**4. Discussion**

#### **4.1. Perculiarities, trend, and pattern**

Majority of the entire 58 patients were first seen at the out-patient clinic, while a few of them presented via the emergency room. Similar to observations in the literature, the more commonly affected anatomic side was the right side (58.5%) compared to 36.9% of the patients who had their problems on the left, with the remaining 4.6% who were mainly Neurofibromatosis-1 patients having bilateral PNSTs. There was a slight male preponderance of 2.4:1 in this study. Most other investigators similarly reported male predominance in their work (**Table 6**). From the observations as shown in the results, the majority of them were injury cases which were generally brachial plexus injuries (n = 30, 44.1%). Among the adult cases, pan-brachial plexus injuries were the commonest (n = 9; 50%), closely followed by upper brachial plexus injuries (n = 7; 38.9%) while lower brachial plexus injuries were the least (n = 2; 11.1%). Most of these presented fairly late (overall average time of presentation was 18.3 months) as a result of considerable length of time required for referral and transfer to our center following occurrence of the injury. As a result, majority of the procedures were done on elective basis instead of as emergencies. A few other factors which were probably responsible for late presentation possibly included poverty, living far away from our institution, initial visitation or consultation to other alternative healers, and sometimes delayed referral from other medical facilities. The follow-up rate at the end of the 2 year period was 95% for adults (**Table 4**) and 91% for the pediatric cases (**Table 5**) of the brachial plexus injury surgeries. The peripheral nerve sheath tumors ranked next in frequency (n = 21, 30.9%). The timing and pattern of presentation of this set of patients did not differ significantly from the nerve injury patients. Similar to the general pattern in the literature [14], the majority of the peripheral nerve tumors were benign. We had only 8 peripheral nerve entrapments while procedures for chronic neuralgia were the fewest (n = 3, 4.4%). Estimated blood loss was negligible in all surgeries except in one case of longstanding left brachial plexus PNST (**Table 6**). The post-operative complications noted in 22.1% of the patients post-operatively were mostly wound infection and post-PNST excision muscle weakness (**Table 6**).

#### **4.2. Outcomes**

injury repairs and PNST excisions formed the bulk of the procedures. Outcomes at 6 month, 1 year and 2 years post-op are as summarized in **Tables 4** and **5**. Complications following

**6 months post-op 1 year post-op 2 year post-op**

**6 months post-op 1 year post-op 2 years post-op**

N 19 (100%) 19 (100%) 18 (95%) No improvements in function 12 (63.2%) 3 (15.8%) — Slight improvement 3 (15.8%) 7 (36.8%). 3 (15.8%) Significant improvement 2 (10.5%) 5 (26.3%) 8 (42.1%) No follow-up 2 (10.5%) 4 (21.1%) 7 (38.9%)

N 11 (100%) 11 (100%) 10 (91%) No improvements in function 3 (27.2%) — — Slight improvement 4 (36.4%) 3 (27.2%) — Significant improvement 2 (18.2%) 5 (45.5%) 8 (72.8%) No follow-up 2 (18.2%) 3 (27.2%) 2 (18.2%)

**Complication n Percentage (%)**

Voice hoarseness 2 13.3 Muscle weakness (post-PNST excision) 3 20.0 Operative wound dehiscence 2 13.3 Operative wound infection 3 20.0 Severe intra-op hemorrhage 1 6.67 Apnoeic attacks 1 6.67 Malunion (following claviculectomy for access) 1 6.67 Deep venous thrombosis of affected limb 1 6.67 Post-op pleural effusion 1 6.67 **Total** 15 100.0

**Table 4.** Summary of outcomes for the adult brachial plexus injury repair.

132 Treatment of Brachial Plexus Injuries

**Table 5.** Summary of functional outcomes for the pediatric brachial plexus injuries.

surgery are as shown in **Table 6**.

**Table 6.** Post-operative complications.

Anyone would agree that timing of surgery is very crucial in the ultimate outcome. Yet, in spite of the fairly late presentation in the majority, it is clear from **Tables 4** and **5** that despite the relatively small number of 58 patients in our series, there was generally a steady rise in number of those with marked improvement of functional recovery, with a simultaneous decline in the proportion of "no improvements at all" over the same period. We did more of adult brachial plexus injury repairs and became less enthusiastic about pediatric cases as our practice developed because the adult cases generally benefitted from surgical repair (**Figure 6**). In our personal experience with managing 196 cases of Erb's and Erb's plus palsies, excellent recoveries were possible in majority of cases with just a proper rehabilitation programme consisting of cerebral retraining and judicious management of co-contracture deformities.

