|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| Rupture of C5 and C6 with intradural avulsion of C7 (FIG. 45-05). In such cases, we refuse to neurotize the C7 root by intercostal nerves, given its diffusion in a large portion of the upper limb; instead, we use the C5 and C6 roots according to the scheme we have described above, as if we were dealing with an isolated lesion of C5 and C6.
Rupture of C5 with indural avulsion of C6 and C7 (FIG. 45-06). Two methods are possible. C5 can be grafted to the suprascapularis nerve and the musculocutaneous nerve, or the suprascapularis nerve can be neurotized with the spinal accessory nerve and C5 grafted to the lateral cord and possibly to the upper origin of the posterior cord.
Intradural avulsion of C5, C6 and C7 with integrity of C8 and T1 (FIG. 45-07). These lesions are infamous because there is no longer possibility of controlling the scapulothoracic articulation. We perform either a spinohumeral neurotization or a neurotization of the supraspinatus muscle with the spinal accessory nerve and the biceps with three intercostal nerves. Figures 45-8 through 45-10 show the results of neurotization of the biceps nerve by the spinal accessory nerve in a 6-year-old boy.
Rupture of C5 and C6 with intradural avulsion of C7, C8 and T1 (Figs. 45-11 to 45-13). When the loss of substance is minimal, the grafting scheme is similar to that used for isolated rupture of C5 and C6, i.e., C8 and TI are neurotized with intercostal nerves. This type of neurotization aims to restore trophic condition and protective sensitivity to the forearm and hand. More than 2 years are needed to obtain such a result (FIG. 45-11).
| Conversely, if the grafts between C5/C6 and the lateral cord must be long, we prefer to use the vascularized ulnar nerve to bridge the loss of substance. The graft can be used as a free graft with microvascular anastomosis (the vascularized free grafts being 12 to 18 cm long) (FIG. 45-12) or for technical reasons, it can be pedicularized on the proximal collateral ulnar artery originating in the brachial artery; in this case, the folded graft is no longer than 20 cm (FIG. 45-13).
Rupture of C5 with intradural avulsion of C6, C7, T1 FIG. 45-14). When only one root can be used, we neurotize the suprascapularis nerve with the spinal accessory nerve; the C5 root is grafted to the musculocutaneous nerve; if the root contains enough fascicles, one or two grafts are directed to the radial nerve. Complementary neurotization can be done to enhance forearm trophic condition by neurotizing C8 and D 1 with intercostal nerves.
Total intradural avulsion of the brachial plexus, from C5 to T1 (FIG. 45-15). In this case, we neurotize the musculocutaneous nerve with the spinal accessory nerve and the inferior trunk with three intercostal nerves; an alternate solution is to neurotize the suprascapular nerve with the spinal accessory nerve and the biceps muscle with intercostal nerves.
RETRO AND INFRACLAVICULAR LESIONS
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