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Brachial plexus endoscopy: Feasibility study on cadavers
Available online at
www.sciencedirect.com Chirurgie de la main 31 (2012) 7–12
Original article
Brachial plexus endoscopy: Feasibility study on cadavers Endoscopie du plexus brachial : étude de la faisabilité sur cadavres J.C. Garcia Jr a, G. Mantovani b, P.-A. Liverneaux c,* a
Center for Advanced Studies in Orthopedics and Neurosurgery, Sports Medicine Division, Pontifical Catholic University of Campinas, São Paulo, Brazil b São Paolo Hand Center, Beneficiencia Portuguesa de Sao Paulo Hospital, São Paolo, Brazil c Hand Surgery Department, Strasbourg University Hospitals, 10, avenue Achille-Baumann, 67403 Illkirch, France Received 3 September 2011; received in revised form 13 December 2011; accepted 15 January 2012
Abstract The development of a minimally invasive technique for exploration of the brachial plexus seems a logical step towards refinement of diagnosis and treatment. For certain pathological conditions, minimally invasive techniques have become the method of choice; for others, they remain as an ancillary option for assistance during open surgery. We have developed a full endoscopic technique for brachial plexus exploration. Our endoscopic technique used saline liquid infusion in seven brachial plexus of four cadavers. Five portals have been described and the endoscopic landmarks also. We were able to demonstrate excellent views and adequate possibilities for cadaver plexus dissection and its anatomic landmarks and portals. Level of evidence. – 4. # 2012 Published by Elsevier Masson SAS. Keywords: Brachial plexus; Arthroscopy; Nerve; Endoscopy
Résumé Le développement d’une technique mini-invasive d’exploration du plexus brachial semble une étape logique pour améliorer le diagnostic et le traitement des paralysies traumatiques du plexus brachial. Dans certaines pathologies, les techniques mini-invasive sont devenues le traitement de choix ; dans d’autres, elles restent une aide technique au cours d’une chirurgie à ciel ouvert. Nous avons développé une technique entièrement endoscopique pour explorer le plexus brachial. Notre technique endoscopique a utilisé une solution saline chez sept plexus brachiaux de quatre cadavres. Cinq voies d’abord ont été décrites ainsi que les repères endoscopiques. Nous pensons avoir démontré que cette technique donnait une excellente vision des repères anatomiques, permettant la dissection du plexus brachial. Niveau de preuve. – 4. # 2012 Publié par Elsevier Masson SAS. Mots clés : Plexus brachial ; Arthroscopie ; Nerf ; Endoscopie
1. Introduction The diagnosis of patients with traumatic closed brachial plexus lesions (BPL) is achieved by clinical neurological assessments, electroneuromyographic studies, and diagnostic imaging assessments, such as magnetic resonance [1–5]. The
* Corresponding author. E-mail addresses: [email protected], [email protected] (P.A. Liverneaux). 1297-3203/$ – see front matter # 2012 Published by Elsevier Masson SAS. doi:10.1016/j.main.2012.01.001
open procedure has become the golden treatment procedure for cases where surgical exploration and repair of rupture of the plexus are necessary [6–8]. Surgeons often encounter intraoperative findings that are not correlated with the preoperative diagnostic study [9]. The best surgical technique can only be determined after exposure. Rupture or root avulsion must be surgically treated as early as possible, in order to ensure the restoration of best muscle function. On the other hand, enough time must be provided for spontaneous recovery. Because of these contradictory factors, the endoscopic exploration of the brachial plexus can facilitate observation
J.C. Garcia Jr et al. / Chirurgie de la main 31 (2012) 7–12
8
of the lesion and provides the best surgical planning using a minimally invasive procedure. Some authors endoscopically observed the cervical roots in goats [10]. Another one observed the brachial plexus in cadaveric model through a mini opening of 2–2.5 cm using retractors [9], although that may not be a reliable procedure in live model. Recently, some authors [11–13] have successfully manipulated the suprascapular nerve in live model using just arthroscopic skills. No previous report has been written about endoscopic technique for the brachial plexus. We report a full endoscopic technique using saline liquid infusion in brachial plexus of cadavers. 2. Materials and methods Seven brachial plexus, in four intact fresh human cadavers, were explored in supine position. A regular 4 mm scope with 308 and a contemporary arthroscopy tower (Stryker1) with a digital video recorder were used. The brachial plexus was explored via five portals, two supraclavicular and three infraclavicular ones. The various parts of the brachial plexus were endoscopically dissected and identified using shavers and probe. The first supraclavicular portal was made at the lateral border of the sternocleidomastoid muscle, approximately 5 cm above its point of insertion on the clavicle, and the second one just above the middle of the clavicle (Fig. 1). The omohyoid was the first muscle visualised through the scope, and a regular basket was used to cut its tendinous core (Fig. 2). The brachial plexus fat protection was right next to the omohyoid muscle. Using a regular shaver (4 mm Stryker1), its protection could be carefully removed and two structures were visualized: the anterior scalenus muscle and the phrenic nerve (Fig. 3). The nerve was then separated from the muscle using a regular probe, and the scalenectomy was performed using the shaver. The shaver was used without aspiration. The C5 and C6 roots were located just underneath the removed scalen muscle (Fig. 4), and
Fig. 3. Endoscopic supraclavicular view: phrenic nerve and anterior scalenus muscle.