**4.4. Steps followed in starting and organizing our peripheral nerve unit**

**4.5. Comparison with previous findings in the literature**

One of the key aspects of the practice that can often lead to discouraging results if not properly addressed especially at the initially starting phase is how to select the right cases for surgery and get them properly managed after surgery. We realized that the ability of our efforts to manage these problems individually was limited. We constituted a multidisciplinary team comprising the neurosurgeons, neurologists, physiotherapists, orthopedician and plastic surgeon to review each patient and ensure adequate and appropriate pre-operative planning. The team met once a week and, this way, we were able to prevent the possibilities of inadequate or suboptimal clinical and electrophysiological localization/understanding of the process in each patient, know of any limitations of nerve repairs per case, plan ahead for accurate and reliable intraoperative electrophysiology as well as for reconstructive procedures at the muscle and tendon level. This arrangement also helped with meeting the need for regularized and effective rehabilitation as well as for motivation & consistent follow-up. At surgery, we utilized cable grafts as much as possible to prevention tension on our repair and made use of the operating microscope to ensure adequate microanastomosis. Interestingly, we did not have to advertise our work. There was already a strong referral pattern in our institution for other neurological/neurosurgical problems, and this was further consolidated for peripheral nerve related-problems by our multidisciplinary team. Regarding the problem of getting late referrals, we could only plan surgery based on how late the presentation was. Luckily, none of the patients in our series was too late on arrival as to benefit from only free muscle transfers. Unfortunately for most of such cases, we could not be in contact with the referring physician or health facility to ensure earlier referrals for subsequent cases.

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135

**Table 7** shows previous publications on surgery for various peripheral nerve problems and the documented outcomes. Reports from some of these studies highlight on a few technical factors positively influencing the results post-operatively. With respect to trauma, single coaptation repair of a donor nerve to the recipient nerve (neurotization repair) without tension is thought to be generally superior than indirect repair with a cable graft [13]. Bhatia et al., clearly demonstrated faster recovery and better functional results with direct coaptation compared to nerve graft interposition in carrying out contralateral C7 transfers while in a retrospective study on the effect of combining direct repair with nerve transfer procedures on the clinical outcomes in 74 patients by Sulaiman et al., all patients who had combination of nerve transfers with direct repair using either C5 or C6 recovered elbow flexion to Medical Research Council grade 3, compared to the same extent of recovery in only 87% of those in whom only nerve transfers were done [29, 36]. This further confirms the effectiveness of bypassing the long distance of regeneration by neurotizing the injured distal nerve stumps with more proximally located dispensable donor nerves [29]. In our experience however, though we did not do any comparative assessments like these authors, we attribute our outcomes as presented to the dedicated techniques and approach along with a strict rehabilitation program. We used combinations of cable graft techniques with direct neurotization transfers for majority of the brachial injury surgeries (**Table 3**) and for the functional priorities, elbow flexion and extension were generally the most important function of target we aimed to restore, closely followed by selective

reinnervation of the median nerve for prehensile hand function or pincer grip.

**Figure 6.** (A) Examination to evaluate function at 1 year post-op for extraplexal neurotization repair in a 19 year old male patient who had right brachial plexus injury involving upper and middle trunks. Notice the quite remarkable extent of power recovered particularly with elbow flexion. (B) Examination to evaluate function at 2 years after surgery for distal intraplexal neurotization repair in another 19-year-old male patient who had injury involving only the upper trunk of his right brachial plexus. Compared with the contralateral limb, he had recovery of power to almost the same level with the pre-morbid state.

#### **4.3. Our challenges**

Among those patients undergoing peripheral nerve procedures for pain, the outcomes were generally poor. The patient with painful neuralgia involving lateral cutaneous nerve of forearm responded only temporarily to two RF (radiofrequency) lesioning procedures, but was relieved completely by proximal neurotomy. However, the same patient eventually later developed another painful neuralgia from the medial antebrachial cutaneous nerve being entrapped in the previous neurotomy surgery scar. The patient who had selective ulnar fasciculotomy for left common palmar digital neuralgia experienced temporary relief for just 2 weeks, followed by recurrence of the same pain. Patients who had DREZ-otomy (dorsal root entry zone lesioning) had excellent initial relief with cessation of incapacitating pain attacks, but constant background neuralgic pain persisted with lesser severity than it was preoperatively. Additionally, for the brachial plexus injury patients, in spite of our meticulous techniques, the restoration of function below the elbow following either partial root avulsion or total root avulsion was our biggest challenge. The benefit of surgery over natural history was not also clear in the cases of OBPI, even despite the fact that only pan-plexus OBPI (Erb's-Klumpke type) were selected for surgical reinnervation. This explains why we did more of adult brachial plexus injury repairs and became less enthusiastic about pediatric repairs as the peripheral nerve programme went on.

