4. ROOTS TRUNKS DIVISON CORDS BRANCHES DORSAL SCAPULAR NERVE C5
LONG THORACIC NERVE C567 SUPERIOR- C56 SUPRASCAPULAR NERVE N.
SUBCLAVIUS
5. LATERAL LATERAL PECTORAL NERVE MUSCULOCUTANEOUS N. LATERAL
DIVISION OF MEDIAN N. MEDIAL - MEDIAL CUTANEOUS N OF ARM MEDIAL
CUTANEOUS NERVE OF FOREARM MEDIAL PECTORAL NERVE MEDIAL BR OF
MEDIAN NERVE ULNAR NERVE POSTERIOR UPPER SUBSCAPULAR NERVE
THORACODORSAL NERVE LOWER SUBSCAPULAR NERVE AXILLARY NERVE RADIAL
NERVE
7. NEUROPRAXIA focal conduction block may recover in hours to
weeks AXONOTEMESIS SUNDERLAND GRADE II d/t stretch axon disrupted
& wallerian degeneration occurs recovery @ 1mm/day or 1inch/mo
occur weeks/years sometimes proximal lesion with distal targetnerve
regenerates but no recovery due to muscle atrophy GRADE III &
IV Recovery is variable & surgical intervention is needed
NEUROTEMESIS - GRADE V Eg Post-ganglionic ruptures &
pre-ganglionic avulsions Sx must.
8. CAUSATIVE CLOSED OPEN TRACTION COMPRESSION COMBINED SHARP
GUNSHOT RADIATION
9. Traction between two anchoring points proximal spinal cord
& distal neuromuscular junction. Coracoid process lever in
forceful abduction of shoulder. Direction & speed of
application of force equally important. Traction injuries in motor
vehicle accidents & ski crashes, workers arm caught &
pulled by machine, rugby players, football & volleyball players
while hitting smash Low energy & high energy
10. If shoulder neck angle is widened upper/middle trunk injury
If scapulo-humeral angle is widened lower trunk injury The
structures protecting cervical nerve from traction are 1. cone
shaped dural continuation into epineurium 2. fibrous attachments
between epineurium of C5,6,7 & transverse process which is
absent in C8,T1. Thus avulsion is more common in C8,T1.
Extra-foraminal rupture is more common in C5,6,7
11. Traction injury in OT Improper positioning GA traction
injury In supine/lateral decubitus position extension & lateral
bending of head can cause upper trunk damage. Positioning of
shoulder on sandbag or roll Suspension of arm from lateral
decubitus when other arm is in hyperabduction Excess abduction of
both arms in prone or supine for spine surgery.
12. Complex trauma with multiple fractures of the cervical
transverse process, clavicle, scapula, rib, and proximal humerus
can cause both compression and traction injury to the brachial
plexus. Disruption of brachial plexus can be found on more than one
site. Associated with vascular damage
13. Assault by knife/sharp objects Associated with
intrathoracic/vascular injuries. Only a part of plexus is involved
carries good prognosis t/t by intraplexal grafting/neurorraphy.
Iatrogenic during block/ tumour resection/central line insertion.
Gunshot injuries may require early repair or may form
pseudoaneurysm & can lead to progressive neural compression
& will require both nerve & vessel repair. Usually
peripheral nerves are radioresistant & can occur after I/L RT
to axilla or breast in Ca. Can present with progressive deficit
surgical exploration usually difficult d/t fibrous tissue
14. Pattern of injury Supraclavic ular Pre- ganglionic Post-
ganglionic C5-C6 C5-C7 C8-T1 Pan plexu Retro- clavicular(
divisions) Infra- clavicular
15. Burners & Stingers transient injuries as a result of
trauma combined with factors stenosis/degenerative disc
(spondylosis) Parsonage turner syndrome - ?post-infectiuos brachial
plexopathy rapid onset severe pain in shoulder & arm followed
by wasting & weakness of muscles.
16. Narakis anatomic classification Group 1 c5, c6 Group 2 c5,
c6, c7 Group 3 Panplexus lesions(C5-T1) Group 4 Panplexus with
Horner syndrome In Sx untreated cases Group 1 - 90% recover Group 2
25% recover Group 3 no recovery but majority achieve good hand
function Group 4 poor or no hand function
17. C5-C6 15% of traumatic injuries Erbs point. Erbs point
C5-C6 15% traumatic injuries Shoulder abduction & rotation
Supra & Infraspinatus Deltoid Subscapularis Elbow flexion
Biceps Brachialis Brachioradialis Supinator + Sensory loss in
C5-C6
18. C5-C7 injury Erbs plus 20-35% - middle trunk injury
Weakness of elbow extension along with variable weakness of wrist
& fingers as C7 contribution varies between pateints Sensory
proximal arm, thumb, index & middle finger.
19. C8-T1 lesions 3 weeks when dural tear has healed. Findings-
obliteration of nerve root sleeve, defect root sleeve shadow,
pseudomeningocele (Nagano six categories) 98% specific, 95%
sensitive when correlated with intra-OP SSEP & extradural
inspection. Doesnt detect partial root avulsions. Ventral root more
vulnerable for avulsions as lesser tensile strength.
43. MRI findings hematoma in verterbral canal, empty dural
sleeve, shift of spinal cord away from midline. MRI with slices of
3mm provide accurate diagnosis of root avulsion in 52% when
compared with intradural inspection. Cant be used in acute setting
due to edema. Angiography in penetrating lesions PFT chest wall
trauma, phrenic nerve dysfunction. Unless PFT1 yr post-injury -
primary reconstruction C/I except in young & distal nerve
transfers (where upto 18 months Sx can be done)
47. TIMING Timing of brachial plexus reconstructive surgery is
based on three principles: (1) better functional outcomes occur in
patients with spontaneous recovery who do not require a surgical
intervention; (2) surgical intervention is indicated for patients
with no hope for spontaneous recovery or for further recovery, (3)
surgical outcome is inversely proportional to the time interval
from injury to surgery (i.e., outcomes are better if surgery is
performed earlier).
48. POSITION Pt supine, head turned to C/L side, the upper part
of the body is elevated, and a small pillow is placed beneath the
ipsilateral scapula to bring the shoulder forward. APPROACH
SUPRACLAVICULAR INFRACLAVICULAR
49. SUPRACLAVICULAR nerve, trunks, suprascapular nerve. From
angle of jaw to posterior border of SCM to mid-clav acular area Can
also be accessed by transverse incisions Cords & terminal
branches by INFRACLAVICULAR approach. Divisions - retroclavicular
by both of them Clavicular insertion of SCM to coracoid process to
deltopectoral groove.
50. Neurolysis Nerve repair Neurorrhaphy End to side coaptation
Nerve graft Nerve transfer or neurotization Functional free muscle
transfer Surgical options