Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 45:
Direct Surgery of Traumatic Lesions of the Brachial Plexus
  We have shown that if the patients underwent surgery before the sixth month postinjury, pain was brought down to tolerable levels in 82% of the cases, and no pain medication was then necessary; coversely, when surgery was performed later than 12 months after the accident, 87% of the patients continued to complain of pain and needed pain medication on an irregular basis. We observed also that the younger the patient, the better he tolerated pain. On the other hand, we did not find a correlation between pain intensity and number of avulsed roots. Furthermore, the earlier the patient goes back to work, the better he will handle the pain; this implies perfect coordination between the trauma centers with their specialists of brachial plexus direct surgery, and the centers for physical therapy and work readaptation.

Prompt surgery significantly lessens pain through the re-establishment of afferences to the spinal cord. Our position regarding systematic surgery for severe lesions of the brachial plexus enabled us to reduce significantly the number of amputations of the upper limb: of 262 patients operated on, only 2 subsequently needed an amputation, which was done at the level of the proximal third of the arm.


We have classified motor results as good, average, or poor. Results were defined as good when the patient recovered almost normal function in daily activities and during work that implied manual labor. Average results were those allowing the patient to cope with everyday activities. Poor results were defined as reinnervation failures rendering absolutely necessary the lateralization of the healthy limb.


Table 45-1 shows that in the supraclavicular lesions, we observed only 13% good results, and over 40% failures. The more distal the lesion, the better the functional results. On the other hand, results were never good with extensive lesions because of the severity of the trauma, the number of avulsed roots, and the length of the grafts. These patients, however, must not be left untreated when nerve regeneration is completed, which can take from 1 1/2 to 2 1/2 years. At the end of this regrowth period, it is reasonable to propose tendon transfers. These transfers may sometimes fall outside the usual schemes for isolated or combined repair of median/ulnar or radial/ulnar nerve palsies to ameliorate flexion and extension of the elbow and stabilization of the hand.52

We have abandoned wrist arthrodesis, attempting instead to reanimate the digital chains. On the other hand, when elbow flexion has not recovered after 12 months, it is appropriate to consider muscle transfers such as transfer of the pectoralis minor, the pectoralis major or the thoracodorsalis muscle. Finally, in borderline cases where none of these three muscles can be used, it is possible to do a Steindler operation when the C8 and T1 roots are still functional.53

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