الفهرس 
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Abstract
The brachial plexus is a network of nerve fusions and divisions that link the brain and spinal cord to the nerves of the upper extremity. Disruption of the nerves of the brachial plexus can be debilitating both functionally and socially. Injury to the brachial plexus results primarily from mechanical forces (ie, traction, compression, and transection), ischemia, inflammation, and radiation exposure. Most traumatic nerve injuries involve a combination of these mechanisms.
Unfortunately, the incidence of traumatic adult brachial plexus injury (ABPI) is increasing, leading to permanent disabilities and handicapping. The two-wheeler vehicular traction accident is the commonest injury mechanism. Open ABPI is uncommon but might be life-threatening necessitating emergency exploration especially if associated with vascular injuries for immediate nerve repair and vascular repair. But in closed traction injuries, conservative treatment is preferred during the first three months aiming to promote the natural nerve healing process,during this peroid we should maintain the range of motion of the extremity, to strengthing the remaining functioning muscle, to protect the denervated dermatomes, and allowing surrounding tissue edema to subside and to decreasing the pain. Also, electrodiagnosis and imaging studies are done to localize the site and possible type of ABPI. The timing of surgery is a crucial factor and a more important predictor in determining the final outcome of these injuries, hence an early referral is mandatory. Partial BPI has remarkable outcomes in a majority of cases, while in global avulsions the results are not very satisfactory and we can help those patients by salvage reconstruction secondary operations. The surgery in BPI has seen a significant revolution due to technological advancement, improvement in surgical, techniques and the new reconstructive procedures . Direct end to end repair for BPI is approached anteriorly in most cases. The approach may be supraclavicular and in the majority of cases, a combined supra and infra-clavicular approach is preferred. Nonabsorbable 8-0 or 10-0 monofilament nylon sutures may be helped by fibrin glue. Epineural repair using 8-0 or 10-0 non-absorbable nylon in a tension-free manner is likely to give the best results after stumps end debridement and appropriate nerve alignment and neurolysis. The latter is aided by inspection for longitudinal blood vessels in the epineurium as well as attending to fascicular alignment.
When the gap between the debrided nerve stumps is more than 3-4 cm direct nerve repair can not be performed without undue tension, so nerve autografting must be undertaken. The sural nerve and medial cutaneous nerve of the forearm are the usual donors. After stumps debridement, the epineurium is dissected away to allow
groups of fascicles to be created at each stump nerve circumcision.
The nerve graft is then sutured in place to the proximal group of fascicles using epineurial and inter-fascicular techniques. The graft should be about 10 % longer than the existing nerve gap. The length of the nerve graft is inversely influencing the motor results, meaning that graft with a length less than 5 cm gives favorable results, while grafts longer than 10 cm give less favorable results.
Surgical evaluation for brachial plexus injuries involves a thorough history and physical examination, imaging, assessment of motor and sensory deficits and pain, electrodiagnostic studies, and identification of potential donor nerves.
Brachial plexus injuries need to be treated in a timely fashion before muscle damage is irreversible. A combination of nerve reconstruction and nerve transfers from intra- or extraplexus functioning donor nerves can provide both functional benefits and pain relief. For delayed presentations, tendon transfers and joint fusion can provide functional improvements.
A multidisciplinary approach including a neurologist, physical medicine and rehabilitation, occupational therapy, and reconstructive surgeons with expertise in peripheral nerve surgery is critical in achieving optimal functional recovery.
Upon data retrieved from our review, BPI in adults is still one of the most devasting injuries which have severe morbidity and very poor outcome which can lead to completely flail and paralyzed limb with a very poor response for treatment. Evaluating outcomes of reconstructive surgery for lesions of the brachial plexus is extremely complex. The time between the accident and surgical intervention is one of the more important factors and may be an important predictor of the final outcome. Delay of more than eight months implied a bad prognosis for functional recovery. This was the first time this had been reported for patients treated surgically for closed lesions of the brachial plexus. The authors recommended that patients be treated surgically within the first three months in order to gain a satisfactory functional recovery.
We found that the preoperative duration inversely influenced the probability of motor recovery. This means that when the duration between the lesion’s origin and the surgical intervention is long, the possibility for recovery is diminished.
Also, the correlation between the number of grafts and the functional outcome was statistically significant. Neurolysis performed before six months implied a good
prognosis for functional recovery. We also found that muscular strength was better when neurolysis was carried out before six months.
Pain after lesions of the brachial plexus has not received much attention. Incomplete reports of patterns of the lesion and inadequate evaluations have disqualified most of these studies from being included in a comparative study. After the surgery was done, we found a significant improvement in pain. This may suggest that surgical treatment produces an analgesic effect. The repair of the brachial plexus is only one part of the treatment. After the nerve regeneration has been completed, any palliative surgery using all available techniques, such as tendon muscular transfers, and arthrodesis, etc., should be done in order to improve the functional results. In brachial plexus lesions, paralysis of the shoulder girdle muscles is frequently associated with paralysis of the elbow flexors. In such lesions, restoration of elbow flexion depends on the stability of the shoulder joint and in some centers frequently solve this problem by arthrodesis. We recommend shoulder arthrodesis in those patients who undergo flexorplasty of the elbow using the pectoralis and sternocleidomastoid muscles and in patients with paralysis of the trapezius and of latissimus dorsi at the same time. In other patients, we suggest doing a transfer of the trapezius or the latissimus dorsi.
When we evaluated the function of the whole upper limb, it was possible to demonstrate the value of neurosurgical repair in lesions of the brachial plexus. When reconstructive procedures were performed after the primary neurosurgical repair, the function of the upper limb was generally improved.