BRACHIAL PLEXUS

1) uLC8LL based on seddons classlflcaLlon

2) LCCA1lCn regangllonlc versus posLgangllonlc

3) Su8CLASSlllCA1lCn lC8 CS1CAnCLlCnlC Supraclavlcular (73) vs lnfraclavlcular (23)

4) Su8CLASS lC8 Su8ACLAvlCuLA8
1 C36 erbeduchene
2 C367
3 an or CompleLe C311
4 C8 11 ue[erlneklumpke
S kL vs CS1GANGLICNIC LLSICN
1 posLgangllonlc also kown as nerve rupLures
2 pregangllonlc are proxlmal Lo Lhe u8C
3 pregangllonlc poor prognosls wlLh no sponLaneous recovery and no ablllLy Lo grafL
4 C8 11 are more llkely Lo be rupLure because of a shoL sLralghL course beLween Lhe splnal cord
and Lhe arm
3 C36 are less llkely Lo rupLure because of a more slgmold / redundanL course beLween Lhe
splnal cord and Lhe arm LhaL wlll dlsslpaLe Lhe force
6 wlLh panplexopaLhy only 20 wlll have compleLe pregangllonlc ln[urles Lo all rooLs reason
for exploraLlon
7
% DIIILkLN1IA1ICN CI kL vs CS1GANGLICNIC LLSICN

l) PemldlaphragmaLlc paralysls C343 Lhus do Cx8 wlLh lnsplraLlon and explraLlon comes
off aL Lhe rooL level and ls suggesLlve of a pregangllonlc ln[ury
ll) Porners 11 12 sympaLheLlc chaln ln[ury suggesLs C8 11 pregangllonlc ln[ury may Lake 2
3 days Lo appear
lll) arasplnal muscle paralysls are lnnervaLed by Lhe dorsal raml
*) levaLor scapula and rhombold funcLlon C3 dorsal scapular nerve comes off aL Lhe rooL
level and ls suggesLlve of a pregangllonlc ln[ury
lv) Sensory flbers have no Wallerlan degeneraLlon (normal nCS)
v) Wlnglng of Lhe scapula long Lhoraxlc nerve ln[ury (C367) comes off aL Lhe rooL level and ls
suggesLlve of a pregangllonlc ln[ury
vl) M8l
v) C1 myeloogram wlLh pseudomenlngoceles roundlng or bulge aL Lhe cord wlLhouL rouLleLs
(black llnes)
vl) LMC of speclflc muscles lnnervaLed aL Lhe rooL level
vll) uLAllL8Ln1A1lCn Aln severe paln ln an anesLheLlc exLremlLy
vlll) abscence of an advanclng 1lnels ln Lhe suprascapular fossa
lx) xray wlLh Lransverse processes fracLures or scapuloLhoraxlc dlssoclaLlon suggesLlve of
severe force
xl) nCS showlng lnLacL sensory loop (SL) sensory nerve cell body ln u8C and absenL moLor
conducLlon


kL kCGNCS1ICS

1) Age ( 40 years worse prognosls for nerve grafLs)
2) 1lme slnce ln[ury

]L
1) SLrengLh
2) SenslblllLy
3) ulses
4) 8rulLs
3) 1lnel's especlally aL L88s polnL
6) LxamlnaLlon of muscles LhaL come off Lhe plexus early may suggesL a pregangllonlc leslon
a Lhe phrenlc (C343)
b serraLus
c parasplnal (dorsal raml)
d rombolds (C3)
e levaLor scapula (C3)
7) Porners suggesLs avulslon of C811
a Mlosls small
b Anhydrosls
c LnophLhalmous
d Losls

kkay

1) Csplne fllms
2) Cx8 (wlLh lnsplraLlon and explraLlon)
3) Shoulder xrays
4) Cmlnous slgns on xray of posslble 8 ln[ury and lncreased rlsk of pregangllonlc leslons
l) abnormal dlaphragm excurslon (phrenlc nerve funcLlon)
ll) 1sL rlb # ass wlLh lower rooL ln[ury
lll) Clavlcle # ass wlLh worse prognosls
lv) scapuloLhoraxlc dlssoclaLlon
v) scapular fracLure
vl) Lransverse process fracLure of Lhe splne

MkI

1) Look for pseudomenlngoceles suggesLlng rooL avulslon (pregangllons leslon)
a exLravagaLlon of C1 conLrasL Lhrough a dural renL
b seen as roundlng or bulge aL Lhe cord wlLhouL rouLleLs (black llnes)
2) MosL accuraLe afLer 3 weeks because of small dural Lears / CSl leaks can lead Lo false poslLlves
3) 73 accuracy
4) 11 lmages show waLer and pseudomenlngoceles besL
3) 12 lmages show faL and Lhe plexus proper besL
6) Shows everyLhlng and more Lhan Lhe C1