Fig. 1. Supraclavicular portals.
Fig. 4. Endoscopic supraclavicular view after scalenectomy: C5 and C6 roots.
Fig. 2. Endoscopic supraclavicular view: omohyoid muscle.
J.C. Garcia Jr et al. / Chirurgie de la main 31 (2012) 7–12
Fig. 5. Endoscopic supraclavicular view after scalenectomy: brachial plexus, trunk area.
Fig. 6. Endoscopic supraclavicular view after scalenectomy: long thoracic nerve and dorsal scapular nerve.
Fig. 7. Endoscopic supraclavicular view after scalenectomy: transverse cervical artery crossing above the superior trunk.
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Fig. 8. Endoscopic supraclavicular view after scalenectomy: suprascapular nerve branching from the superior trunk.
they joined to create the superior trunk (ST) (Fig. 5). Returning the view upwards to the C5 root, one could see the dorsal scapular nerve, and just after it, the long thoracic nerve. These two nerves presented difficult dissection (Fig. 6). The middle trunk was just inward to the ST and the inferior trunk was immediately next to the middle trunk (Fig. 5). When dissecting the ST in the clavicle direction, one could see the subclavian nerve and the transverse cervical artery crossing the ST right above it (Fig. 7). Following the ST in the same direction, the suprascapular nerve branched out from it (Fig. 8). Concerning subclavicular exploration, a lateral portal (LP) was made in the shoulder 0.5 cm posterior to the anterolateral corner of the acromion. Other portal (AP) was made just beside the coracoid (Fig. 9). The endoscope was inserted in the LP and a shaver was inserted in the AP. Subdeltoid dissection was performed above the subscapularis muscle and the axillary nerve was found just below the subscapularis muscle. Moving the scope inwards and into the subcoracoid space, the fat plexus
Fig. 9. Infraclavicular portals.
10
J.C. Garcia Jr et al. / Chirurgie de la main 31 (2012) 7–12
acromioclavicular joint. Inserting the scope inwards the shoulder, the suprascapular artery could be found. Rarely, the artery pass under the ligament [13]. The cleaning of this space could be made through the posterior medial portal. In order to obtain the best location for this portal, an 18-gauge needle was used. It was inserted just above the scapular spine and below the clavicle, 1–2 cm medial and parallel to the acromioclavicular joint. The transverse superior ligament was located under the suprascapular artery and beside the conoid ligament, near the coracoid’s base. The fat that protects the nerve could also be removed at this moment. After completion of the endoscopic exploration, open dissection was performed for reidentification and verification of the structures, as well as assessment of possible injury to neurovascular structure. 3. Results Fig. 10. Endoscopic infraclavicular view below the pectoralis minor muscle and medial to the coracoid: lateral cord and axilary artery.
