Timing, Delayed Surgery

Indications for Surgery

The main question is: which is the ideal time for surgery?

There is a general agreement that the time to repair a BP lesion must not exceed the 6 months from injury while different opinions exist about how early a repair a brachial plexus lesion must be performed. There are few indications to operate in emergency, generally in association with vascular lesions; in these situations it is quite impossible to assess the real level of traction injuries and consequently to perform a correct complete repair. Moreover the longer operative time added to the emergency vascular repair may be dangerous in these kind of patients; nevertheless the cooperation of the plexus surgeon with the vascular surgeon, whenever possible, may help to facilitate the vascular reconstruction, sparing in this way the nerve structures which will be repaired in better conditions in a second time. Some surgeons suggested in the past to operate traumatic plexus traction injuries within the first week with the purpose to avoid fibrotic scar tissue; the advantage is real from the technical point of view, nevertheless we think that the risks are really higher than benefits The only exceptions are the rare sharp wounds of the brachial plexus, since there is the possibility to repair the nerves immediatly with direct sutures.
In all the other cases we consider that the ideal time for surgery is between the 2nd and the 3rd month from injury; this would be a sufficient time to allow the stabilization of the associated lesions and the general conditions of the patient and to better assess the possible spontaneous recovery.

Due to the frequent complex associated lesions (skeletal , cutaneous,vascular etc) it is advisable to wait the stabilization of general conditions of the patient before surgical repair.
We consider that between the second an the thir months from the trauma is the ideal time for surgical reapir of the brachial plexus. The age of the patient is not more considered a real limitation for surgery since whe have experienced functional recovery even in over sixties patients. In conclusion face to a brachial plexus lesions once the diagnosis has been correctly assessed we suggest to wait the time necessary to solve the associated lesions: meanwhile an early rehabilitation program should be started whenever possible.

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 :

  1. 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.
  2. 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..
  3. 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 .
  4. 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).
  5. 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)
  6. 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.
  7. 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.