Surgical outcomes of the brachial plexus lesions caused by gunshot wounds in adults

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Abstract

Background

The management of brachial plexus injuries due to gunshot wounds is a surgical challenge. Better surgical strategies based on clinical and electrophysiological patterns are needed. The aim of this study is to clarify the factors which may influence the surgical technique and outcome of the brachial plexus lesions caused by gunshot injuries.

Methods

Two hundred and sixty five patients who had brachial plexus lesions caused by gunshot injuries were included in this study. All of them were male with a mean age of 22 years. Twenty-three patients were improved with conservative treatment while the others underwent surgical treatment. The patients were classified and managed according to the locations, clinical and electrophysiological findings, and coexisting lesions.

Results

The wounding agent was shrapnel in 106 patients and bullet in 159 patients. Surgical procedures were performed from 6 weeks to 10 months after the injury. The majority of the lesions were repaired within 4 months were improved successfully. Good results were obtained in upper trunk and lateral cord lesions. The outcome was satisfactory if the nerve was intact and only compressed by fibrosis or the nerve was in-contunuity with neuroma or fibrosis.

Conclusion

Appropriate surgical techniques help the recovery from the lesions, especially in patients with complete functional loss. Intraoperative nerve status and the type of surgery significantly affect the final clinical outcome of the patients.

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Most cited references 43

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Brachial plexus injury: a survey of 100 consecutive cases from a single service.

Annie S Dubuisson, David G Kline (2002)

We analyzed the epidemiology, preoperative management, operative findings, operative treatment, and postoperative results in a group of 99 patients who sustained 100 injuries to the brachial plexus. The charts of 100 consecutive surgical patients with brachial plexus injuries were reviewed. The patient group comprised 80 males and 19 females ranging from 5 to 70 years of age. One male patient had bilateral brachial plexus palsy. Causes of injury were largely sudden displacement of head, neck, and shoulder and included 27 motorcycle accidents. There were 23 open wounds, including 8 gunshot wounds, 6 other penetrating wounds, and 9 wounds caused by operative or iatrogenic trauma. Loss was exhibited at C5-C6 in 19 patients, at C5-C7 in 15 patients, and at C5-T1 in 39 patients, and 8 patients had another spinal root pattern of injury. Nineteen patients had injury at the cord or the cord to nerve level. Associated major trauma was present in 59 patients. Emergency surgery for vessel or nerve repair was necessary in 18 patients. Myelography (n = 57) or magnetic resonance imaging (n = 7) revealed at least one root abnormality in 52 patients. The median interval from trauma to operation was 7 months. Operative exposures used included anterior supraclavicular, infraclavicular, combined supra- and infraclavicular, or a posterior approach in 5, 14, 77, and 4 patients, respectively. The surgical procedures performed included neurolysis alone in 12 patients and nerve grafting, end-to-end anastomosis, and/or neurotization in 81, 5, and 47 patients, respectively. Postoperative follow-up of at least 36 months was conducted in 78% of the patients. Grade 3 recovery according to Louisiana State University Medical Center criteria means contraction of proximal muscles against some resistance and of distal muscles against at least gravity. Among the 18 patients with open wounds, 14 (78%) recovered to a Grade 3 or better level, as did 35 (58%) of 60 patients with stretch injuries. In all cases of C5-C6 stretch injuries repaired by nerve grafting (n = 10), the patients recovered useful arm function. Brachial plexus injury represents a severe, difficult-to-handle traumatic event. The incidence of such injuries and the indications for surgery have increased during recent years. Graft repair and neurotization procedures play an important role in the treatment of patients with such injuries.

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Management and outcomes in 318 operative common peroneal nerve lesions at the Louisiana State University Health Sciences Center.

