Brachial Plexus Lesions

Transcription

1 Brachial Plexus Lesions

2 Springer-Verlag Berlin Heidelberg GmbH

3 Chantal Bonnard Albert (Bart) C.J. Slooff Editors Brachial Plexus Lesions Drawings of Explorations and Reconstructions by Algimantas Otonas N arakas r r:l~. I>J ' Springer

4 Chantal Bonnard, MD Plastic, ReconSlruclive and Handsurgeon Clinique C hirurgicale et Permanence de Longeraie Avenue de la Gare 9, 1003 Lausanne, Switzerland and Consultant Peripheral Nerve and Plexus Surgery Centre Hospitalier Un iversitaire, Lausanne, Switzerland Barl (A.C.l.) Slooff, MD, PhD Neurosurgeon (emeritus). Consultant Nerve and Plexus Lesions Academic Neurosurgical Cenler l..imburg, Heerlen1Maastricht and Neurosurgical Department. Academic Hospital, Free University Amsterdam, The Netherlands Private ad,ess: Rozenlaan 20,3620 Lanaken, Belgium Cip data a pplied (or. Die Deut$(he Bibliothek - Cip-Einheitsaufnahme Brachial plexus lesions: drawings of explorations and reconslruclions by Aigimantas Olonas NarakasJChantal Bonnard: Albert (Bart) c.j. Slooff. - Berlin: Heidelberg: New York; Bareelona; Hong Kong; London; Milan: Paris; Singapore; Tokyo: Springer, 1999 ISBN ISBN (ebook) DOI / This work is subject 10 copyright. AII righls are reserved, whether Ihe whole or pari of Ihe material ;s concerned, specifically Ihe rights of translation, reprinting, reuse of iilustration, recitation, broadcasting, reproduction on microfilm o r in any other ways, and storage in data banks. Duplication of Ihis publication or paris thereof is permitted only under Ihe provisions o( the German Copyright Law of 5eptember 9, 1965, in ils currenl version, and permission fo r use must always be obtained from Springer-Ve rlag. Violations are liable for proseculion under the German Copyright Law. le) Springer-Verlag Berlin Heidelberg 1999 Originally published by SpringeT-Verlag Berlin Heidelberg New York in 1999 The use of general descriptive names, registered names, trademarks, elc. in this publication does noi impl y, even in the absence of a specific slatement, that $uch names are exempt {rom the relevant proteclive laws and regulations and therefore free for general use. Produet liability: The Publisher eannol guaranlee Ihe aceuracy of any info rmation about dosage and application contained in this book. In every individual case Ihe user must eheek such information by eonsulting the relevant literature. Data conversion: Elsner & Behrens GdbR, Oflersheim SPIN: / I Printed on add-free paper.

5 Photographs (pp. V and VI) taken by H. Vonken in 1993 during a workshop on obstetric brachial plexus lesions in Heerlen, The Netherlands, 8 months before Narakas' death. Introduction in Narakas' guest book.

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7 Foreword All who knew Algimantas Narakas and all who benefited from his life and work will welcome Dr. Bonnard's and Dr. Slooffs tribute to the memory ofthis great man. Narakas overcame illness, physical handicap and the eccentricities of European politics to become the leading figure of the day in the surgery of the upper limb and in particular in that of lesions of the brachial plexus. His painstaking and innovative work on the brachial plexus and on closed lesions of that structure led, with Millesi's, to the great advance in this field that took place in the 1970s and 1980s. It was extended, with similar consequences, to include obstetric injuries and radiation neuropathy. While engaged in this exacting work, Narakas found time to make important contributions to other aspects of the surgery of the upper limb, including in particular paralysis of the muscles of the shoulder girdle and entrapments at or near the thoracic outlet. Narakas was a bold, patient and tireless surgeon, a careful observer and a meticulous recorder, original in thought and action, and widely read in his own and other fields ofstudy. Himselfaware ofpain, sufferingand disability, Narakas treated patients with steady care and consideration, not sparing himself in the taskofalleviatingdisabilitybyadvice and action. He owed much ofhis triumph to his happy marriage to Colette Kenel and to his happy home with her, his son Alexandre and his daughter Diane. The work was by no means the whole of the man: Narakas was a polymath - probably, a genius - with a wide knowledge of languages and literature, a keen appreciation of art, and an easy familiarity with world history. He took pleasure in fine wines and good food, sailed and won prizes, and handled fast cars accurately and well. An evening with him lit the dull mind and spurred the active mind to new heights. No participant will ever forget the annual brachial plexus conferences in Lausanne, carefully organised by Narakas and his colleagues and conducted by him with the easy authority of a master of his subject who is also a master of seven languages. The conferences provided the opportunity for exchange of information and for proposals for new lines of approach; the lively discussions stimulated interest and revived minds wearied by the long search. The genial spirit of the host suffused the whole assembly and dominated the concluding festivites.

