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

When the surgical indication is doubtful, our position is to ask for a second electromyographic study after an interval of 8 weeks. At that time, evaluation of the lesions can be more precise.

To enhance the results, we believe it important that the necessary surgery be done in the first few months postinjury. The electromyographic examination, however, is not in itself sufficient to identify the lesions of the brachial plexus. Myelography, CT scanning, and more recently magnetic resonance imaging are all useful for precise determination of root avulsion injuries.

Rupture of the subclavian artery or the axillary artery raises the questions of emergency surgical procedure. Our opinion has changed over the years. At the beginning of our surgical experience, we advocated immediate operative repair of the subclavian or axillary artery. Presently, we refrain from operating when there is no ischemic condition of the upper limb. The reason is that the vascular surgeon will most likely repair the artery by a bypass procedure in the middle of a hematoma that makes it impossible to identify the elements of the brachial plexus. During secondary surgery in the brachial plexus, the vascular bypass is often found adhering to the neuroma; dissection is then difficult and dangerous and it is sometimes necessary to do a new bypass. If the patient is operated on during the weeks or months following the accident and if the absence of a radial pulse is not accompanied by clinical abnormalities, we prefer to repair the vessels during the secondary intervention, at the same time as the brachial plexus.


Surgical Possibilities

Direct surgery of the brachial plexus necessitates the level of technical equipment and team proficiency found in all vascular and nerve microsurgical centers. Operating times are relatively long, from 3 to 10 hours depending on the nature of the lesions. The incision starts at the mastoid, follows the sternocleidomastoid muscle, then the anterior aspect of the clavicle and the deltopectoral groove, and may extend, with a Z-shaped plasty, into the axillary region and even into the brachial canal. When the preoperative diagnosis is precise, a shorter incision may suffice, centered on either the supraclavicular or the deltopectoral area.

In the first 100 operations of our series, we were led three times to divide the clavicle; this was done to gain better access to the C8 and Dl roots that were adhering to the subclavian artery or was made necessary by a significant retraction of the fasciculi behind the clavicle.

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