title: Penetrating injuries due to gunshot wounds involving the brachial plexus.
abstract: The authors review 118 operative brachial plexus gunshot wounds (GSWs), causing 293 element injuries that were managed over a 30-year period at Louisiana State University Health Sciences Center (LSUHSC). Retrospective chart reviews were performed. Using the LSUHSC grading system for motor sensory function, each element's grades were combined and averaged. Most of the 293 injured elements were found to have gross continuity at operation and of 202 elements with complete neurological loss, only 16 (8%) exhibited total disruption. Of 293 injuries, 128 elements with complete or incomplete loss were not only in continuity when explored but also had positive intraoperative nerve action potentials (NAPs). After neurolysis, 120 of 128 elements in continuity (94%) improved to greater than or equal to Grade 3 function. Elements not regenerating early usually required repair. One hundred fifty-six of 202 completely or incompletely injured elements (77%) required resection and suture or graft repair based on intraoperative NAPs. Neurolysis achieved greater than or equal to Grade 3 results in 42 (91%) of 46 elements with complete loss. Suture repair resulted in good outcomes in 14 (67%) of 21 and in 73 (54%) of 135 undergoing graft repairs (1 to 3.5 cm length) and presenting with complete loss. Of 91 incomplete elements, intraoperative NAPs were positive in 82 (90%) and 78 of 82 had good results. Nine had negative NAPs and six elements required suture repair. Three required grafts with results of greater than or equal to Grade 3 in five (83%) of six and two (67%) of three, respectively. Based on 118 patient results with 293 injured elements, guidelines for the management of GSWs were established as described in this paper.
authors.affiliation: Department of Neurosurgery, Stanford University Medical Center, Stanford, California 94305-5327, USA. neurokim@stanford.edu
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Kim
authors.forename: Judith A
authors.initials: JA
authors.lastname: Murovic
authors.forename: Robert L
authors.initials: RL
authors.lastname: Tiel
authors.forename: David G
authors.initials: DG
authors.lastname: Kline
mesh_terms: D000200:Action Potentials; D000700:Analgesics / Q000627:therapeutic use; D000714:Anastomosis, Surgical; D001808:Blood Vessels / Q000293:injuries; D001917:Brachial Plexus / Q000293:injuries* / Q000601:surgery; D020516:Brachial Plexus Neuropathies / Q000209:etiology; D002422:Causalgia / Q000209:etiology / Q000628:therapy; D006801:Humans; D016343:Monitoring, Intraoperative; D009416:Nerve Regeneration; D016067:Nerve Transfer; D010146:Pain / Q000209:etiology; D059408:Pain Management; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013536:Suture Techniques; D013562:Sympathectomy; D016896:Treatment Outcome; D014948:Wounds, Gunshot / Q000601:surgery*
chemical_list: D000700:Analgesics