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Vol. 22. Núm. 6.Enero 2011Páginas 488-607
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Vol. 22. Núm. 6.Enero 2011Páginas 488-607
DOI: 10.1016/S1130-1473(11)70107-5
Técnicas de reconstrucción nerviosa en cirugía del plexo braquial traumatizado Parte 2: Transferencias nerviosas intraplexuales
Nerve Reconstruction Techniques in Traumatic Brachial Plexus Surgery. Part 2: Intraplexal nerve transfers
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J. Robla-Costales??, J. Fernández-Fernández, J. Ibáñez-Plágaro, J. García-Cosamalón
Servicios de Neurocirugía. Universidad de Buenos Aires. Buenos Aires, Argentina
M. Socolovsky*, G. Di Masi*, D. Robla-Costales**, L. Domitrovic*, A. Campero*
* Hospital de Clínicas. Universidad de Buenos Aires. Buenos Aires, Argentina
** Cirugía plástica. Hospital de León. León. España
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Información del artículo
Resumen

Tras el gran entusiasmo generado en las décadas de los ‘70 y ‘80 del siglo pasado, como consecuencia entre otras de la incorporación de las técnicas de microcirugía, la cirugía del plexo braquial se ha visto sacudida en las últimas dos décadas por la aparición de las técnicas de transferencia nerviosa o neurotizaciones. Se denomina así a la sección de un nervio que llamaremos dador, sacrificando su función original, para unirlo con el cabo distal de un nervio receptor, cuya función se ha perdido durante el trauma y se busca restablecer. Las neurotizaciones se indican cuando un nervio lesionado no posee un cabo proximal que pueda ser unido, mediante injerto o sin él, con el extremo distal. La ausencia de cabo proximal se produce en el plexo braquial cuando una raíz cervical se avulsiona de su origen a nivel de la médula espinal. Sin embargo, en los últimos años, y dados los resultados francamente positivos de algunas de ellas, las técnicas de transferencia nerviosa se han estado empleando inclusive en algunos casos en los que las raíces del plexo estaban preservadas.

En las lesiones completas del plexo braquial, se recurre al diagnóstico inicial de la existencia o no de raíces disponibles (C5 a D1) para utilizarlas como dadores de axones. De acuerdo a la cantidad viable de las mismas, se recurre a las transferencias de nervios que no forman parte del plexo (extraplexuales) como pueden ser el espinal accesorio, el frénico, los intercostales, etc., para incrementar la cantidad de axones transferidos al plexo lesionado. En los casos de avulsiones de todas las raíces, las neurotizaciones extraplexuales son el único método de reinervación disponible para limitar los efectos a largo plazo de una lesión tan devastadora.

Dada la avalancha de trabajos que se han publicado en los últimos años sobre las lesiones traumáticas del plexo braquial, se ha escrito el presente trabajo de revisión con el objetivo de clarificar al interesado las indicaciones, resultados y técnicas quirúrgicas disponibles en el arsenal terapéutico quirúrgico de esta patología. Dado que la elección de una u otra se toma generalmente durante el transcurso del mismo procedimiento, todos estos conocimientos deben ser perfectamente incorporados por el equipo quirúrgico antes de realizar el procedimiento. En una primera entrega se analizaron las transferencias nerviosas extraplexuales; este trabajo viene a complementar al anterior revisando las transferencias intraplexuales, y así completando el análisis de las transferencias nerviosas disponibles en la cirugía del plexo braquial.

Palabras clave:
Plexo braquial
Avulsión radicular
Transferencia nerviosa
Neurotizaciones intraplexuales
Injerto nervioso
Summary

After the great enthusiasm generated in the ‘70s and ‘80s in brachial plexus surgery as a result of the incorporation of microsurgical techniques and other advances, brachial plexus surgery has been shaken in the last two decades by the emergence of nerve transfer techniques or neurotizations. This technique consists in sectioning a donor nerve, sacrificing its original function, to connect it with the distal stump of a receptor nerve, whose function was lost during the trauma. Neurotizations are indicated when direct repair is not possible, i.e. when a cervical root is avulsed at its origin in the spinal cord. In recent years, due to the positive results of some of these nerve transfer techniques, they have been widely used even in some cases where the roots of the plexus were preserved.

In complete brachial plexus injuries, it is mandatory to determine the exact numer of roots available (not avulsed) to perform a direct reconstruction. In case of absence of available roots, extraplexual nerve transfers are employed, such as the spinal accessory nerve, the phrenic nerve, the intercostal nerves, etc., to increase the amount of axons transferred to the injured plexus. In cases of avulsion of all the roots, extraplexal neurotizations are the only reinnervation option available to limit the long-term devastating effects of this injury.

Given the large amount of reports that has been published in recent years regarding brachial plexus traumatic injuries, the present article has been written in order to clarify the concerned readers the indications, results and techniques available in the surgical armamentarium for this condition. Since the choice of either surgical technique is usually taken during the course of the procedure, all this knowledge should be perfectly embodied by the surgical team before the procedure. In a previous paper extraplexual nerve transfers were analyzed; this literature review complements the preceding paper analyzing intraplexual nerve transfers, and thus completing the analysis of the nerve transfers available in brachial plexus surgery.

Key words:
Brachial plexus
Root avulsion injury
Nerve transfer
Intraplexal neurotizations
Nerve graft
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Robla-Costales, J.; Socolovsky, M.; Di Masi, G.; Robla-Costales, D.; Domitrovic, L.; Campero, A.; Fernández-Fernández, J.; Ibáñez- Plágaro, J.; García-Cosamalón, J.: Técnicas de reconstrucción nerviosa en cirugía del plexo braquial traumatizado. Parte 2: Transferencias nerviosas intraplexuales. Neurocirugía 2011. 22; 521–534

Copyright © 2011. Sociedad Española de Neurocirugía
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