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
  In these cases of partial lesions, the prognosis is good because it is relatively easy to reconstitute the general fascicular organization of the nerve trunks. Such partial wounds must be repaired immediately. Neglecting them would lead to dangerous and complex secondary microsurgical procedures; during these, intraneural dissection would have to separate the neuroma from uninjured fasciculi, with a significant risk of lesion to these intact structures.

Also, at the beginning of our experience, we attempted immediate repair of stretch injuries of the brachial plexus. The four cases operated on following this scheme had to undergo secondary surgery, with fascicular grafting or neurotization. Fresh lesions of the brachial plexus usually necessitate dissection in the middle of a diffuse hematoma. Because we had underestimated the extent of the plexus lesions, our primary repairs by suture (or in a few cases by grafts) failed, and we had to perform secondary procedures.


Most traumatic ruptures of the brachial plexus can be repaired by fascicular grafts according to Millesi's principles.9,11 Appropriate restoration of the fascicular organization of the brachial plexus is a "Mission Impossible." In the last 100 years, there were numerous attempts at clarifying the anatomy of the brachial plexus; these studies started with Herringham,27 Agostini,28 Adolfi,29 followed by Kerr (1918), Ko Hirasawa,30 and Billet.31 More recently, Sunderland,32 Seddon,33,34 and Bonnel35,36 contributed to the study of the fascicular organization of the brachial plexus. Their studies show that there is no systematization of the brachial plexus, that variations from root to root among individuals are great, and that both sides of the same individual do not have the same organization.


The in-depth studies of F. Bonnel35,36 have shown that fascicular organization in a given root varies with each subject. Microsurgery helps to better analyze the fascicular disposition and enhance the quality of graft/fascicle abutments. The quality of these abutments and the rapidity with which they can be performed have been further ameliorated by the recent availability of biologic glues (Biocol and Tissucol).37

Microsurgical techniques also make it possible to remove the connective tissue surrounding the fascicular groups. Bonnel has showed that 70% of a cross section of the axillary nerve is occupied by connective tissue; the ulnar nerve contains even more, i.e., 82%.35,36 The repair strategy is greatly influenced by the type of lesion and by the number of roots or trunks that can be repaired.

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