Finally, among the several investigative imaging modalities required as standard pre-operative evaluation for peripheral nerve problems, one imaging modality which is emerging as a useful tool in preoperative selection and planning of peripheral nerve surgery is the MR neurogram [4, 41] but this was unavailable for investigating our patients at the time of their evaluation.

#### **4.4. Steps followed in starting and organizing our peripheral nerve unit**

One of the key aspects of the practice that can often lead to discouraging results if not properly addressed especially at the initially starting phase is how to select the right cases for surgery and get them properly managed after surgery. We realized that the ability of our efforts to manage these problems individually was limited. We constituted a multidisciplinary team comprising the neurosurgeons, neurologists, physiotherapists, orthopedician and plastic surgeon to review each patient and ensure adequate and appropriate pre-operative planning. The team met once a week and, this way, we were able to prevent the possibilities of inadequate or suboptimal clinical and electrophysiological localization/understanding of the process in each patient, know of any limitations of nerve repairs per case, plan ahead for accurate and reliable intraoperative electrophysiology as well as for reconstructive procedures at the muscle and tendon level. This arrangement also helped with meeting the need for regularized and effective rehabilitation as well as for motivation & consistent follow-up. At surgery, we utilized cable grafts as much as possible to prevention tension on our repair and made use of the operating microscope to ensure adequate microanastomosis. Interestingly, we did not have to advertise our work. There was already a strong referral pattern in our institution for other neurological/neurosurgical problems, and this was further consolidated for peripheral nerve related-problems by our multidisciplinary team. Regarding the problem of getting late referrals, we could only plan surgery based on how late the presentation was. Luckily, none of the patients in our series was too late on arrival as to benefit from only free muscle transfers. Unfortunately for most of such cases, we could not be in contact with the referring physician or health facility to ensure earlier referrals for subsequent cases.

#### **4.5. Comparison with previous findings in the literature**

**4.3. Our challenges**

134 Treatment of Brachial Plexus Injuries

the pre-morbid state.

peripheral nerve programme went on.

evaluation.

Among those patients undergoing peripheral nerve procedures for pain, the outcomes were generally poor. The patient with painful neuralgia involving lateral cutaneous nerve of forearm responded only temporarily to two RF (radiofrequency) lesioning procedures, but was relieved completely by proximal neurotomy. However, the same patient eventually later developed another painful neuralgia from the medial antebrachial cutaneous nerve being entrapped in the previous neurotomy surgery scar. The patient who had selective ulnar fasciculotomy for left common palmar digital neuralgia experienced temporary relief for just 2 weeks, followed by recurrence of the same pain. Patients who had DREZ-otomy (dorsal root entry zone lesioning) had excellent initial relief with cessation of incapacitating pain attacks, but constant background neuralgic pain persisted with lesser severity than it was preoperatively. Additionally, for the brachial plexus injury patients, in spite of our meticulous techniques, the restoration of function below the elbow following either partial root avulsion or total root avulsion was our biggest challenge. The benefit of surgery over natural history was not also clear in the cases of OBPI, even despite the fact that only pan-plexus OBPI (Erb's-Klumpke type) were selected for surgical reinnervation. This explains why we did more of adult brachial plexus injury repairs and became less enthusiastic about pediatric repairs as the

**Figure 6.** (A) Examination to evaluate function at 1 year post-op for extraplexal neurotization repair in a 19 year old male patient who had right brachial plexus injury involving upper and middle trunks. Notice the quite remarkable extent of power recovered particularly with elbow flexion. (B) Examination to evaluate function at 2 years after surgery for distal intraplexal neurotization repair in another 19-year-old male patient who had injury involving only the upper trunk of his right brachial plexus. Compared with the contralateral limb, he had recovery of power to almost the same level with

Finally, among the several investigative imaging modalities required as standard pre-operative evaluation for peripheral nerve problems, one imaging modality which is emerging as a useful tool in preoperative selection and planning of peripheral nerve surgery is the MR neurogram [4, 41] but this was unavailable for investigating our patients at the time of their **Table 7** shows previous publications on surgery for various peripheral nerve problems and the documented outcomes. Reports from some of these studies highlight on a few technical factors positively influencing the results post-operatively. With respect to trauma, single coaptation repair of a donor nerve to the recipient nerve (neurotization repair) without tension is thought to be generally superior than indirect repair with a cable graft [13]. Bhatia et al., clearly demonstrated faster recovery and better functional results with direct coaptation compared to nerve graft interposition in carrying out contralateral C7 transfers while in a retrospective study on the effect of combining direct repair with nerve transfer procedures on the clinical outcomes in 74 patients by Sulaiman et al., all patients who had combination of nerve transfers with direct repair using either C5 or C6 recovered elbow flexion to Medical Research Council grade 3, compared to the same extent of recovery in only 87% of those in whom only nerve transfers were done [29, 36]. This further confirms the effectiveness of bypassing the long distance of regeneration by neurotizing the injured distal nerve stumps with more proximally located dispensable donor nerves [29]. In our experience however, though we did not do any comparative assessments like these authors, we attribute our outcomes as presented to the dedicated techniques and approach along with a strict rehabilitation program. We used combinations of cable graft techniques with direct neurotization transfers for majority of the brachial injury surgeries (**Table 3**) and for the functional priorities, elbow flexion and extension were generally the most important function of target we aimed to restore, closely followed by selective reinnervation of the median nerve for prehensile hand function or pincer grip.


