Relocating the C5 nerve stump in C5 nerve grafting to prevent iatrogenic phrenic nerve injury.
Brachial plexus
Brachial plexus exploration
Brachial plexus nerve graft
Nerve graft
Phrenic nerve
Journal
Acta neurochirurgica
ISSN: 0942-0940
Titre abrégé: Acta Neurochir (Wien)
Pays: Austria
ID NLM: 0151000
Informations de publication
Date de publication:
03 2021
03 2021
Historique:
received:
02
12
2020
accepted:
11
01
2021
pubmed:
29
1
2021
medline:
20
7
2021
entrez:
28
1
2021
Statut:
ppublish
Résumé
Exploration and grafting of the brachial plexus remains the gold standard for post-ganglionic brachial plexus injuries that present within an acceptable time frame from injury. The most common nerves available for grafting include C5 and C6. During the surgical exposure of C5 and C6, the phrenic nerve is anatomically anterior to the cervical spinal nerves, making it vulnerable to injury while performing the dissection and nerve stump to graft coaptation. We describe a novel technique that protects the phrenic nerve from injury during supraclavicular brachial plexus exposure and grafting of C5 or upper trunk ruptures or neuromas in-continuity. A 4-step technique is illustrated: (1) The normal anatomic relationships of the phrenic nerve anterior to C5 is displayed in the face of the traumatic scarring. (2) The C5 spinal nerve stump is then transposed from its anatomic position posterior to the phrenic nerve to an anterior position. (3) The C5 stump is then moved medially for retrograde neurolysis of C5 from its phrenic nerve contribution. The graft coaptation to C5 is performed in this medial position, which minimizes retraction of the phrenic nerve. (4) The normal anatomic relationship of the phrenic nerve and the C5 nerve graft is restored. We have been routinely relocating the C5 spinal nerve stump around the phrenic nerve for the past 10 years. We have experienced no adverse respiratory events. This technique facilitates surgical exposure and prevents iatrogenic injury on the phrenic nerve during nerve reconstruction.
Sections du résumé
BACKGROUND
Exploration and grafting of the brachial plexus remains the gold standard for post-ganglionic brachial plexus injuries that present within an acceptable time frame from injury. The most common nerves available for grafting include C5 and C6. During the surgical exposure of C5 and C6, the phrenic nerve is anatomically anterior to the cervical spinal nerves, making it vulnerable to injury while performing the dissection and nerve stump to graft coaptation. We describe a novel technique that protects the phrenic nerve from injury during supraclavicular brachial plexus exposure and grafting of C5 or upper trunk ruptures or neuromas in-continuity.
METHODS
A 4-step technique is illustrated: (1) The normal anatomic relationships of the phrenic nerve anterior to C5 is displayed in the face of the traumatic scarring. (2) The C5 spinal nerve stump is then transposed from its anatomic position posterior to the phrenic nerve to an anterior position. (3) The C5 stump is then moved medially for retrograde neurolysis of C5 from its phrenic nerve contribution. The graft coaptation to C5 is performed in this medial position, which minimizes retraction of the phrenic nerve. (4) The normal anatomic relationship of the phrenic nerve and the C5 nerve graft is restored.
RESULTS
We have been routinely relocating the C5 spinal nerve stump around the phrenic nerve for the past 10 years. We have experienced no adverse respiratory events.
CONCLUSION
This technique facilitates surgical exposure and prevents iatrogenic injury on the phrenic nerve during nerve reconstruction.
Identifiants
pubmed: 33507373
doi: 10.1007/s00701-021-04713-6
pii: 10.1007/s00701-021-04713-6
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
829-834Références
Al-Qattan MM (2004) Identification of the phrenic nerve in surgical exploration of the brachial plexus in obstetrical palsy. Journal of Hand Surgery 29(3):391–392. https://doi.org/10.1016/j.jhsa.2003.12.018
doi: 10.1016/j.jhsa.2003.12.018
Barman A, Chatterjee A, Prakash H, Viswanathan A, Tharion G, Thomas R (2012) Traumatic brachial plexus injury: Electrodiagnostic findings from 111 patients in a tertiary Care Hospital in India. Injury 43(11):1943–1948. https://doi.org/10.1016/j.injury.2012.07.182
doi: 10.1016/j.injury.2012.07.182
pubmed: 22884248
Bertelli JA, Ghizoni MF (2006) Use of clinical signs and computed tomography myelography findings in detecting and excluding nerve root avulsion in complete brachial plexus palsy. J Neurosurg 105(6):835–842. https://doi.org/10.3171/jns.2006.105.6.835
doi: 10.3171/jns.2006.105.6.835
pubmed: 17405253
Clarke HM, Al-Qattan MM, Curtis CG, Zuker RM (1996) Obstetrical brachial plexus palsy: results following neurolysis of conducting neuromas-in-continuity. Plast Reconstr Surg 97(5):974–982; discussion 983-4. https://doi.org/10.1097/00006534-199604001-00014
doi: 10.1097/00006534-199604001-00014
pubmed: 8619001
Golarz SR, White JM (2020) Anatomic variation of the phrenic nerve and brachial plexus encountered during 100 supraclavicular decompressions for neurogenic thoracic outlet syndrome with associated postoperative neurologic complications. Ann Vasc Surg 62(January):70–75. https://doi.org/10.1016/j.avsg.2019.04.010
doi: 10.1016/j.avsg.2019.04.010
pubmed: 31207398
Loukas M, Kinsella CR, Louis RG, Gandhi S, Curry B (2006) Surgical anatomy of the accessory phrenic nerve. Ann Thorac Surg 82(5):1870–1875. https://doi.org/10.1016/j.athoracsur.2006.05.098
doi: 10.1016/j.athoracsur.2006.05.098
pubmed: 17062263
Moran, Steven L, Scott P Steinmann, and Alexander Y Shin. (2005). “Adult brachial plexus injuries: mechanism, patterns of injury, and physical diagnosis.” Hand Clin 21 (1): 13–24. https://doi.org/10.1016/j.hcl.2004.09.004
Sharma MS, Loukas M, Spinner RJ (2011) Accessory phrenic nerve: a rarely discussed common variation with clinical implications. Clin Anat. https://doi.org/10.1002/ca.21142