Davidge Kristen M, Ho Emily S, Curtis Christine G, Clarke Howard M
Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada.
Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada.
J Bone Joint Surg Am. 2021 Mar 18. doi: 10.2106/JBJS.20.01359.
Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk.
We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment.
Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement.
In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
在臂丛神经产伤中，C5或C6神经根撕脱而中、下干完整的情况较为罕见。在这些病例中，仅有1条近端神经根可用于神经丛内重建。本研究的目的是确定当单根重建在上干的前后部结构间达到平衡时这些患者的治疗效果。
我们对1993年至2014年间接受一期神经重建的臂丛神经产伤患者的前瞻性收集数据进行了回顾性队列研究。纳入的患者为孤立性上干损伤且中、下干完整。研究组为C5或C6神经根撕脱。对照组为上干连续性神经瘤或断裂。采用主动运动量表和臂丛神经功能评估量表评估治疗效果。使用Wilcoxon符号秩检验来评估治疗前后的变化。
撕脱队列纳入了10例臂丛神经产伤患者。手术重建包括神经瘤切除以及将单条可用神经根的神经移植至所有远端靶点并保持平衡，可选择或不选择副神经至肩胛上神经移位。在肩外展、肩前屈、外旋、肘前屈和旋后方面，撕脱组和对照组在治疗后均有显著改善。平均随访54.5±8.8个月时，撕脱组患者的肘前屈主动运动量表评分为6.8±0.4，肩前屈和外展为6.5±0.9，外旋恢复较差（3.3±2.8）。所有可进行臂丛神经功能评估量表评估的患者均表现出功能性运动。
在1条上干神经根撕脱的情况下，通过将另一条上干神经根移植至该上干进行神经重建可改善运动功能，获得较高的主动运动量表评分，并根据臂丛神经功能评估量表显示出满意的功能。这些数据支持了一种在上干损伤情况下确保对上干进行充分重建的策略。
治疗性III级。有关证据水平的完整描述，请参阅作者须知。