**Table 7.** Previous publications on outcomes of various surgical techniques for peripheral nerve problems. Regarding tumors, Guha et al., in managing 201 peripheral nerve sheath lesions (182 benign and 19 malignant) in 175 patients over a 17-year period, observed that subtotal resection was associ

Starting A Peripheral Nerve Surgery Unit in an Area of Limited Resources - Our Experience

ated with the increased recurrence of the benign lesions and that the probability of motor function worsening postoperatively was much less in patients in whom the tumors were fully resected [35]. They also observed that the extent of resection in those who had schwannoma was greatly influenced by tumor location, with lesions located in the extremities being more likely to be fully resected than plexal tumors that were brachial, thoracic, or lumbosacral [35]. This was likely due to better anatomical accessibility [35]. They concluded by suggesting gross total resection for all benign lesions as much as possible [35]. In our own strategy however, we similarly dissected the tumor in its subcapsular plane for PNSTs to ensure that non-involved fascicles remained function

ally intact but observed no recurrence of the benign lesions in any of our patients whereas onco

**4.6. General principles**

ing on the particular clinical circumstance [

injury preferably within 4 weeks of the injury [

*4.6.1. Brachial plexus injury repairs*

spine x-rays might indicate root avulsion at the same level [

investigations for diagnosis of problems involving the brachial plexus [

injury [ 3, 5,

problems [

interventions [

logical resection and not subcapsular dissection was our goal for the malignant ones (MPNST) in view of the life-threatening nature of the pathology, even at the cost of functional compromise.

Detailed examination of these patients should be followed up by nerve conduction studies and radiological imaging to localize and characterize peripheral nerve lesions or associated neurologic

myelogram (CT), magnetic resonance imaging (MRI), ultrasound (US), as well as positron emis

sion tomography (PET) all have their various indications in the management of peripheral nerve

can be preoperatively decided upon. CT myelography can be used to define the level of nerve root

situations for localizing peripheral nerve entrapment and for image guidance in percutaneous

selection and planning of peripheral nerve surgery is the MR (magnetic resonance) neurogram [3, 15, 37]. Of all these modalities, MRI and CT myelogram are generally the main radiological

Electrodiagnostic studies are equally essential, particularly electromyography (EMG) and nerve conduction studies (NCS). For example, preservation of sensory nerve action potentials (SNAPs) in extensive brachial plexus injuries with severe motor deficits is highly indicative of preganglionic injury and root avulsion. Additionally, serial compound motor action potential (CMAP) studies at 6 week periods give the surgeon an estimate of the spontaneous recovery potential of an injury (i.e., the classical neuropraxia and axonotmesis injury versus neurotmesis patterns) [18, 25]. When the electrophysiology findings are combined with the longitudinal clinical evaluation of motor

Intra-operatively, the integrity of the donor nerve is a major determining factor for successful outcomes [13]. Single coaptation repair of a donor nerve to the recipient nerve (neurotization

recovery, the surgeon can then better decide upon timing and extent of repair required.

3, 5,

8, 22]. The appropriate imaging modalities for evaluation should be selected depend

3, 40]. For instance, transverse process fractures of the cervical vertebrae on cervical

3, 10]. One imaging modality which is emerging as a useful tool in preoperative

8]. Plain-film X-ray, computerized tomography

3, 22]. Ultrasound may be used in some selected

3, 5,

3, 22] and a distal neurotization repair

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9, 37, 40].


137




Regarding tumors, Guha et al., in managing 201 peripheral nerve sheath lesions (182 benign and 19 malignant) in 175 patients over a 17-year period, observed that subtotal resection was associated with the increased recurrence of the benign lesions and that the probability of motor function worsening postoperatively was much less in patients in whom the tumors were fully resected [35]. They also observed that the extent of resection in those who had schwannoma was greatly influenced by tumor location, with lesions located in the extremities being more likely to be fully resected than plexal tumors that were brachial, thoracic, or lumbosacral [35]. This was likely due to better anatomical accessibility [35]. They concluded by suggesting gross total resection for all benign lesions as much as possible [35]. In our own strategy however, we similarly dissected the tumor in its subcapsular plane for PNSTs to ensure that non-involved fascicles remained functionally intact but observed no recurrence of the benign lesions in any of our patients whereas oncological resection and not subcapsular dissection was our goal for the malignant ones (MPNST) in view of the life-threatening nature of the pathology, even at the cost of functional compromise.