Antonie D. Kline, Judith A Murovic, Robert Tiel … (2004)

This study analyzes 318 operative knee-level common peroneal nerve lesions managed at the Louisiana State University Health Sciences Center between 1967 and 1999. Each patient was retrospectively evaluated for injury mechanism, preoperative neurological status, electrophysiological studies, lesion type, and operative technique, i.e., neurolysis, suture, or graft repair. All lesions in continuity had intraoperative nerve action potential recordings. There were 141 stretch/contusions without fracture/dislocations (44%), 39 lacerations (12%), 40 tumors (13%), 30 entrapments (9%), 22 stretch/contusions with fracture/dislocations (7%), 21 compressions (7%), 13 iatrogenic injuries (4%), and 12 gunshot wounds (4%). After neurolysis, 107 (88%) of 121 knee-level common peroneal nerve lesions with recordable intraoperative nerve action potentials recovered useful function. Nineteen patients underwent end-to-end suture repair, and 16 (84%) of these achieved good recovery by 24 months. Graft repair was performed in 138 peroneal injuries. Thirty-six patients (26%) had grafts less than 6 cm long, of which 27 (75%) achieved Grade 3 or greater peroneal function. Twenty-four (38%) of 64 patients with 6- to 12-cm grafts, and only 6 (16%) of 38 patients with 13- to 24-cm grafts, attained good peroneal function. Longer grafts correlated with more severe injuries and thus poorer outcomes. Thirty-two (80%) of 40 tumors were resected with preservation of preoperative clinical function. Surgical exploration and repair of peroneal nerve lesions achieved good results with timely operations and thorough intraoperative evaluations. Useful function was achieved in 27 (75%) of 36 patients with grafts less than 6 cm in length and in only 88 (44%) of 202 patients with grafts greater than 6 cm in length.

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Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center.

Jun Cho, Robert Tiel, S. H. Kim … (2003)

Outcomes of 1019 brachial plexus lesions in patients who underwent surgery at Louisiana State University Health Sciences Center during a 30-year period are reviewed in this paper to provide management guidelines. Causes of brachial plexus lesions included 509 stretches/contusions (50%), 161 plexus tumors (16%), 160 thoracic outlet syndromes (TOSs, 16%), 118 gunshot wounds (12%), and 71 lacerations (7%). Many features of clinical presentation, including prior treatment, patient's neurological status, results of electrophysiological studies, intraoperative findings, and postoperative level of function, were studied. The minimum follow-up period was 18 months and the mean follow-up period was 42 months. Repairs were best for injuries located at the C-5, C-6, and C-7 levels, the upper and middle trunk, the lateral cord to the musculocutaneous nerve, and the median and posterior cords to the axillary and radial nerves. Conversely, results were poor for injuries at the C-8 and T-1 levels, and for lower trunk and medial cord lesions, with the exception of injuries of the medial cord to the median nerve. Outcomes were most favorable when patients were carefully evaluated and selected for surgery, although variables such as lesion type, location, and severity, as well as time since injury also affected outcome. This was true also of TOSs and tumors arising from the plexus, especially if they had not been surgically treated previously. Surgical exploration and repair of brachial plexus lesions is technically feasible and favorable outcomes can be achieved if patients are thoroughly evaluated and appropriately selected.

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Author and article information

Journal

Journal ID (nlm-ta): J Brachial Plex Peripher Nerve Inj

Title: Journal of Brachial Plexus and Peripheral Nerve Injury

Publisher: BioMed Central

ISSN (Electronic): 1749-7221

Publication date Collection: 2009

Publication date (Electronic): 23 July 2009

Volume: 4

Page: 11

Affiliations

[1 ]Department of Neurosurgery, Gulhane Military Medical Academy, 06018 Etlik-Ankara, Turkey

[2 ]Department of Neurosurgery, Kocaeli University Medical Faculty, Kocaeli, Turkey

Article

Publisher ID: 1749-7221-4-11

DOI: 10.1186/1749-7221-4-11

PMC ID: 2718880

PubMed ID: 19627573

SO-VID: 1c128a58-c363-4934-bb16-87ee07b591cb

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Surgical outcomes of the brachial plexus lesions caused by gunshot wounds in adults

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Abstract

Background

Methods

Results

Conclusion

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Karger: Neurology and Neuroscience

Most cited references 43

Brachial plexus injury: a survey of 100 consecutive cases from a single service.

Management and outcomes in 318 operative common peroneal nerve lesions at the Louisiana State University Health Sciences Center.

Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center.

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