DECISION-MAKING PROCESS IN UPPER BRACHIAL PLEXUS PALSIES - POINT OF NO RETURN?

Abstract

Upper brachial plexus palsy is characterized by inability to perform elbow flexion, shoulder abduction, and external rotation. This study presents a comprehensive review of a 40-year experience with upper brachial plexus palsy surgery at a single center, outlining our surgical approach and current management trends. Surgeries were typically performed between 3 and 6 months after the injury to allow for potential spontaneous recovery. During this period, a total of 1,473 procedures were carried out, targeting various nerve components: C5-C7 roots to upper/middle trunks (n=126), musculocutaneous nerve (n=661), axillary nerve (n=573), and suprascapular nerve (n=113). Functional recovery, defined as M3-M5, was achieved in 85.7% of the cases. In some cases, exploring and repairing nerve lesions may be ineffective, leaving nerve transfers as the sole viable option. The decision-making process is significantly influenced by preoperative evaluations. When imaging confirms that structural continuity of nerve elements is preserved, preoperative electrodiagnostic testing may not effectively differentiate between preserved and disrupted functional continuity. In contrast, when imaging reveals disrupted structural continuity, the absence of advanced imaging techniques complicates the confirmation of root avulsion and the differentiation between supraganglionic and infraganglionic root injuries. Final surgical decisions are made intraoperatively, using neuromonitoring to assess the functional continuity of the nerve elements. If functional continuity is maintained, only supraclavicular exploration and decompression may be needed. For infraganglionic root avulsion, supraclavicular nerve grafting might be required based on the extent of the nerve defect. Nerve transfers are reserved for cases involving complete supraganglionic avulsion of all roots.

Keywords

• UPPER BRACHIAL PLEXUS PALSIES