8 VIII For word Narakas died at the height of his fame and at the peak of his career, working, teaching and looking forward almost to the last. The old motto "immer vorwarts" might have been coined for him: it well expresses his steadfast spirit and his constant search for knowledge. His work is his memorial; it is well crowned by the tribute from Narakas' friends and colleagues Dr. Slooff and Dr. Bonnard emiment among the many who carry of the work and who treasure the memory of one of the best and greatest men they have ever known. No one could better convey to posterity the character and the achievement of this man. George Bonney, MS Formerly Orthopedic Surgeon, St. Mary's Hospital Paddington, London, United Kingdom 2nd February 1998 Rolfe Birch, Mchir, FRCS Orthopedic Surgeon, Royal National Orthopedic Hospital Peripheral Nerve Unit, Stanmore, Middlesex, United Kingdom and Visiting Professor, Department of Neurology, The Royal London Hospital Visiting Professor, Shanghai Honorary Orthopedic Surgeon, National Hospital for Nervous Diseases Honorary Orthopedic Surgeon to the Royal Navy

9 Preface After his death in November 1993, Narakas bequeathed to us careful observation on a vast series of brachial plexus lesions; he has operated on more than 1000 cases. The importance of his work rests not only on the number of cases, but even more on the scientific way in which he performed the operations, analyzing the types of lesions and at the same time seeking anatomical anomalies and trying to understand the mechanism of injury. Every intervention was finished with a meticulous description of what was found and why the method of nerve repair was chosen. Finally a color, artistic drawing was his personal touch. Although Narakas wrote a great number of publications, we wanted to present an original, more complete, and personal illustration of his work. As a result, this book is totally different. We have selected 60 of the most representative cases and patients with different lesions. You will find the original color drawings, with his interesting remarks and comments. The cases are clinically described, including the examinations, the intervention itself, the secondary procedures, and outcome. We conclude the book with an overview of his personal approaches to the lesions and his preferred procedures. We, who count ourselves amongst his pupils, think that we had to complete his work in this way. We owe this to this great master, inspiring teacher, and honest friend, not least as a gesture of honor. We thank Madame Colette Narakas and the Clinique de Longeraie for allowing us to publish this book. We are very grateful to Springer Verlag, especially to Dr. Agnes Heinz and her staff, who had the courageous view to publish this unique edition, in an outstanding - audacious - presentation and thank Baxter Hyland-Immuno, Vienna, for their kind support. We hope that you will enjoy reading this Narakas book. Chantal Bonnard and Bart Slooff

