Amputation may improve outcomes in select patients with brachial plexus injuries
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Patients with brachial plexus injuries who underwent amputation had decreased mechanical pain, increased employment rates and a high rate of postoperative satisfaction, according to published results.
“Amputation is an effective treatment for select patients with brachial plexus injuries for whom surgical reconstruction is unsuccessful,” Alexander Y. Shin, MD, of the Mayo Clinic, told Healio. “Patients who underwent amputation reported decreased mechanical pain, increased employment rates and a high rate of satisfaction following surgery. In amputees with sufficient nonintuitive electromyographic signals, myoelectric prostheses allow for terminal grasp/release and are associated with high rates of prosthesis use.”
Shin and colleagues retrospectively reviewed demographics, injury and reconstruction details, amputation characteristics, outcomes and complications of 32 patients with brachial plexus injuries who underwent elective upper-extremity amputation between June 2000 and June 2020. Researchers also assessed prosthesis use and myoelectric prosthesis function.
Among 29 patients with pan-plexus injuries, one patient with a partial C5-sparing pan-plexus injury, one patient with a lower-trunk with lateral cord injury and one patient with a lower-trunk injury, researchers identified 18 transhumeral amputations, 12 transradial amputations and two wrist disarticulations. Researchers noted 10 patients were fitted for a myoelectric prosthesis with electromyographic signal control from muscles not normally associated with the intended function.
Results showed a decrease in average VAS pain scores from 4.8 pre-amputation to 3.3 post-amputation for the myoelectric prosthesis group and from 5.4 to 4.4 for the non-myoelectric prosthesis group. Researchers also found a decrease in average DASH questionnaire scores from 35 pre-amputation to 30 post-amputation for the myoelectric prosthesis group and from 43 to 40 for the non-myoelectric prosthesis group. However, researchers noted the decrease was not significant.
Researchers found patients were more likely to be employed following amputation than they were before amputation, and no patient expressed regret about undergoing amputation. Regular use of the prosthesis was reported in 100% of patients in the myoelectric prosthesis group vs. 29% of patients with a traditional prosthesis, according to results. Researchers noted useful functional terminal grasp/release was reported by all patients in the myoelectric prosthesis group.
“This study presents a paradigm shift from stigma that amputation for brachial plexus injury patients represented a failure of surgical treatment, to amputation being a treatment option in a select group of patients,” Shin said. “Although amputation and myoelectric prosthetic (MEP) fitting are currently reserved for patients with brachial plexus injuries that are refractory to modern reconstructive techniques, continued improvements in prosthetic technology may allow for MEPs to facilitate a degree of terminal extremity control unachievable through reconstructive surgery for pan-plexus injuries.”
Perspective
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This interesting article by Sean R. Cantwell, MD, and colleagues reminds us that even in 2022, the neurological reconstruction of severe brachial plexus injuries remains far from universally successful. There is still a role for amputation for the patient with an insensate, heavy, functionless arm that has failed reinnervation procedures. Of the 32 patients in this setting who accepted amputation, satisfaction was high, employment improved and pain decreased (moderately, 1 to 1.5 points on a 10-point VAS scale). The interesting twist in this study is that even though the residual stump in this group of patients theoretically has little effective motor innervation, the authors found that application of a myoelectric prosthesis led to higher prosthetic usage rates compared with conventional prostheses, and an effective terminal grasp/release in all patients.
It must be remembered that amputation is for a select group (32 of 2,200 patients during a 20-year period) and that only 10 of these patients were fitted with a myoelectric prosthesis. Additionally, the long period of time (36 months in this group) between the last (failed) reconstructive procedure and the subsequent amputation is difficult for the patient, and it would be interesting to know if there were any early identifiable factors that could potentially shorten this period. Overall, this study enhances our ability to care for the severe brachial plexus injury population that has failed neurological reconstruction.
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