Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center

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Object. Outcomes of 1019 brachial plexus lesions in patients who underwent surgery at Louisiana State University Health Sciences Center during a 30-year period are reviewed in this paper to provide management guidelines.

Methods. Causes of brachial plexus lesions included 509 stretches/contusions (50%), 161 plexus tumors (16%), 160 thoracic outlet syndromes (TOSs, 16%), 118 gunshot wounds (12%), and 71 lacerations (7%). Many features of clinical presentation, including prior treatment, patient's neurological status, results of electrophysiological studies, intraoperative findings, and postoperative level of function, were studied. The minimum follow-up period was 18 months and the mean follow-up period was 42 months. Repairs were best for injuries located at the C-5, C-6, and C-7 levels, the upper and middle trunk, the lateral cord to the musculocutaneous nerve, and the median and posterior cords to the axillary and radial nerves. Conversely, results were poor for injuries at the C-8 and T-1 levels, and for lower trunk and medial cord lesions, with the exception of injuries of the medial cord to the median nerve. Outcomes were most favorable when patients were carefully evaluated and selected for surgery, although variables such as lesion type, location, and severity, as well as time since injury also affected outcome. This was true also of TOSs and tumors arising from the plexus, especially if they had not been surgically treated previously.

Conclusions. Surgical exploration and repair of brachial plexus lesions is technically feasible and favorable outcomes can be achieved if patients are thoroughly evaluated and appropriately selected.

Article Information

Address reprint requests to: Daniel H. Kim, M.D., Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California 94305–5327. email: neurokim@stanford.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Intraoperative photograph and trace demonstrating NAP recording in a patient with a stretch injury. Intraoperatively, the NAP was recordable when the upper trunk (arrow) was stimulated and a recording was made from the lateral cord (arrowhead). C = clavicle; SSN = suprascapular nerve; Trig = trigger.

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    Intraoperative photograph and trace demonstrating NAP recording across a neuroma in continuity of the upper trunk. The stimulating electrode on C-5 (arrow) and the recording electrodes on the anterior division (arrowhead) are placed across the lesion to record the NAP. No NAP could be recorded across the lesion.

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    Intraoperative photograph of a stretch lesion in continuity that did not transmit NAPs. The lesion was resected and interfascicular graft repairs were performed with sural nerve grafts from the middle and upper trunks (MT and UT) to the lateral (arrow) and posterior (arrowhead) cords.

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    Example of a brachial plexus nerve sheath tumor. Left: Coronal T1-weighted MR image revealing a nerve sheath tumor mass (arrowheads) arising from the supraclavicular portion of the brachial plexus. Right: Intraoperative photograph showing the surgical dissection of a schwannoma (black arrowheads) arising from the middle trunk (white arrow) of the plexus. The upper trunk (black arrow) is adherent to the superior surface of the tumor.

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    Modified algorithm for surgical management of a brachial plexus injury. Reprinted from Neurol Clin 10, Dubuisson A, Kline DG: Indications for peripheral nerve and brachial plexus surgery, 935–951, copyright 1992, with permission from Elsevier. CT = computerized tomography scan; EMGs = EMG studies.

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