Lesiones del plexo braquial en adultos: una revisión narrativa de la literatura / Brachial plexus injuries in adults: a narrative review of the literature

La patología traumática del plexo braquial comprende un amplio espectro de lesiones potencialmente devastadoras para la funcionalidad de los pacientes. El objetivo del presente trabajo es realizar una revisión narrativa de la literatura enfocada en el diagnóstico y estudio de las lesiones del plexo braquial en adultos, además de entregar nociones básicas sobre el manejo de esta compleja patología

Traumatic brachial plexus injuries comprise a wide spectrum of lesions that are potentially devastating to the functionality of the patients. The aim of the present review is to perform a narrative review of the literature focused on the diagnosis and study of brachial plexus injuries in adults, in addition to providing basic guidelines on the management of this complex pathology.

Restoration of Elbow Flexion for Upper Trunk Brachial Plexus Injuries: Evaluation of Nerve Transfers and Modified Steindler Flexorplasty

@#INTRODUCTION: In patients with delayed presentation between 6 to 12 months, surgical treatment guidelines are not well defined in brachial plexus injury. Still, several authors have agreed that functional outcomes in patients treated within six months from the date of injury have the best results. Nerve transfers are still considered one of the treatment options in the said subset of patients even after six months. In contrast, a primary Steindler flexorplasty, or proximal advancement of the flexor-pronator group, is an ideal technique for elbow flexion with an elapsed time from injury >6 to 9 months. OBJECTIVE: The purpose of this investigation was to compare the clinical outcome s of nerve transfers versus modified Steindler flexorplasty for the restoration of elbow flexion in upper type brachial plexus injuries (BPI). METHODS: A retrospective review of 28 patients who underwent nerve transfers (NT) and 12 patients who underwent modified Steindler flexorplasty (MSF) was done to determine the outcome of treatments. The manual muscle testing using the Medical Research Council scaling system, Visual Analog Scale for pain, active range of motion, and Disabilities of the Arm, Shoulder and Hand form scores were taken as dependent variables. RESULTS: The NT group had a median age of 27.5 years, with 26 men, a median surgical delay of 5.6 months, and a median follow-up of 33 months. Twenty out of 28 patients (71%) had ≥M3 with a median range of 117.6° elbow flexion motion. Median postoperative DASH (n=16) and VAS scores were 29.2 and 3, respectively. For the MSF patients, the median age was 27 years, including ten men, the median surgical delay was 12 months, and the median follow-up was 18.4 months. All the 12 patients had ≥M3, with a median range of motion of 106°. The median postoperative DASH score (n=5) and VAS score were 28.3 and 0, respectively. In the NT group, 73.3% (11/15) achieved ≥M3 elbow flexion if the operation was done in <6 months. CONCLUSION: Nerve transfers and the modified Steindler procedure are still excellent options for successful elbow flexion reanimation in patients with brachial plexus injuries. Our results also showed that those with surgical delays of less than six months had the highest rate of achieving ≥M3 elbow flexion strength in the nerve transfer group.

Restoration of Elbow Flexion in Traumatic Upper Brachial Plexus Palsy in Adults: Outcome with Intraplexus Distal Nerve Transfers in 78 Patients

Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n » 43), or a fascicle of themedian nerve (group B, n » 16) or a combination of both (group C, n » 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar þ median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer. Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.

Parálisis obstétrica del plexo braquial: resultados preliminares de la transferencia del nervio espinal accesorio al nervio supraescapular en 10 casos / Accessory nerve to suprascapular nerve transfer in obstetrical brachial plexus palsy: prelininary results in 10 cases

Objetivo: Evaluar los resultados preliminares en 10 casos de transferencias del nervio espinal accesorio al nervio supraescapular en parálisis obstétricas del plexo braquial. Materiales y Métodos: Entre 2010 y 2012, se realizaron 16 transferencias del nervio espinal accesorio al nervio supraescapular en parálisis obstétricas del plexo braquial. Se incluyeron 10 casos con un seguimiento mínimo de 18 meses. Se evaluó la fuerza muscular del hombro según la escala de Gilbert y se usaron escalas funcionales de Mallet y de Gilbert. Se compararon valores preoperatorios y posoperatorios, así como las diferencias entre parálisis de tipo parcial y total. Se usó la prueba de Student para valorar la significancia estadística de los datos. Resultados: El seguimiento promedio fue de 20.9 meses. Se hallaron valores medios preoperatorios de fuerza de abducción de 0,48 M, y posoperatorios de 2,70 M; los valores de rotación externa preoperatorios fueron de 0 M y, al final del seguimiento, de 2,4 M. Todos los pacientes mostraban patrones preoperatorios de tipo 1 tanto de la escala de Mallet como la de Gilbert, con valores posoperatorios promedio de 3,2 y 3,5, respectivamente. Se hallaron diferencias estadísticamente significativas entre estos valores. Conclusiones: Esta serie presenta valores preliminares con un seguimiento corto y su principal crítica es el bajo número de casos. Los resultados funcionales obtenidos coinciden con los de otros reportes, y avalan su uso en las reconstrucciones del plexo braquial que requieran aporte extraplexual.

Background: To evaluate the preliminary results of spinal accessory nerve to suprascapular nerve transfer in obstetric brachial plexus palsy. Methods: Between 2010 and 2012, 16 transfers of spinal accessory nerve to suprascapular nerve were performed in obstetric brachial plexus palsy. Ten patients with a minimum follow-up of 18 months were included. Values of muscle power were assessed according to the Gilbert scale, and functional scales of the shoulder (Mallet and Gilbert) were used. Preoperative and postoperative values, and the differences between partial and total paralysis results were compared. Student test was used for the statistical analysis. Results: The average follow-up was 20.9 months. Preoperative shoulder abduction power was 0.48 M, preoperative external rotation power was 0 M, and those values at the end of the follow-up were 2.70 M and 2.4 M, respectively. All patients had type 1 patterns of the Gilbert and Mallet scales, with mean postoperative values of 3.2 and 3.5, respectively. Statistically significant differences were found between these values. Conclusions: Limitations of this preliminary report are the short follow-up and the low number of cases. However, the functional results obtained are consistent with those from other reports, and they support the use of the spinal accessory nerve to suprascapular nerve transfer in brachial plexus reconstructions requiring an extra-plexual contribution.