protection could be carefully removed. The lateral cord and its divisions were exposed (Figs. 10 and 11): the musculocutaneous nerve and median nerve. The axillary artery was right below the structures mentioned before. Right next the coracoid and through the pectoralis minor muscle an anteromedial portal could be opened, guided by an 18-gauge needle in order to manipulate the lateral and medial cord. The inferior cord was not easily seen. The scope was withdrawn from the sub coracoid and sub pectoralis minor spaces and it was inserted into the subacromial space towards the coracoclavicular ligaments in order to expose the suprascapularis nerve. Subacromial space and the subacromial decompression were performed using a combination of a mechanical shaver and a radiofrequency device to allow visualization of the subacromial space. The acromioclavicular joint was found. Coracoclavicular ligaments were located under the clavicle next to the
Average duration of the procedure was about 2 hours. The landmark structures used to identify the different parts of the brachial plexus were summarized above. Identification of the omohyoid muscle leaded to the upper trunk exposure. Therefore, other brachial plexus nerves, trunks and arteries could be identified as well. The clavicle and the sternocleidomastoid muscle serve as external landmarks for supraclavicular plexus dissection. The plexal structures were also identified distally exposing their corresponding cords and nerves. Even at the level of subclavicular dissection, the posterior arch of the first rib, the pleural dome, and then the C8 and T1 roots could not be easily found. The coracoid process and subscapularis muscle are leading structures in the infraclavicular approach. As the clavipectoral fascia was slit, the first part of the axillary artery could be observed, around which the plexal structures were located. At this level, the lateral cord and musculocutaneous nerve lied beside the axillary artery. The posterior cord lied underneath and behind the axillary artery. Identifying these cords and tracing them in the appendicular direction leaded to the corresponding nerves. The plexus anatomic features were constant in all dissected specimens. We encountered muscular structures variations. The neurovascular structures have presented regular anatomy. No vascular or nerve injuries were observed in the specimens. 4. Discussion
Fig. 11. Endoscopic infraclavicular view below the pectoralis minor muscle and medial to the coracoid: division of the lateral cord in median and musculocutaneous nerves.
The development of a minimally invasive technique for exploration of the brachial plexus seems a logical step towards refinement of diagnosis and treatment. For certain pathological conditions, minimally invasive techniques have become the method of choice; for others, they remain as an ancillary option for assistance during open surgery or for cosmetic reasons. Endoscopic techniques have gained popularity. The idea of using endoscopic techniques to dissect soft tissue without a predefined space is not new; rotator cuff lesions, arthroscopic Bristow-Latarjet-like [14] and suprascapular nerve decompression [11–13] are examples. To our knowledge, there is just one
J.C. Garcia Jr et al. / Chirurgie de la main 31 (2012) 7–12
11
description of an endoscopic method for observation of the brachial plexus among human subjects using a mini open and spacers [9]. In our experience, the method mentioned above has not proved to be viable in live beings, and it has not shown satisfactory results in cadaveric models, either. The study we report here is a preparation for the clinical application of endoscopic exploration of the brachial plexus. We were able to demonstrate excellent views and adequate possibilities for cadaver plexus dissection. The indications for plexus exploration in closed injuries are based on serial clinical examinations [1,5]. A favourable time for endoscopic exploration of the injured brachial
plexus would be within one week after the injury, when scarring has not yet occurred. A tear or rupture in the brachial plexus can be previously detected by using the endoscopic technique. This might offer the advantage of advancing surgical decisions, and the planning of the best reconstruction method at an early stage, when conditions are favourable. Moreover, it would be sufficient to dissect only structures that are involved in the reconstruction, without dissecting all of the brachial plexus. For simple injuries, where neurolysis is the only appropriate method, endoscopy can be successfully performed. Electrostimulation seems possible through brachial plexus endoscopy, even if unable on our cadaver model. The scalenectomy can also be indicated by scope. Robotic surgery and procedures using neurotubs may be associated with the endoscopy in the future [15,16]. Other applications can include dissection of Sibson’s fascia or fibrous bands when compressing the brachial plexus and causing thoracic outlet syndrome. It is also possible to apply the technique for treatment of other nerve entrapment syndromes, such as suprascapular nerve entrapment. Future studies in live animal model can reveal the advantages and disadvantages of this method. In live humans, the use of the scope has enabled us to visualize the lateral cord, the suprascapular (Fig. 12), the musculocutaneous (Fig. 13), the median and the axilary nerves (Fig. 14). Endoscopic exploration of the brachial plexus can be feasible. Our data, using fresh human cadavers, have demonstrated that the risks of injury to major neurovascular structures can be minimized by being careful when dissecting and by increasing familiarity with the instrumentation and the two-dimensional findings. Endoscopic exploration of the brachial plexus may play an important role in early identification of the type of nerve lesion involved, thus enabling early decision-making regarding the method of reconstruction.
Fig. 13. Musculocutaneous nerve, aclavicular view below the pectoralis minor muscle and medial to the coracoid. Live patient.
Fig. 14. Axillary nerve, infraclavicular view subdeltoid. Live patient.
