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Multi-level Nerve Injury of the Upper Extremity Management and Review of Brachial Plexus Literature: A Case Report

Received: 20 November 2020     Accepted: 7 December 2020     Published: 11 December 2020
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Abstract

Backround: Brachial plexus injuries are complex cases requiring a thorough understanding of nerve physiology and upper extremity anatomy. Standard approaches and management have been developed but certain situations still arise where these are not feasible options. Objectives: A case of brachial plexus injury is discussed in this report. The patient was a young male who was referred to our center with weakness of the left upper extremity, C5-C7 distribution. Certain components of his injury, such as extensive soft tissue scarring and identification of a long neuroma at the injury site, obliged the surgeons to use unconventional nerve transfers during his surgery. In this paper, we discuss these alternative options in order to support their potential use in complex brachial plexus cases. Other concepts such as single fascicular harvest for nerve transfers and nerve graft augmented nerve transfers are discussed as they were successfully used in this report. Methodology and Results: The patient underwent a total of five surgeries which were a combination of nerve and tendon transfers. Some nerve transfers were augmented with long autologous nerve grafts reaching up to fifteen centimeters in length. Throughout the patients sequence of surgeries, certain nerves, such as the ulnar nerve branch to the flexor carpi ulnaris, successfully served as a donor nerve in more than one occasion. Muscle groups where single nerve fascicles were previously used as a donor nerves also yielded adequate muscle strength and were successfully subsequently used in tendon transfers. Ultimately, the patient was able to achieve good muscle strength, range of motion and outcome scores on his left upper extremity after two years from his final surgery. Conclusion: This report offers multiple alternative options in managing complex brachial plexus cases as well as challenges some concepts in nerve grafting. Alternative donor nerves are offered for transfers, some of which are not previously used in literature. Aside from this, the use of long autologous nerve grafts, single fascicular nerve transfers and repeated use of certain nerves as donor were performed successfully. We hope these procedures and techniques can be added to each hand specialist arsenal for managing complex brachial plexus injuries, specifically when the standard techniques are not feasible.

Published in International Journal of Clinical and Experimental Medical Sciences (Volume 6, Issue 6)
DOI 10.11648/j.ijcems.20200606.17
Page(s) 149-154
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2020. Published by Science Publishing Group

Keywords

Peripheral Nerve Injury, Brachial Plexus Injury, Multi-level Nerve Injury, Outcome Following Brachial Plexus Injury, Nerve Transfers, Tendon Transfers