#### **4.6. General principles**

Detailed examination of these patients should be followed up by nerve conduction studies and radiological imaging to localize and characterize peripheral nerve lesions or associated neurologic injury [3, 5, 8, 22]. The appropriate imaging modalities for evaluation should be selected depending on the particular clinical circumstance [3, 5, 8]. Plain-film X-ray, computerized tomography myelogram (CT), magnetic resonance imaging (MRI), ultrasound (US), as well as positron emission tomography (PET) all have their various indications in the management of peripheral nerve problems [3, 40]. For instance, transverse process fractures of the cervical vertebrae on cervical spine x-rays might indicate root avulsion at the same level [3, 22] and a distal neurotization repair can be preoperatively decided upon. CT myelography can be used to define the level of nerve root injury preferably within 4 weeks of the injury [3, 22]. Ultrasound may be used in some selected situations for localizing peripheral nerve entrapment and for image guidance in percutaneous interventions [3, 10]. One imaging modality which is emerging as a useful tool in preoperative selection and planning of peripheral nerve surgery is the MR (magnetic resonance) neurogram [3, 15, 37]. Of all these modalities, MRI and CT myelogram are generally the main radiological investigations for diagnosis of problems involving the brachial plexus [3, 5, 9, 37, 40].

Electrodiagnostic studies are equally essential, particularly electromyography (EMG) and nerve conduction studies (NCS). For example, preservation of sensory nerve action potentials (SNAPs) in extensive brachial plexus injuries with severe motor deficits is highly indicative of preganglionic injury and root avulsion. Additionally, serial compound motor action potential (CMAP) studies at 6 week periods give the surgeon an estimate of the spontaneous recovery potential of an injury (i.e., the classical neuropraxia and axonotmesis injury versus neurotmesis patterns) [18, 25]. When the electrophysiology findings are combined with the longitudinal clinical evaluation of motor recovery, the surgeon can then better decide upon timing and extent of repair required.

#### *4.6.1. Brachial plexus injury repairs*

**Authors** 

**No. of** 

**Mean age**

**Sex** 

**Type of lesion/**

**Surgical techniques** 

**Key results/outcomes**

Less motor deficits with full resection

29.5 months

136 Treatment of Brachial Plexus Injuries

of tumor;

Increased recurrence with subtotal

resections.

**Maximum/mean** 

**follow-up**

**evaluated**

**distribution** 

**injury**

**(M:F)**

**and year**

Guha et al.

175

45.2 years

96:79

19 MPNSTs, 133

N/A

schwannomas, 49

neurofibromas

2017 [35]

Bhatia et al.

22

23 years

19:3

Brachial plexus

Contralateral C7 transfer:

Direct coaptation group

 = flexion in wrist + fingers in 10; Grade 2

flexion in 2

Nerve graft group

 = wrist + fingers in only 2; Grade 2 flexion

in 7; total failure in 1

Grade 3 flexion in

28.5

months

for nerve graft

group

Grade 3

26

months for

direct coaptation

group;

By direct coaptation in 12

With graft interposition

in 10

injuries

for direct

coaptation

group;

24

years for

nerve graft

group

Sulaiman

74

32 years

60:14

Brachial plexus

Medial pectoral to

Recovery of elbow flexion to MRC

3.5 years

in all (100%) who had both

nerve transfer + direct repair with C5/

C6 combined, but in only 87 and 22% of

those who had only nerve transfers in

musculocutaneous N.

grade 3

transfers (Group

Intercostal to

musculocutaneous N.

transfers (Group

 2) Neurolysis; graft repairs;

nerve transfers

Group

1 and Group

2 respectively

Improvement from preoperative average

23.5 months

biceps grade of 0 to 1/5 to average

postoperative biceps grade of 2.9 and

average shoulder abduction grade of 2.5

Recovery to functional level in 7 (MRC

3.4 years

 1);

injuries; tumor;

irradiation

et al., 2009

[29]

Badr et al.,

16

16 months

N/A

OBPI (2 Erbs, 6

Erbs plus, 8 Erb-Klumpke palsies)

2009 [4]

Sequeira

10

24.8 years

9:1

Complete brachial

Nerve transfers: phrenic

to musculocutaneous

Grade 3

in 5; Grade 4 in 2) No clinically significant respiratory

problem in all 10 cases.

