상완 신경총 손상에서 자연 회복과 신경 재건술간의 비교

백구현,정문상,서중배,박진수,박용범,전득수,Baek, Goo-Hyun,Chung, Moon-Sang,Seo, Joong-Bae,Park, Jin-Soo,Park, Yong-Bum,Jun, Deuk-Soo 대한미세수술학회 1996 Archives of reconstructive microsurgery Vol.5 No.1

서울대학교 의과대학 정형외과학 교실에서는 1985년 1월부터 1994년 12월까지 치험하였던 103명의 환자를 대상으로 최소한 8개월간 보존적 치료를 시행하며 자연 회복을 기다렸고, 수상 후 8개월에서 10개월까지 3개월마다 반복된 근전도 검사상 회복이 없거나 경미한 31명에 대하여 신경 복원술을 시행하여 다음과 같은 결과를 얻었다. 1) 자연 회복은 상완 신경총 손상 환자의 47명(46%)에서 일어났으며, 자연 회복된 환자의 3분의 2(31명)에서 근전도 검사상의 변화가 3개월에서 9개월 사이에 처음 발견되었고, 나머지 3분의 1(16명)의 환자에서 9개월에서 16개월 사이에 발견되어, 평균 7.8개월에 시작됨을 보여주었다. 수정된 AMA score상 내원 당시 14.8점에서 최종 추시 관찰시 39.8점으로 개선되었다. 2) 신경 복원술을 실시한 31명 중 52%가 기능적 호전을 보여주었고 수정된 AMA score상 술전 21.5점에서 술후 36.3점으로 14.8점이 개선되었다. 3) 양군에서 기능적 호전을 보인 비율은 유의한 수준이 아니지만, 기능적 호전의 정도는 25점과 14.8점으로 자연 회복군이 신경 복원술을 실시한 군보다 통계적으로 더 우수한 기능적 호전을 보임을 알 수 있었다(p<0.05). 4) 결국 저자들은 현재까지 손상의 부위와 정도를 정확하게 진단할 수 있는 방법이 부족한 상태에서 이론적으로 많은 문제점을 가지고, 기껏해야 근력 3 내지 4등급의 회복을 위해 환자에게 큰 부담을 주는, 결과가 확실하지도 않은 수술을 하는 것보다 복잡한 해부학적 구조 및 이에 따른 많은 변종을 가진 상완신경총 손상 환자에게 일단 회복이 되면 더 많은 기능 회복을 줄 수 있는 보존적 요법을 시행하며 자연 회복을 기다리는 것이 났다고 생각한다. 그러므로 저자들은 자연 회복이 수상 후 평균 7.8개월에 시작됨으로 자연 회복을 기대하며 1년간 기다려 본 후 1년이 경과하여도 자연회복이 되지 않는 경우에서 수술적 치료를 시행할 것을 제안한다. There has been no general agreement about optimal time for nerve surgery in the closed brachial plexus injury(BPI). From our early experiences, we knew by chance that spontaneous recovery in BPI patients may begin even later than 8 months after injury. Authors' strategy, which was based on our early experiences, for the treatment of closed fresh injury was 'wait and see' unlit 8 months after injury. From 1985 to 1994, we observed 103 patients with BPI. All of them did not have any operation until 8 months after injury. There were 95 men and 8 women with a mean age of 29 years. Motorcycle injury(31%) and vehicle accident(28%) were main causes of injury. Whole plexus types were observed in 56 patients(54%), upper plexus types in 29(28%), lower plexus types in 3(3%), and infraclavicular types in 15(15%). Electromyography was performed in all patients. This was repeated every three months to detect the recovery. Results were evaluated by authors' criteria, in which AMA system of brachial plexus impairment was modified. Duration of follow up was average 25 months. 47 patients(46%) showed spontaneous improvement, which was initially detected at average 7.8 months(range,3 months-16 months) after trauma by electromyography. The average score of these 47 patients improved from 14.8 points to 39.8 points.31 patients(30%) had nerve surgery such as nerve graft, neurotization or neurolysis. Average duration from injury to nerve surgery, was 10 months. Among 31 patients who had nerve surgery, 16 patients improved from preoperative 21.5 points to postoperative 36.3 points in average. Because spontaneous recovery began in average 7.8 months after injury, we think that it would be better to 'wait and see' for at least one year in patients with closed BPI expecting spontaneous recovery.

