Surgery for lesions of the brachial plexus

Current diagnostic workup and surgical management of stretch injuries, gunshot wounds, lacerations, iatrogenic injuries, tumors, and thoracic outlet syndromes involving the brachial plexus are reviewed. Use of appropriate radiologic and electrodiagnostic studies to work up such patients is summarized as is selected literature concerning the more controversial aspects of their management. Some of the arguments both for and against operation on stretch injuries are presented and it is concluded that surgery can be of value for well-selected patients. Although a number of patients with gunshot wounds involving the plexus recover spontaneously, many still require an operation. Experience with tumors arising from the plexus suggests the need for early and relatively aggressive removal. Use of magnification and intraoperative recording permits removal of some but not all neurofibromas without further deficit. Timing for repair of lacerating injuries to the plexus, as well as iatrogenic injuries, selection of the few patients with thoracic outlet syndrome who require operation, and a brief review of plexus neuropathy are also presented. Importance of evaluating individual plexus injuries in terms of how complete or incomplete loss is in the distribution of each individual element is stressed. Development of intraoperative stimulation and recording methods to help sort out lesions, use of magnification for repair, and improved grafting techniques where gaps result from resection have helped to restimulate interest in managing these patients.