C1 MLLCGkAM

1) Look for pseudomenlngoceles
a 1hese are a hallmark of pregangllonlc rooL avulslons
b exLravagaLlon of C1 conLrasL Lhrough a dural renL
c seen as roundlng or bulge aL Lhe cord wlLhouL rouLleLs (black llnes)
2) C1 myelogram more accuraLe Lhan plaln myelogram
3) Should be delayed by 3 weeks Lo avold small poslLlves due Lo small dural Lears leaklng CSl

ANGICGkAM

1) lnulCA1lCnS
l) Any open ln[ury or peneLraLlng ln[ury
ll) progresslve deLerloraLlon
lll) Px of vascular ln[ury
lv) mechanlsm (conLroverslal)
v) paLlenL requlrlng arch anglo for oLher reasons
vl) lnclude subclavlan arLery and axllary arLery
2) vascular ln[urles presenL ln 10 of plexus ln[urles

LLLC1kCDIAGNCSI1IC 1LS1S

1) 3 Lypes
a nCS
b LMC
c SL

NCS

1) deLermlnes conducLlon veloclLy by sLlmulaLlng a nerve aL one polnL and recordlng aL anoLher
2) do for sensory (SnA) or moLor flbers (MnA)
3) uC nC1 nLLu A1lLn1 CCCL8A1lCn
4) presence of an lnLacL SnA and no MnA ls suggesLs a pregangllonlc leslon because Lhe
sensory cell body ls ln Lhe u8C
3) ln posLgangllonlc leslon boLh Lhe SnA and MnA are absenL because of Wallerlan degeneraLlon
2) Pelps dlfferenLlaLe prevsposLgangllonlc
6) lnadequaLe conducLlon across a neuroma ln conLlnulLy ls an lndlcaLlon for posslble exclslon and
nerve grafLlng


SL Sensory Lvoked otent|a|s

1) measuremenL of elecLrlcal response ln Lhe cerebral corLex
2) does nC1 requlre paLlenL cooperaLlon
3) conflrms lnLacL conLlnulLy of Lhe sLlmulaLed flbers Lo Lhe level of Lhe cerebral corLex
4) can use epldural SL lnLraoperaLlvely Lo conflrm Lrue avulslons
3) anesLheLlc arm wlLh a normal SnA and no SL ls suggesLlve of a pregangllonlc leslon

LMG

1) 8esL afLer 3 weeks
2) prevsposL gangllonlc ln[ury can be suggesLed by resulLs of LesLlng
l) parasplnal muscles
ll) levaLor scapula
lll) rhombolds
lv) dlaphragm
v) serraLus anLerlor
3) needle elecLrodes measure muscle acLlvlLy LhaL ls volunLary or evoked
4) needs cooperaLlon
3) normal muscle ls sllenL when lnacLlve
6) lower moLor neuron ln[ury shows flbrlllaLlons and sharp wave wlLhln lnacLlvlLy Lhese sLarL
appear 3 WLLkS afLer ln[ury
7) LMC may show recovery relnnervaLlon poLenLlals Lhese do noL predlcL Lhe degree of recovery

IN1kACLkA1IVL LLLC1kCDIAGNCS1IC 1LS1ING

1) use SnA and MnAs nCS
2) checks for pregangllonlc versus posLgangllonlc leslons
3) checks Lo see lf acLlon poLenLlals are passlng Lhrough Lhe nerve flbers

1IMING

1) lmmedlaLe only lf vascular grafL repalr aL lnlLlal C8 Lo avold laLe vascular grafL ln[ury
2) key wlndow for posLgangllonlc leslons ls 3 6 monLhs
3) lf no recovery aL 3 monLhs Lake Lo C8
4) lf recovery leave alone as Lhls may worsen Lhe slLuaLlon
3) lf aL 6 wk looks llke compleLe avulslons ln[ury conslder earller C8

GLNLkAL SUkGICAL kINCILLS

1) mosL are aggresslve as surglcal exploraLlon ls very unllkely Lo make Lhe paLlenL worse
2) wlLh panplexopaLhy on 20 have avulslon of all 3 rooLs Lhus llkely someLhlng Lo repalr
3) wlLh blasL ln[urles Lhere may be a mulLllevel ln[ury (10) Lhus explore Lhe enLlre plexus
4) wlLh laceraLlon can explore only Lhe ln[ured slLe

INDICA1ICN ICk SUkGLk (ADUL1)
1) laceraLlng open ln[urles
2) ln[urles wlLh no evldence of recovery wlLhln a reasonable perlod of Llme
l) usually 3 monLhs
ll) monlLor for recovery of muscle sLrengLh change ln elecLrodlagnosLlc LesLs advanclng
1lnels
3) ln[ury wlLh plaLeau of recovery buL noL Lo a funcLlonal or useful level afLer a reasonable perlod of
walLlng usually 6 monLhs
4) ln[ury wlLh dlsLal buL noL proxlmal recovery