N +

spinal accessory to

suprascapular N

N/A, information not available; MPNSTs, malignant peripheral nerve sheath tumors; MRC, Medical Research Council; OBPI, obstetric brachial plexus injury.

Previous publications on outcomes of various surgical techniques for peripheral nerve problems.

plexus palsy

and

Martins,

2009 [27]

**Table 7.**

2017 [36]

**patients** 

**studied**

Intra-operatively, the integrity of the donor nerve is a major determining factor for successful outcomes [13]. Single coaptation repair of a donor nerve to the recipient nerve (neurotization repair) without tension is generally considered superior to indirect repair with a cable graft, since only one microanastomosis is required [13, 45]. This is particularly important for weak donor nerves such as the spinal accessory nerve [13, 51]. According to functional priorities, elbow flexion and extension are generally the most important function to restore [19, 43]. Active shoulder control and stability is then considered next most important [50], followed by abduction, external rotation, wrist extension and scapular stabilization prioritized in that order [19]. Finally, managing each patient's expectations is perhaps the most important part of pre-operative planning and preparation [19]. Patients must be made to understand the limits of the best possible outcome and the possibility that either no improvement at all or limited functional improvement may occur after surgery [19].

*4.6.3. Tumors*

*4.6.4. Rehabilitation*

The goal of surgical intervention in PNST is excision of the tumor to alleviate the symptoms caused by neural compression without incurring a sensorimotor deficit [14]. In MPNST, however, oncological resection is the goal given the life-threatening nature of the pathology, even at the cost of functional compromise. In such situations, nerve graft repair can be planned preoperatively. General, regional or local anesthesia may be used [14]. For general anesthesia, anesthetist must avoid the use of muscle relaxants since these agents would ultimately prevent the use of intraoperative stimulation and monitoring [14]. The limb should be exposed so as to monitor the distal muscle response to fascicular stimulation (**Figure 3**). The incision should be made over the involved portion of the nerve starting from 2 to 4 cm proximal to and extending 2 to 4 cm distal to the tumor [14]. The probability of malignant degeneration of a PNST to MPNST should be assessed preoperatively by (1) size, (2) presence and character of pain, (3) radiological criteria (MRI, PET), and (4) the presence of type 1 neurofibromatosis (which has a 20% propensity for MPNST). If suspicion of MPNST is low, a subcapsular enucleation of the tumor mass (usually schwannomatous) offers the best chance of gross total excision with relief of compressive symptoms and simultaneous functional preservation of the nerve fascicles. However, when any combination of these features indicate high suspicion of an MPNST, thorough preoperative planning and counseling should be done for nerve sacrifice to maintain oncologically complete resection and subsequent grafting repair. Oncologically speaking, the option of initial tumor biopsy for confirming the histology followed by total resection is not ideal since violation of soft tissue planes leads to a higher chance for adjacent tissue seeding of sarcomatous cells and even delayed distant recurrence. If a nerve graft was done, the limb should be immobilized with a splint for 2–3 weeks to allow for epineural healing without tension at the anastomosis [14].

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139

Fortunately, the majority of peripheral nerve tumors are benign [14].

rest. This phase can extend up to 6–9 months post-operatively.

Rehabilitation constitutes the remaining postoperative period until the patient achieves maximal functional and neurological recovery [49]. This can often be rather prolonged, and major depression related to extent of injury and surgery is a common factor that needs specific attention in order to improve outcomes. Once the concerned limb can be mobilized, the primary goals are prevention of contracture by passive ROM (range of motion) [41, 49]. This helps prevent complex regional pain syndrome (CRPS), and allows for a more useful limb once muscle reinnervation occurs. Within this time frame, orthotics is useful in preventing contractures at

Once a flicker of contraction was found in the concerned muscles, we began isolating and strengthening them with gravity initially, progressing to "against gravity," and then with resistance. Once the patient could move against gravity, it was useful to add functional tasks into the exercise programme since motor coordination is as important as strength in recovery [41]. With this process, the patient would gradually develop "different" ways of doing old tasks to compensate for weakness of the primary effector muscle. This was achieved by utilizing the secondary effector muscles which changed the appearance of task performance. It remained with the physiotherapist to track recovery and see if these different ways were

