Download Examination for root avulsion

Examination for root avulsion
• Paralyzed diaphragm:
– Diaphragm C3-C5
– Implies C5 avulsion
• Exam: chest percussion
(excursion)
• X-ray inspiration/exspiration
views
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Examination for root avulsion: Horner‘s
syndrome
• Features
– Ptosis
– Miosis
– Enophtalmus
• Implies C8/TH1 avulsion
• Caused by interruption of sympathetic
pathway
• Descends in spinal cord exiting via C8-TH2
spinal nerves
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Examination for root avulsion
• Absence of Tinel‘s sign or percussion,
tenderness in supraclavicular fossa
• Parascapular muscle atrophy
• Shift of the head away from the injured side
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Postganglionic exam features
• Tinel‘s sign in one or more plexus dermatome
(advancing =stretch with recovery)
• Percussion tenderness supra- or infraclavicular
• Preserved movement
• Sweating in palm
• Muscle force testing BMRC (M1-M5) grade
– With referral to spinal level and pathway to
each msucle
– Repeated (if immediate surgery deferred) to
follow recovery
– Careful and complete documentation
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Documentation
Initial
examination
2 years after
surgery
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Conclusion of physical exam
• History and physical exam = surgeon‘s most powerful tool
– Must be complete, methodical
• Life before limb injuries
• Identify possible root avulsion (phrenic nerve, rhomboid,
serratus ant palsy, horner sign, absent tinel‘s sign)
• Systematic repeated exams:
– Identify common patterns of injury
– Determine complete vs incomplete lesion
– Follow recovery
– Plan surgical reconstruction 3-6 months (postganglionic
lesions, preganglionic lesions as early as possible)
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Diagnostics
• Myelo CT
• MRI
• Electrophysiologic tests (SSEP‘s)
• Intra-operative options
– Acetylcholintransferase activity (CAT
measurement),
– SSEP‘s (somatosensory evoked potential‘s)
– Direct nerve stimulation (C5)
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Pattern of plexus lesions
• (all roots intact, distal lesion)
• Rupture of C5-C7, avulsion of C8,TH1
• Rupture of C5,C6, avulsion of C8,TH1
• Rupture of C5, avulsion of C6-TH1
• „Flail arm : < 20% avulsion of all roots
• Supraclavicular injuries 70%
• Infraclavicular injuries 30%
Hentz et al. In Green, Operative
Hand Surgery, 2005
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Timing of surgery
• Immediate: open lesions, ischemia of major blood vessels
to the arm
• > 3-6 months after primary accident: closed lesions
depending of simultaneous injuries
– In case of documented root avulsion preferred early
reconstruction
• Surgical options:
§  < 12 months:
§  > 12 months:
- direct nerve repair (rare)
- grafting
- nerve transfer
- tendon transfers
- free neurotized muscle transfers,
- joint fusions
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Priorities of surgery
• Elbow flexion
• Shoulder stabilization and motion
– Abduction and external rotation
– Serratus ant/scapular stabilization
• Median nerve sensibility
Elhassan B et al. J Hand Surg
2010;35(7):1211
Yamada T et al. J Hand Surg
2010;35(9):1427
Ihara K et al. J Hand Surg
1996;21(3):381
• Radial motor function (Triceps, Wrist/digit extension)
• Useful median/ulnar motor function generally
no realistic goal
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Immediate vs early vs late surgery
• Time needed for nerve recovery (1mm/day)
– 50% muscle loss after 2-3 months of denervation
– Loss of motor endplates @ 12-18 months
• Early: 0-6 months
• Late: 9-12 months
• Intact roots, distal lesions
– Intraplexular nerve transplantations
• Avulsion of roots
– Nerve transfer
• The more extensive the plexus lesion the more modest
the expecting reconstructive result
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Priority of reconstructions
• Shoulder function
– Scapulohumeral (trapezius, rhomboids, serratus
anterior muscles)
– Glenohumeral
• ABD: (Deltoid, supraspinatus muscle):
– Intraplexal nerve transfers: spinal accessory nerve à
suprascapular nerve
– Trapezius muscle transfer
• Rotation (IR: pectoral, subscapular muscles AR:
infraspinate muscle)
– In global lesions no reconstruction
• Glenohumeral arthrodesis: 15°F+Abd,45°IR
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Priority of reconstructions
• Elbow flexion
– Biceps, brachialis m
• If C5,C6 present: intraplexal reconstructions with nerve
grafts
• if C5,C6 avulsion:
– Nerve transfer: ulnar/median nerve branch à
Oberlin et al JBJS
musculocutaneous nerve (double Oberlin)
2004;86A:1485
– Med. pectoral nerve à musculocutaneous nerve
– Intercostal nerves à musculocutaneous nerve Merrel et al J Hand
Surg 2001;26A:303
• If global avulsion: {pectoral muscles <M4); intercostal
nerves, phrenic nerve, hypoglossus nerve, contralateral
C7 (only in children) nerve transfer à musculocutaneous
nerve}
Chuang et al J
Hand Surg 2012;37
36
(2):270
Nerve transfers (elbow flex)
MacKinnon et al J Hand
Surg 2005;30A:978
lateral
medial
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Nerve transfers (shoulder abd)
Pruksakorn et al Clin anat
2007;20(2):140
• Spinal accessoryà suprascapular nerve
SSN
SAN
SAN
SSN
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Nerve transfers (elbow ext)
Leechavengvongs
et al J Hand Surg
2003;28A:628
• Radial nerve branche àaxillary nerve
Axillary
nerve
Radial
nerve
Axillary
nerve
Radial nerve
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Options of nerve transfers
• Early:
– Spinal accessory nerve (1700 axons, pure motor)à
Suprascapular nerve
– Intercostal nerves (1300 axons, 2-3 nerves ICN III-VI best
with sensory components)à musculocutaneous nerve
– Medial pectoral nerve à radial nerve
– Ulnar/median nerve branches à musculocutaneous
nerve
– Radial nerve branchà axillary nerve
• Other donors:
– Phrenic nerve (800 axons, hemidiaphragm paralysis,
adults only),
– Contralateral C7 (only children), hypoglossal, cervical
plexus
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Late Reconstructions
• Tendon transfers
line of pull à straight, one tendon = one function
– Shoulder abduction/external rotation
• Upper/lower trapezius muscle transfer
– Elbow flexion
• Steindler transfer
• Pectoralis major transfer
• Latissimus dorsi bipolar transfer
– Grasp
• ECRLàFDP; BRàFPL;EIPàopponensplasty
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Late: free neurotized muscle
• Innervated proximally –> power distally
• Can span long distance à waiting for nerve
recovery
– Elbow flexion
– Wrist extension
– Finger extension
– Finger flexion
– Single or double (elbow flex and wrist ext)
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Late: free neurotized muscle
– Doi s procedure(Taiwan):
– Double gracilis muscle
transfer
– 1. Gracilis m,
ant obt n à spinal
accessory nerve à elbow
flexion + wrist extension
– C5/C6 à suprascapular +
axillary nerves,
Phrenic nà suprascapular
nerve
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Late: free neurotized muscle
– 2. Gracilis muscle,
intercostal nerves à ant obt
nerve
à Finger flexion
– if good elbow flexion à
fascia lata graft between
gracilis muscle and finger
flexors (Oberlin)
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Free neurotized muscle transfer
• Power
– Intraplexal: AIN
– Extraplexal: Spinal accessory nerve, intercostal
nerves
• Vascular supply
– Thoraco-acromial trunk
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Late reconstructions
• Bony
– Arthrodesis
• Glenohumeral
• Wrist
• Thumb
– CMC, IP
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