Surgical Indications

The therapeutic approach depends on the recovery during the first month and the anatomopathological lesions defined by repeated clinical examination and paraclinical tests (CT myelography, EMG).

• In the majority of cases there is no indication for an emergency surgical exploration, except for acute upper limb ischemia: the ideal strategy in these cases is to graft the vascular lesions and to locate potential nerve lesions, making a secondary nerve repair as easy as possible. In some cases, periscapular anastomoses provide sufficient distal blood supply and allow early secondary vascular and nerve repair. Reconstruction of vascular lesions and improvement of the distal supply is very important for nerve regeneration.

• Associated skeletal lesions should be treated in the emergency department: an anterior dislocation of the shoulder should be reduced immediately. In the majority of cases immobilization of the upper limb in a brace for one week can be followed by rehabilitation (without traction on the roots) to avoid stiffness of the shoulder.

• Surgical exploration is indicated if there is no clinical recovery within a period of 6 weeks to 2 months after trauma.

The whole plexus must be explored (15% of lesions occur at two levels) through a long zig-zag incision extending from the neck to the axillary region (Fig. 12.2) and the surgical technique must be based on the results of preoperative investigations and adapted to the intraoperative findings.

Incision Line Picture Branchial Cyst
Fig. 12.2. A long zig-zag incision extending from the neck to the axillary region is necessary for the exploration of the entire brachial plexus.

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