Acta Neurochirurgica (2019) 161:899–906 https://doi.org/10.1007/s00701-019-03871-y ORIGINAL ARTICLE - PERIPHERAL NERVES Traumatic brachial plexus injury: a study of 510 surgical cases from multicenter services in Guangxi, China Guang-Yao Li1 & Ming-Qiang Xue1 & Jing-Wei Wang1 & Xiang-Yong Zeng1 & Jun Qin1 & Ke Sha1 Received: 29 August 2018 /Accepted: 3 March 2019 /Published online: 15 March 2019 # Springer-Verlag GmbH Austria, part of Springer Nature 2019 Abstract Background Traumatic brachial plexus injuries are severe lesions, and the incidence of these injuries has been increasing in recent years. Methods The clinical data of 510 operated patients with brachial plexus injury recruited from 74 hospitals in Guangxi from 2004 to 2016 were retrospectively studied. Results Our study included 447 males and 63 females, with an average age of 29.04 years. Traffic accidents were the most common cause of injury (64.71%), especially motorcycle accidents. Closed injuries accounted for 88.24% of cases, and 83.53% of patients had associated injuries, the most common of which were fractures (76.27%). The preoperative predictive value of root injury of MRI and CT was 74.71% and 71.28%, respectively. 44.71% of patients underwent an initial operation within 6 months after the trauma. Regarding the surgery, neurolysis alone, brachial plexus reconstruction, and free functioning gracilis graft accounted for 16.67%, 75.50%, and 4.51%, respectively. A total of 415 patients were followed up with an average time of 47.95 (25–68) months, and anxiety or depression were found among 81.20% of them. Two hundred seventy-six patients suffered from nerve pain, with mild pain present in 67.03% of patients. Additionally, 347 patients were followed up for more than 3 years, 76.81% of patients with C5-C6 injury recovery to useful function, and the procedure of neurolysis alone demonstrated the best efficacy (79.45%). Conclusions Brachial plexus injury is still a challenging trauma for surgeons, and traffic accidents are the dominant cause. Timely and effective surgery is important for functional limb recovery. Keywords Brachial plexus . Nerve injury . Nerve transfer . Clinical outcome . Epidemiology Abbreviations Introduction BPI Brachial plexus injury BP Brachial plexus Traumatic brachial plexus injury (BPI) is regarded as one of the MRI Magnetic resonance imaging most devastating lesions of the upper limb and causes tremen- CT Computed tomography dous loss to affected individuals, their families, and society. In VAS Visual analog scale 1970, surgeons were pessimistic about the therapy for BPI be- LSUMC Louisiana State University Medical Center cause of the poor outcome, and only conservative treatment was NAP Nerve action potential generally recommended. Fortunately, with the advances in micro-neurosurgery over the last few decades, surgery as an important treatment has significantly changed the outcomes of BPI [8, 15, 26]. Jain et al. [15] noted that 57% of patients in India This article is part of the Topical Collection on Peripheral Nerves were able to return to their jobs, on average 8.6 months after the trauma. Dubuisson and Kline [8] also reported that 78% of pa- * Ke Sha tients with open injury and 58% of patients with closed injury [email protected] restored useful function after surgery, and the authors noted a few important points regarding the management of BPI, such as the 1 Department of Orthopedic Trauma and Hand Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang necessity of classifying the severities of each brachial plexus Autonomous Region 530021, People’sRepublicofChina (BP) element, determining the indication as well as best time 900 Acta Neurochir (2019) 161:899–906 for surgery, and determining the best strategy for surgeries by presentation of paralytic muscles at that time indicated the degree applying intraoperative electrophysiology. Since the 1980s, the of injury. Successful results were defined as the achievement of number of patients has been increasing because of the improve- grade 3 or higher [18]. We attempted to contact all the patients or ment in emergency management and the application of helmets, their families; although only 415 patients participated in the fol- and the severity of lesions in the vessels as well as nerves has low-up, they constituted a sufficiently representative group in become greater in recent years [25]. The technological refine- which to assess overall posttreatment status. All treatments in- ments in the preoperative assessment and repair of nerve injuries cluded in the study were performed under the direction of my impelled us to perform a retrospective study on the epidemiolo- hospital to ensure that the data were of good quality. gy, clinical management, and outcome of 510 successive patients with BPI. Results Materials and methods Epidemiology This study recruited 510 consecutive operated patients with BPI Among the cases, 447 males and 63 females were included, and between January 2004 and December 