• Brachial Plexus Injury

    History

    • HPI – 16 yo male with no significant past medical history, suffered a “stinger” with immediate flail left arm during football practice.
    • Patient initially managed expectantly but at 6 weeks had failed to make any improvement in proximal motor or sensory function
    • Patient referred for evaluation after initial and follow-up EMG/NCS demonstrates no evidence of motor reinnervation of C5/6/7 at 3 months
    • PMH – negative
    • PSurgHx – negative
    • Meds – none
    • All – NKDA
    • SocHx – student, non-smoker, lives with parents

    Exam

    • Neurologically AAO x 3
    • Cranial nerves intact, no horner’s
    • 5/5 intrinsics, normal strength and tone on the right, on the left upper extremity: 0/5 shoulder abduction/external rotation, 0/5 elbow flexion, 0/5 elbow extension, 3/5 grip, normal palmaris longus and flexor digitorum profundus of the 3rd and 4th digit. 3/5 wrist flexion -mild ulnar deviation, normal pronation, 0/5 wrist extension
    • Diffuse numbness involving C5/6/7 dermatomes
    • Delayed MRI from the outside hospital demonstrates a questionable left C7 meningocele
    • Meds – none
    • All – NKDA
    • SocHx – student, non-smoker, lives with parents

    Figure 1.

    Figure 2. EMG/NCS

    1. The best management would be:

    2. Nerve transfers can still be performed up to what maximal time point:

    3. Goals of reconstruction should focus primarily on:

    4. Which of the following describes you?

    5. I practice in one of the following locations.

    6. Please add any suggestions or comments regarding this case:

    • Exam is incomplete... no mention of rhomboid function and EMG findings
    • This was a tearing of the proximal roots of the cervical region it is indicate to operate on since there was not imporovement after 3 months and teh graffting is the indicate procedure.
    • Best timing for nerve transfers from 3-6 months. Previous to dividing the receptor nerve, stimulate it directly to test if any residual function.
    • I am 79 or will be in 10 days so quite retired but a good case and appreciate that you haveput it up for comment. Thanks Dave Kline now retired and in Lenoir, NC
    • The pathophysiology is not obvious. This is unusually severe injury stretch injury without other dost tissue injury. Given young age, can wait and watch for at least 6 months from injury for evidence of re-innervation of supraspinatus.
    • In our (large) pediatric brachial plexus clinic, we would do plexus exploration first, then secondary transfers as a function of what recovers later. Eg plexus first, Oberlin later or tendon transfer for wrist extension etc. No single answer. This is the value of a clinic with NS, upper extremity Ortho and PMR services.
    • Patient has an upper and middle trunk injuries, probably due to nerve root avulsions of C5,6 and 7, without spinal cord rupture, as there is no mention of scapualar winging nor weakness of the rhomboids nor diaphragm paralysis, and there is no severe neuritic nor complex regional pain. One could wait to reassess with NCS/EMG and MN neurogram again in 6 months, but why bother when tne diagnosis is strait forward and recovery in this sort of injury tends to be poor? Patient needs care by dedicated peripheral nerve surgeon, as surgical anatomy is difficult to understand and nerve transfers require a dedicated intellectual process. Nerve grafting is a relatively easy exercise. He would probaby benefit from finger extensor tendon transfers during the recovery process, so a dedicated Hand Surgeon should be part of the therapeutic team.
    • 3 months is still early for eventual outcome and final treatment plannining.
    • I practice in el salvador central america but it is not in the file never????why?
    • I would have done the triple neurotization already. At three months, I expect the deltoid already to be atrophied massivly, which means it can be too late already.

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