The workhorse of brachial plexus repair surgery is still largely the neurotization transfers and nerve grafting [5, 6, 13, 17, 19, 23, 24, 29, 38, 42, 44, 48, 50, 51]. The muscles of the shoulder and the biceps brachii have classically been the main targets for repair of brachial plexus injuries [17, 29, 38, 48]. However, there is now more importance on equally focusing on restoring at least elbow extension for functionality and even newer attempts at selective reinnervation of the median nerve for prehensile hand function or pincer grip [33, 39, 42]. For proximal upper limb functions, the two most important distal transfers are neurotization of the suprascapular nerve with spinal accessory nerve through a posterior approach for shoulder abduction and Oberlin's double fascicular transfer of ulnar and median nerve fascicles to the biceps and brachialis branches of the musculocutaneous nerve for elbow flexion [8, 19, 23, 24, 26, 31, 33, 38, 47]. Case series reports have demonstrated very low long term donor nerve functional impairment resulting from thoracoscopic full-length phrenic nerve harvest and transfers and contralateral C7 transfer [8, 12, 13, 19, 27, 28, 33, 43, 44]. Our experience with these two procedures was very similar. Microsurgical dorsal root entry zone lesioning (DREZ) has been used to effectively control the intractable pain that follows brachial plexus injuries, particularly for the refractory cases [7, 11].

#### *4.6.2. Nerve entrapments and painful neuropathies*

For treatment of cubital tunnel syndrome, the anterior transposition of ulnar nerve may be done in either the subcutaneous or the intramuscular plane [30]. In situ decompression of the ulnar nerve with or without medial epicondylectomy as an alternative technique has also been well described with its pros and cons [30]. For patients with Guyon's canal syndrome, initial approach should be conservative care including immobilization, ergonomic modifications of habitual movement, and local injection of cortisone is advocated except for the refractory cases [2]. However, early motor involvement is common and one should then proceed to surgical decompression. At surgery, the skin incision should extend to both the wrist and palmar line, and the ulnar nerve and artery should be adequately freed at the level of the Guyon's canal [2] (**Figure 4A** and **B**). Posterior interosseous nerve (PIN) entrapment creates a functionally disabling pure motor deficit. For PIN release, the nerve must first be identified proximally between brachioradialis and extensor carpi radialis longus and distally between extensor carpi radialis brevis and extensor digitalis communis at the point where it enters the supinator, and should also include adequate division of the compressive supinator fibers.

#### *4.6.3. Tumors*

repair) without tension is generally considered superior to indirect repair with a cable graft, since only one microanastomosis is required [13, 45]. This is particularly important for weak donor nerves such as the spinal accessory nerve [13, 51]. According to functional priorities, elbow flexion and extension are generally the most important function to restore [19, 43]. Active shoulder control and stability is then considered next most important [50], followed by abduction, external rotation, wrist extension and scapular stabilization prioritized in that order [19]. Finally, managing each patient's expectations is perhaps the most important part of pre-operative planning and preparation [19]. Patients must be made to understand the limits of the best possible outcome and the possibility that either no improvement at all or

The workhorse of brachial plexus repair surgery is still largely the neurotization transfers and nerve grafting [5, 6, 13, 17, 19, 23, 24, 29, 38, 42, 44, 48, 50, 51]. The muscles of the shoulder and the biceps brachii have classically been the main targets for repair of brachial plexus injuries [17, 29, 38, 48]. However, there is now more importance on equally focusing on restoring at least elbow extension for functionality and even newer attempts at selective reinnervation of the median nerve for prehensile hand function or pincer grip [33, 39, 42]. For proximal upper limb functions, the two most important distal transfers are neurotization of the suprascapular nerve with spinal accessory nerve through a posterior approach for shoulder abduction and Oberlin's double fascicular transfer of ulnar and median nerve fascicles to the biceps and brachialis branches of the musculocutaneous nerve for elbow flexion [8, 19, 23, 24, 26, 31, 33, 38, 47]. Case series reports have demonstrated very low long term donor nerve functional impairment resulting from thoracoscopic full-length phrenic nerve harvest and transfers and contralateral C7 transfer [8, 12, 13, 19, 27, 28, 33, 43, 44]. Our experience with these two procedures was very similar. Microsurgical dorsal root entry zone lesioning (DREZ) has been used to effectively control the intractable pain that follows brachial plexus injuries, particularly for

For treatment of cubital tunnel syndrome, the anterior transposition of ulnar nerve may be done in either the subcutaneous or the intramuscular plane [30]. In situ decompression of the ulnar nerve with or without medial epicondylectomy as an alternative technique has also been well described with its pros and cons [30]. For patients with Guyon's canal syndrome, initial approach should be conservative care including immobilization, ergonomic modifications of habitual movement, and local injection of cortisone is advocated except for the refractory cases [2]. However, early motor involvement is common and one should then proceed to surgical decompression. At surgery, the skin incision should extend to both the wrist and palmar line, and the ulnar nerve and artery should be adequately freed at the level of the Guyon's canal [2] (**Figure 4A** and **B**). Posterior interosseous nerve (PIN) entrapment creates a functionally disabling pure motor deficit. For PIN release, the nerve must first be identified proximally between brachioradialis and extensor carpi radialis longus and distally between extensor carpi radialis brevis and extensor digitalis communis at the point where it enters the supinator, and should also include adequate division of the compressive

limited functional improvement may occur after surgery [19].

the refractory cases [7, 11].