2016 from 33 tertiary the male:female ratio was 7.10:1.00. The average age of the hospitals, 39 secondary hospitals, and 2 primary hospitals. subjects was 29.04 (1–73) years. Subjects aged between 20 Diagnosis was confirmed by clinical features, radiological as- and 39 years accounted for 59.41% of all cases (Fig. 1), and sessment (magnetic resonance imaging [MRI], computed to- rural residents accounted for 77.65% of cases. Most of the sub- mography [CT], plain radiography, and angiography), and elec- jects were laborers (34.90%), farm workers (17.25%), or unem- trophysiology studies (sensory nerve action potentials, ployed (17.45%). Patients with medium to low incomes or no electromyoneurography). The collected data included gender, income accounted for 88.04% of the sample. Regarding educa- age, address, occupation, injury mechanism, associated injuries, tion level, 73.33% of the patients had a secondary education. and results of the preoperative evaluation. Additionally, the time Among the causes of BPI (Table 1), the majority of injuries elapsed from injury to BP surgery, the surgical procedures ap- were attributed to traffic accidents (64.71%), falls (16.08%), plied, and the intraoperative finding of avulsion, rupture, or scar and machine traction (7.84%). Among the traffic accidents, of all BP elements were also recorded. Regarding the topogra- 71.52% involved motorcycles and 14.24% involved electric phy, we classified BPI into supraclavicular and infraclavicular scooters. lesions and assorted them according to the affected roots. After surgery, we followed up patients through the outpatient depart- ment or by phone or mail to investigate the psychological state of Preoperative status patients and used the visual analog scale (VAS) to evaluate the degree of limb pain, utilizing the grading system of Louisiana 95.88% of the patients first visited the hospital within 24 h State University Medical Center (LSUMC) to evaluate the func- after injury, and 70.78% of the patients were transferred to tion of the upper limb. In brief, in accordance with the LSUMC different hospitals at least once. Many patients did not timely system, individual muscle-level progressed from 0 (no contrac- receive surgical treatment, and 44.71% of all cases underwent tion) to 5 (movement against the greatest resistance), and the an initial operation within 6 months after the trauma (Fig. 2). Fig. 1 Histogram of the distribution of patients’ ages Acta Neurochir (2019) 161:899–906 901 Table 1 Causes of brachial plexus injury C7, and C5-C6 injuries were 42.66%, 18.00%, and 13.50%, Mechanism No. of patients Ratio (%) respectively. Additionally, the nerve damage was often more severe in the supraclavicular area (Table 5), and scar was the Traffic accidents major intraoperative finding, which was often extensive. In Motorcycle 236 46.27% most cases, scar was combined with a traumatic neuroma in Electric scooter 47 9.22% the continuity of BP elements. Regarding root avulsion, C7- Car 24 4.71% T1 nerve roots were more likely to be avulsed than C5-C6 Other 23 4.51% nerve roots, especially the C7 nerve root (n =210). Falls 82 16.08% Necrolysis alone was performed in 86 patients (Table 6) Machine traction 40 7.84% because all the elements were found in continuity and trans- Hit by falling object 30 5.88% mitted a nerve action potential (NAP). Direct end-to-end su- Sharp injury 16 3.14% turing was performed in 14 patients, with the following distri- Operative iatrogenic injury 7 1.37% bution: C5-C6 (n = 3), C5-C7 (n =2),C7-T1(n =1),andme- Gunshot wound 5 0.98% dian nerve, radial nerve, or axillary nerve (n = 8). Nerve Total 510 100.00% grafting alone was performed in 31 patients and included the median nerve, musculocutaneous nerve, axillary nerve as well as radial nerve (n = 10), the superior trunk to the posterior and anterior branches (n = 19), C7 to the middle trunk (n = 1), and Closed injury accounted for 88.24% of cases. 51.60% of the medial cord to the median nerve (n =1). the patients had left-sided injuries, 44.26% had right-sided Nerve transfer alone (n =256)orcombinedwithgrafting injuries, and one patient was affected on both sides. In addi- (n = 84) was performed using C5 to the posterior division of tion, 83.53% of the patients had associated injuries, with frac- the superior trunk (n = 51), superior trunk (n = 44), anterior tures and brain or spinal cord injuries accounting for 76.27% and posterior divisions of the superior trunk (n = 37), or pos- and 14.31%, respectively (Table 2). Upper limb fractures terior cord (n = 24); C6 to the anterior division of the superior accounted for 65.31% of all fractures (Table 3). Horner’ssign trunk (n = 48) or superior trunk (n = 65); homolateral C7 to the was present in 158 patients, and trapezius, hemidiaphragm inferior trunk (n = 41), superior trunk (n =32),oranterioror palsy, and alar scapula were present in 105, 30, and 22 pa- posterior divisions of the superior trunk (n = 6); C8 or T1 to tients, respectively.