References
[1] Landers ZA, Jethanandani R, Lee SK, Mancuso CA, Seehaus M, Wolfe SW. The Psychological Impact of Adult Traumatic Brachial Plexus Injury. J Hand Surg Am. 2018; 43 (10): 950. e1-950. e6.
[2] Thatte MR, Babhulkar S, Hiremath A. Brachial plexus injury in adults: Diagnosis and surgical treatment strategies. Ann Indian Acad Neurol. 2013 Jan-Mar; 16 (1): 26–33.
[3] Liu Y, Lao J, Gao K, Gu Y, Xin Z. Outcome of nerve transfers for traumatic complete brachial plexus avulsion: results of 28 patients by DASH and NRS questionnaires. Journal of Hand Surgery (European Volume). 2012; 37 (5): 413-421.
[4] Martin, E., Senders, J. T., DiRisio, A. C., Smith, T. R., & Broekman, M. D. (2018). Timing of surgery in traumatic brachial plexus injury: a systematic review, Journal of Neurosurgery JNS, 130 (4), 1333-1345. Retrieved Sep 16, 2020.
[5] Birch R: Timing of surgical reconstruction for closed traumatic injury to the supraclavicular brachial plexus. J Hand Surg Eur. 2015; 40: 562–7.
[6] Carlsen BT, Bishop AT, Shin AY: Late reconstruction for brachial plexus injury. Neurosurg Clin N Am. 2009; 20: 51–64.
[7] Korus L, Ross DC, Doherty CD and Miller TA. Nerve Transfers and Neurotization in Peripheral Nerve Injury, from Surgery to Rehabilitation. Journal of Neurology, Neurosurgery and Psychiatry. 2016; 87: 188-197.
[8] Houschyar KS, Momeni A, Pyles MN, Cha JY, Maan ZN, Duscher D, Jew OS, Siemers F, van Schoonhoven J. The Role of Current Techniques and Concepts in Peripheral Nerve Repair, Plastic Surgery International, vol. 2016, Article ID 4175293, 8 pages, 2016. https://doi.org/10.1155/2016/4175293.
[9] Ray WZaps: Autografts, allografts, nerve transfers, and end to side neurorrhaphy. Experimental Neurology 223 (2010) pp 77-85.
[10] Gu, Yu-dong; Use of the Phrenic Nerve for Brachial Plexus Reconstruction, Clinical Orthopaedics and Related Research: February 1996 - Volume 323 - Issue - p 119-121.
[11] Liu Y, Lao J, Gao K, Gu Y, Zhao X. Comparative study of phrenic nerve transfers with and without nerve graft for elbow flexion after global brachial plexus injury. Injury. 2014; 45 (1): 227-231. doi: 10.1016/j.injury.2012.12.013.
[12] Schusterman MA 2nd, Jindal R, Unadkat JV, Spiess AM. Lateral Branch of the Thoracodorsal Nerve (LaT Branch) Transfer for Biceps Reinnervation. Plast Reconstr Surg Glob Open. 2018; 6 (3): e1698. Published 2018 Mar 19. doi: 10.1097/GOX.0000000000001698.
[13] Nath RK, Mackinnon SE, Shenaq SM. New nerve transfers following peripheral nerve injuries. Operative techniques in plastic and reconstructive surgery. 1997; 4 (1): 2-11. doi: 10.1016/S1071-0949(97)80012-1.
[14] Soldado F, Ghizoni MF, Bertelli J. Thoracodorsal nerve transfer for triceps reinnervation in partial brachial plexus injuries: thoracodorsal nerve transfer to the triceps. Microsurgery. 2016; 36 (3): 191-197. doi: 10.1002/micr.22386.
[15] Vanaclocha VV, Ortiz-Criado JM, Saiz-Sapena N, Vanaclocha N. Nerve Transfers in the Treatment of Peripheral Nerve Injuries. Peripheral Nerve Regeneration – From New Therapeutic Approaches Including Biomaterials and Cell-Based Therapies Development. 2017.
[16] Wolfe SW, Johnsen PH, Lee SK, Feinberg JH, Long-nerve grafts and nerve transfers demonstrate comparable outcomes for axillary nerve injuries. Journal of Hand Surgery. 2014; 39 (7): 1351-1357.
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  • APA Style

    Monica Pecache, Rahul Patil, Raya Abughanmi, Tsu Min Tsai. (2020). Multi-level Nerve Injury of the Upper Extremity Management and Review of Brachial Plexus Literature: A Case Report. International Journal of Clinical and Experimental Medical Sciences, 6(6), 149-154. https://doi.org/10.11648/j.ijcems.20200606.17

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    ACS Style

    Monica Pecache; Rahul Patil; Raya Abughanmi; Tsu Min Tsai. Multi-level Nerve Injury of the Upper Extremity Management and Review of Brachial Plexus Literature: A Case Report. Int. J. Clin. Exp. Med. Sci. 2020, 6(6), 149-154. doi: 10.11648/j.ijcems.20200606.17

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    AMA Style

    Monica Pecache, Rahul Patil, Raya Abughanmi, Tsu Min Tsai. Multi-level Nerve Injury of the Upper Extremity Management and Review of Brachial Plexus Literature: A Case Report. Int J Clin Exp Med Sci. 2020;6(6):149-154. doi: 10.11648/j.ijcems.20200606.17

