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Daniel H. Kim and David G. Kline

DG , Happel LT : A quarter century's experience with intraoperative nerve action potential recording. Can J Neurol Sci 20 : 3 – 10 , 1993 Kline DG, Happel LT: A quarter century's experience with intraoperative nerve action potential recording. Can J Neurol Sci 20: 3–10, 1993 6. Lusk MD , Kline DG , Garcia CA : Tumors of the brachial plexus. Neurosurgery 21 : 439 – 453 , 1987 Lusk MD, Kline DG, Garcia CA: Tumors of the brachial plexus. Neurosurgery 21: 439–453, 1987 7. Millesi

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Daniel H. Kim, Andrew C. Kam, Padmavathi Chandika, Robert L. Tiel and David G. Kline

, deltoid, and triceps, and the more distal muscles would be the brachioradialis, supinator, and ECR. Sensory loss is less significant and more variable with an RN lesion than with a median or ulnar nerve lesion. Therefore, sensory grading is not included when function for the whole RN is graded. Surgical Anatomy Radial Nerve in the Arm The larger of the two terminal branches of the posterior cord of the brachial plexus, the RN lies posterior to the third portion of the axillary artery at its origin. It descends to be posterior to the pectoralis major

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Daniel H. Kim, Andrew C. Kam, Padmavathi Chandika, Robert L. Tiel and David G. Kline

brachial plexus (C5—T1 roots), forming the characteristic “V” overlying the third portion of the axillary artery ( Fig. 1 ). Initially lying anterior or anterolateral to the axillary artery, the MN descends lateral to the brachial artery. At the midportion of the arm, the nerve crosses the brachial artery anteriorly in a lateral-to-medial direction, piercing the medial intermuscular septum. In the distal arm, the MN can pass through a fibroosseous tunnel formed by the ligament of Struthers, a rare anatomical anomaly present in approximately 1% of the population. 17

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Daniel H. Kim, Yong-Jun Cho, Robert L. Tiel and David G. Kline

% of patients with plexus injuries. 2, 3, 26, 29, 41 Such outcomes need to be and can be improved. Especially difficult to evaluate and treat are patients with stretch/avulsion and suspected TOS. Surgery for plexus tumors, although usually indicated, remains challenging. In this paper, the outcomes of 1019 brachial plexus injuries, entrapments, and tumors surgically treated during a 30-year period are analyzed to provide guidelines for evaluation, selection, and operative approach. Clinical Material and Methods Patient Population Between 1968 and 1998

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Daniel H. Kim, Kisoo Han, Robert L. Tiel, Judith A. Murovic and David G. Kline

Anatomy and Exposure Ulnar Nerve in the Arm The ulnar nerve originates from the medial cord of the brachial plexus at an axillary level. Initially posterior to the brachial artery, it courses down the upper arm toward the olecranon notch. While descending, it lies posterior to the pectoralis major muscle and medial or posteromedial to the brachial artery. At the midarm level, the nerve diverges medially from the brachial artery and either passes beneath, or less frequently, pierces the medial intermuscular septum approximately 8 cm above the medial epicondyle. The

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David G. Kline and Daniel H. Kim

, Lee GW , Hashem F , et al : Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 96 : 122 – 128 , 1995 Chuang DC, Lee GW, Hashem F, et al: Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 96: 122–128, 1995 6. Coene LN , Narakas AO : Operative management of lesions of the axillary nerve

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Daniel H. Kim, Judith A. Murovic, Robert L. Tiel and David G. Kline

Object

The authors report the surgery-related results obtained in 143 patients with stretch-induced infraclavicular brachial plexus injuries (BPIs). The entire series comprised 1019 operative BPIs managed at the Louisiana State University Health Sciences Center between 1968 and 1998.

Methods

Infraclavicular lesions represented 143 (28%) of the total of 509 stretch injuries involving both the infra-and supraclavicular brachial plexus, of which 366 (72%) were supraclavicular lesions. The operative approach is thoroughly outlined, and common patterns and combinations of involvement of nerves peculiar to the infraclavicular area are presented. Overall, the results of suture and graft repair were favorable for the lateral and posterior cord and their outflows. Repair of medial cord–median nerve also yielded acceptable results. The results of medial cord and medial cord–ulnar nerve, however, were poor. The incidence of associated injuries in the infraclavicular as opposed to the supraclavicular area, including shoulder dislocation and fracture and humeral fractures as well as vascular injuries including axillary artery injury was higher. Results of a literature search supported the finding that vascular injuries were increased due to the juxtaposition of vessels among the brachial plexus elements.