1IMING
1) open laceraLlng ln[urles are repalred wlLhln uA?S
2) blasL ln[urles lf golng Lo Lhe C8 for oLher reasons should be Lagged (repalr ls conLroverslal) Lhen
reLurn aL 3 monLhs dependlng on recovery
3) for closed ln[urles besL recovery ls lf surgery ls done 6 monLhs Lhus C8 lf nC recovery aL 3 monLhs
or lnadequaLe recovery aL 6 monLhs

1kLA1MLN1 kICkI1ILS
(varlable by surgeon)
1) Llbow flexlon musculocuLenaous nerve (laLeral cord)
2) Shoulder sLablllLy or abducLlon suprascapular nerve for sLablllLy and laLeral cord for abducLlon
3) WrlsL and flnger flexlon laLeral cord
4) wrlsL flnger exLenslon
3) lnLrlnslcs
6) newer Lrend ls Lo LreaL proxlmal muscles flrsL because of hlgher raLes of success and llmlLed
avallable grafLs
7) ln adulLs nerve grafLs and lnLacL proxlmal rooLs are noL generally used Lo reconsLrucL lower Lrunk
ouLflow (C811) because of Lhe llmlLed reasource and poor recovery of funcLlon here

C1ICNS ICk 1kLA1MLN1 (In Crder Cf reference)
1) neurolysls rarely done
2) rlmary nerve repalr (neurorraphy)
3) nerve garfLs
4) nerve Lransfer neuroLlzaLlon
3) 1endon Lransfer
6) lree muscle Lransfer
7) ArLhrodesls / Lenodesls
8) AmpuLaLlons

INDICA1ICNS ICk NLUkCLSIS
1) lnLacL fasclcles wlLh some A movlng across however ln slgnlflcanL scar Llssue
2) lnLernal neurolysls nC1 uCnL as declslon for nerve resecLlon and grafLlng versus nooperaLlve Lx
made prlor Lo C8

INDICA1ICNS ICk NLkVL GkAI1ING WnICn 1AkL kICkI1
*) grafL mosL dlsLal lnLacL opLlon
*) always cuL back Lo normal Llssue
*) cuL grafL 10 longer Lhan necessary
*) preferred meLhod for posLgangllonlc ln[ury
*) donors lncludes
l) sural nerve (usually 33 cm avallable ln each leg)
ll) medlal anLebrachlal cuLaneous nerve
lll) anLebrachlal cuLaneous nerve
lv) ulnar nerve ln prooven C8 11 rooL avulslon ln[ury ln and adulL
v) *) conslder vascularlzed ulnar nerve grafL ln a poorly vascularlzed bed LhaL ls 7 cm
*) flbrln glue ls fasLer and easler and produces equal resulLs
1) Llbow flexlon (C6) anLerlor dlvlslon of upper Lrunk laLeral cord musculocuLaneous nerve
2) Shoulder sLablllLy (C3) upper Lrunk posLerlor dlvlslon axlllary nerve suprascapular nerve
3) Llbow and wrlsL exLenslon (C7) posLerlor cord or radlal nerve

kIMAk NLkVL kLAIk
1) rarely posslble excepL sLab wounds and laLrogenlc ln[urles
2) wlLh LracLlon ln[urles prlmary repalr wlLhouL Lenslon ls rarely posslble afLer exclslon of Lhe neuroma
ln conLlnulLy

DCNCk NLkVL C1ICNS
1)Sural 33 cm
2)ulnar nerve lpsllaLeral ln severe ln[ury wlLh avulslon of lower rooLs (C8 11) ln an adulL
3)medlal cuLanous n of forearm
4)laLeral cuLanous n of forearm
3)sup radlal nerve
6)vascularlzed ulnar for conLralaLeral C7 conLroverslal ln a poorly vascularlzed bed LhaL ls 7 cm

C1ICNS ICk NLkVL 1kANSILkS (NLUkC1I2A1ICN% + WnLN DCNL

*) lndlcaLed when no donor grafL avallable Lo brldge gap or lndlcaLed ln a rooL avulslon pregangllonlc
leslon
*) uses alLernaLlve sources of moLor neurons Lo relnnervaLe crlLlcal moLor nerve funcLlon
1) Splnal acessory common for suprascapular nerve ls lmporL nerve Lo Lrapezlus only Lransfer splnal
acessory dlsLal Lo Lhe 1sL maln moLor branch Lo Lrapezlus Lo malnLaln Lrapezlus funcLlon
2) Cross conLralaLeral plexus C7
3) lnLercosLals 1343 (MosL common esp all of 1343 for elbow flexlon Lo musculocuLaneous nerve
ensure no dlaphragm paralysls as conLralndlcaLlon as ls hls of scar or chesL Lubes
4) medlal pecLoral
3) fascllce of ulnar nerve lCu Lo Lhe musculocuLaneous especlally ln Lhose 40yrs C8L8LlnS
6) lf less Lhan 40 yr of age and 6 monLhs slnce ln[ury 90 successful for 3)
7) hrenlc nerve conLroverslal
8) cervlcal plexus (C2343)
9) always aLLempL Lo avold lnLerposlLlon nerve garfLs by performlng dlrecL anasLamoses

