Brachial Plexus Lesions: Drawings of Explorations and Reconstructions by Algimantas Otonas Narakas

This unique text atlas on brachial plexus surgery and pathology describes 60 different lesions in very detailed and instructive color drawings by one of the foremost pioneers and experts in this field. After his death in 1993, Narakas is still greatly admired and many specialists are eagerly awaiting this book. Anatomical variations of the lesions, the problem and the surgical treatment are presented. Clinical data and follow-up of the patients are included with each lesion. Traumatic lesions, tumors and obstetric and irradiation lesions are presented.

• Language: English
• Publisher: Springer
• Release date: Dec 6, 2012
• ISBN: 9783642583780

Book preview

Introduction and Outline of the Cases

Chantal Bonnard MD¹,² and Bart Slooff MD, PhD³,⁴,⁵Neurosurgeon (emeritus), Consultant Nerve and Plexus Lesions

(1)

Plastic, Reconstructive and Handsurgeon, Clinique Chirurgicale et Permanence de Longeraie, Avenue de la Gare 9, 1003, Lausanne, Switzerland

(2)

Consultant Peripheral Nerve and Plexus Surgery, Centre Hospitalier Universitaire, Lausanne, Switzerland

(3)

Academic Neurosurgical Center Limburg, Heerlen/Maastricht, The Netherlands

(4)

Neurosurgical Department, Academic Hospital, Free University, Amsterdam, The Netherlands

(5)

Rozenlaan 20, 3620, Lanaken, Belgium

The drawings, with Professor Narakas’ written comments, are the most interesting part, the heart, of this work. To elucidate his treatment plan, it was necessary to add the clinical data, a summary of the primary surgery, and the eventual secondary procedures. A short comment is provided concerning the most important aspects of the intervention and outcome. The well-known charts complete this page. We wish to stress that in each case Professor Narakas emphasized the importance of a very detailed history of the trauma for assessing the severity of impact, its location, and the mechanism [24, 63, 126]. In his clinical examination he was very thorough; he examined each muscle, considered the appearance of the skin, assessed sensory function, and looked for a Tinel’s sign and a Horner’s syndrome. He paid special attention to pain. He noted associated injuries as these may indicate a double-level lesion or additional severity of the injury. Any associated vascular lesion can certainly aggravate the lesion and cause severe difficulties during surgical intervention [65].

In contrast to the neurophysiological and neuroradiological investigations, although very useful, Professor Narakas always showed the predominant importance of the history and clinical examination [1, 40, 41, 128, 144, 158, 161, 172, 175, 183, 197, 200]. In the Epilogue we describe his incisions, special approaches, and techniques and comment on certain aspects of various plexus lesions.

The present series of 60 cases selected from Prof. Narakas’ material is organized in the following way:

Traumatic Lesions

Traction/Compression Lesions

Avulsions

C5, C6: Cases 1–5

C5, C6, C7: Cases 6–9

C7, C8, T1: Case 10

(C7), C8, T1 and ruptures of upper spinal nerves: Cases 11–15

Avulsions of four or five spinal nerves: Cases 16–24

A special combination: Case 25

Ruptures

C5, C6: Cases 26–29

(Sub)total ruptures of spinal nerves or at trunk level: Cases 30–33

Cord-level lesions, possibly with axillary/suprascapular lesion: Cases 34–38

Infraclavicular, distal lesions at the origin of the peripheral nerves: Cases 39–46

Rupture of axillary and suprascapular nerve: Cases 47–49

Rupture of musculocutaneous nerve: Cases 50, 51

Rupture of axillary nerve and a miscellaneous injury: Cases 52, 53

Lacerations: Case 54

Gunshot Wounds: Cases 55, 56

Iatrogenic Lesions: Case 57

Obstetric Lesions: Case 58

Tumors: Case 59

Irradiation Injury: Case 60

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Presentation of the Cases, 1–60

Chantal Bonnard MD¹,² and Bart Slooff MD, PhD³,⁴,⁵Neurosurgeon (emeritus), Consultant Nerve and Plexus Lesions

(1)

Plastic, Reconstructive and Handsurgeon, Clinique Chirurgicale et Permanence de Longeraie, Avenue de la Gare 9, 1003, Lausanne, Switzerland

(2)

Consultant Peripheral Nerve and Plexus Surgery, Centre Hospitalier Universitaire, Lausanne, Switzerland

(3)

Academic Neurosurgical Center Limburg, Heerlen/Maastricht, The Netherlands

(4)

Neurosurgical Department, Academic Hospital, Free University, Amsterdam, The Netherlands

(5)

Rozenlaan 20, 3620, Lanaken, Belgium

surgical findings and reconstruction (2 May 1989): Routine supraclavicular approach. C5 was ruptured between the scalene muscles with two branches to the long thoracic nerve still intact. C6 was avulsed with a ganglion outside the foramen. C5 was connected with one graft to the posterior division of the upper trunk and with two grafts to the central part of C6. The accessory nerve was connected directly to the origin of the suprascapular nerve and to a small fascicle to the lateral cord. The motor branches of T3 and T4 and the total branch of T5 neurotized the musculocutaneous nerve using a short graft once. Neurorrhaphies with Tissucol and sutures.

comments: The teres major is an adductor coupled with an internal rotator. To make it an external rotator its humeral insertion is shifted to the rotator cuff. The result of this transfer is sometimes jeopardized by the difficulty in carrying out the phasic conversion in such a way that the adductor function is maintained. The transfer then improves the external rotation in a transverse plane (elbow against the chest) but not in a frontal plane, as in this case.

Fig. 1.

1 Dorsal scapular nerve; 2 long thoracic nerve; 3 branch to the upper trapezius muscle; 4 avulsion C6; 5 posterior cord; 6 lateral cord; 7 medial cord; 8 intercostal neurotization of the musculocutaneous nerve using motor branches of T3 and T4, and motor/sensory branch T5

surgical findings and reconstruction (28 Mar. 1979): Scar tissue in the upper part of the scalene triangle. After dissection C5 was distal to the branches of the levator scapulae muscle, a stretch injury. More distally the avulsed C6 was found with a ganglion outside the foramen. C7 was only slightly injured. After an osteotomy of the clavicle infraclavicular exploration revealed no abnormalities. C5 was left as it was, presuming the fascicles to be sufficient for function. An intercostal (T3, T4) neurotization was performed with sural grafts to the motor part of C6. Iatrogenic injury to the pleura was treated by drainage.

comments: Narakas decided not to perform a direct neurotization of the musculocutaneous nerve with intercostal nerves because he expected some recovery of the biceps through C5 and/or C7. Therefore he preferred neurotization of the motor part of C6. Nowadays we know that neurotization using intercostal nerves with a long intermediate graft yields poor results, and this technique has therefore been more or less abandoned. Complete elbow flexion in this case, without a trumpet’s sign, is the result more of healthy epitrochlean muscles than of biceps recovery. To improve the strength of elbow flexion Narakas proposed a Steindler’s flexorplasty, but the patient refused. This patient had a clavicle osteotomy. Material was removed 18 m later, and after 1 week he again broke his clavicle. A new osteosynthesis was carried out. Having a healthy hand and forearm increases the risk of such a secondary fracture. Therefore in such cases, Narakas left the material for an eventual clavicle