PubMed · 12117369
The source did not provide an abstract. Follow the original record for more information.
Explore connections, maps & timelines
Brian Murray, Asa J Wilbourn. 2002. Brachial plexus.. https://doi.org/10.1001/archneur.59.7.1186
Cite the original work for its findings. Save a collection to share your selection of sources.
KEEP EXPLORING
The charts of the 173 consecutive patients who underwent microsurgical reconstruction for obstetrical brachial plexus palsy from 1988 to 1999 (inclusive) in the Division of Plastic Surgery at the Hospital for Sick Children were analyzed. The overall complication rate was 33.5 percent, and there was no mortality in this series. The most significant intraoperative complication was accidental extubation, which occurred five times in the first 84 patients (6 percent of this early group; 2.9 percent of the whole series). This complication was addressed by suturing the endotracheal tube to the membranous septum and by using a transparent drape to allow direct visualization of the tube in all 89 subsequent patients. There have been no further accidental extubations. Postoperative fluid overload occurred in 14 patients (8.1 percent), three (1.7 percent) of whom developed pulmonary edema. Intensive care unit admission was required in two of those patients. Diuretic treatment was required in seven patients. No patient receiving less than or equal to 4 ml/kg/hour developed fluid overload, whereas 50 percent of the patients receiving greater than or equal to 10 ml/kg/hour did. Currently, the authors' policy is to strictly limit intravenous maintenance fluids to 4 ml/kg/hour or less. Despite the long and complex procedure required to reconstruct obstetrical brachial plexus palsy, the incidence of significant complications can be minimized with simple precautions, such as suturing the endotracheal tube to the septum or reducing the amount of fluids administered during the operation.
Severe trauma to the brachial plexus most often occurs in young adult men and is a crippling injury that requires management in a timely fashion for optimal functional recovery and pain control. The surgical management of such injuries is well established, and the techniques continue to evolve. Current management options consist of primary repair in the acute setting, neurolysis, neuroma resection and nerve grafting, motor and sensory nerve transfers, and muscle and tendon transfers. Shoulder andwrist fusion can also play a role in the overall management of these patients. The best operative plan varies depending on the patient's level and extent of injury and the surgeon's preference and experience. The pre- and postoperative care of these patients is ideally managed by a team that has experience with such problems, including personnel knowledgeable in their postoperative rehabilitation. The total reconstructive process generally consists of more than one operation, and the postoperative rehabilitation is long and intensive. Nevertheless, with a highly motivated patient and a dedicated and specialized surgical team, the prognosis for functional recovery is good, and these patients can still lead productive and satisfying lives.
Primary surgery for obstetrical brachial plexus lesions is a young field of surgical expertise that offers the possibility of improved functional ability in carefully selected patients who would otherwise be faced with lifelong impairment and secondary skeletal deformities. One major challenge in this area of peripheral nerve surgery is the selection of patients most likely to derive benefit from surgical intervention. The key to the development of selection criteria and to the resolution of other considerations (such as the determination of root avulsion) is consistency, accuracy, and careful reporting of natural history and outcome data. In particular, we strongly feel that a statistically sound technique of assessment must be consistently applied from the time of presentation through long-term follow-up. Advancement to date has resulted from the application of evidence-based recommendations from large, well-designed, meticulous studies. As the field of obstetrical brachial plexopathy management continues to evolve, we can expect that questions will continue to be answered using such scientific methodology.