RU2845901C1 - Method for taking a medial cutaneous nerve of shoulder and a medial cutaneous nerve of forearm for autoneural brachiplex plasty - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to neurosurgery, and can be used for sampling a medial cutaneous nerve of arm and a medial cutaneous nerve of forearm for autoneural brachiplex plasty. Medial cutaneous nerve of shoulder and the medial cutaneous nerve of forearm are approached at the level of a middle one-third of the shoulder along a medial furrow of the shoulder in length of 3-5 cm. That is followed by a sharp and blunt tissue dissection. Above nerve trunks are taken with using Kapron suture material. Govenko's mobiliser is delivered in the distal and proximal directions. Nerve structures are cut off and taken. In the proximal direction, the Govenko's mobiliser is advanced against the stop to a medial fascicle of a brachiplex.

EFFECT: method provides the minimally invasive sampling of the nerve bundles due to the specific features of delivering of Govenko's mobiliser.

1 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, in particular to neurosurgery, namely to peripheral nerve surgery. This technical solution can be used for the purpose of using an additional source of material for autoneuroplasty, isolated by a device for harvesting a sural nerve (hereinafter referred to as the Govenko mobilizer) [Patent No. 2040914 C1 Russian Federation, IPC A61B 17/3205, A61B 17/32. device for harvesting a sural nerve: No. 4659185/14: declared 06.03.1989: published 09.08.1995 / F. S. Govenko; applicant A.L. Polenov Leningrad Research Neurosurgical Institute. - EDN UVXGIE.], in case of extensive and total lesions of peripheral nerve structures.

In case of extensive brachial plexus injuries, it is impossible to perform surgical intervention in the volume of the “end-to-end” suture due to the significant size of the diastasis. To solve the problem of restoring the innervation of the muscles of the upper limb, the method of interfascicular autoneuroplasty is used [N., Ochiai., Akira, Nagano., H., Sugioka., T., Hara. (1996). Nerve grafting in brachial plexus injuries: results of free grafts in 90 patients. Journal of Bone and Joint Surgery-british Volume, 78(5):754-758. doi: 10.1302/0301-620X.78B5.0780754]. Before the operation, ultrasound diagnostics are performed to visualize the extent of the injury, ENMG to assess the conductivity of the brachial plexus. The intervention is performed under general anesthesia with the patient lying on his back with the upper limb abducted at 90 degrees. An incision in the skin and soft tissues is made along the posterior edge of the sternocleidomastoid muscle and the upper edge of the clavicle. The anterior scalene muscle is found, along the anterior surface of which the phrenic nerve passes. By tracing its course, one can find the spinal nerve C5, which laterally connects with the spinal nerve C6, forming the upper trunk of the brachial plexus. Next, the middle trunk is isolated, usually formed by the spinal nerve C7. The subclavian artery is located lowest, behind which is the posterior trunk, most often formed by the spinal nerves C8, Th1. Neurolysis and isolation of the distal and proximal ends of the interrupted nerves from the scars are performed, with an assessment of the magnitude of their diastasis [Hanna A. Anatomy of spinal nerves and approaches to them. - 2020].

Next, autografts are collected. Using the Govenko mobilizer, both sural nerves are isolated and extracted; their length, as a rule, does not exceed 30 cm. In case of total extended damage to the brachial plexus, autografts of such length will not be enough for a full reconstruction of its trunks. Therefore, the optimal additional sources of donor nerves are the sensory nerves of the non-functioning limb. Such nerves are the medial cutaneous nerve of the arm and the medial cutaneous nerve of the forearm. If it is impossible to obtain the sural nerves (damage to the shin tissue), the medial cutaneous nerves of the arm and forearm will be the main donor nerves for autoneural grafting.

On the abducted non-functioning upper limb, an incision is made in the middle third of the medial surface of the arm along the medial groove of the arm, 3-5 cm long. Using sharp and blunt tissue dissection, the medial cutaneous nerve of the arm and the medial cutaneous nerve of the forearm are found under the subcutaneous fat and superficial fascia, which are ligated using the "Kapron" suture material. Then the nerves are crossed and alternately in the distal and proximal directions under the navigation of the ultrasound apparatus are isolated and taken for uatoneuroplasty using the Govenko mobilizer. Thus, in addition to the autografts of the sural nerves, a 15-20 cm autograft of the medial cutaneous nerve of the arm and 30-35 cm of the medial cutaneous nerve of the forearm are obtained. The obtained nerve structures are used for interfascicular autoneuroplasty.

