Brachial Plexus Reconstruction – A Case Capsule
A young 29-year-old Pakistani male was involved in a traumatic accident caused by a concrete block wall falling on him while at work. He sustained multiple injuries including head injury, rib fractures, clavicle fracture, scapula fracture and developed pneumothorax. He was seen at an outside hospital and was referred to Universal Hospital for management.
The patient was admitted to the ICU and managed by a multidisciplinary team of doctors. He was stabilized and after 2 weeks underwent surgical repair of his clavicle and scapular fractures with plate and screw fixation by Dr. Harikrishna, Specialist Orthopedic Surgeon. At this time, the patient was detected to have a brachial plexus injury involving the left upper limb and was referred for further management to Department of Plastic and Reconstructive Surgery.
The patient had developed partial paralysis of his left upper limb and shoulder which was not responding to conservative treatment. Upon clinical evaluation, the patient had features of C5 and C7 plexopathy with grade 1(absent) shoulder abduction and grade 2 elbow extension.
The patient had an MRI done which was read by Dr. Imran Khan, Specialist Radiologist, with findings of a postganglionic injury with neuroma formation of divisions and cords of brachial plexus (infraclavicular portion).
A neurology consultation was obtained and Dr. Fazil Thaha, Specialist Neurologist, did a nerve conduction study with EMG which confirmed features of postganglionic brachial plexus injury.
Three months after the injury, with confirmation of the diagnosis and the fact that the affected segments were not recovering, the patient was taken to surgery by Dr. Leon Alexander, Specialist Plastic Surgeon, and underwent a complex surgical procedure lasting close to 11 hours for nerve reconstruction with neurolysis, nerve grafting and nerve transfer.
The patient had the following:
Ø Nerve reconstruction was done between C5 root to posterior cord (axillary fascicle) with 3 cable grafts of sural nerve grafts ( 9 cm each) for shoulder abduction with 9-0 nylon under microscope (12.5X magnification).
Ø Nerve reconstruction done between C7 root to posterior cord (radial fascicle) with 3 cable grafts of sural nerve (9 cm each) for elbow extension with 9-0 nylon under microscope (12.5X magnification).
Ø Nerve transfer done between spinal accessory nerve (11th cranial nerve) to supra-scapular nerve for shoulder abduction with 9-0 nylon under microscope (12.5X magnification).
Figure 1 – Intraoperative findings confirming the postganglionic injury with neuroma formation of cords and divisions (infraclavicular portion) of left brachial plexus
Figure 2 - Brachial Plexus Reconstruction (neurolysis, nerve grafting and nerve transfer done.)