10 Eulogy Algimantas Otonas Narakas( ) Dr. Narakas and Sir Sydney Sunderland during the first plexus Symposium in Lausanne, Switzerland Algimantas Otonas Narakas left us on 25 November 1993 at the age of66, after a short and painful illness. With great courage he pursued his full professional and surgical activities until the very last days of his life - a courage combined with reserve, tact, and the strength to spare relatives and colleagues the knowledge of the dreadful end that he knew he was to face. Algimantas Narakas was born on 23 March 1927 in Kaunas, the old Lithuanian capital. He was proud ofhis mother country. His great happiness, when his native land regained its freedom, also accounts for a secret suffering at having been separated from it all his life. He had made plans to return there at long last, a kind of sentimental pilgrimage, which he also saw as a social and political journey that he wanted to experience with his two children. Death deprived him ofthis ultimate joy. Juozas, his father, was Commander in Chief of the Lithuanian Air Force, future Deputy Minister and Minister of Home Affairs. Algimantas Narakas was sent to Switzerland in 1938 to be treated medically for an osteitis affecting his left tibia and an osteomyelitis of his right hip, which kept him bedridden until penicillin freed him in He used this forced inactivity to devour all the German and French literature that he could find. This sparked his wide interest in culture and his curiosity in all things. Dr. Narakas spent his secondary school years at the monastery school of Einsiedeln, in the German-speaking part of Switzerland. He thus became perfectly trilingual, as he spoke Lithuanian, German, and French. Later he learned English, Italian, and Spanish. In 1949 he obtained his "Maturity" Type B (Latin-English) diploma (the equivalent of the French "Baccalaureat"). When Switzerland established diplomatic relations with the Soviet Union in 1946, Lithuania having become a Soviet republic, he lost his nationality. Only in 1962 did he acquire Swiss citizenship. Two children were born from his marriage with Colette Kenel: a son, Alexandre and a daughter, Diane. From 1949 until 1957 he carried out his studies at the Medical School of Lausanne University. He spent one year as "medical clerk" at the Frenchay Hospital, then at the Southmead Hospital in Bristol. His studies took him more time, as he had to earn his living in turn as milkman, gardener, mechanic, editor, and then scientific and medical journalist.

11 xn Eulogy Aligmantas Otona araka ( ) In 1957 Dr. Narakas received his degree as M.D., but he was still a foreigner. The Swiss M.D. degree was awarded to him only in 1963, after he had become a Swiss citizen and had again passed his final medical examinations, as required by Swiss Law. His great surgical dexterity - regardless of the anatomical area - stemmed from his wide postgraduate training, which included complete training in general surgery, two years of neurosurgery, two years of orthopedic surgery, one year of ear-nose-throat and plastic surgery, and then four years of hand and peripheral nerve surgery. In 1969 he obtained his degree as a specialist in general surgery, and in 1989 that of specialist in hand surgery, at the time when this field was officially recognized as subspeciality in Switzerland. From 1969 Narakas collaborated with Prof. Claude Verdan and Dr. Carlos Simonetta at the Clinique Longeraie in Lausanne. He became Medical Director ofthe Clinique in He assumed a position on the medical faculty in Accident Medicine in 1971 and was made Associate Professor in 1978 and assumed the chair of Assecurology at Lausanne University in In 1977 he became a consultant at the University Hospital of Lausanne for plastic and reconstructive surgery, and hand and peripheral nerve surgery; from 1980 consultant for brachial plexus and late reconstruction surgery at the Children's Hospital of Bern University; and for hand and peripheral nerve surgery at the Children's Hospital, Lausanne. Dr. Narakas was a member - either ordinary, corresponding, or honorary - of more than 25 national or international societies. He authored a total of 216 papers, which were published in various medical journals, magazines, and books, mainly on brachial plexus, peripheral nerves, the hand, the wrist, epicondylitis, and surgery of the shoulder. He was Chief Editor of the Peripheral Nerve Repair and Regeneration Journal, Associate Editor of the Journal of Reconstructive Microsurgery, the International Review ofspinal, Root and Nerve Surgery, and of the European Medical Bibliography for Hand Surgery. He also served as scientific coeditor of Microsurgery. Narakas loved life with a passion. He became an automobile enthusiast, and took part in the 24-hour Le Mans car race. He acquired a splendid old Aston Martin, and in 1989 he bought a Honda NSX, which he loved driving. He was also passionately fond of sailing and won many boat races in his category on the lake.. As soon as he became acquaintedwith hand surgery, Narakas focused his intereston nerve repair. In his last publication, he expressed himselfinthis way:

12 Eulogy AJigmanlas Olona Naraka ( ) XIII At this point I pray the reader to accept introduction of my personal experience. It may shed some additional light on the inside story of present day BP [brachial plexus] surgery. My former chief Professor Claude Verdan, a pioneer in hand surgery and a promotor of peripheral nerve repair, including nerve grafting, belonged to the school of those who explored brachial plexuses. He introduced me to this type of surgery in the early sixties. He favoured my interest in microsurgery for which I was initially trained by Yasargil in Zurich. With Verdan's encouragement I started in 1966 to use autologous grafts for repair of infraclavicular then in 1967 of supraclavicular BPI [brachial plexus injury], obtaining some positive results... Dr. Narakas was endowed with all the qualities needed: an adventurous and imaginative spirit, and the physical and intellectual strength needed for the initial operations. One of these lasted 19 h. His greatest gift, however, was compassion. And also rigor. All his operations were reported with precision, accompanied by appropriate drawings. Perioperative discoveries were compared to preoperative status. Thanks to the charts which he had also meticulously made, he could establish rules for classifying lesions: the routes, first, primary, then secondary repairs, and palliative operations. He also wanted to share his new knowledge, and for this he organized symposia. The first of these took place in Lausanne in This was attended by Sir Sydney Sunderland, with whom he became friend. Apart from his skill as a surgeon, he was also gifted with two other talents: He loved teaching, and taught with gusto, thrilling his audience. He was also able, with a single question, to relaunch a debate at a scientific meeting, and carry it much further. An additional ability of his was related to the first: Narakas could draw. Any scientific demonstration that Narakas presented was supported by his drawings. Those that he included in his operation reports attest to his artistic proficiency. We are deeply indebted to Chantal Bonnard and Bart Slooff for their initiative and diligence. Through this book they provide all of those who are interested in brachial plexus surgery access to the immense experience, knowledge, and expertise of Algis Narakas. For all of those who knew Algis Narakas, and those who had the privilege of working with him, this is the best possible way for us to remember him and to honor his memory. Daniel V. Egloff Professor of Plastic and Reconstructive Surgery Medical Director of the Clinique de Longeraie, Lausanne, Switzerland

13 Contents Foreword VII George Bonney and Rolfe Birch Preface IX Chantal Bonnard and Bart Sloot! Eulogy XI Daniel Egloff Introduction and Outline of the Cases 1 Presentation of the Cases, Outcome Photographs 125 Epilogue 131 Bibliography 137

14 Abbreviations AbdV Add I APB APL Delt Dors II-IV DREZ ECR ECRB ECRL ECU EDC EPB EPL FCR FCU FDP FDS FPL Infra spin 10 Dors I 10 Palm IP Latiss dor Lev sc Mo-Ms MC MP MRI OPP PID PIP PL Prop m. abductor digiti quinti m. adductor pollicis m. abductor pollicis brevis m. abductor pollicis longus m. deltoid m. interosseus dorsalis II-IV dorsal route entry zone m. extensor carpi radialis m. extensor carpi radialis brevis m. extensor carpi radialis longus m. extensor carpi ulnaris m. extensor digitorum communis m. extensor pollicis brevis m. extensor pollicis longus m. flexor carpi radialis m. flexor carpi ulnaris m. flexor digitorum profundis m. flexor digitorum sublimis m. flexor pollicis longus m. infraspinatus m. interosseus dorsalis I m. interosseus palmaris interphalangeal joint m. latissimus dorsi m.levator scapulae grades 0-5 in the international muscle grading system musculocutaneous nerve metacarpophalangeal joint magnetic resonance imaging m. opponens pollicis distal interphalangeal joint proximal interphalangeal joint m. palmaris longus m. extensor digitorum proprius

15 VIII bbrevialion PT Rhomb. SO-S4 Serratus ant SS Supra spin Ter min TOS Trap m. pronator teres m. rhomboid grades 0-4 in the international sensory grading system m. serratus anterior suprascapular nerve m. supraspinatus m. teres minor thoracic outlet syndrome m. trapezius