138 Treatment of Brachial Plexus Injuries

supinator fibers.

*4.6.2. Nerve entrapments and painful neuropathies*

The goal of surgical intervention in PNST is excision of the tumor to alleviate the symptoms caused by neural compression without incurring a sensorimotor deficit [14]. In MPNST, however, oncological resection is the goal given the life-threatening nature of the pathology, even at the cost of functional compromise. In such situations, nerve graft repair can be planned preoperatively. General, regional or local anesthesia may be used [14]. For general anesthesia, anesthetist must avoid the use of muscle relaxants since these agents would ultimately prevent the use of intraoperative stimulation and monitoring [14]. The limb should be exposed so as to monitor the distal muscle response to fascicular stimulation (**Figure 3**). The incision should be made over the involved portion of the nerve starting from 2 to 4 cm proximal to and extending 2 to 4 cm distal to the tumor [14]. The probability of malignant degeneration of a PNST to MPNST should be assessed preoperatively by (1) size, (2) presence and character of pain, (3) radiological criteria (MRI, PET), and (4) the presence of type 1 neurofibromatosis (which has a 20% propensity for MPNST). If suspicion of MPNST is low, a subcapsular enucleation of the tumor mass (usually schwannomatous) offers the best chance of gross total excision with relief of compressive symptoms and simultaneous functional preservation of the nerve fascicles. However, when any combination of these features indicate high suspicion of an MPNST, thorough preoperative planning and counseling should be done for nerve sacrifice to maintain oncologically complete resection and subsequent grafting repair. Oncologically speaking, the option of initial tumor biopsy for confirming the histology followed by total resection is not ideal since violation of soft tissue planes leads to a higher chance for adjacent tissue seeding of sarcomatous cells and even delayed distant recurrence. If a nerve graft was done, the limb should be immobilized with a splint for 2–3 weeks to allow for epineural healing without tension at the anastomosis [14]. Fortunately, the majority of peripheral nerve tumors are benign [14].

#### *4.6.4. Rehabilitation*

Rehabilitation constitutes the remaining postoperative period until the patient achieves maximal functional and neurological recovery [49]. This can often be rather prolonged, and major depression related to extent of injury and surgery is a common factor that needs specific attention in order to improve outcomes. Once the concerned limb can be mobilized, the primary goals are prevention of contracture by passive ROM (range of motion) [41, 49]. This helps prevent complex regional pain syndrome (CRPS), and allows for a more useful limb once muscle reinnervation occurs. Within this time frame, orthotics is useful in preventing contractures at rest. This phase can extend up to 6–9 months post-operatively.

Once a flicker of contraction was found in the concerned muscles, we began isolating and strengthening them with gravity initially, progressing to "against gravity," and then with resistance. Once the patient could move against gravity, it was useful to add functional tasks into the exercise programme since motor coordination is as important as strength in recovery [41]. With this process, the patient would gradually develop "different" ways of doing old tasks to compensate for weakness of the primary effector muscle. This was achieved by utilizing the secondary effector muscles which changed the appearance of task performance. It remained with the physiotherapist to track recovery and see if these different ways were 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.

or shoulder function by 3 months of age as the indication for surgery in obstetric brachial plexus injury (OBPI), while others use 4 months or even 9 months as the time limit [4, 32]. In our personal experience with managing 196 cases of Erb's and Erb's plus palsies, excellent recoveries were possible in majority of cases with a proper rehabilitation programme consisting of cerebral retraining and judicious management of co-contracture deformities. Some would argue that deformities are less common with early nerve repair in OBPI, but

Starting A Peripheral Nerve Surgery Unit in an Area of Limited Resources - Our Experience

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Finally, even though microsurgical repair of nerve injuries has advanced significantly over time, satisfactory functional recovery still remains a challenge [29]. The ultimate goal of a nerve repair should be a functional improvement that creates satisfaction for the patient in his or her daily activities and occupation and not simple improvement in the muscle power grading. This requires dedicated efforts in physical, psychological and vocational rehabilitation. Augmentation of the paralyzed limb using reanimative muscle or tendon transfer surgeries by the plastic surgeon often improves outcomes. Hence, a multidisciplinary team

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

this is yet to be proven definitively.

is ideal.

the world.

None.

**Competing interests**

**Funding/material support**

The authors declare that they have no competing interests.

**6. Conclusion**
