Brachial plexus tumours (BPT) and peripheral nerve sheath tumours (PNST) are largely benign in nature, with malignant tumours being rare and presenting significant surgical challenges. Excision of benign tumours may relieve pain and other symptomology. This retrospective study analysed data from 138 PNST and 92 BPT patients managed by a single consultant orthopaedic or plastic surgeon experienced in nerve tumour surgery between January 1999 to December 2019. The most common benign tumours were schwannomas and neurofibromas, with sarcomas being the most common malignant tumour. In the PNST group 30 patients were managed by observation only. Twenty patients underwent trucut biopsy, 21 patients underwent biopsy and surgical excision and 56 patients underwent surgical excision only. There were nine complications, with two significant neurological deficits requiring further surgical intervention. No recurrence of tumours occurred in this group. In the BPT group 16 patients were managed by observation only. Seven patients underwent trucut biopsy, 16 patients biopsy and surgical excision and 44 BPT patients underwent surgical excision only. Sixteen patients had complications with two significant complications requiring urgent further surgical intervention. Seven patients had recurrence of tumours which presented as metastases, with three patients requiring further surgery to remove recurrence of tumours. BPT patients are more complex and present with both benign and malignant lesions and are therefore more prone to complications due to the complex nature of the surgery and higher recurrence rate of tumours than PNST. Benign tumours in both groups can be safely managed conservatively if patients’ symptomology is acceptable.
Myotome values for the upper limb appear to have been established in the early twentieth century based on historical work. Supraclavicular brachial plexus injuries present with a pattern of neurological loss consistent to the nerve roots affected. Recent advances in radiological imaging and intraoperative nerve stimulation have allowed confirmation of the affected nerve roots. The records of 43 patients with partial injuries to the supraclavicular brachial plexus were reviewed. The injuries covered the full range of injury patterns including those affecting C5, C5-6, C5-7, C5-8, C7-T1 and C8-T1 roots. All cases with upper plexus injuries had surgical exploration of the brachial plexus with the injury pattern being classified on the basis of whether the roots were in continuity, ruptured, or avulsed, and, if seen in continuity, the presence or absence of a response to stimulation. For lower plexus injuries the classification relied on identification of avulsed roots on Magnetic Resonance Imaging. Muscle powers recorded on clinical examination using the MRC grading system. In upper plexus injuries paralysis of flexor carpi radialis indicated involvement of C7 in addition to C5-6, and paralysis of triceps and pectoralis major suggested loss of C8 function. A major input from T1 was confirmed for flexor digitorum superficialis, flexor digitorum profundus (FDP) to the radial digits, and extensor pollicis longus. C8 was the predominant innervation to the ulnar side of FDP and intrinsic muscles innervated by the ulnar nerve with some contribution from C7. A revised myotome chart for the upper limb is proposed.
Our unit has pursued a policy of using donor nerves from the same limb for grafting. Nerves which have already been affected by the primary injury are selected where possible, thus avoiding any new sensory deficit. 36 of the 41 brachial plexus repairs were available for outcome data collected prospectively over 2 years. Over a nine year period, donor nerves used for the 41 brachial plexus repairs included the lateral cutaneous nerve of the forearm, superficial radial, medial cutaneous of the forearm, ulnar and sural nerves. Patients were grouped into having injured nerve grafts only (A), injured and uninjured nerve grafts (B) and uninjured nerve grafts. The repaired brachial plexus nerves were assessed by measuring the MRC grading of the power of movement of the muscle innervated by that nerve (i.e. elbow flexion for musculocutaneous nerve). These were graded as good (MRC grading 3 or better), fair (MRC grade 1 or 2), or poor (MRC 0). The greatest success for nerve grafting was elbow flexion with good results in 22 out of 27 assessments. Using Mann-Whitney test, Group A had significantly better results (p=0.025) than group C. However, ignoring the poorer results of shoulder abduction there was no significant difference between all 3 groups of patients. We conclude that using injured nerve grafts taken distal to the lesion in the brachial plexus is as effective as using nerve material from an uninjured limb.
