Figure 5.

A 32-year-old man from overseas sustained a right global avulsion plexopathy and severe postavulsion pain secondary to a high-velocity motor vehicle accident. Preoperatively, he presented with a flail, anesthetic arm (a). At 5 months postinjury, he had a DREZ procedure (cervical laminectomy of C6–T1 levels) by a neurosurgical colleague. Postoperatively, he was pain free and could easily concentrate on his rehabilitation. A left brachial plexus exploration took place at 6 months postinjury. Intraoperative findings showed avulsion of all the roots except C5. Brachial plexus reconstruction included distal accessory to axillary neurotization, C4 motor to suprascapular nerve, and neurotization via a vascularized ulnar nerve graft from C5 root to left MC, median, and radial nerves. The patient had also wrist fusion and banked nerves placed from C2 to C4 motors for future free muscle neurotization. Two years postinjury, a free gracilis was transferred for finger extension neurotized by cervical motor donors. Three years after the initial reconstruction, the patient demonstrated excellent shoulder abduction and elbow flexion but he recovered only a weak triceps. The right free latissimus dorsi was transferred to the left upper extremity neurotized by two intercostals for elbow extension. Patient seen 6 years after injury, demonstrated powerful elbow extension (b) and flexion (c) with full range of motion. The wrist fusion stabilized his wrist, and now he has a useful left “assist” extremity (d and e).