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MICROSURGERY AND NERVE RECONSTRUCTION IN COMPLEX

BRACHIAL PLEXUS INJURIES: PROGNOSIS AND LIMITATIONS

Felipe Guimarães Betini1

Matheus Carvalho Meneghetti2

Ricardo Felipe dos Santos Silva3

João Pedro do Valle Varela4

Roberta dos Santos Abreu5

Juliana da Silva Deascanio6

Bruno de Figueiredo Moutinho7

Maria Clara Gama Pessanha8

Sayd Guedes Saib Abi-Habib9

Raissa Resende Moreira10

Izabele von Krüger de Alcântara e Silva11

Letícia Isadora Miosso12

Leandro de Oliveira Camara13

Nathalia Costa Buzatto14

1 Unoeste

2 Unoeste

3 H. Municipal Ronaldo Gazolla

4 UniSãoCarlos

5 UniSãoCarlos

6 UniSãoCarlos

7 UniRedentor

8 Faculdade de Medicina de Campos

9 Faculty Multivix Vitória

10 PUC Minas

11 PUC Minas

12 Univille

13 Faculty Souza Marques

14 Faculty Multivix Vitória

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Leonardo Nasser Pauferro15

Rafael Stephan Faion16

Abstract: Complex brachial plexus injuries represent a major challenge in medicine, as they can result

in severe motor and sensory decits, signicantly impacting patients’ quality of life. Microsurgery

and nerve reconstruction techniques have evolved to restore upper limb function, but they still have

limitations in terms of full recovery of functionality. The prognosis varies according to the severity of

the injury, the time elapsed before the intervention and the surgical approaches used. This study aims

to analyze the advances in microsurgery in brachial plexus reconstruction, assessing the prognosis

and limitations of these approaches in patients with complex injuries. This is a bibliographic review

with qualitative premises, using the SciELO, PubMed and Google Scholar databases to search for

scientic articles. To rene the search, the health descriptors “brachial plexus”, “microsurgery”,

“nerve reconstruction” and “nerve transfers” were used, applying Boolean operators to optimize

the results. The time frame covers the years 2019 to 2023, according to the date of the rst and

last reference selected. Advances in microsurgery have allowed for better functional recovery rates,

especially with techniques such as nerve grafts, nerve transfers and neurotizations. Nerve transfers

have stood out for reducing reinnervation time, favoring better motor results. However, factors such

as the chronicity of the injury, surgical time and the patient’s neural plasticity signicantly inuence

outcomes. Limitations include the need for prolonged rehabilitation, variability in functional results and

diculty in restoring ne movements and adequate muscle strength. It is concluded that microsurgery

and nerve reconstruction are fundamental strategies in the rehabilitation of patients with complex

brachial plexus injuries, providing partial or signicant recovery of upper limb function. Despite

advances, challenges such as prolonged recovery time and limitations in complete nerve regeneration

still persist. New approaches, including regenerative therapies and tissue engineering, may contribute

to better prognoses in the future.

15 University of Vila Velha

16 PUC Minas

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Keywords: General Surgery; Brachial Plexus Surgery; Microsurgery; Nerve Reconstruction.

INTRODUCTION

Brachial plexus injuries represent one of the most complex challenges in reconstructive

surgery, with signicant impacts on upper limb functionality and patients’ quality of life. These

injuries can occur due to high-energy trauma, such as automobile accidents and traction injuries,

and often result in severe motor and sensory decits. Treatment involves conservative and surgical

approaches, and reconstructive microsurgery is a fundamental strategy to try to reestablish neural

function (SOUZA; PEREIRA, 2020).

Reconstructive brachial plexus microsurgery is based on sophisticated neurorrhaphy, nerve

grafting, and nerve transfer techniques. Technological advances and improved knowledge about

neurophysiology have allowed a renement of these techniques, increasing the chances of functional

recovery, although there are still signicant limitations, such as nerve regeneration time and peripheral

nervous system plasticity (LIMA et al., 2019). The choice of surgical technique depends on factors

such as the location and extent of the lesion, the time elapsed since the trauma, and the presence of

viable donor nerves (MARTINS; ALMEIDA, 2022).

Despite advances in microsurgery, functional recovery after extensive brachial plexus

injuries remains a challenge. The prognosis is directly related to the precocity of the intervention,

the type of injury (avulsion or rupture) and the ecacy of postoperative rehabilitation (CARVALHO;

RIBEIRO, 2021). Many patients face diculties in regaining full upper limb function, requiring

prolonged rehabilitation and, in some cases, additional surgical procedures for functional improvement

(SANTOS et al., 2020).

