In the case of avulsions, surgical reconstruction may include nerve transfers or tendon traansfers. When the C-5 root is not avulsed, it may serve as a useful intraplexal donor to allow a nerve graft.If the roots have not been avulsed, neurolysis (removal of scar tissue) and testing with nerve stimulation may reveal the potential for recovery without additional surgery, or resection of segments of injured nerve with reconstruction using nerve grafts may be needed.
Because the success of this type of surgery is best when performed by 6 months after injury, we will often check nerve studies at 6 and 12 weeks after injury to discern whether any sign of spontaneous recovery exists. When no such good news is present, however, surgical exposure of the plexus, and intraoperative testing is indicated.
Intraoperative nerve testing includes direct stimulation of the nerve roots and assessment for cortical evoked potentials, to prove that avulsions are not present. Nerve action potentials (NAPs) can be assessed to discern whether segments of nerve are healthy and likely to regenerate; if not resection of neuroma and grafting or nerve transfer may be an option.
The video clips below show preoperative exam of a patient with reported 5th-7th cervical root avulsions. Intraoperative stimulation showed that C-5 was not avulsed, and following neurolysis of the upper trunk, stimulation ellicited contraction of the deltoid and biceps. Further, stimulation of the suprascapular nerve ellicited contraction of the supraspinatus muscle. Thus, the potential for further recovery without nerve transfers or grafting exists.
Surgical intervention for such devastating injury relies on thorough understanding of brachial plexus anatomy, skilled interpretation of intraoperative nerve stimulation, and expert execution of a carefully considered surgical plan.
