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Surgical Procedures for Total Paralysis
Surgery in brachial plexus injuries involves re-establishment of the connection between the central nervous system (brain and spinal cord) and the target muscles in the upper limb. A source of growing nerve fibers (a stump of a spinal nerve) is an essential pre-requisite for this purpose. The gap between this nerve end and the specific target nerves is bridged by placing nerve graft cables. These cables are derived from cutaneous nerves (those supplying sensation to the skin) from the legs. This procedure does not produce any deficit in the legs. The cables are stitched at each end using fine nylon threads under the operating microscope. The nerve grafts serve as pathways to direct the growth of the nerve fibers towards the target nerves.

Surgical Procedures for Incomplete Paralysis
In 25-30% of patients, only the upper roots of the brachial plexus (C56 or C567) are affected while the lower roots are partly injured or spared. In such cases, the patient loses power in the shoulder and the elbow while the movements of bending and straightening of the fingers are retained. Function in the shoulder and elbow can be restored in a large percentage of cases (80%) by means of nerve transfers or nerve grafting from available root stumps in the neck. Hence, such patients are more likely to regain almost full use of the affected upper limb.
The retained function in the lower roots (C8T1 and ulnar nerve) implies that an additional donor of growing nerve ends is available. Professor Christophe Oberlin of Paris showed that 10% of fibers of the ulnar nerve could be safely transferred to the biceps in the arm (Journal of Hand Surgery 1994) without producing any deficit in the hand. The biceps function is regained rapidly (4-6 months) in 80% of suitable patients.
As a result, other nerve transfers (spinal accessory and intercostal nerves) can be deployed for restoration of shoulder function and elbow extension. In such patients with retained hand functions, diverting the intercostal nerves to the triceps muscle can facilitate reaching out for objects.

Treatment of complete brachial plexus injuries in adults

This is an attempt to restore control of the paralysed upper limb. The number of muscles that can be provided nerve supply depends upon the number of functioning nerves found. These can be the stumps of the broken original nerves (roots) in the neck on the same side, a nerve that supplies the muscle for shrugging (spinal accessory nerve), nerves that supply muscles for breathing (intercostals) or a nerve from the opposite (normal) brachial plexus (the contralateral C7). All of these are utilised in one major nerve operation to attempt restoration of function at the shoulder, elbow and the hand. Results of such nerve procedures are consistent for restoration of shoulder stability and some abduction (at 6-8 months from the operation) and elbow flexion (after 8-12 months). However, restoration of useful hand function is still a dream. Connecting nerve stumps in the neck or the opposite C7 to the median nerve has produced some bending of the wrist and fingers after 1.5-2 years. However, that does not translate into the ability to perform any useful actions such as holding and releasing objects independently. Currently, we are studying the veracity of the claim of Wang Shufeng of  Beijing that direct repair to the lower trunk improves the strength of grip regained. This is the best option in the present situation.

Obstetrical Palsy
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