Nagano A
Department of Orthopaedic Surgery, The University of Tokyo Hospital Branch, 3-28-6 Mejirodai, Bunkyo-ku, Tokyo 112, Japan.
J Orthop Sci. 1998;3(1):71-80. doi: 10.1007/s007760050024.
A brachial plexus injury is the most severe nerve injury of the extremities. To achieve good results from treatment, correct diagnosis and early nerve repair are mandatory. The brachial plexus should be explored as early as possible if there is an incised wound, if clinical findings or diagnostic imaging indicate that at least one root is avulsed, if there is damage to the subclavian artery, and if there is total-type injury. With an upper-type injury with no clinical signs of a preganglionic lesion, the patient should be treated conservatively for 3 months and if there are no signs of recovery, then the brachial plexus should be explored. During this exploration, recording of the spinal cord evoked potential (ESCP) or the somatosensory evoked potential (SEP) is mandatory to determine the site of injury. Nerve grafting is indicated for a rupture in the root demonstrating a positive ESCP or SEP potential, in the trunk or in the cord. Exploration of the brachial plexus should be extended distally as far as possible to achieve good results after nerve grafting; when this was done more than M3 (MRC grading) power of the infraspinatus, deltoid, and biceps was achieved in more than 70% of our 32, 30, 33 patients, respectively. Results of nerve grafting for the forearm muscles have been very poor. Intercostal nerve transfer is recommended to restore elbow flexion in root avulsion type of injury, with elbow flexion to more than M3 being regained in 70% of our 221 patients. The best results of intercostal nerve transfer were achieved in patients younger than 30 years who received the operation within 6 months after injury. Motor recovery of hand function after intercostal nerve transfer was poor but protective sensation was restored in fingers innervated by the median nerve. The recommended treatment for each type of injury is described according to the results achieved.
臂丛神经损伤是四肢最严重的神经损伤。为了获得良好的治疗效果，正确的诊断和早期神经修复是必不可少的。如果存在切割伤、临床检查结果或诊断性影像学显示至少有一根神经根撕脱、锁骨下动脉受损以及存在全臂丛神经损伤，则应尽早探查臂丛神经。对于无节前损伤临床体征的上干型损伤患者，应保守治疗3个月，若没有恢复迹象，则应探查臂丛神经。在探查过程中，必须记录脊髓诱发电位（ESCP）或体感诱发电位（SEP）以确定损伤部位。对于神经根、干或束出现ESCP或SEP阳性电位的断裂，需进行神经移植。应尽可能向远侧延长臂丛神经探查范围，以便在神经移植后获得良好效果；当我们对32例、30例、33例患者分别进行此项操作后，冈下肌、三角肌和肱二头肌在M3（医学研究委员会分级）以上力量的患者分别超过了70%。前臂肌肉神经移植的效果一直很差。对于神经根撕脱型损伤，建议采用肋间神经移位术恢复屈肘功能，在我们的221例患者中，70%的患者屈肘恢复到M3以上。肋间神经移位术在伤后6个月内接受手术的30岁以下患者中取得了最佳效果。肋间神经移位术后手部功能的运动恢复较差，但正中神经支配的手指恢复了保护性感觉。根据取得的结果描述了针对每种损伤类型的推荐治疗方法。
