Abbreviations

in a longitudinal fashion, parallel to the side where the ventral roots stood. No SC incisions are performed. The proximal ends of the NGs are sutured intradurally to C4 above and to T1 below. In the only publication that we have found, the dorsal NRs are not repaired [33]. The dura is closed with interrupted stitches reinforced with fibrin glue. No cervical fusion is

The advantage of this double approach is that it is more conservative to the muscles. The disadvantage is that long NGs are needed, making the distance between the motoneuron and the muscular end plates still larger. To the best of our knowledge, there is only a single publication attesting the validity of this technique [33]. It is of particular interest that ventral NR regeneration can be achieved by laying the NGs subpially at the SC without having to

Some clinical studies have reported definitive although limited motor and sensory improvements particularly in the proximal limb areas after NR reimplantation in complete BPAs [15, 30, 32, 33, 45, 185]. The best motor recovery was seen at the deltoid, pectoralis, infraspinatus, biceps and triceps muscles [15, 30, 45, 185, 209]. One patient showed signs of partial recovery of the flexor digitorum superficialis and another of the first dorsal interosseous muscle [45]. A functional recovery of the hand has only been reported in a 9-year-old child with a complete BPA [29]. Hand intrinsic muscle motor grade 2 recovery was reported by Amr et al. [33]. The best sensory improvement was patent at dermatomes C5, C6 and T1, particularly at C5 [33, 45]. One of the reasons by which only proximal muscles show signs of reinnervation in the work of Kachramanoglou et al. is because only the C5–C7 NRs are reimplanted as C8 and T1 are more technically demanding and they were reluctant to risk neurological complications on handling the SC at these levels [45]. This could also be the reason by which Amr et al. [33] report hand intrinsic muscle grade 2 motor recovery, as they did repair the C8 and T1 roots. Another extremely important reason is that when the regenerating axons reach the distal limb muscles, they are already atrophied and fibrotic [72, 73]. The C5 and T1 sensory recovery can in part be due to overlapping sensory covering

NRA keeps being in an area in which improvement is desperately needed, particularly in complete BPAs in which not many alternatives are possible. As clinical results in humans keep being dismal, further research is needed. The administration of drugs, preferably orally, has to be pursued to find a combination of them that helps to achieve a successful limb recovery. NR reimplantation has to be undertaken as soon as the patients' clinical condition allows it.

Ventral NRt implantation provides better results than its posterior counterparts.

insert them inside the SC tissue through myelotomies [33].

from nearby dermatomes (C4 for C5 and T2 for T1) [32, 45].

6. Conclusions

5. Clinical results in human beings

applied.

60 Treatment of Brachial Plexus Injuries