흉강경을 통한 교감신경 절제술 후 발생한 상완신경총 손상

문정림,강세윤,양승한,신지남 大韓再活醫學會 1997 Annals of Rehabilitation Medicine Vol.21 No.6

상완 신경총 손상후 주관절 근력 회복을 위한 광배근 전이술

한정수,정덕환,소재호,Han, Chung-Soo,Chung, Duke-Whan,Soh, Jae-Ho 대한미세수술학회 1998 Archives of reconstructive microsurgery Vol.7 No.1

The incidence of brachial plexus injury is increasing because of the development of motor vehicle but the the results of treatment was reported poor due to its complex anatomical structure and changes of function and sensory during the recovery after trauma. But the results of treatment has been improved by the recently introduced high sensitive diagnostic method that can evaluate accurately the site and extent of the injury and treatment method. Restoration of the elbow flexion is the most important goal of treatment after brachial plexus injury and nerve graft, neurotization and muscle transfer were used for methods of treatment. From December 1992 to May 1994, the author performed 6 cases of latissimus dorsi transfer at the same side for the improvement of elbow flexion in the patients of brachial plexus injury. There were 5 cases of male, one case of female and average age was 22 years old. The causes of injury were traffic accident in 3 cases, gun shot injury, falldown and birth injury in each one case and in all cases, the type of injury were upper arm type. The average follow up period were 1 year 5 months ranging from 12 months to 4 years 5 months. In all cases, active elbow flexion was impossible before operation and average muscle power was grade I. We analysed the active range of motion, muscle power and the functional results. At the last follow up, range of active elbow flexion was average $124^{\circ}$ and flexion contracture was average 11 degrees and the average of muscle power was grade IV. In the functional analysis, there were two cases of excellent, three cases of good and 1 case of fair. There was no complications including wound infection, vascular compromise and donor site problem. The results of latissimus dorsi transfer for improvement elbow flexion in the patients of brachial plexus injury is one of the useful mettled for the restoration of elbow flexion.

둔상에 의한 쇄골하동맥과 상완신경총의 동반 손상

한승백,김준식,백광제,김아진,신동운,이용주,백완기 대한응급의학회 2001 대한응급의학회지 Vol.12 No.1

Subclavian artery(SCA) injuries are rare, accounting for only 1 to 2% of all acute vascular injuries. The majority of SCA injuries are occured by motor vehicle accident and by penetrating trauma, only 1 to 5% of all subclavian artery injuries occurred by blunt mechanisms. The incidence of brachial plexus injury is also rare and 60% of brachial plexus injuries induced by blunt injury is occurred by motor vehicle accident. Aggressive diagnostic work-up is recommended for the patients with high suspicious index and repair is essential for the successful management of these rare vascular injuries, We report the experience of one case of combined subclavian artery and brachial plexus injuries due to blunt trauma.

Brachial Plexus Injury in Adults

Park Hye Ran,이광수,Kim Il Sup,Chang Jae-Chil 대한말초신경학회 2017 The Nerve Vol.3 No.1

Brachial plexus injury (BPI) is a severe peripheral nerve injury affecting upper extremities, causing functional damage and physical disability. The most common cause of adult BPI is a traffic accident, and the incidence has steadily increased since the 1980s. BPIs can be divided into three types; preganglionic lesion, postganglionic lesion, and a combination of both. Whether the continuation of the root and the spinal cord is preserved is a critical factor in determining the treatment strategy. The level of lesion can be analogized by clinical manifestations. But imaging studies including computed tomography (CT) myelography and magnetic resonance imaging (MRI) as well as electrodiagnostic studies are helpful in diagnosis of BPI. If diagnostic electromyography suggests that the damage is non-degenerative, conservative management is indicated. However, a reconstructive plan should be formulated, when there is no evidence of spontaneous recovery within 6 months of injury. Operative options used in BPI include nerve grafting, neurotization (nerve transfer), and other brachial plexus reconstructive techniques including the transplantation of various structures. In this review article, the mechanism and classification of injury, clinical manifestations, updated diagnostic studies, recent treatment strategies, and pain after BPI would be discussed.

Risk of Encountering Dorsal Scapular and Long Thoracic Nerves during Ultrasound-guided Interscalene Brachial Plexus Block with Nerve Stimulator

( Yeon Dong Kim ),( Jae Yong Yu ),( Junho Shim ),( Hyun Joo Heo ),( Hyungtae Kim ) 대한통증학회 2016 The Korean Journal of Pain Vol.29 No.3

Background: Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach. Methods: A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded. Results: Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively. Conclusions: Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety. (Korean J Pain 2016; 29: 179-84)

성인에서의 외상성 절전형 상완신경총 손상

김동철,김상수 圓光大學校 醫科學硏究所 1998 圓光醫科學 Vol.14 No.1

In civilian life, motorcycle accidents are the most common cause of traumatic brachial plexus lesions. The lesions can be situated at any level from the nerve roots to the division of the brachial plexus in the axillary region. Preganglionic root avulsion is an irreparable brachial plexus injury. So functional restoration is best achieved by neurotization. But the number of donor nerves available for nerve transfer in the reconstruction of brachial plexus root avulsion injuries is always insufficient. This study was performed to analyze the outcome of neurotization for each donor nerve of 143 donor nerves in 53 patients. Multiple neurotization using the ipsilateral intercostal nerves, phrenic nerve, spinal accessory nerve and supraclavicular nerve is a common procedure in the patients with preganglionic brachial plexus lesions to restore active elbow flexion, shoulder abduction and protective sensation of forearm. As a result, an improvement of motor and sensory score was evident. In the 48 of 143 donor nerve (33.5%), excellent or good results were observed and in the 95 of 143 donor nerve (66.5%), fair or poor results were noted. After surgery, pain was improved grade 1 in 5 patients and more than grade 2 in 20 patients. But, nevertheless surgery, pain was not improved in 10 patients and more aggravated in 2 patients. These results show that the multiple neurotization was partially helpful for the overall functional improvement and improvement of the denervation pain syndrome.

