Timing, Delayed Surgery
Indications for Surgery
Delayed and late Surgery
Very few reports in literature regard the late repair of nerve lesions and of brachial plexus in particular.
There is a general consensus to define as late a surgery performed at least one year after the trauma.
The presence of fibrillation detected with an EMG study is considered a prerequisite to attempt a late repair of the plexus.
Even if there are many evidences of possible recovery of single muscles, generally biceps or supraspinatus, through neurotizations (nerve transfers) after 2 years from the trauma, the results are still unpredictable;
this fact renders late surgery a rescue repair which may be attempted in some case if not widely suggestible.
A correct treatment of brachial plexus injuries needs multiple and different competences possibly coordinated by the same person/s
- Advanced diagnostic (clinical, neurophysiology, imaging)
- Primary neurosurgical repair
- Treatment of neuropathic pain
- Physical terapy and rehabilitation
- Secondary palliative surgery
For these reasons we will suggest, face to a brachial plexus lesion :
- to direct to an experienced brachial plexus surgeon in order to achieve an early correct assessment of the lesion.
A correct clinical examination gives to you a lot of useful informations about the type of the lesion and the indication for the correct timing and type of surgery.
- A correct information of the patient and/or parents about a realistic prognosis is fundamental for so severe type of lesions; therefore exhaustive informations should
be given by a BP specialist who will moreover indicate the most appropriate investigations (which and when). This will avoid useless and expensive examination when
they are done not in the appropiate time and way..
- If a neuropathic pain is present (usually in avulsion type lesions and mainly in total palsies)
the patient must be referred to a specialised center dedicated to neuropathic pain
treatment. Since it may frequently reach unbearable levels for the patient, it needs to be
treated as early as possible since it can interfere with the rehabilitation programme.
Patient must be aware that nerve surgery itself has no influenece in relief of pain .
- Once the type of lesion has been assessed and a surgical plan has been decided, a rehabilitation programme must be started, interrupted only during the immobilization period after surgery.
Patient must be aware that rehabilitation will be a a long lasting treatment (at least two years for upper palsies and until 4 years for total palsies).
- Usually the patient is reviewed by the surgeon after 6 months from the surgical reapair just to control the correct evolution of the rehabilitation program. At one year
after surgery the first electromyographical examination will be performed to detect the initial first sign of reinnervation of the more proximal muscle (i.e the muscles nearest to the point of nerve repair)
Usually clinical controls will be organized every 6 month to control the evolution of the functional recover. This repeated clinical controls are very important since as already mentioned it is still possible
if no suitable recovery will appear in expected time, a late nerve repair will be still possible reasonably between 12 and 15 months of delay.
Palliative surgery (i.e. tendon or muscle transfer) to reconstruct function not achieved by primary surgery will be indicated whenever possible only after at least 2 years in upper palsies and 4 years in total palsies.