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  • @article{10.11648/j.ijcems.20200606.17,
      author = {Monica Pecache and Rahul Patil and Raya Abughanmi and Tsu Min Tsai},
      title = {Multi-level Nerve Injury of the Upper Extremity Management and Review of Brachial Plexus Literature: A Case Report},
      journal = {International Journal of Clinical and Experimental Medical Sciences},
      volume = {6},
      number = {6},
      pages = {149-154},
      doi = {10.11648/j.ijcems.20200606.17},
      url = {https://doi.org/10.11648/j.ijcems.20200606.17},
      eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ijcems.20200606.17},
      abstract = {Backround: Brachial plexus injuries are complex cases requiring a thorough understanding of nerve physiology and upper extremity anatomy. Standard approaches and management have been developed but certain situations still arise where these are not feasible options. Objectives: A case of brachial plexus injury is discussed in this report. The patient was a young male who was referred to our center with weakness of the left upper extremity, C5-C7 distribution. Certain components of his injury, such as extensive soft tissue scarring and identification of a long neuroma at the injury site, obliged the surgeons to use unconventional nerve transfers during his surgery. In this paper, we discuss these alternative options in order to support their potential use in complex brachial plexus cases. Other concepts such as single fascicular harvest for nerve transfers and nerve graft augmented nerve transfers are discussed as they were successfully used in this report. Methodology and Results: The patient underwent a total of five surgeries which were a combination of nerve and tendon transfers. Some nerve transfers were augmented with long autologous nerve grafts reaching up to fifteen centimeters in length. Throughout the patients sequence of surgeries, certain nerves, such as the ulnar nerve branch to the flexor carpi ulnaris, successfully served as a donor nerve in more than one occasion. Muscle groups where single nerve fascicles were previously used as a donor nerves also yielded adequate muscle strength and were successfully subsequently used in tendon transfers. Ultimately, the patient was able to achieve good muscle strength, range of motion and outcome scores on his left upper extremity after two years from his final surgery. Conclusion: This report offers multiple alternative options in managing complex brachial plexus cases as well as challenges some concepts in nerve grafting. Alternative donor nerves are offered for transfers, some of which are not previously used in literature. Aside from this, the use of long autologous nerve grafts, single fascicular nerve transfers and repeated use of certain nerves as donor were performed successfully. We hope these procedures and techniques can be added to each hand specialist arsenal for managing complex brachial plexus injuries, specifically when the standard techniques are not feasible.},
     year = {2020}
    }
    

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  • TY  - JOUR
    T1  - Multi-level Nerve Injury of the Upper Extremity Management and Review of Brachial Plexus Literature: A Case Report
    AU  - Monica Pecache
    AU  - Rahul Patil
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    DO  - 10.11648/j.ijcems.20200606.17
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    JF  - International Journal of Clinical and Experimental Medical Sciences
    JO  - International Journal of Clinical and Experimental Medical Sciences
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    AB  - Backround: Brachial plexus injuries are complex cases requiring a thorough understanding of nerve physiology and upper extremity anatomy. Standard approaches and management have been developed but certain situations still arise where these are not feasible options. Objectives: A case of brachial plexus injury is discussed in this report. The patient was a young male who was referred to our center with weakness of the left upper extremity, C5-C7 distribution. Certain components of his injury, such as extensive soft tissue scarring and identification of a long neuroma at the injury site, obliged the surgeons to use unconventional nerve transfers during his surgery. In this paper, we discuss these alternative options in order to support their potential use in complex brachial plexus cases. Other concepts such as single fascicular harvest for nerve transfers and nerve graft augmented nerve transfers are discussed as they were successfully used in this report. Methodology and Results: The patient underwent a total of five surgeries which were a combination of nerve and tendon transfers. Some nerve transfers were augmented with long autologous nerve grafts reaching up to fifteen centimeters in length. Throughout the patients sequence of surgeries, certain nerves, such as the ulnar nerve branch to the flexor carpi ulnaris, successfully served as a donor nerve in more than one occasion. Muscle groups where single nerve fascicles were previously used as a donor nerves also yielded adequate muscle strength and were successfully subsequently used in tendon transfers. Ultimately, the patient was able to achieve good muscle strength, range of motion and outcome scores on his left upper extremity after two years from his final surgery. Conclusion: This report offers multiple alternative options in managing complex brachial plexus cases as well as challenges some concepts in nerve grafting. Alternative donor nerves are offered for transfers, some of which are not previously used in literature. Aside from this, the use of long autologous nerve grafts, single fascicular nerve transfers and repeated use of certain nerves as donor were performed successfully. We hope these procedures and techniques can be added to each hand specialist arsenal for managing complex brachial plexus injuries, specifically when the standard techniques are not feasible.
    VL  - 6
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    ER  - 

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Author Information
  • Christine M Kleinert Institute for Hand and Microsurgery, Louisville, United States of America

  • Christine M Kleinert Institute for Hand and Microsurgery, Louisville, United States of America

  • Christine M Kleinert Institute for Hand and Microsurgery, Louisville, United States of America

  • Christine M Kleinert Institute for Hand and Microsurgery, Louisville, United States of America

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