**6. Conclusion**

acceptable or not, followed by modification of the therapy plan as required. For example, the patient may develop "whip-like" movements to initiate shoulder abduction. If there was little hope of recovering deltoid function, then focusing on stabilizing the involved muscles above and below became more practical than utilizing electrical current to recover this muscle's mass. If the chance of functional recovery was high, then training the concerned muscle to become activated at the correct time in the kinetic chain became more useful than just purely strengthening it. Once the reinnervation waiting period was over, one of three patterns would usually emerge: (1) the patient recovers function in the limb and uses it, (2) the nerve fails to reach and innervate the muscle, or (3) the reinnervation occurs but disuse would have reduced cortical representation and then, the patient may not know "how to" use the muscle. Electrophysiology was useful in differentiating such cases, and modifying the rehabilitation

plan taken into consideration depending on which of these patterns was the case.

In spite of a growing number of good surgical alternatives currently available such as introduction of phrenic nerve transfer to medial root of median nerve for prehensile hand function, the restoration of function below the elbow following either partial root avulsion or total root avulsion presently remains the biggest challenge in brachial plexus surgery [8, 13, 25, 33, 39, 42]. Avulsion injuries from C5 to T1 have been shown to be amenable to restoration of good shoulder and elbow function, but the restoration of satisfactory distal function is still yet to be well demonstrated [8]. However, new techniques to circumvent this problem have recently been proposed [39, 42]. For the obstetric brachial plexus injuries, another particular challenge is the restoration of abduction and external rotation in the shoulder joint [18] which is largely

Regarding investigation and preoperative planning, EMG and nerve conduction studies have their own limitations [18, 25]. EMG itself only reflects the function of the individual motor units in a nerve and not really that of the entire nerve or the cerebral retraining required to establish function [25]. Also, in severe cases with a flail anesthetic arm, the absence of SNAPs often clearly indicates damage to post-ganglionic elements but cannot exclude a mixed lesion

Furthermore, there are currently only limited algorithms to guide the surgeon on carrying out nerve transfers [13, 52]. The choice of which transfer to utilize in each case is largely dependent on each surgeon's philosophy, knowledge and experience as well as patientrelated factors, a clear understanding of the involved anatomy of the brachial plexus in each patient, what is uninjured and still viable for nerve transfer repair, as well as available facilities and equipment [8, 13, 52]. A combination of long and variable recovery periods, variable patterns of injury, individual patient recovery factors and lack of uniformity in rehabilitation all lead to the overall lack of objective evidence-based guidelines for management. For pediatric patients, the criteria and timing of surgical intervention also still remains controversial [4]. Some have used the absence of recovery of the biceps muscle

**5. Present challenges with peripheral nerve surgery**

limited due to developmental apraxia which occurs at a cerebral level.

with associated root avulsion [18].

140 Treatment of Brachial Plexus Injuries

In this chapter, we have described the pattern and trend of peripheral nerve problems in our practice, and presented our challenges and outcomes, as well as the steps we followed to organize our peripheral nerve unit, followed by a review of general guidelines and principles of care. Peripheral nerves related problems, are unfortunately only palliated in most developing countries across the world. Although our experience in surgically treating these problems is still developing and with the few limitations as presented, the final outcomes demonstrate that surgical intervention is still better than just palliative measures alone or even nothing at all. We could still manage the problems successfully with fairly good outcomes despite few setbacks such as late presentation of patients, as well as unavailability of full investigative imaging modalities required as standard pre-operative evaluation for peripheral nerve problems. We are hopeful that this brief presentation would be a useful impetus for the introduction, development and implementation of nerve surgery programmes in other developing countries around the world.
