Download Document

Treatment of Injuries to the Brachial
Plexus and Upper Extremity
Andrew I. Elkwood, MD, FACS
Plastic & Reconstructive Surgery
Director, The Center for Treatment of Paralysis and
Reconstructive Nerve Surgery
Rehabilitative Surgery
Patients with disabilities can do more with less
(depending upon the quality of their rehabilitation
treatment)
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Nerve Surgery
The
“Garage Door”
Analogy
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Nerve Surgery






The “Garage Door” Analogy
Outlet = spinal cord
Wire = nerve
Motor = muscle
Chair = tendon
Door = hand or foot
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Rehabilitative Surgery
is a process not an event
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Rehabilitative Surgery
Surgical Algorithm
Nerve Repair
Nerve Grafting
Neurotization
Tendon Transfer
Tenodesis
Joint Fusion
Splinting
Elegance
Simplicity
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Nerve Grafting





Self transfer (i.e. Sural Nerve)
Manufactured Nerve
Processed Nerve
Cadaver Transplant
Living Related Transplant
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
IN THE AREA OF THE PLEXUS





NERVES
BONES
ARTERY
VEIN
LUNG
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
BRACHIAL PLEXUS INJURIES








BIRTH INJURY
MOTOR VEHICLE ACCIDENTS
MOTORCYCLES
FALLS
INDUSTRIAL ACCIDENTS
SPORTS INJURIES
TUMORS
RADIATION
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
BRACHIAL PLEXUS INJURIES



4% OF ALL MOTORCYCLE ACCIDENTS
19% ARE COMATOSE
13% HAVE C-SPINE INJURIES
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
THREE BASIC FACTORS



PAIN
SENSIBILITY
MOTION
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
OVERVIEW






DIAGNOSIS
WORK-UP
NERVE STUDIES
NERVE REPAIR
POST-OP
REHABILITATION
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
DIAGNOSIS





Often clouded by coma, etc
Often clouded by orthopedic injuries
Often ignored
Often misinformed
May be subtle
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
WORK UP

PRELIMINARY WORK UP OF NERVE STUDIES
STARTS RIGHT AWAY
 FIRST EMG AT 6 WEEK TO 3 MONTHS
 CXR
 MRI
 CT MYELOGRAM
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
WORK UP

REPEAT EMG AT 6 MONTHS IF NO
IMPROVEMENT

IF IMPROVEMENT REASSESS AT 9 MONTHS

IF NO IMPROVEMENT OPERATE
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
TIMING






THE TEXTBOOKS ARE WRONG
DO NOT WAIT A YEAR
IF NOT IMPROVED BY 3 MONTHS, THEY WILL NOT
IMPROVE
EMG AT 6-8 WEEKS
REPAIR AT ABOUT 3 MONTHS
ALLOWS FOR “SECOND SHOT” BEFORE ONE YEAR
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
SURGERY
TEAM APPROACH






SURGEONS
CONSULTANTS
NURSES
THERAPISTS
HOME CARE
FAMILY
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
RECOVERY



WHEN NERVE REPAIR IS REQUIRED,
RECOVERY IS DELAYED
1 - 2 MONTH LATENCY
NERVE GROWTH



1 mm/day
1 inch/month
LONGER DISTANCE, LONGER
RECOVERY TIME
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
POST-OP CARE





UNDERLYING DISEASE
MULTIPLE OPERATIONS
 PAIN RESISTANCE
SEVERAL OPERATIVE SITES
IMMOBILIZATION
LONG PROCEDURES
 ANESTHESIA TIME
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
REHABILITATION


IMMOBILIZATION
3 - 6 WEEKS POST-OP
AGGRESSIVE REHAB
KEEP JOINTS SUPPLE
MAINTAIN STRENGTH
BUILD NEW STRENGTH
RELEARN MUSCLE MOVEMENT
BIOFEEDBACK
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Accessory Neurotization
Brachial Plexus Palsy
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
BRACHIAL PLEXUS PALSY
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Nerve Transplants





Its all about spare parts
No need to prioritize
Can’t go to home depot
Cadaver
Living related donor
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Nerve Transplant




NO NEED TO PRIORITIZE
NO NEED TO PRIORITIZE
NO NEED TO PRIORITIZE
NO NEED TO PRIORITIZE
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Nerve Transplantation





Allograft
Abo Compatibility
Prograf
Wrist Monitoring
Steroid Rescue
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Nerve Transplantation

Who’s a candidate?
 Injury about 1 year
 Good health
 Good support system
 Massive injury
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Nerve Transplantation

Who’s a good donor?
 Good health
 Abo match
 No communicable disease
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Nerve Transplantation
CADAVER
VS.
LIVING RELATED DONOR
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Can we treat spinal cord injuries like bilateral
brachial plexus injuries?
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Tetraplegic Hand Surgery
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Hand Surgery








Minimize Spasticity
Maximize passive range of motion
Maximize active range of motion
Tendon Lengthening
Joint Stabilization/Joint Fusion
Splinting Static/Dynamic
Tendon Transfer/ Tenodesis Effect
Neurotization
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Paralysis
We can’t fix the problem but we can help to
RESTORE FUNCTION
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury





Need for Functioning Donors
Nerve donors above the lesion
Muscle donors for tendon transfers
Free muscle donors
Sacrifice contra lateral side?
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Paralysis



Level of Injury
Cranial nerves always spared
Cervical plexus always spared
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Paralysis







Prioritize Function
Arm Abduction
Triceps
Bicep
Wrist Extension
Finger Extension/Flexion
Individualize for Patient
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Timing






Need to let injury evolve
Need to maximize therapy
Need to maintain existing function
Motor end plates do not degrade
Spasm must be balanced
Can take advantage of two-stage procedures
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury






Trapezius to Deltoid Transfer
Neurotization from spinal accessory nerve
Nerve to levator scapulae
Nerve to sternocleidomastoid
Latissmmus to bicep
Latissimus to triceps
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Stroke
Why can’t we treat a stroke patient like a brachial plexus
patient?
• Medical problems
• Spasm
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Pressure Sores






Can occur over any bony prominence
Sacrum most common
Scalp
Ischium
Hip
Heels
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Pressure Sores







Prevention
Prevention
Prevention
Prevention
Prevention
Prevention
Prevention
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Pressure Sores






Any pressure above capillary perfusion pressure is to high
Only a Clinitron works to heal a wound
Other mattresses may work to help prevent
Floating the pressure point is best
Extra padding is bad
Prevention is HARD work
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Treatment of Pressure Sores







Grading scale has no value
Maximize inflow
Maximize protoplasm
Remove “bacteria food”
Means of debridement is not of great importance
Re-educate patient
The VAC does not debride
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Pressure Sore Treatment






High recurrence rate
Maximize everything
Quality of soft tissue coverage
Bed trial
Social support
Prognosis
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Pressure Sores







Prevention
Prevention
Prevention
Prevention
Prevention
Prevention
Prevention
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Pressure Sores

Neurotization for protective sensibility
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Spinal Cord Injury
Summary




We do not have a cure
We have treatments to deal with complications
We have cutting edge methods to maximize function and
impact lives
Education is our greatest hurdle
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Thank You!
Center for Treatment of Paralysis and Reconstructive Nerve Surgery
Complex Injuries:
“A Legal Perspective”
James Maggs, Esq
Maggs & McDermott, LLC