상완 신경총 손상에서 신경 봉합술과 신경이식술

이태균,윤준오,신영호,김재광 대한수부외과학회 2017 대한수부외과학회지 Vol.22 No.3

Brachial plexus injuries (BPI) can have devastating effects on upper extremity function, however, treatment in this injuries remains a difficult problem. Several kinds of surgical methods have been used to treat BPI, and nerve repair and nerve grafting have been traditionally used in postganglionic injury of brachial plexus. Because the several studies reported that nerve transfer to restore shoulder and elbow function has yielded superior results to historical reports for nerve grafting in partial BPI, the indication of nerve repair and nerve grafting has been decreased. Nonetheless, nerve repair and nerve grafting is still useful in focal damage in brachial plexus, such as laceration or gunshot wound and postganglionic neuroma in continuity without conduction of nerve action potential. In this paper, we described the basic concept, detailed indication and outcomes of nerve repair or nerve grafting in BPI. 상완 신경총 마비는 상지의 기능에 심각한 장해를 초래하지만 아직 그 치료 결과가 만족스럽지 못한 실정이다. 최근 미세 수술 기법의 발달로 여러 가지 수술적 방법이 시행되고 있는데, 신경 봉합술이나 신경이식술은 후신경절 손상에서 전통적으로 시행되고 있는 수술 방법이다. 여러 연구에서 상부형 상완 신경총 손상에서 견관절과 주관절 기능회복에서 있어서 신경이전술이 신경이식술보다 좋은 결과를 보인다고 보고하여, 신경이식술의 적응증은 감소하고 있다. 하지만 신경 봉합술이나 신경이식술은 신경 열상이나 총상에 의한 국소적인 손상이나 명확한 후신경절 손상으로 신경 전도가 되지 않는 신경종이 형성된 경우에는 일차적인 신경 재건 방법으로 여겨진다. 따라서 저자들은 신경 봉합술이나 신경이식술의 기본 개념과 적응증, 수술 결과에 대해 구체적으로 언급하고자 한다.

성인에서의 상완신경총 손상

강한빛,이주엽 대한의사협회 2017 대한의사협회지 Vol.60 No.12

As the number of survivors of motor vehicle accidents and extreme sporting accidents increases, more people must live with brachial plexus injuries. Brachial plexus injuries also occur in multiple trauma patients and can be debilitating. Although the injured limb will never return to normal, an improved understanding of the pathophysiology of nerve injury and repair, as well as advances in microsurgical techniques, have provided the upper extremity reconstructive surgeons with opportunities to improve function in patients with these life-altering injuries. The purpose of this review is to present in detail some of the current concepts in the treatment of adult brachial plexus injuries and to give the reader an understanding of the nuances of the timing of treatment, the available treatment options, and the outcomes of treatment.

상완 신경총 손상에서의 수술 전 평가와 치료 계획

유재성,박성배,김종필 대한수부외과학회 2017 대한수부외과학회지 Vol.22 No.3

Brachial plexus injury is regarded as one of the most devastating injuries of the upper extremity. Accurate diagnosis is important to obtain the successful results. Basic preoperative evaluation includes simple radiography, cervical myelography. Magnetic resonance imaging, angiography, electrophysiologic studies and intraoperative studies. Furthermore, proper timing of surgery, surgical indication, plan and sufficient understanding of patients about the prognosis are the key for the satisfactory outcomes. This article provides an overview of the evaluation, diagnosis, intraoperative monitoring, and proper surgical planning for the treatment of posttraumatic brachial plexus injuries. 상완 신경총 손상은 상지의 가장 심각한 손상으로 정확한 진단을 내리는 것이 성공적인 결과를 얻는 데에 있어 중요하다. 기본적인 수술 전 평가에는 단순방사선 촬영, 경부 척수조영, 자기공명영상, 혈관조영술, 전기생리학적 검사 및 수술시의 평가가 있다. 또한, 적절한 수술 시기와 적응증, 수술계획과 환자의 예후에 대한 충분한 예후가 만족스러운 결과를 얻기 위한 필수적 조건이다. 저자들은 상완 신경총 손상의 진단, 수술 시의 관찰과 외상 후 상완신경총 손상 치료의 적절한 수술 계획에 대해 기술하고자 한다.