Preface

**Section 5 Treatment of Brachial Plexus Long Term Consequences 101**

Chapter 6 **Treatment of Neuropathic Pain in Brachial Plexus Injuries 103**

Chapter 7 **Starting A Peripheral Nerve Surgery Unit in an Area of Limited**

Chiazor U. Onyia, Ravi Sankaran and Ashok Pillai

Ortiz-Criado, L. Vanaclocha and Nieves Vanaclocha

**Section 6 Challenges in Peripheral Nerve Surgery 123**

**VI** Contents

**Resources - Our Experience 125**

Nieves Saiz-Sapena, Vicente Vanaclocha-Vanaclocha, José María

The human shoulder requires a wide range of motion to allow a great variety of movements, among them, throwing objects. This capability is precisely what afforded our ancestors in the distant past the skills of hunting and self-defense. In fact, the oldest known defensive objects are common cobblestones found in a cave in Ukraine. These round stones, which came from a nearby river, were supposedly used by the region's primitive inhabitants to defend themselves from potential predators. Pitching a projectile is a significant task for the delicate configuration of a humerus that barely articulates with the shoulder blade, which in turn only articulates at a very small joint with the clavicle, which itself articulates with the sternum, again by way of a very small joint. The entire stability of the shoulder depends on the muscles that move and support it.

The shoulder's wide range of movements is a great evolutionary advance, but it is also a source of problems. At times, the joint can move excessively, inducing luxation of the hu‐ merus head or damage to the soft tissues, among them, the brachial plexus. In fact, both upper and lower extremities are made by extension and fusion of the given somites. As muscles are made from more than one somite, nerves have to anastomose between them to allow a proper innervation of each muscle. This creates the necessity for a well-formed nerve plexus at the root of the limb.

The combination of a nerve plexus with a wide range of movement in a highly mobile joint at the shoulder creates the perfect scenario for a brachial plexus injury. In normal childbirth, there is already stretching of the brachial plexus as the infant's head and shoulder (usually the right one) are moved in opposite directions. Such injuries are always a possibility when the newborn is large and the mother's pelvis outlet is perhaps small; this is particularly true if the quality of obstetric attention is suboptimal.

As we grow, we start to move in multiple ways. Motorbikes and bicycles are economical transportation, particularly in big cities. They are relatively inexpensive, can adapt to small roads or to heavy traffic conditions and can be parked almost anywhere. But unfortunately, accidents are common. The head is perhaps protected with a helmet, but the shoulder re‐ mains exposed and can be separated violently from the head, inducing a great variety of brachial plexus injuries.

Once a brachial plexus injury is established, there exists a large array of treatment strategies. Conservative measures can help in some cases, but many injuries may need some sort of surgical repair. In these cases, nerve transfers opened a door allowing the repair of lesions once considered irrecoverable. In fact, even when a successful nerve suture, with or without intervening grafts was achieved, regenerating axons reached the distal muscles that were fibrotic and functionally dead. There is still much room for improvement: this is the arena of

nerve root avulsions, particularly when all or almost all the brachial plexus nerve roots are avulsed. Some attempts to reimplant avulsed roots have been tried, but clinical results in humans have been dismal.

This book offers a new look at the field of brachial plexus injuries, taking advantage of the vast experience and knowledge of great figures who treated these dreadful conditions over many years. We hope the reader enjoys the book as much as the authors did writing it.

#### **Vicente Vanaclocha**

**Introduction**

**Section 1**

Assistant Professor Department of Neurosurgery Hospital General Universitario Valencia, Spain

#### **Nieves Sáiz-Sapena**

University of Valencia Valencia, Spain

**Section 1**
