Brachial plexus injuries.

Injuries to the brachial plexus are common and are the most severe of all lesions of peripheral nerves, but the last 25 years have seen considerable advances in treatment. Much of this improvement followed the restatement of surgical principles regarding the treatment of wounds, and the application of methods of diagnosis and techniques of nerve repair which had been established much earlier. In 1954 a Special Report of the Medical Research Council commenting on 170 open war-time injuries concluded that ‘‘with the possible exception of lesions of the upper trunk, operative repair is valueless’’. This view was supported at the Paris SICOT meeting in the mid 1960s and was probably incorrect then. It is certainly incorrect now. History. The Iliad contains descriptions both of open wounds and closed injuries of the brachial plexus. Flaubert (1827) described the findings at necropsy in a case of attempted late closed reduction of dislocation of the shoulder with fatal outcome. He found rupture of the subclavian artery, avulsion of spinal nerves from the spinal cord and haematoma within the spinal canal. The patient showed signs of a Brown-Séquard lesion before death. Frazier and Skillern (1911) confirmed by hemilaminectomy that spinal nerves had been torn directly from the spinal cord in a patient who gave an eloquent description of pain wholly characteristic of intradural injury. Thorburn (1900) performed the first repair of a traction rupture in 1896 and a number of other reports followed this. Surgical repair lost favour, however, because of difficulties in diagnosis and in measuring outcome, and because there were deaths. Inevitably, warfare stimulated study. The First World War led to seminal work on the effects of ischaemia and aneurysm on peripheral nerves, and the papers of the great French surgeon-anatomists on the exposure of deep-seated blood vessels, summarised by Fiolle and Delmas (1921), are still influential. After the Second World War, the contributions of those brought together by the British Medical Research Council laid the foundation of much modern work. Brooks (1955) established the place of nerve grafting; Seddon (1963) described the first case of active elbow flexion after intercostal transfer; Strange (1947) developed the vascularised nerve graft on a pedicle; and Young and Medawar (1940) introduced fibrin-clot glue. Later wars helped to stimulate the development of reliable techniques for repair of blood vessels. Much work was done in London at the Royal National Orthopaedic Hospital and St Mary’s Hospital on the diagnosis and treatment of the closed lesions. Bonney introduced simple clinical tests to distinguish between preand postganglionic injury, an advance of fundamental importance (Bonney 1954; Bonney and Gilliatt 1958). Electrophysiological examination was refined and extended by Landi et al (1980) who demonstrated the value of cortically evoked potentials. From other centres, Celli and Rovesta (1987) combined EMG examination of paravertebral muscles with preand intraoperative sensory evoked potentials, and Sugioka and Nagano (1989) compared preand intraoperative electrophysiology with the findings at operation. The value of myelography was established in the 1960s (Yeoman 1958; Davies, Sutton and Bligh 1966), but Marshall and de Silva (1986) showed that CT with contrast enhancement was more accurate. Despite these developments, the few surgeons persisting with the repair of closed lesions became disappointed with their results, but interest was rekindled by the work of Narakas in Lausanne and Millesi and his colleagues in Vienna in the early 1960s. Their work stimulated others; and there is a useful summary in the collection of essays published by the Groupe d’Étude de la Main in 1989. It is now time to take stock of the considerable experience which has been collected since 1970 (Tables I and II).