This study aims to analyze the prognoses and limitations of microsurgical techniques

in brachial plexus nerve reconstruction in complex lesions. The literature review will address

advances in surgical techniques, the factors that inuence nerve recovery, and future perspectives

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for the management of these cases. A detailed understanding of these aspects is essential to improve

therapeutic approaches and optimize functional outcomes for aected patients (GOMES; SILVEIRA,

2023).

This study aims to analyze the advances of microsurgery in brachial plexus reconstruction,

evaluating the prognosis and limitations of these approaches in patients with complex lesions.

MATERIALS AND METHODS

This is a literature review with qualitative premises, using the SciELO, PubMed and Google

Scholar databases to search for scientic articles. To rene the research, the health descriptors “brachial

plexus”, “microsurgery”, “nerve reconstruction” and “nerve transfers” were used, applying Boolean

operators to optimize the results. The time frame comprises the years 2019 to 2023, according to the

date of the rst and last selected reference.

Guiding Question:

What is the eectiveness of microsurgical techniques in brachial plexus reconstruction and

what are the main challenges and recent advances in this approach?

Inclusion Criteria:

Articles published between 2019 and 2023.

Studies that address microsurgery, nerve transfers, and functional prognosis in brachial

plexus reconstruction.

Works indexed in recognized scientic databases (SciELO, PubMed and Google Scholar).

Studies available in full, published in Portuguese, English or Spanish.

Systematic reviews, case studies, clinical trials, and narrative reviews with clinical relevance.

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Exclusion Criteria:

Studies published before 2019.

Works not available in full or in open access.

Articles that deal only with anatomical aspects without clinical application.

Research addressing brachial plexus injuries without focusing on microsurgical reconstruction.

Duplicate publications or preliminary versions of already selected studies.

Boolean Markers:

The descriptors were combined with Boolean operators for search optimization:

(“Brachial plexus” AND “Microsurgery”)

(“Nerve Reconstruction” OR “Nerve Transfers”)

(“Brachial Plexus” AND (“Microsurgery” OR “Nerve Transfers”)

THEORETICAL FOUNDATION

The brachial plexus is a complex network of nerves originating from the C5 to T1 cervical

roots, responsible for the motor and sensory innervation of the upper limb. Its lesions can be classied

according to the location and degree of involvement, with the main categories being root avulsion,

nerve rupture, and stretch or compression injuries. The impact of these injuries depends on the

severity and extent of the damage, and may result in irreversible motor and sensory decits if there is

no adequate intervention (MACHADO et al., 2022).

The pathophysiology of brachial plexus lesions involves processes of Wallerian degeneration

and subsequent neuronal regeneration. However, the regenerative capacity of the peripheral nerve is

limited and depends on factors such as the patient’s age, the time of ischemia, the distance between the

nerve stumps, and the presence of brotic scarring. Surgical techniques such as neurorhaphy, nerve

grafts, and nerve transfers are essential to optimize regeneration and improve functional outcomes

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(SILVA et al., 2023).

Nerve microsurgery has been widely used for brachial plexus reconstruction in cases of

complex injuries. Direct neurorrhaphy is indicated for lesions with minimal loss of nerve substance,

allowing the reconnection of the stumps without excessive tension. In cases of extensive loss of

nervous tissue, the use of autologous grafts, such as the sural nerve, is an eective alternative to

restore neural continuity (FERNANDES; MORAES, 2021).

In addition to nerve grafts, nerve transfers have emerged as an innovative approach to restore

function in irreparable or dicult-to-recover injuries. These techniques involve redirecting functional

nerves to injured nerves, speeding up the rehabilitation process. Studies indicate that nerve transfers

oer greater recovery potential when performed early, reducing muscle degeneration and promoting

neural plasticity (COSTA et al., 2022).

Functional recovery after brachial plexus reconstruction is inuenced by multiple factors,

including the precocity of the surgery, the type of technique used, and the patient’s adherence to

postoperative rehabilitation. Studies show that interventions performed within six months after the

injury have better prognosis, due to the greater viability of muscle targets (BARROS; SOUZA, 2021).

In addition to the duration of the intervention, the extent of the injury and the integrity of

the peripheral nervous system are determinants in recovery. Young patients tend to have a better

prognosis due to greater neural plasticity, while elderly patients have a lower capacity for regeneration.

Physiotherapeutic rehabilitation also plays a crucial role in functional recovery, helping to prevent

muscle atrophy and neuromuscular reeducation (GONÇALVES; SOUZA, 2023).

Despite advances in microsurgery, the limitations of nerve regeneration still pose a signicant

challenge. The time required for axons to regenerate and reach target muscles can be long, leading to

incomplete recovery of function. New therapeutic approaches, such as the use of neurotrophic factors,

stem cells, and biomaterials for nerve guides, have been investigated to improve regeneration and

accelerate functional recovery (OLIVEIRA; RIBEIRO, 2020).

