1. 1. Dr. Vijay Kumar Loya, JR II, Orthopaedics JIPMER
2. 2. ROOTS TRUNKS DIVISION CORDS BRANCHES SUPRACLAVICULAR PLEXUS RETROCLAVICULAR PLEXUS INFRACLAVICULAR PLEXUS SURGICAL ANATOMY
3. 3. Ref (1)
4. 4. ROOTS TRUNKS DIVISON CORDS BRANCHES DORSAL SCAPULAR NERVE C5 LONG THORACIC NERVE C567 SUPERIOR- C56 SUPRASCAPULAR NERVE N. SUBCLAVIUS
5. 5. LATERAL LATERAL PECTORAL NERVE MUSCULOCUTANEOUS N. LATERAL DIVISION OF MEDIAN N. MEDIAL - MEDIAL CUTANEOUS N OF ARM MEDIAL CUTANEOUS NERVE OF FOREARM MEDIAL PECTORAL NERVE MEDIAL BR OF MEDIAN NERVE ULNAR NERVE POSTERIOR UPPER SUBSCAPULAR NERVE THORACODORSAL NERVE LOWER SUBSCAPULAR NERVE AXILLARY NERVE RADIAL NERVE
6. 6. CLASSIFICATION SEDDONS SUNDERLAND 1. NEUROPRAXIA 2. AXONOTEMESIS 3. NEUROTEMESIS 1 ALL INTACT 2 AXON DISRUPTED 3 - AXON & ENDONEURIUM 4- AXON, ENDO, PERINEURIUM 5 ALL DISRUPTED 6 (MAKINNON) MIXED INJURIES
7. 7. NEUROPRAXIA focal conduction block may recover in hours to weeks AXONOTEMESIS SUNDERLAND GRADE II d/t stretch axon disrupted & wallerian degeneration occurs recovery @ 1mm/day or 1inch/mo occur weeks/years sometimes proximal lesion with distal targetnerve regenerates but no recovery due to muscle atrophy GRADE III & IV Recovery is variable & surgical intervention is needed NEUROTEMESIS - GRADE V Eg Post-ganglionic ruptures & pre-ganglionic avulsions Sx must.
8. 8. CAUSATIVE CLOSED OPEN TRACTION COMPRESSION COMBINED SHARP GUNSHOT RADIATION
9. 9. Traction between two anchoring points proximal spinal cord & distal neuromuscular junction. Coracoid process lever in forceful abduction of shoulder. Direction & speed of application of force equally important. Traction injuries in motor vehicle accidents & ski crashes, workers arm caught & pulled by machine, rugby players, football & volleyball players while hitting smash Low energy & high energy
10. 10. If shoulder neck angle is widened upper/middle trunk injury If scapulo-humeral angle is widened lower trunk injury The structures protecting cervical nerve from traction are 1. cone shaped dural continuation into epineurium 2. fibrous attachments between epineurium of C5,6,7 & transverse process which is absent in C8,T1. Thus avulsion is more common in C8,T1. Extra-foraminal rupture is more common in C5,6,7
11. 11. Traction injury in OT Improper positioning GA traction injury In supine/lateral decubitus position extension & lateral bending of head can cause upper trunk damage. Positioning of shoulder on sandbag or roll Suspension of arm from lateral decubitus when other arm is in hyperabduction Excess abduction of both arms in prone or supine for spine surgery.
12. 12. Complex trauma with multiple fractures of the cervical transverse process, clavicle, scapula, rib, and proximal humerus can cause both compression and traction injury to the brachial plexus. Disruption of brachial plexus can be found on more than one site. Associated with vascular damage
13. 13. Assault by knife/sharp objects Associated with intrathoracic/vascular injuries. Only a part of plexus is involved carries good prognosis t/t by intraplexal grafting/neurorraphy. Iatrogenic during block/ tumour resection/central line insertion. Gunshot injuries may require early repair or may form pseudoaneurysm & can lead to progressive neural compression & will require both nerve & vessel repair. Usually peripheral nerves are radioresistant & can occur after I/L RT to axilla or breast in Ca. Can present with progressive deficit surgical exploration usually difficult d/t fibrous tissue
14. 14. Pattern of injury Supraclavic ular Pre- ganglionic Post- ganglionic C5-C6 C5-C7 C8-T1 Pan plexu Retro- clavicular( divisions) Infra- clavicular
15. 15. Burners & Stingers transient injuries as a result of trauma combined with factors stenosis/degenerative disc (spondylosis) Parsonage turner syndrome - ?post-infectiuos brachial plexopathy rapid onset severe pain in shoulder & arm followed by wasting & weakness of muscles.
16. 16. Narakis anatomic classification Group 1 c5, c6 Group 2 c5, c6, c7 Group 3 Panplexus lesions(C5-T1) Group 4 Panplexus with Horner syndrome In Sx untreated cases Group 1 - 90% recover Group 2 25% recover Group 3 no recovery but majority achieve good hand function Group 4 poor or no hand function
17. 17. C5-C6 15% of traumatic injuries Erbs point. Erbs point C5-C6 15% traumatic injuries Shoulder abduction & rotation Supra & Infraspinatus Deltoid Subscapularis Elbow flexion Biceps Brachialis Brachioradialis Supinator + Sensory loss in C5-C6
18. 18. C5-C7 injury Erbs plus 20-35% - middle trunk injury Weakness of elbow extension along with variable weakness of wrist & fingers as C7 contribution varies between pateints Sensory proximal arm, thumb, index & middle finger.
19. 19. C8-T1 lesions 3 weeks when dural tear has healed. Findings- obliteration of nerve root sleeve, defect root sleeve shadow, pseudomeningocele (Nagano six categories) 98% specific, 95% sensitive when correlated with intra-OP SSEP & extradural inspection. Doesnt detect partial root avulsions. Ventral root more vulnerable for avulsions as lesser tensile strength.
20. 43. MRI findings hematoma in verterbral canal, empty dural sleeve, shift of spinal cord away from midline. MRI with slices of 3mm provide accurate diagnosis of root avulsion in 52% when compared with intradural inspection. Cant be used in acute setting due to edema. Angiography in penetrating lesions PFT chest wall trauma, phrenic nerve dysfunction. Unless PFT1 yr post-injury - primary reconstruction C/I except in young & distal nerve transfers (where upto 18 months Sx can be done)
21. 47. TIMING Timing of brachial plexus reconstructive surgery is based on three principles: (1) better functional outcomes occur in patients with spontaneous recovery who do not require a surgical intervention; (2) surgical intervention is indicated for patients with no hope for spontaneous recovery or for further recovery, (3) surgical outcome is inversely proportional to the time interval from injury to surgery (i.e., outcomes are better if surgery is performed earlier).
22. 48. POSITION Pt supine, head turned to C/L side, the upper part of the body is elevated, and a small pillow is placed beneath the ipsilateral scapula to bring the shoulder forward. APPROACH SUPRACLAVICULAR INFRACLAVICULAR
23. 49. SUPRACLAVICULAR nerve, trunks, suprascapular nerve. From angle of jaw to posterior border of SCM to mid-clav acular area Can also be accessed by transverse incisions Cords & terminal branches by INFRACLAVICULAR approach. Divisions - retroclavicular by both of them Clavicular insertion of SCM to coracoid process to deltopectoral groove.
24. 50. Neurolysis Nerve repair Neurorrhaphy End to side coaptation Nerve graft Nerve transfer or neurotization Functional free muscle transfer Surgical options
25. 51. Thank you