Brachial Plexus Avulsion Injuries
These injuries most commonly occur during motor vehicle or motorcycle accidents when the arm and shoulder are severely stretched during the collision. When this occurs, the nerves of the arm are pulled so hard that the nerves are actually yanked out of the spinal cord. The end result is a partially or completely paralyzed arm. This is the most severe and difficult type of peripheral nerve injury to treat. Nevertheless, we perform several surgical techniques that have been developed to allow patients to recover useful function in paralyzed shoulders and arms.
Nerve transfers, in which a normal nerve is taken from its original (less important) muscle, and inserted into a different (more important) muscle whose nerve supply has been damaged. In this fashion, fairly useless muscle functions may be sacrificed so that more important muscle functions may be regained. Common nerve transfers include accessory-to-suprascapular nerve or triceps branch-to-axillary nerve to regain shoulder abduction, and ulnar-to-musculocutaneous nerve or intercostal-to-musculocutaneous nerve to regain arm flexion.
Figure 1. Pseudomeningocele.
Figure 2. Intraoperative view of accessory nerve (A) and suprascapular nerve (S) just prior to nerve transfer in a patient with an upper trunk brachial plexus avulsion injury.
Figure 3. Intraoperative view of patient in Figure 1 following accessory-to-suprascapular nerve transfer; accessory nerve is traced in yellow, suprascapular nerve is traced in green. This nerve transfer will eventually allow the patient to lift his arm over his head.
Figure 4. Intraoperative view of patient with an upper trunk brachial plexus avulsion injury following ulnar-to-musculocutaneous nerve transfer; ulnar nerve (U), Musculocutaneous nerve (M). This nerve transfer will eventually allow the patient to bend his arm. Harvesting a small portion of the ulnar nerve, as shown here, surprisingly results in no ulnar nerve deficits postoperatively.