Palsies Resulting from Supraclavicular Lesions

These are the most common (75%) among all injuries of the brachial plexus.

Total Palsy with Avulsion of the Lower Roots (C7, C8, T1)

Repair depends on the number of upper roots spared:

• In the cases that C5 is the only spared root, C5 is connected to the anterior part of the upper trunk through sural nerve grafts and the supras-capular nerve is neurotized by transfer of the spinal accessory nerve. The goal is to obtain stabilization of the shoulder, adduction of the arm (pec-toralis major), flexion of the elbow and protective sensibility of the hand.

• In the cases that two roots are spared (C5, C6), it is also possible to graft the posterior cord. In general the anterior part of the root is used to graft the anterior plane of the plexus and vice versa. Some flexion or extension of the wrist or the fingers without pain may be obtained.

Total Palsies with Avulsion of all Roots

• Neurotization is the only possibility: the spinal accessory nerve, the superficial cervical plexus and the intercostal nerves are connected to the musculocutaneous nerve and elbow flexion is obtained in 75% of cases.

• In some cases, spontaneous partial recovery may be noticed: when the recovery is rapid at the C8 and T1 levels but is absent in the upper roots, exploration in the scalenic region and repair of any rupture should be performed, whereas if the recovery is slow and goes from the shoulder to the hand, surgical exploration and neurolysis or repair is indicated.

• After shoulder dislocation a total palsy recovers in 80-90% of cases. Partial Palsies Involving the C5, C6 or C5, C6, C7 Roots

The hand is normal and in the majority of cases the lesions are located in the scalenic region or in the upper trunks.

• In cases of rupture of C5, C6 in the scalenic region the proximal stumps are transferred to the anterior part of the upper trunk with the use of nerve grafts (sural nerve) and the suprascapular nerve is connected with the spinal accessory nerve.

• In the cases that C5, C6 are avulsed and grafting is impossible, the spinal accessory nerve is used to neurotize the suprascapular nerve in order to stabilize the shoulder and provide a slight external rotation of the arm. Elbow flexion can be obtained with a muscle transfer or with neurotization of the nerve for the biceps, through direct suture with a fascicular group from the ulnar nerve.

• When C5, C6, C7 are avulsed, the same procedures are used to obtain shoulder and elbow function, whereas muscle transfers are used for the wrist and hand function. Another option for this situation is to perform a lateral suture of the upper and middle trunk to the lower trunk, however the results of this procedure have not been reported yet.

Partial Palsies Involving the C8, T1 Roots

In cases that CT myelography indicates an avulsion of C8 and T1 roots, surgical exploration is not justified. However, surgical exploration is necessary for the diagnosis and potential repair of lesions in cases with normal CT myelography and absence of spontaneous regeneration.

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