Fig. 12. Endoscopic release of the suprascapular nerve, view posterior and medial to the coracoclavicular ligaments through infraclavicular portals. Live patient.
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Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Doi K, Otsuka K, Okamoto Y, Fujii H, Hattori Y, Baliarsing AS. Cervical nerve root avulsion in brachial plexus injuries: magnetic resonance imaging classification and comparison with myelography and computerized tomography myelography. J Neurosurg 2002;96:277–84. [2] Hems TE, Birch R, Carlstedt T. The role of magnetic resonance imaging in the management of traction injuries to the adult brachial plexus. J Hand Surg 1999;24B:550–5. [3] Landi J, Copeland AS. Value of the Tinel sign in brachial plexus lesions. Ann R Coll Surg Engl 1979;61:470–1. [4] Landi A, Copeland SA, Parry CB, Jones SJ. The role of somatosensory evoked potentials and nerve conduction studies in the surgical management of brachial plexus injuries. J Bone Joint Surg 1980;62B: 492–6. [5] Stevens JH. Brachial plexus injuries. Clin Orthop 1988;237:4–8. [6] Millesi H. Brachial plexus injuries: management and results. In: Terzis JK, editor. Microreconstruction of Nerve Injuries. Philadelphia: W.B. Saunders Co; 1987. p. 347–60.
[7] Narakas A. Surgical treatment of traction injuries of the brachial plexus. Clin Orthop Rel Res 1978;133:71–90. [8] Narakas A. The treatment of brachial plexus injuries. Int Orthop 1985;9:29–36. [9] Krishnan KG, Pinzer T, Reber F, Schackert G. Endoscopic exploration of the brachial plexus: technique and topographic anatomy-a study in fresh human cadavers. Neurosurgery 2004;54:401–9. [10] Monsivais JJ, Narakas AO, Turkof E, Sun Y. The endoscopic diagnosis and possible treatment of nerve root avulsions in the management of brachial plexus injuries. J Hand Surg 1994;19B:547–9. [11] Bhatia DN, de Beer JF, van Rooyen KS, du Toit DF. Arthroscopic suprascapular nerve decompression at the suprascapular notch. Arthroscopy 2006;22:1009–13. [12] Lafosse L, Tomasi A, Corbett S, Baier G, Willems K, Gobezie R. Arthroscopic release of suprascapular nerve entrapment at the suprascapular notch: technique and preliminary results. Arthroscopy 2007;23:34–42. [13] Garcia JC. Arthroscopic decompression of the suprascapular nerve: surgical technique. Tech Shoulder Elbow Surg 2009;10:157–9. [14] Garcia JC, Garcia JPM, Mattos CA, Zabeu JLA. Arthroscopic BristowLatarjet-like procedure: surgical technique. Tech Shoulder Elbow Surg 2009;10:94–8. [15] Taleb C, Nectoux E, Liverneaux PA. Telemicrosurgery: a feasibility study in a rat model. Chir Main 2008;27:104–8. [16] Nectoux E, Taleb C, Liverneaux P. Nerve repair in telemicrosurgery: an experimental study. J Reconstruc Microsurg 2009;4:261–5.
