ANALYSIS OF THE ANATOMIC VARIATIONS OF THE BRACHIAL PLEXUS AND ITS BRANCHES AT THE LEVEL OF FORMATION AND BRANCHING OF ITS TRUNCI

Milutin Mrvaljević, S. Pajić, P. Popović, J. Grujić, M. Petrovic, Ljudmila Jablan, Sonja Giljača, Petre Stavrevski, N. Rancic, S. Knežević
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Abstract

Although the terminal branches of brachial plexus that originate from lateral and medial fasciculus are well protected by muscle mass and vascular-neuronal petal of axilla and upper arm, the number of traumatic damage and injuries increases, according to the published reports of neurosurgeons working on pathology of peripheral nerves, as well as traumatologists, orthopedics, microsurgeons and plastic surgeons. This is certainly contributed by urbanization, industrialization, migration and increased number of traffic accidents. Knowing the microstructure of the peripheral nerve truncus leads to the possibility of applying various techniques of nerve grafting, as well as possibility of re-implantation of detached spinal roots, seen in traction injuries of brachial plexus, in which the mechanism of injury needs to be considered. Considering frequent injuries of terminal branches of lateral and medial fasciculus and a substantial pathology of plexus brachialis, the aim of our research was to study surgical-anatomical relations between terminal branches of medial and lateral fasciculus and substantial morphology of terminal branches of both fasciculi, particularly regarding the place and way of formation, as well as the number of their anastomoses. The studies of the terminal branches of medial and lateral fasciculus on our preparation materials are based on the dissection of axilla and anterior part of the upper arm, on 50 cadavers, adults of both genders, at Institute of Anatomy and Institute of Forensic Medicine at School of Medicine in Belgrade. The way of formation of the terminal branches of lateral fasciculus on our preparation materials was always the same. These branches were usually formed after the bifurcation or diverging of lateral fasciculus to radix lateralis nervi mediani and musculocutaneous nerve. Exceptionally, after fusion of lateral fasciculus and medial root of nervus medianus, there is no bifurcation, and formed nervous truncus is a result of existence of the pre- or postfixational type of brachial plexus. Analyzing our preparation materials, we determined that high bifurcation of lateral fasciculus (LF) exists in 18% of cases and that it is projected in the line of anterior edge of clavicle. Medium high bifurcation of LF is projected in the line of the top of the acromion of scapula and is seen in 61% of all cases. Low bifurcation is usually placed in the line of inferior edge of pectoral minor muscle, in 8% of cases. Fasciculus without bifurcation is noticed in 13% of cases. Measuring the shortest distance between anterior edge of clavicle and the point of bifurcation of LF resulted in a wide range from 0.5 to 9.7 cm, with 4.2 cm average. In cases of transplantation, implantation and re-implantation of nervous trunci of plexus brachialis, it is very important to consider the shape and the thickness of nervous truncus, the number of fasciculi, the number of nerve fibers, as well as the quantity and schedule of peri- and intrafascicular connective tissue, providing the normal irrigation of the nerve. Finally, we can conclude that mentioned facts prompted us to undertake a systematic research of great terminal branches of plexus brachialis that originate from lateral and medial fasciculus, trying to ensure that our anatomical findings receive a comprehensive clinical confirmation.
臂丛及其分支在臂丛干的形成和分支水平上的解剖变异分析
根据周围神经病理学神经外科医生、创伤外科医生、骨科医生、显微外科医生和整形外科医生发表的报告,尽管源自外侧和内侧束的臂丛末梢分支受到腋窝和上臂肌肉质量和血管神经元花瓣的良好保护,但创伤性损伤和损伤的数量仍在增加。这当然是城市化、工业化、移民和交通事故数量增加造成的。在臂丛牵引性损伤中,了解周围神经干的微观结构,可以应用各种神经移植技术,以及分离的脊髓根再植入术,这需要考虑损伤的机制。考虑到臂丛外侧和内侧束末梢分支损伤频繁,且臂丛神经丛的病理特点,我们的研究目的是研究内侧和外侧束末梢分支之间的外科解剖关系,以及两束末梢分支的实质形态,特别是它们的形成位置、方式和吻合口的数量。我们在制备材料上对内侧和外侧束末梢分支的研究是基于在贝尔格莱德医学院解剖研究所和法医学研究所对50具成年男女尸体的腋窝和上臂前部的解剖。在我们的制备材料上,外侧束终支的形成方式是相同的。这些分支通常在外侧神经束向内侧神经根和肌皮神经分叉或分叉后形成。特殊情况下,侧束与正中神经内侧根融合后没有分叉,形成的神经干是固定前或固定后臂丛存在的结果。分析我们的准备材料,我们确定外侧束(LF)高分叉存在于18%的病例中,并且它投射在锁骨前缘线上。中高位分岔在肩胛骨肩峰顶部线上,在所有病例中占61%。低分叉通常位于胸小肌下缘线,占8%。13%的病例未见分叉束。测量锁骨前缘到LF分岔点的最短距离,其范围为0.5 ~ 9.7 cm,平均4.2 cm。在臂丛神经干的移植、植入术和再植入术中,要考虑神经干的形态和厚度,神经束的数量,神经纤维的数量,以及束周和束内结缔组织的数量和安排,以保证神经的正常灌溉。最后,我们可以得出结论,上述事实促使我们对起源于外侧和内侧束的臂丛大末梢分支进行系统的研究,以确保我们的解剖学发现得到全面的临床证实。
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