88ACPlAL LLxuS 1LnuCn 18AnSlL8S

INIDICA1ICNS

1) SPCuLuL8
a fallure of recovery 18 monLhs Lo 2 years afLer ln[ury or repalr
2) LL8CW
a fallure of recovery 18 monLhs Lo 2 years afLer ln[ury or repalr

LLISCCC AND nCIILk

1) lor lack of exLernal roLaLlon wlLh no lnLernal roLaLlon conLracLure
2) LaLlsslmus and Leres ma[or Lransfer posLerlorly and laLerally onLo Lhe humerus Lo provlde
exLernal roLaLlon L'LlSCCC
3) may aLLach Lo roLaLor cuff Lo provlde exLernal roLaLlon and some degree of abducLlon PCllL8
4) lf conLracLure exlsLs do pec ma[or release and shoulder capsule release and posslbly
subscapularls release
3) 1hese surgerles do resulL ln halLlng of Lhe abnormal remodellng of Lhe glenohumeral [olnL

SnCULDLk Ak1nkCDLSIS

1) besL lf Lrapezlus and serraLus are funcLlonal Lo provlde some conLrol over Lhe scapulaarm
complex
2) luse aL 2030 degrees abducLlon 30 degrees of anLerlor flexlon and 30 degrees of lnLernal
roLaLlon hand Lo mouLh poslLlon
3) lncreased rlsk of fracLures
4) aLlenL dlscomforL

SnCULDLk S1A8ILI2A1ICN

1) LLplscopo
2) ArLhrodesls

LL8CW ILLkICN

1) SLelndler flexoroplasLy
2) laLlsslmusc Lransfer (8l monopolar ) mosL common
3) pec ma[or (Clarks Lransfer) bl or monopolar
4) AnLerlor Lrlceps leasL common

S1LINDLLk ILLkCkCLAS1

1) Moves Lhe flexorpronaLor mass orlgln Anu medlal eplcondyle proxlmally onLo Lhe anLerlor
humerus
2) Cnly Lo augmenL elbow flexlon (alone provldes only +3 elbow felxlon)
3) uoes noL sLablllze Lhe shoulder
4) MusL have 3/3 wrlsL flexors

LA1ISSIMUS 1C 8ICLS

1) rovldes shoulder sLablllzaLlon and elbow flexlon
2) 1ake Lendon of laLlss lnLo coracold process and Lube orlgln lnLo blceps Lendon
3) 1horacodorsal nerve (posLerlor cord C367)
4) alLernaLlvely leave humeral orlgln lnLacL and place lnserLlon lnLo Lhe blcep Lendons
a above done by Clson / MorharL
3) favored Lransfer
6) ulSAuvAn1ACL supplled by C367 whlch ls Lhe same as blceps so lL ls ofLen unavallable lf
performed wlLh a muscle of decreased sLrengLh resulLs are poor

LC MAICk (CLAkkS%

1) Llbow flexlon and shoulder sLablllLy
2) Medlal pecLoral nerve (C811) and laLeral pecLoral nerve (C367)
3) ALLach Lendon Lo coracold and medlal lnserLlon of muscle Lubed Lo blceps Lendon
4) lnclude aLLachmenL Lo recLus fascla Lo allow for exLenslon of Lhe muscle
3) alLernaLlvely leave orlgln lnLacL and Lube lnserLlon Lo Lhe blceps Lendon

AN1LkICk 1kICLS

1) LasL resorL as loose elbow exLenslon
2) 1ake Lrlceps lnserLlon and wrap medlally Lo lnserL Lo blcpes Lendon

WkIS1 MCVLMLN1 AND S1A8ILI1

1) preserve even weak wrlsL movemenLs as Lhese allow for Lenodesls and lmproved flnger funcLlon
2) lf Lhe wrlsL ls unsLable (lacklng wrlsL exLensors or flexors) conslder fuslon

nAND ] DIGI1 IUNC1ICN

1) use same prlnclples as for perlpheral nerve Lransfers

AMU1A1ICNS


1) now rarely done
2) lnulCA1lCnS chronlc lnfecLlon wlLh sofLLlssue breakdown and mulLlple nonulons
3) ls proprocepLlon aL elbow remalns above elbow ls beLLer Lhan below elbow
4) always consulL rehablllLaLlon medlclne prlor Lo an ampuLaLlon