www.sciencedirect.com Chirurgie de la main 31 (2012) 7–12
Original article
Brachial plexus endoscopy: Feasibility study on cadavers Endoscopie du plexus brachial : étude de la faisabilité sur cadavres J.C. Garcia Jr a, G. Mantovani b, P.-A. Liverneaux c,* a
Center for Advanced Studies in Orthopedics and Neurosurgery, Sports Medicine Division, Pontifical Catholic University of Campinas, São Paulo, Brazil b São Paolo Hand Center, Beneficiencia Portuguesa de Sao Paulo Hospital, São Paolo, Brazil c Hand Surgery Department, Strasbourg University Hospitals, 10, avenue Achille-Baumann, 67403 Illkirch, France Received 3 September 2011; received in revised form 13 December 2011; accepted 15 January 2012
Abstract The development of a minimally invasive technique for exploration of the brachial plexus seems a logical step towards refinement of diagnosis and treatment. For certain pathological conditions, minimally invasive techniques have become the method of choice; for others, they remain as an ancillary option for assistance during open surgery. We have developed a full endoscopic technique for brachial plexus exploration. Our endoscopic technique used saline liquid infusion in seven brachial plexus of four cadavers. Five portals have been described and the endoscopic landmarks also. We were able to demonstrate excellent views and adequate possibilities for cadaver plexus dissection and its anatomic landmarks and portals. Level of evidence. – 4. # 2012 Published by Elsevier Masson SAS. Keywords: Brachial plexus; Arthroscopy; Nerve; Endoscopy
Résumé Le développement d’une technique mini-invasive d’exploration du plexus brachial semble une étape logique pour améliorer le diagnostic et le traitement des paralysies traumatiques du plexus brachial. Dans certaines pathologies, les techniques mini-invasive sont devenues le traitement de choix ; dans d’autres, elles restent une aide technique au cours d’une chirurgie à ciel ouvert. Nous avons développé une technique entièrement endoscopique pour explorer le plexus brachial. Notre technique endoscopique a utilisé une solution saline chez sept plexus brachiaux de quatre cadavres. Cinq voies d’abord ont été décrites ainsi que les repères endoscopiques. Nous pensons avoir démontré que cette technique donnait une excellente vision des repères anatomiques, permettant la dissection du plexus brachial. Niveau de preuve. – 4. # 2012 Publié par Elsevier Masson SAS. Mots clés : Plexus brachial ; Arthroscopie ; Nerf ; Endoscopie
1. Introduction The diagnosis of patients with traumatic closed brachial plexus lesions (BPL) is achieved by clinical neurological assessments, electroneuromyographic studies, and diagnostic imaging assessments, such as magnetic resonance [1–5]. The
* Corresponding author. E-mail addresses: [email protected], [email protected] (P.A. Liverneaux). 1297-3203/$ – see front matter # 2012 Published by Elsevier Masson SAS. doi:10.1016/j.main.2012.01.001
open procedure has become the golden treatment procedure for cases where surgical exploration and repair of rupture of the plexus are necessary [6–8]. Surgeons often encounter intraoperative findings that are not correlated with the preoperative diagnostic study [9]. The best surgical technique can only be determined after exposure. Rupture or root avulsion must be surgically treated as early as possible, in order to ensure the restoration of best muscle function. On the other hand, enough time must be provided for spontaneous recovery. Because of these contradictory factors, the endoscopic exploration of the brachial plexus can facilitate observation
J.C. Garcia Jr et al. / Chirurgie de la main 31 (2012) 7–12
8
of the lesion and provides the best surgical planning using a minimally invasive procedure. Some authors endoscopically observed the cervical roots in goats [10]. Another one observed the brachial plexus in cadaveric model through a mini opening of 2–2.5 cm using retractors [9], although that may not be a reliable procedure in live model. Recently, some authors [11–13] have successfully manipulated the suprascapular nerve in live model using just arthroscopic skills. No previous report has been written about endoscopic technique for the brachial plexus. We report a full endoscopic technique using saline liquid infusion in brachial plexus of cadavers. 2. Materials and methods Seven brachial plexus, in four intact fresh human cadavers, were explored in supine position. A regular 4 mm scope with 308 and a contemporary arthroscopy tower (Stryker1) with a digital video recorder were used. The brachial plexus was explored via five portals, two supraclavicular and three infraclavicular ones. The various parts of the brachial plexus were endoscopically dissected and identified using shavers and probe. The first supraclavicular portal was made at the lateral border of the sternocleidomastoid muscle, approximately 5 cm above its point of insertion on the clavicle, and the second one just above the middle of the clavicle (Fig. 1). The omohyoid was the first muscle visualised through the scope, and a regular basket was used to cut its tendinous core (Fig. 2). The brachial plexus fat protection was right next to the omohyoid muscle. Using a regular shaver (4 mm Stryker1), its protection could be carefully removed and two structures were visualized: the anterior scalenus muscle and the phrenic nerve (Fig. 3). The nerve was then separated from the muscle using a regular probe, and the scalenectomy was performed using the shaver. The shaver was used without aspiration. The C5 and C6 roots were located just underneath the removed scalen muscle (Fig. 4), and
Fig. 3. Endoscopic supraclavicular view: phrenic nerve and anterior scalenus muscle.
Fig. 1. Supraclavicular portals.
Fig. 4. Endoscopic supraclavicular view after scalenectomy: C5 and C6 roots.
Fig. 2. Endoscopic supraclavicular view: omohyoid muscle.
J.C. Garcia Jr et al. / Chirurgie de la main 31 (2012) 7–12
Fig. 5. Endoscopic supraclavicular view after scalenectomy: brachial plexus, trunk area.