The Govenko mobilizer allows for the collection of nerve structures using minimally invasive approaches.

The objective of the claimed invention is to obtain autoinsertions from the medial cutaneous nerve of the shoulder and the medial cutaneous nerve of the forearm using the Govenko mobilizer using a minimally invasive approach in order to increase the effectiveness of surgical treatment of extensive nerve damage.

The solution to the problem is ensured by the fact that the method of minimally invasive collection of the medial cutaneous nerve of the shoulder and the medial cutaneous nerve of the forearm using the Govenko mobilizer uses an incision in the skin and soft tissues, from which it is possible to isolate the listed nerves without resorting to extensive access.

The essence of the claimed invention is to use a minimally invasive approach to obtain an autoneural insertion. Then, by isolating structures in a blunt manner, the medial cutaneous nerve of the shoulder is identified, which is isolated from the distal and proximal parts using the Govenko mobilizer under the navigation of an ultrasound device. The resulting autoinsertions are used for extensive damage to nerve structures.

The claimed invention is explained with the help of Fig. 1-5, which show:

Fig. 1 – stage of access to the medial cutaneous nerves of the shoulder and forearm in the projection of the medial groove of the shoulder

Fig. 2 – isolation of the medial cutaneous nerves of the shoulder and forearm using suture material

Fig. 3 - collection of medial cutaneous nerves of the shoulder and forearm in the proximal direction using the Govenko mobilizer

Fig. 4 – autograft obtained by harvesting the medial cutaneous nerve of the shoulder using the Govenko mobilizer

Fig. 5 – use of an autograft for plastic surgery of the brachial plexus injury.

The method is performed as follows: if an additional autograft is required for extensive defects, as well as in case of a shortage of materials for plastic surgery (it is impossible to extract n. suralis due to amputation of the limb or its shortage for complete restoration of the defect), access is obtained to the medial cutaneous nerve of the arm and the medial cutaneous nerve of the forearm at the level of the middle third of the arm along the medial groove of the arm 3-5 cm long. Then, after the incision, the above-mentioned nerve trunks are isolated by sharp and blunt dissection of the tissues, fixed with the suture material "Kapron", crossed and the nerve structures are collected in the distal and proximal directions using the Govenko mobilizer. In this case, in the proximal direction it is necessary not to go further than the stop to preserve the medial bundle of the brachial plexus, which is assisted by navigation of the ultrasound apparatus. The isolated autoneural inserts are used for interfascicular autoneuroplasty. In Fig. 1 shows the approach to the nerve trunks at the stage of blunt tissue separation. Fig. 2 shows 1 - the isolated medial cutaneous nerve of the arm. Fig. 3 shows the collection of the autograft of the medial cutaneous nerve of the arm, under the number 1 - the Govenko immobilizer. Fig. 4 shows the trunk of the medial cutaneous nerve of the arm obtained during collection. Fig. 5 shows the brachial plexus plastic surgery with autoinserts n. suralis (2) and n. cutaneous brachii medialis (1).

Clinical case: patient F., 32 years old, with confirmed data of electroneuromyography, magnetic resonance imaging and ultrasound examination of right-sided plexopathy, root avulsions from the spinal cord at the level of C5-C8 on the right. During the operation (described above), autoneural insertions from n. suralis taken from both sides with the Govenko mobilizer were insufficient. A 5 cm linear incision was made along the medial surface of the shoulder. The medial cutaneous nerve of the shoulder was found and isolated. The nerve was taken in the distal and proximal directions, additional autoinsertions were formed, which made it possible to perform the plastic surgery in full. Under an operating microscope using microsurgical techniques, autografts were interfascicularly sutured with the spinal nerves (C5, C6 and C7) and the trunks of the brachial plexus (upper, middle and lower). The postoperative period proceeded without complications and peculiarities (the wound healed by primary intention, night pain syndrome and hypesthesia regressed.

Claims (1)

A method for harvesting the medial cutaneous nerve of the arm and the medial cutaneous nerve of the forearm for autoneural plasty of the brachial plexus, characterized by the fact that access is obtained to the medial cutaneous nerve of the arm and the medial cutaneous nerve of the forearm at the level of the middle third of the arm along the medial groove of the arm 3-5 cm long, sharp and blunt tissue dissection is performed, the above-mentioned nerve trunks are harvested using Kapron suture material; the Govenko mobilizer is carried out in the distal and proximal directions, nerve structures are cut and harvested; in the proximal direction, the Govenko mobilizer is carried out until it stops in the medial bundle of the brachial plexus.