American Society for Peripheral Nerve

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Early Nerve Surgery in Adult Brachial Plexus Traction Injuries - Why Wait ?
Willem Pondaag, MD, PhD; Martijn J.A. Malessy, MD, PhD
Neurosurgery, Leiden University Medical Center, Leiden, Netherlands

Introduction: Timing for surgical intervention in case of adult brachial plexus traction injuries (ABPTI) is traditionally delayed for several months to await spontaneous recovery to occur. Spontaneous recovery, however, will not occur in case of root-avulsion or rupture. Results of nerve surgery decrease with increasing interval between trauma and operation. Since 2009, we endeavour to operate ABPTI as soon as possible in patients with evidence or high suspicion of root avulsion. Here we present our first experience and preliminary results.

Materials & Methods: Between 2009 and 2011 42 ABPTI patients were operated, for whom 35 follow-up data were available. The biceps muscle was the main target of the nerve reconstruction using nerve grafting or nerve transfer. Early nerve reconstruction was defined as surgery performed within two weeks of the trauma.

Results: Five of 35 ABPTI patients were operated early. All patients had at least one root avulsion as diagnosed on preoperative MRI and confirmed intra-operatively. Reinnervation of the biceps muscle was pursued by grafting 2 times and by transfer 3 times. All five ‘early’ patients recovered biceps force ?MRC 4, as compared with 12 of 30 patients who were operated late.

We experienced the following advantages of early surgery. The absence of scar formation facilitated identification of proximal stumps. Additionally, distally retracted plexus elements could be repositioned thereby shortening graft length. Direct electrical stimulation of distal stumps of ruptured or avulsed nerves showed muscle responses, because Wallerian degeneration was not yet complete, which facilitated anatomical identification. Dorsal root ganglions and anterior root filaments could be easily identified. Conclusions: Early surgery in ABPTI is feasible and has surgical advantages. In our experience, early surgical exposure is more convenient, leading to superior reconstruction strategy, and maybe the ability to use shorter nerve grafts. Our preliminary results suggest that result may be superior. A treatment algorithm will be presented to decide which patients are eligible for early surgical intervention for ABPTI.

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