border / Spine of Scapula Spine Suprascapular Notch
(Suprascapular Nerve) Spinal Accessory Nerve Recipient Donor Recipient Recipient Recipient Donor Donor (N) spinal accessory Recipient (N) C7 pectoral fascicle Donor Donor (N) spinal accessory Recipient (N) C7 pectoral fascicle Donor Motor End-to-side
Neuroectomy Proximal Crush I. II. Spinal Accessory to Suprascapular Nerve Transfer End-to-end Motor End-to-side sacrifice lower trapezius backfill trapezius by reinnervating entire muscle Donor Recipient Recipient Donor Donor Recipient Neuroectomy Proximal Crush Post-operative Results Post-operative Results Medial Triceps to Axillary Nerve Transfer
Spinal Accessory to Suprascapular ETE Nerve Transfer Bands of Fontana Motor Branch Sensory Branch Motor Regeneration Femoral Nerve End-to-side Regeneration With Injury Crush Partial Neurectomy I. II. Types of End-to-side III. End-to-side Proximal Crush Neurectomy Fluorescence End-to-side (Atraumatic) End-to-side (Compression) End-to-side (Epineurotomy) Transgenic GFP Models Compression Epineurotomy Atraumatic Regenerative Sprouting Experimental Studies Pannucci C, et al . End-to-side nerve repair: review of the literature. Restor Neurol Neurosci. 25:45-63, 2007. Radial Nerve Stimulation Middle Trunk Stimulation Donor Recipient Recipient Donor Donor Recipient Recipient Donor Donor Recipient Recipient Donor Donor Recipient Recipient Donor Serratus Anterior Therapy Donor Recipient Donor Recipient Pectoral Fascicle of Middle Trunk (N) C7 pectoral fascicle Donor Donor Nerve Long Thoracic Neurities Spinal Accessory Neurities Suprascapular Neurities Recipient Nerve Recipient Nerve Recipient Nerve (N) spinal accessory Recipient (N) suprascapular Recipient (N) long thoracic Recipient Median sensory to distal 3rd webspace End-to-side Total Avulsion Reconstructive Options Total Avulsion 0-9 Months Following Injury
nerve transfers
donors - intercostals and spinal accessory
[donor - contra-lateral C7 cross chest]

>9 Months Following Injury
free muscle transfers
trapezius muscle transfer
shoulder arthrodesis
wrist fusion 1st Degree 2nd Degree 3rd Degree 4th Degree 5th Degree 6th Degree Nerve Transfers Lower Plexus Injury (-) finger flexion, AIN, median intrinsics, ulnar ex/intrinsics, ulnar sensation (+) shoulder, elbow, wrist/finger extension, pronator, FCR (-/+) EPL Pre-operative Therapy Post-operative Therapy Delayed neurological motor deficit Radial Median Ulnar Axillary Nerve - C5,6 Triceps Brachii
Brachioradialis
Wrist Extension
Supinator
Finger/Thumb Extension C7,8
C5,6
C6,7
C6(7)
C6,7,8 -
-
-
-
- +/-
+/-
+/-
+/-
-
+ -
-
-
- Etiology - Viral "Event", Surgery, or ? Supraclavicular Exposure - Scalenectomy Upper Trunk Middle Trunk Upper Trunk Upper Trunk Lower Trunk Middle Trunk Possible
Parsonage-Turner
Syndrome Resting Length of Muscle Initial Post-operative Therapy Continued Post-operative Therapy Brachialis to AIN Nerve Transfer Scarred Brachial Plexus Traditional BP Nerve Grafts
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