Fig. 6. Endoscopic supraclavicular view after scalenectomy: long thoracic nerve and dorsal scapular nerve.
Fig. 7. Endoscopic supraclavicular view after scalenectomy: transverse cervical artery crossing above the superior trunk.
9
Fig. 8. Endoscopic supraclavicular view after scalenectomy: suprascapular nerve branching from the superior trunk.
they joined to create the superior trunk (ST) (Fig. 5). Returning the view upwards to the C5 root, one could see the dorsal scapular nerve, and just after it, the long thoracic nerve. These two nerves presented difficult dissection (Fig. 6). The middle trunk was just inward to the ST and the inferior trunk was immediately next to the middle trunk (Fig. 5). When dissecting the ST in the clavicle direction, one could see the subclavian nerve and the transverse cervical artery crossing the ST right above it (Fig. 7). Following the ST in the same direction, the suprascapular nerve branched out from it (Fig. 8). Concerning subclavicular exploration, a lateral portal (LP) was made in the shoulder 0.5 cm posterior to the anterolateral corner of the acromion. Other portal (AP) was made just beside the coracoid (Fig. 9). The endoscope was inserted in the LP and a shaver was inserted in the AP. Subdeltoid dissection was performed above the subscapularis muscle and the axillary nerve was found just below the subscapularis muscle. Moving the scope inwards and into the subcoracoid space, the fat plexus
Fig. 9. Infraclavicular portals.
10
J.C. Garcia Jr et al. / Chirurgie de la main 31 (2012) 7–12
acromioclavicular joint. Inserting the scope inwards the shoulder, the suprascapular artery could be found. Rarely, the artery pass under the ligament [13]. The cleaning of this space could be made through the posterior medial portal. In order to obtain the best location for this portal, an 18-gauge needle was used. It was inserted just above the scapular spine and below the clavicle, 1–2 cm medial and parallel to the acromioclavicular joint. The transverse superior ligament was located under the suprascapular artery and beside the conoid ligament, near the coracoid’s base. The fat that protects the nerve could also be removed at this moment. After completion of the endoscopic exploration, open dissection was performed for reidentification and verification of the structures, as well as assessment of possible injury to neurovascular structure. 3. Results Fig. 10. Endoscopic infraclavicular view below the pectoralis minor muscle and medial to the coracoid: lateral cord and axilary artery.
protection could be carefully removed. The lateral cord and its divisions were exposed (Figs. 10 and 11): the musculocutaneous nerve and median nerve. The axillary artery was right below the structures mentioned before. Right next the coracoid and through the pectoralis minor muscle an anteromedial portal could be opened, guided by an 18-gauge needle in order to manipulate the lateral and medial cord. The inferior cord was not easily seen. The scope was withdrawn from the sub coracoid and sub pectoralis minor spaces and it was inserted into the subacromial space towards the coracoclavicular ligaments in order to expose the suprascapularis nerve. Subacromial space and the subacromial decompression were performed using a combination of a mechanical shaver and a radiofrequency device to allow visualization of the subacromial space. The acromioclavicular joint was found. Coracoclavicular ligaments were located under the clavicle next to the
Average duration of the procedure was about 2 hours. The landmark structures used to identify the different parts of the brachial plexus were summarized above. Identification of the omohyoid muscle leaded to the upper trunk exposure. Therefore, other brachial plexus nerves, trunks and arteries could be identified as well. The clavicle and the sternocleidomastoid muscle serve as external landmarks for supraclavicular plexus dissection. The plexal structures were also identified distally exposing their corresponding cords and nerves. Even at the level of subclavicular dissection, the posterior arch of the first rib, the pleural dome, and then the C8 and T1 roots could not be easily found. The coracoid process and subscapularis muscle are leading structures in the infraclavicular approach. As the clavipectoral fascia was slit, the first part of the axillary artery could be observed, around which the plexal structures were located. At this level, the lateral cord and musculocutaneous nerve lied beside the axillary artery. The posterior cord lied underneath and behind the axillary artery. Identifying these cords and tracing them in the appendicular direction leaded to the corresponding nerves. The plexus anatomic features were constant in all dissected specimens. We encountered muscular structures variations. The neurovascular structures have presented regular anatomy. No vascular or nerve injuries were observed in the specimens. 4. Discussion
Fig. 11. Endoscopic infraclavicular view below the pectoralis minor muscle and medial to the coracoid: division of the lateral cord in median and musculocutaneous nerves.
