Adult brachial plexus reconstruction with the level of injury: Review and personal experience

Background: Adult brachial plexus reconstruction remains a dilemma to the reconstructive microsurgeon, especially when attempting to reconstruct cases of total root avulsion. A significant improvement in results has been achieved by a better understanding of various methods of reconstruction and prolonged postoperative rehabilitation. Methods: This study was based on review of the literature and personal experience with 819 patients operated on between 1986 and 2003. To better understand these improved results, the author classified patients into four levels of injury: level 1, preganglionic root; level 2, postganglionic spinal nerve; level 3, preclavicular and retroclavicular; and level 4, infraclavicular brachial plexus injury. Neurolysis, nerve repair, nerve graft, vascularized ulnar nerve graft, nerve transfer, and functioning free-muscle transplantation were used for early reconstructions. Tendon transfer, functional or functioning muscle transfer, ar- throdesis, or orthotics were used for late palliative reconstructions. Results: Results accomplished by means of different reconstructive strategies with different levels of injury are summarily listed. Personal opinions regarding the controversial strategies are discussed. Conclusion: Brachial plexus surgery, consisting of primary nerve and late palliative reconstruction, is now a worthy surgical pursuit that makes a useless limb useful. (Plast. Reconstr. Surg. 124: 359e, 2009.).