Brachial Plexus repair - Obstetrical Paralysis

The operation is done under general anesthesia. The wound is infiltrated with 1/1000 adrenalin in order to avoid bleeding: in our series of 1.000 babies operated on, blood transfusion was never necessary.

The incision is supra clavicular for access to an upper roots lesion (C5, C6, C7) or supra and infraclavicular for a complete lesion (in the drawing the red arrows show the extent of supra and infraclavicular lesion).

In these cases we feel that the osteotomy of clavicle is mandatory and gives a better and less risky access to the lower roots. The arrows show the level were the damaged nerves are resected. The clavicle is repaired and will heal in two weeks.

Brachial Plexus repair

How the scar looks like on the donor area two years later

There are two types of surgeries that are done. The " primary surgery" involves exploration and nerve repair (grafting). There are also many types of "secondary" procedures that may be necessary. "Primary surgery" This operation is done at the age of 3 months or shortly after. lt is possible to do it later when the child is seen too late (up to 2 or 3 years) but in the older child, the quality of recovery seems to be lower.
		The operation is done under general anesthesia. The wound is infiltrated with 1/1000 adrenalin in order to avoid bleeding: in our series of 1.000 babies operated on, blood transfusion was never necessary.

		The incision is supra clavicular for access to an upper roots lesion (C5, C6, C7) or supra and infraclavicular for a complete lesion (in the drawing the red arrows show the extent of supra and infraclavicular lesion).

		In these cases we feel that the osteotomy of clavicle is mandatory and gives a better and less risky access to the lower roots. The arrows show the level were the damaged nerves are resected. The clavicle is repaired and will heal in two weeks.

How the scar looks like on the donor area two years later		Once the plexus is exposed and the lesions determined, repair is done rarely by direct suture and usually with grafts. The grafts are the sural nerves. They are taken by longitudinal incisions on the calf of both legs. These nerves are very delicate and need a complete exposure if they are to be harvested without damage. The suppression of these nerves do not induce any severe defect in the legs. Immediately after harvesting the nerve, there is a slight lost of sensation on the lateral part of the foot, which will progressively diminish with time.

The grafts are prepared on the table; cables are tailored at the exact necessary length and glued together, using biological glue.
The grafts are put in place and glued		The cable trunk is then fit into the defect and the extremities glued under the microscope. Since almost 15 years, we rarely use sutures but quite only fibrin glue. In some cases where most roots are avulsed from the spinal cord, it is necessary to use donor nerves from other parts of the plexus or extraplexual. Several donor areas have been used as spinal accessory nerve, intercostal nerves, cervical plexus, controlateral side.
After the repair, the clavicle is sutured if it was osteotomized and the skin closed. lmmobilization is maintained for 3 weeks using a head and thorax splint. Altogether, the duration of the operation varies from 45 mn to 2 hours, depending on the extent and complexity of the case.

After the operation the baby is immobilized in a ready-made plastic head and thorax splint for 3 weeks. After 4 days, the parents are taught to remove the splint without risks, allowing for change of dressings and bathing every day or every other day.
		The skin sutures in the neck and the legs do not need to be removed as they are absorbable. At 3 weeks, the splint is removed and physiotherapy is resumed. Physiotherapy does not change anything in the nerve recovery but will make it more efficient by keeping the joints supple and by stimulating the child's interest in his limb.

In our Institutions, the baby is seen every 3 months for the first 2 years, then every 6 months between the age of 2 to 5 years and every year after that, until adolescence. It is fundamental that the surgeon responsible for the diagnosis and surgery, follow-up with the child throughout his/her years. If the child has only one person in charge of him/her then a very close relationship will occur. This relationship will become very important during the teenage years when functional, cosmetic and psychological difficulties may occur. Teenagers will needs to be able to speak in confidence. What can we expect from primary surgery? There is difficulty in the fact that surgical results can be assessed only at the end of the growth years or at least after 4 to 8 years and that currently very few teams have the long term results. The final result is a combination of the results from all of the surgeries, and, of course, the huge amount of work done during physiotherapy and at home with the child's family. Even with excellent nerve recovery, we may still obtain a poor final result, if the child does not use his extremity and rejects it. On the contrary, some very obstinate children will use a limb with limited recovery to its maximum. It is of the utmost importance for the family to understand that a passive attitude may lead to a poor functional result even with an excellent surgical recovery. However, there are a few publications that are reporting long term results and they are very encouraging. Our experience, being the longest, has enabled us to assess the results of our surgeries after several years. In order to assess the children we have developed a grading system that is now used internationally. According to this grading system the results are the following. · For the shoulder: At 4 years, 80% of the children have good or excellent result in C5 C6 lesions. In the C5 C6 C7 lesions, only 61% have good or excellent results. Even in complete palsy, the results after 8 years are 77% of average, good or excellent results. · For the elbow: Results are always good. Even with more severe, complete paralysis, 81% show good or excellent results after 8 years · For the hand: After complete paralysis, the results are quite encouraging. Although at 2 years, only 35% of the children have a useful hand, after 8 years and several tendon transfers, 76% of the children have a useful hand. This shows that even lower root avulsion must be repaired and that the hand recovery is a mandatory aim. As was said previously, these results are analytical and do not always reflect the full reality. They do not take in account the shortening of the arm, the scars, the lack of control of the limb, and all the psychological difficulties of the child.