Article
Reconstructive techniques in adult brachial plexus lesions – Is there a “nerve transfer” scotoma?
Rekonstruktionstechniken in der Behandlung traumatischer Plexus brachialis Läsionen – Haben wirein Nerventransfer-„Skotom“?
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Authors
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Christian Heinen
- Evangelisches Krankenhaus Campus Carl-von-Ossietzky-Universität Oldenburg, Universitätsklinik für Neurochirurgie, Oldenburg, Deutschland
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Thomas Schmidt
- Evangelisches Krankenhaus Campus Carl-von-Ossietzky-Universität Oldenburg, Universitätsklinik für Neurochirurgie, Oldenburg, Deutschland
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Thomas Kretschmer
- Klinikum Klagenfurt, Neurochirurgie, Klagenfurt, Austria
| Published: | May 8, 2019 |
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Outline
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Objective: There is a recent trend to reduce brachial plexus (BP) surgery to faster and deficit guided direct nerve transfers. Time consuming BP exploration, neurolysis and autologous grafting are increasingly omitted. This may not be appropriate in all cases. The value of open exploration, evaluation for most appropriate method and after intraoperative decision-making combination of all above mentioned modalities including nerve transfers should be reconsidered. We present our series in support of an individually tailored treatment concept.
Methods: We retrospectively assessed all patients receiving brachial plexus surgery at our institution from 2009 to 2017.
Results: N=99 traumatic brachial plexus lesions were operated on by the senior authors. N=32 received neurolysis, n=17 nerve transfer, n=35 autologous graft reconstructions and n=2 direct neuromuscular neurotisation. In n=13 we combined nerve transfer and autologous grafting. N=76/83 (n=16 lost to follow-up) patients regained useful reinnervation after a follow-up of at least 6 months. This accounted for n=27/27 (n=5 lacking follow-up) of the neurolysed patients, n=11/14 (n=3 lacking follow-up) in nerve transfer, n=28/33 (n=2 lacking follow-up) in autologous grafts and n=8/8 (n=5 lacking follow-up) in the combination, respectively. Accessory nerve (n=18), ulnar nerve (n=9), intercostal nerves (n=9; ipsi- and contralateral), medial pectoral nerve (n=2; ipsi- and contralateral) and phrenic nerve (n=2) were used as axon donors. N=3 contralateral C7 transfers were performed. Jump grafts were applied in n=5 patients.
Conclusion: Appropriately chosen neurolysis was superior to the other methods in terms of results. Apart from neurolysis there was no clear superiority of one reconstructive method on its own. The choice of microsurgical treatment modality should be based on timing, lesion type, depth, and exploration. Without exploration cases for neurolysis will be missed and go straightforward to nerve transfer. Limiting brachial plexus surgery to nerve transfers only may also neglect powerful axon donors such as spinal nerves and miss elements with good functional potential after neurolysis only. In our experience, an individually tailored approach combining all available techniques of reinnervation still best reflected patient’s needs.
