|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| In any case, these neurotization techniques have two goals, namely, to avoid amputation of the paralyzed arm and to provide trophic condition and comfort compatible with everyday life. The result is usually a live arm that performs as poorly as a prosthesis or even worse. A brachial plexus contains at least 150,000 fibers and the number of fibers usable by the surgeon for arm neurotization is no greater than 1300 in each intercostal nerve and 1700 in the spinal accessory nerve.
Repair Indications According to Lesion Type
Rupture of C5 and C651 (FIG. 45-01). In the case of repairable ruptures of the C5 and C6 root, we systematically graft the suprascapularis nerve with one or two grafts originating in the posterosuperior quadrant of the C5 root. The remaining portion of the root is connected by a graft to the lateral cord and sometimes to the upper origin of the posterior cord. The C6 root can be shared by the lateral cord and the posterior cord. This operation is often accompanied by a neurolysis of the C7 root. In all of our cases in which C5 and C6 were ruptured and C7 was in continuity, the latter was consistently the site of an elongation, indicated at best by an intense epineural reaction.
Rupture of C5 and avulsion of C6 (FIG. 45-02). There is no doubt that a graft must be placed between C5 and the suprascapularis nerve. If the C5 root contains enough fascicles, a portion of the fibers is directed toward the lateral cord and the upper origin of the posterior cord. If the root contains too few fascicles, fibers will be directed in priority toward the lateral cord and even more so toward the musculocutaneous nerve.
Intradural avulsion of C5 and C6 (FIG. 45-03). We prioritize the recovery of the biceps through a spinohumeral neurotization. An alternate solution is to neurotize the biceps by three intercostal nerves and to use the spinal accessory nerve to neurotize the suprascapularis muscle. In our experience, however, it is important to check the condition of the C4 root and to search for possible phrenic palsy; the latter is an adverse condition because it is often associated with a partial lesion of the spinal accessory nerve, which proscribes its use for neurotization.
LESIONS OF C5, C6 AND C7
Rupture of C5, C6 and C7 (FIG. 45-04). This is a relatively rare lesion that at least has the advantage of permitting anatomic restoration by short grafts. It is preferable to separate the anterior plane from the posterior plane, knowing that the C7 root distributes itself to the whole brachial plexus and can interfere with the results by co-contraction phenomena. It is therefore prudent to use the C7 root on the posterior plane.
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