Primary Brachial Plexus Reconstruction

Brachial Plexus is made up of nerves arising from five vertebral segments, namely 5,6,7,8 Cervical and 1st Thoracic vertebra. During process of birth these nerves may sustain four different type of injuries.

Neuropraxia : It is compression injury of nerve roots leading to nerve oedema. It typically resolves in 6 weeks and child regains all movement by this time.

Axontmesis : Here nerve fibres get torn but the overlying nerve sheath remains intact. Nerve fibres heal along the intact tract in 6 to 9 months. Fortunately, Type -1 & 2 injuries comprise of 90% of total injuries. About 80-90% of these patients improve spontaneously.

Rutpure Neurotmesis : In this type, both the nerve fibres & overlying sheath gets torn. The area between two torn segment heals with neuroma which may or may not conduct electric signals through it.

Root Avulsion : Nerve roots may get avulsed from its origin in spinal cord. This is most severe form of injury. Although Type -3 & 4 comprise of only 10% of total injuries, 90% of these may need early plastic neural reconstruction.

Following pictorial presentation will make understanding of injury type easy.

Primary brachial plexus reconstruction is required in cases of root avulsion and rupture neurotmesis. The optimum time of this surgery is a topic of debate. But there are two clear subset of patients. First, child with complete flaccid limb and associated Horner's Syndrome ( Drooping of eyelid) required primary reconstruction at three months. Second, child with incomplete recovery will need intervention between six and nine months, depending on their recovery pattern.

Procedure : Proper exploration of brachial plexus is done from supraclavicular approach. If required surgery is extended below collar bone up to axilla.

Proximal and distal ends of damaged and transected nerves are identified. Repair of damaged nerves is done with Sural nerve graft taken from both legs. As the donor nerves are sensory nerves, patients do not have any motor deficit. Neither they have any sensation deficit. Nerve repair is consolidated with the help of tissue glue(fibrin glue).

Child's limb is immobilised for one month. After that physiotherapy is started. This children require prolonged physiotherapy on road to recovery. Surgery for nerve reconstruction is of prime importance in children with flaccid limb due to brachial plexus birth palsy.