Strategy of Repair

Paralysis of the Upper Roots

In the majority of cases a neuroma is found between the roots and the division of the upper trunk, at the level of the clavicle.

After resection of the neuroma, the gap is bridged with grafts from the two sural nerves; the grafts are secured in place with the use of fibrin glue (Fig. 12.3).

The results are good if at least one root (C5 or C6) can be grafted. After nerve repair, good or excellent results on the shoulder are expected in more than 50% of cases.

Sometimes, the quality of the root can not be judged and the surgeon has to choose between leaving the root in place or neurotizing it.

In these cases the only possibility is the neurotization of the upper trunk with the spinal accessory nerve, the intercostal nerves or even the contralateral C7 root.

Nerve Repair
Fig. 12.3. In C5-C6 ruptures, after excision of the neuromas, the proximal stumps can be connected to the upper trunk with the use of nerve grafts.

Lateral sutures of the upper trunk to the middle or the lower trunk have been performed recently but the results have not been reported yet.

Complete Paralysis

• Rupture of C5, C6 and avulsion of C7, C8 and T1

Reconstruction is complex in these cases and grafting procedures are associated with neurotization procedures. The aim is to obtain a functional hand, elbow flexion and shoulder stability (Fig. 12.4).

• Avulsion of four roots

In cases that one root is spared, grafting and extraplexal neurotization from the spinal accessory nerve or intercostals can be performed (Fig. 12.5). Recently, an end to side nerve coaptation to the spared root has been performed with glue.

• Avulsion of all roots

Exploration of the plexus should be complete in these cases and an osteotomy of the clavicle is necessary to dissect lower roots. Dissection should be as proximal as possible to define the lesions precisely.

A useful hand can be obtained with neurotization procedures in more than 50% of the cases.

At the end of the surgical procedure the child is placed into a protective splint immobilizing the upper body, the neck and head (Fig. 12.6).

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