NEUROTISATION FOR ELBOW

FLEXION ON ADULT TRAUMATIC

BRACHIAL PLEXUS INJURY
MUHAMMAD NASRULLOH
OVERVIEW

• Devastating injury
• Complete recovery is difficult
• Severity: injury and concomitant
TARGET

• Elbow flexion
• Shoulder abduction
• Wrist and finger flexion and sensation in the median nerve distribution
• Wrist and finger extension
• Intrinsic muscle function
 DEMOGRAPHIC

• 3% trauma cases
• Age: 27, 3 yo
• Motorvehicle acicident about 76,1 %
• 62,3 % has concomitant injury: fractures and brain injury
• 70% complete, upper type 15%, extended upper 14%, lower 1%

suroto et al. Traumatic brachial plexus injury in Indonesia: an experience from a developing country. Jreconstrucmicrosurgery.2021
TYPE OF LESION

• Upper type : C5 C6 (C7)

• Lower type: C8 T1
• Pan plexal with horner syndrome
 TIMED

• ENMG
• 3 to 6 month, more apoptosis more than 6 months
• Central and peripheral changes

suroto et al. apoptosis of proximal stump postgranglionic brachial plexus injury, before and after six months post trauma. Annal
medicine and surgery.2021
RULES

• Donor distal
• Recipient proximal
• No graft
• Non tension on ROM
OBERLIN

• Motor nerve of ulnar to biceps

• Simple, fast, no nerve graft
• Most cases, upper type
• 4+ elbow flexion
MACKINNON

• Oberlin modified, proposed in 2005

• Motor branch of median to brachialis
• Recent studies: no objective difference
INTERCOSTAL NERVE

• Only: ICN 3rd to 6th (each 1200 axon)

• Tsuyama and Hara: 2 ICN to MCN; Celli: ICN to root of BP; Dolonec: ICN to MCN, radial,
axillar, ulnar; Oberlin: ICN to triceps
• Oberlic technique, without intercostal vascular
• Sural nerve graft interposition
• Brunelli technique: direct neurotisation on biceps
• Contra: ipsilateral phrenic palsy, serratus anterior palsy, rib fracture
• Pleural rupture, Atelectasin in infant.
MEDIAL PECTORAL NERVE

• 73% from C8-T1(1100 to 2100 motor)

• Redundant pectoralis major by median and lateral pectoralis nerve
• Deltopectoral approach, direct suture to biceps braach of MCN
• MPN+ICN
THORACODOSAL NERVE

• Posterior chord of C7, C8 less C6C8

• 1530 to 2470 motor
• Anterior dissection direct to MCN of biceps and brachialis
• Neurotisation to axillary, suprascapular, spinal, serratus anterior
SPINAL ACCESSORY NERVE

• C1 to C6 with 1500 motor

• Anterior approach connect with sural graft
• M3 power
• Posterior approach: transfer to suprascapular and Somsak procedure
PHRENIC NERVE

• C3 C4 C5 with 800 motor branch

• Connect with long graft
• Contraindicated in previous lung disease dan child under 2 yo
CERVICAL PLEXUS C3 C4

• Anterior branches 14000 axon

• Long intervening graft
 CONTRALATERAL C7

• 1992 and 1993

• 8467 (+1019) motor neuron
• Long graft nerve, transfer to Median nerve concomitant with other elbow nurotisation
• Whole, ¾ or ½ root
• High complication in prespinal route

Yuan-Kun et.al. Surgical treatment for total root avulsion type brachial plexus injuries by neurotisation: a prospective comparison
study between total and hemicontralateral c7 nerve root transfer. Microsurgery 2014
WHAT NEXT..

• Train surgeon
• Using nerve graft and nerve transfer
• FFMT
• Robotic limb replacement
• Regenerative medicine research
Terima kasih