Conclusions

Thus, although less common than their supraclavicular counterpart, infraclavicular stretch injury lesions when they occur are technically more difficult to treat and are associated with a higher incidence of vascular and dislocation/fraction injuries. Favorable results were obtained for lateral and posterior cord lesions and their outflows, with acceptable outcome after medial cord–median nerve stretch injury repair. The results of medial cord and medial cord to ulnar nerve, however, were poor.

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Daniel H. Kim, Judith A. Murovic, Robert L. Tiel and David G. Kline

Object

The authors focus on injury mechanisms involved in 1019 operative brachial plexus injuries (BPIs) managed between 1968 and 1998 at Louisiana State University Health Sciences Center (LSUHSC).

Methods

Data regarding these mechanisms of injury were obtained via retrospective chart reviews of patients who had undergone operations at LSUHSC.

Five main mechanisms of injury to the brachial plexus occurred in the series. These included 509 stretch/contusion injuries (49%) with four patterns of presentation in 366 patients: 208 C5–T1 nerve injuries; 75 C5–7, 55 C5–6 injuries; and 28 involving the C8–T1 or C7–T1 nerves. Stretch/contusion injury was followed in frequency by gunshot wound (GSW), resulting in 118 injuries (12%). Most of the 293 involved plexus elements had some gross continuity when surgically exposed. Seventy-one lacerations involved the brachial plexus (7%), including 83 sharp lacerations caused by knives or glass; 61 blunt transections due to automobile metal, fan, and motor blades, chain saws, or animal bites.

Nontraumatic BPIs included 160 cases of thoracic outlet syndrome or 16% of the total of 1019 BPIs. There were 161 tumors (16%) of neural sheath origin including 55 solitary neurofibromas (34%), 32 neurofibromas associated with von Recklinghausen disease (20%), 54 schwannomas (34%), and 20 malignant nerve sheath tumors (20%) removed. Obstetrical BPI was not included in the original series; however, the current literature is reviewed in this paper.

Conclusions

The conclusion of this study is that the brachial plexus can be injured by multiple mechanisms of which stretch/contusion injury is the most frequently encountered, followed by GSWs.

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Daniel H. Kim, Judith A. Murovic, Robert L. Tiel and David G. Kline

The authors review 118 operative brachial plexus gunshot wounds (GSWs), causing 293 element injuries that were managed over a 30-year period at Louisiana State University Health Sciences Center (LSUHSC). Retrospective chart reviews were performed. Using the LSUHSC grading system for motor sensory function, each element's grades were combined and averaged.

Most of the 293 injured elements were found to have gross continuity at operation and of 202 elements with complete neurological loss, only 16 (8%) exhibited total disruption. Of 293 injuries, 128 elements with complete or incomplete loss were not only in continuity when explored but also had positive intraoperative nerve action potentials (NAPs). After neurolysis, 120 of 128 elements in continuity (94%) improved to greater than or equal to Grade 3 function. Elements not regenerating early usually required repair. One hundred fifty-six of 202 completely or incompletely injured elements (77%) required resection and suture or graft repair based on intraoperative NAPs. Neurolysis achieved greater than or equal to Grade 3 results in 42 (91%) of 46 elements with complete loss. Suture repair resulted in good outcomes in 14 (67%) of 21 and in 73 (54%) of 135 undergoing graft repairs (1 to 3.5 cm length) and presenting with complete loss.

Of 91 incomplete elements, intraoperative NAPs were positive in 82 (90%) and 78 of 82 had good results. Nine had negative NAPs and six elements required suture repair. Three required grafts with results of greater than or equal to Grade 3 in five (83%) of six and two (67%) of three, respectively.

Based on 118 patient results with 293 injured elements, guidelines for the management of GSWs were established as described in this paper.

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Daniel H. Kim, Judith A. Murovic, Robert L. Tiel, Gregory Moes and David G. Kline

tumors located in the upper extremities, 38 tumors in the lower extremities, and 33 in the brachial plexus region. There was only one tumor located in the pelvic plexus. TABLE 1 Number and location of 111 benign PNNSTs treated at LSUHSC Brachial Plexus Region Upper-Extremity Nerve Pelvic Plexus Lower-Extremity Nerve Tumor Location No. Location No. Location No. Location No. ganglion cyst suprascapular nerve 4 median 4 femoral 2 radial—PIN 3 obturator 1