The development of a minimally invasive technique for exploration of the brachial plexus seems a logical step towards refinement of diagnosis and treatment. For certain pathological conditions, minimally invasive techniques have become the method of choice; for others, they remain as an ancillary option for assistance during open surgery or for cosmetic reasons. Endoscopic techniques have gained popularity. The idea of using endoscopic techniques to dissect soft tissue without a predefined space is not new; rotator cuff lesions, arthroscopic Bristow-Latarjet-like [14] and suprascapular nerve decompression [11–13] are examples. To our knowledge, there is just one
J.C. Garcia Jr et al. / Chirurgie de la main 31 (2012) 7–12
11
description of an endoscopic method for observation of the brachial plexus among human subjects using a mini open and spacers [9]. In our experience, the method mentioned above has not proved to be viable in live beings, and it has not shown satisfactory results in cadaveric models, either. The study we report here is a preparation for the clinical application of endoscopic exploration of the brachial plexus. We were able to demonstrate excellent views and adequate possibilities for cadaver plexus dissection. The indications for plexus exploration in closed injuries are based on serial clinical examinations [1,5]. A favourable time for endoscopic exploration of the injured brachial
plexus would be within one week after the injury, when scarring has not yet occurred. A tear or rupture in the brachial plexus can be previously detected by using the endoscopic technique. This might offer the advantage of advancing surgical decisions, and the planning of the best reconstruction method at an early stage, when conditions are favourable. Moreover, it would be sufficient to dissect only structures that are involved in the reconstruction, without dissecting all of the brachial plexus. For simple injuries, where neurolysis is the only appropriate method, endoscopy can be successfully performed. Electrostimulation seems possible through brachial plexus endoscopy, even if unable on our cadaver model. The scalenectomy can also be indicated by scope. Robotic surgery and procedures using neurotubs may be associated with the endoscopy in the future [15,16]. Other applications can include dissection of Sibson’s fascia or fibrous bands when compressing the brachial plexus and causing thoracic outlet syndrome. It is also possible to apply the technique for treatment of other nerve entrapment syndromes, such as suprascapular nerve entrapment. Future studies in live animal model can reveal the advantages and disadvantages of this method. In live humans, the use of the scope has enabled us to visualize the lateral cord, the suprascapular (Fig. 12), the musculocutaneous (Fig. 13), the median and the axilary nerves (Fig. 14). Endoscopic exploration of the brachial plexus can be feasible. Our data, using fresh human cadavers, have demonstrated that the risks of injury to major neurovascular structures can be minimized by being careful when dissecting and by increasing familiarity with the instrumentation and the two-dimensional findings. Endoscopic exploration of the brachial plexus may play an important role in early identification of the type of nerve lesion involved, thus enabling early decision-making regarding the method of reconstruction.
Fig. 13. Musculocutaneous nerve, aclavicular view below the pectoralis minor muscle and medial to the coracoid. Live patient.
Fig. 14. Axillary nerve, infraclavicular view subdeltoid. Live patient.
Fig. 12. Endoscopic release of the suprascapular nerve, view posterior and medial to the coracoclavicular ligaments through infraclavicular portals. Live patient.
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J.C. Garcia Jr et al. / Chirurgie de la main 31 (2012) 7–12
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Doi K, Otsuka K, Okamoto Y, Fujii H, Hattori Y, Baliarsing AS. Cervical nerve root avulsion in brachial plexus injuries: magnetic resonance imaging classification and comparison with myelography and computerized tomography myelography. J Neurosurg 2002;96:277–84. [2] Hems TE, Birch R, Carlstedt T. The role of magnetic resonance imaging in the management of traction injuries to the adult brachial plexus. J Hand Surg 1999;24B:550–5. [3] Landi J, Copeland AS. Value of the Tinel sign in brachial plexus lesions. Ann R Coll Surg Engl 1979;61:470–1. [4] Landi A, Copeland SA, Parry CB, Jones SJ. The role of somatosensory evoked potentials and nerve conduction studies in the surgical management of brachial plexus injuries. J Bone Joint Surg 1980;62B: 492–6. [5] Stevens JH. Brachial plexus injuries. Clin Orthop 1988;237:4–8. [6] Millesi H. Brachial plexus injuries: management and results. In: Terzis JK, editor. Microreconstruction of Nerve Injuries. Philadelphia: W.B. Saunders Co; 1987. p. 347–60.
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