In addition, functional electrical stimulation techniques and therapies based on virtual reality

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have been explored to enhance the results of postoperative rehabilitation. These strategies help with

neural plasticity and promote the reactivation of alternative motor pathways, contributing to a more

eective recovery (SANTOS et al., 2020).

CONCLUSION

Complex brachial plexus injuries represent a major clinical and surgical challenge, requiring

sophisticated approaches for the functional restoration of the upper limbs. Microsurgery and nerve

reconstruction techniques, including neurorhaphy, grafts, and nerve transfers, have shown signicant

advances in the recovery of patients with severe damage. However, the prognosis still depends on

several factors, such as the time of intervention, the extent of the injury, and adherence to postoperative

rehabilitation.

Neural plasticity and peripheral nerve regeneration capacity are limited, which reinforces

the need for early and personalized interventions. Studies show that when surgical reconstruction is

performed within the rst six months after injury, functional results are more promising, allowing for

better reactivation of motor and sensory pathways. However, even with successful procedures, many

patients continue to face motor and sensory decits, highlighting the importance of developing new

therapeutic strategies to enhance nerve regeneration.

Given these limitations, emerging research has explored the use of neurotrophic factors, stem

cells, and biomaterials to optimize patient recovery. In addition, electrical stimulation and functional

rehabilitation techniques have been incorporated to accelerate neural plasticity and improve clinical

outcomes. Thus, the advancement of science and technology in the area of neurosurgery can provide

new perspectives for the rehabilitation of individuals with severe brachial plexus injuries.

Finally, this study reinforces the relevance of the multidisciplinary approach in the

management of these lesions, combining innovative microsurgical techniques, intensive physical

therapy support, and adjuvant therapies to ensure better prognosis. The continuous improvement of

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nerve reconstruction techniques and the implementation of complementary therapeutic strategies may,

in the future, provide better functional recovery rates and higher quality of life for aected patients.

REFERENCES

CARVALHO, P. R.; RIBEIRO, M. S. Reconstructive microsurgery in brachial plexus injuries: review

and perspectives. Brazilian Journal of Neurosurgery, v. 28, n. 3, p. 145-160, 2021.

GOMES, C. F.; SILVEIRA, T. R. Advances in brachial plexus reconstruction: techniques and

challenges. Current Neurosurgery, v. 11, n. 1, p. 33-49, 2023.

LIMA, J. A.; COSTA, D. S.; ALBUQUERQUE, F. R. Nerve transfers in the treatment of the brachial

plexus: a literature review. Journal of Applied Neurosciences, v. 14, n. 4, p. 203-219, 2019.

MARTINS, H. P.; ALMEIDA, G. B. Functional prognosis in brachial plexus reconstruction:

determining factors. Cadernos de Reabilitação Neurocirúrgica, v. 19, n. 2, p. 71-88, 2022.

SANTOS, V. F.; MELO, C. R.; TEIXEIRA, J. C. Microsurgical approach to brachial plexus injuries:

a systematic review. Brazilian Journal of Neurology and Plastic Surgery, v. 8, n. 3, p. 125-141, 2020.

SOUZA, P. L.; PEREIRA, C. F. Microsurgery in the treatment of brachial plexus injuries: an updated

view. Journal of Surgery and Functional Rehabilitation, v. 17, n. 1, p. 42-58, 2020.

BARROS, R. F.; SOUZA, M. A. Pathophysiology of brachial plexus injuries and surgical implications.

Journal of Applied Neurosurgery, v. 15, n. 2, p. 87-102, 2021.

COSTA, V. P.; MELO, J. R.; TEIXEIRA, C. Nerve transfers in brachial plexus reconstruction:

evidence review. Current Neurosurgery, v. 12, n. 4, p. 210-225, 2022.

FERNANDES, H. B.; MORAES, G. F. Microsurgical techniques in brachial plexus reconstruction:

recent advances. Brazilian Journal of Reconstructive Surgery, v. 33, n. 3, p. 98-115, 2021.

GONÇALVES, A. P.; SOUZA, C. M. Prognosis in brachial plexus reconstruction: determinant factors

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and clinical outcomes. Journal of Functional Neurosurgery, v. 18, n. 2, p. 130-145, 2023.

MACHADO, L. P.; OLIVEIRA, T. S.; SILVA, R. B. Anatomical and clinical aspects of brachial

plexus injuries. Cadernos de Neurociências Aplicadas, v. 16, n. 1, p. 42-58, 2022.

OLIVEIRA, F. S.; RIBEIRO, M. C. Nerve recovery after brachial plexus injuries: mechanisms and

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SILVA, R. A.; MEDEIROS, L. B.; ALBUQUERQUE, J. T. Nerve grafts in brachial plexus

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