Management of brachial plexus injuries

While plexo-plexal nerve grafting has been the classic method for repair of brachial plexus injuries, nerve transfers are being increasingly utilized. Indeed nerve transfers are the only option where the proximal spinal nerve roots have been avulsed from the spinal cord. The procedure essentially involves the coaption of a proximal foreign nerve to the distal denervated nerve, so that the latter will be reinnervated by the donated axons. The primary goal of surgery in the pan plexus palsy case is to return proximal arm function, particularly elbow flexion and a stable, dynamic shoulder that can abduct and externally rotate. Neural input should thus be directed first to the biceps via the musculocutaneous or its branches, and next to reconstructing the suprascapular and/or axillary nerve. If donor nerve sources are available following repair of these elements, further repairs can be directed to the radial (for wrist and finger extension) and median (for elbow and finger flexion and critical hand sensibility) nerves.