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2. Cedera Plexus Brachialis

CEDERA PLEXUS BRACHIALIS

Oleh Dr H Subagyo SpB - SpOT

 

BAB I

PENDAHULUAN

Informasi mengenai insiden brachial plexus injuries cukup sulit untuk ditemukan.Sampai saat ini tidak ada data epidemiologi yang mencatat insiden brachial plexus injury per setiap negara di seluruh dunia.Tetapi, menurut Office of Rare Disease of National Institutes of Health, brachial plexus injury termasuk dalam penyakit yang jarang terjadi.Kejadiannya kurang dari 200.000 jiwa per tahun dihitung pada populasi di Amerika Serikat.Sebagian besar korbannya adalah pria muda yang berusia 15-25 tahun. Narakas menuliskan mengenai rule of seven seventies.[1][2]

Penelitian oleh Foad SL, et al mencatat insiden obstetrical brachial plexus injury di Amerika Serikat sebesar 1-2 kasus per 1000 kelahiran. Terdapat 3 macam obstetrical brachial plexus injury: Erb’s palsy adalah yang paling sering terjadi, insidennya sekitar 90% kasus, total plexus injury sebesar 9% kasus, dan Klumpke’s palsy sebesar 1% kasus. Insiden ini semakin menurun setiap tahunnya. Dari berbagai analisis, didapati bahwa kejadian shoulder dystocia memiliki resiko 100 kali lebih besar terjadinya obstetrical brachial plexus injury, sedangkan forceps delivery memiliki resiko 9 kali lebih besar, dan bayi besar dengan berat >4,5 kg memiliki resiko 4 kali lebih besar untuk terjadinya cedera. Setidaknya 46% kejadian obstetrical brachial plexus injury memiliki satu atau lebih faktor resiko, sedangkan 54%-nya tidak ditemukan adanya faktor resiko.[3]

Pengobatan cederaplexus brachialisada yang memerlukan operasi dan ada yang tidak, disesuaikan dengan kasusnya.Terdapat berbagai macam tindakan operasi pada cederaplexus brachialis, tergantung jenis cedera saraf yang terjadi.Saat ini banyak kemajuan yang telah dicapai dalam bidang pembedahan, tetapi trauma plexus brachialis seringkali masih menjadi masalah karena membutuhkan biaya yang besar dan waktu yang lama.

 

Secara keseluruhan, kecelakaan motor merupakan penyebab tersering. Menurut Narakas, dari seluruh kecelakaan motor, 2%-nya menyebabkan cedera plexus brachialis. Sekalipun jarang terjadi, high injury pada plexus brachialis seringkali menibulkan kecatatan bagi penderitanya.Referat ini membahas sebagian kecil dari trauma ini mulai dari anatomi hingga pengobatan dan macam-macam operasinya.

 

BAB II

CEDERA PLEXUS BRACHIALIS

 

3.1     Definisi

Cedera plexus brachialisadalah cedera jaringan saraf yang berasal dari C5-T1.Plexus brachialis adalah persarafan yang berjalan dari leher ke arah axilla yang dibentuk oleh ramus ventral saraf vertebra C5-T1. Cedera pada plexus brachialis dapat mempengaruhi fungsi saraf motorik dan sensorik pada membrum superium.[8]

 

3.2     Epidemiologi

Penelitian oleh Foad SL, et al mencatat insiden obstetrical brachial plexus injury di Amerika Serikat sebesar 1-2 kasus per 1000 kelahiran.Terdapat 3 macam obstetrical brachial plexus injury: Erb’s palsy adalah yang paling sering terjadi, insidennya sekitar 90% kasus, total plexus injury sebesar 9% kasus, dan Klumpke’s palsy sebesar 1% kasus. Insiden ini semakin menurun setiap tahunnya. Dari berbagai analisis, didapati bahwa kejadian shoulder dystocia memiliki resiko 100 kali lebih besar terjadinya obstetrical brachial plexus injury, sedangkan forceps delivery memiliki resiko 9 kali lebih besar, dan bayi besar dengan berat >4,5 kg memiliki resiko 4 kali lebih besar untuk terjadinya cedera. Setidaknya 46% kejadian obstetrical brachial plexus injury memiliki satu atau lebih faktor resiko, sedangkan 54%-nya tidak ditemukan adanya faktor resiko.[1][2]

Informasi mengenai insiden cedera brachial plexuscukup sulit untuk ditemukan.Sampai saat ini tidak ada data epidemiologi yang mencatat insiden cederabrachial plexus per setiap negara di seluruh dunia.Tetapi, menurut Office of Rare Disease of National Institutes of Health, brachial plexus injury termasuk dalam penyakit yang jarang terjadi.Kejadiannya kurang dari 200.000 jiwa per tahun dihitung pada populasi di Amerika Serikat.Sebagian besar korbannya adalah pria muda yang berusia 15-25 tahun. Narakas menuliskan mengenai rule of seven seventies:

  • Kira-kira 70% disebabkan oleh kecelakan kendaraan bermotor.
  • Darikecelakaan kendaraan bermotor tersebut, 70%-nya disebabkan oleh sepeda motor.
  • Dari pengendara-pengendara tersebut, 70%-nya disertai dengan multiple injuries.
  • Dari kejadian multiple injuries tersebut, 70%-nya termasuk dalam supraclavicular injuries.
  • Dari kejadian supraclavicular injuries tersebut, 70%-nya didapati root avulsed.
  • Dari kejadian avulsed roots tersebut, 70%-nya termasuk lower C7, C8, T1.
  • Dari kejadian avulsed roots tersebut, 70%-nya berhubungan dengan nyeri kronik.[3]

 

3.3     Etiologi

Ditemukan lebih dari 30 penyebab terjadinya cedera plexus brachialis. Tetapi etiologi yang lebih sering, antara lain:

  • Trauma

Secara keseluruhan, kecelakaan motor merupakan penyebab tersering. Menurut Narakas, dari seluruh kecelakaan motor, 2%-nya menyebabkan cederaplexus brachialis.Trauma olahraga juga merupakan salah satu penyebab cedera plexus brachialis yang sering terjadi.

  • Trauma persalinan

Menurut Ruchelsman DE, et al, setidaknya terdapat 8 faktor resiko yang menjadi penyebab terjadinya obstetrical brachial plexus injury:

-          Shoulder dystocia

-          Vacuum atau forceps delivery

-          Macrosomia atau bayi besar dengan berat >4,5 kg

-          Kelahiran sunsang

-          Prolonged second stage of labor

-          Riwayat kelahiran anak dengan obstetrical brachial plexus injury

-          Multiparitas

-          Maternal diabetes

  • Compression syndrome(Gambar 15)

Sindrom kompresi di daerah bahu seringkali menyebabkan cedera plexus brachialis, seperti: scalene syndrome, kompresi oleh sabuk pengaman, kompresi akibat membawa beban berat di bahu, costoclavicular syndrome, hyperabduction syndrome).

  • Tumor

Salah satu tumor yang sering menyebabkan cedera plexus brachialis adalah tumor apikal paru.[9][10][11]

 

3.4     Klasifikasi : Terdapat berbagai macam versi sistem klasifikasi brachial plexus injury, tetapi yang paling banyak digunakan adalah Leffert’s classification system (Tabel 7), yang digolongkan berdasarkan etiologi dan level injuri. Cedera plexus brachialis dapat mengenai lebih dari 1 lesi.[12]

 

Gambar 15.Kompresi akibat hiperekstensi pada scalene syndrome.

Tabel 7.Leffert’s classification system of brachial plexus injury.

Sumber: Leffert RD. Brachial-Plexus Injuries. The New England Journal of Medicine.1974; 291:1059-1067.

Classification

Etiology

Level of the Injury

Characteristics

I

Open (usually from stabbing, gunshot)

 

 

II

Closed (usually from MVA, traction, compression)

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

 

 

 

 

 

 

 

Supraclavicular

 

   - Preganglionic

    (nerve root avulsion)

 

 

- avulsion of nerve roots, usually from high speed injuries with other injuries and LOC

- no proximal stump, no neuroma formation (Tinel's sign negatif)

- pseudomeningocele, denervation of neck muscles are common

 

- Horner's sign positif (ptosis, miosis, anhydrosis)

   - Postganglionic

     (traction injuries)

 

 

 

- roots remain intact

- usually from traction injuries

- there are proximal stump and neuroma formation (Tinel's sign positif)

- deep dorsal neck muscles are intact, and pseudomeningoceles will not develop

B

 

Infraclavicular

 

C

 

Combined

 

III

Radiotherapy induced

 

 

IV

Obstetric

 

 

 

 

 

A

 

Upper root (Erb's palsy)

 

B

 

Lower root (Klumpke's palsy)

 

C

 

Mixed

 

MVA = Motor Vehicle Accident; LOC = Lost of Consciousness.

 

3.5     Macam-MacamNerve Injuries

Spinal nerves terdiri dari 3 layer jaringan penyambung (Gambar 16) yang membungkus axon: (1) Endoneurium yang mengelilingi individual axon; (2) Perineurium yang mengelilingi fascicles(bundles of axons); (3) Epineurium yang mengelilingi seluruh nervus.[13][14]

Gambar 16.Spinal nerve pada potongan transversus.

Sumber: Tortora GJ, Derrickson B. Principles of Anatomy and Physiology. Unites States of America: Wiley; 2009.

 

Terdapat 2 klasifikasi nerve injuries.Klasifikasi pertama dipublikasikan oleh Seddon pada tahun 1943, kemudian yang kedua dipublikasikan oleh Sunderland tahun 1951.Klasifikasi Seddon digunakan untuk memahami dasar anatomi dari cedera.Klasifikasi Sunderland baik untuk menentukan prognosis dan strategi pengobatan.Kombinasi klasifikasi ini membagi nerve injury menjadi 5. Perbedaannya dapat dilihat padaTabel 8 dan Tabel 9 di bawah:

  1. Tingkat 1 (neuropraxia)

Neuropraxia adalah nerve injury yang paling sering terjadi.Lokasi kerusakan pada serabut myelin, hanya terjadi gangguan kondisi saraf tanpa terjadinya degenerasi wallerian.Karakteristiknya, defisit motorik > sensorik.Saraf akan sembuh dalam hitungan hari setelah cedera, atau sampai dengan 4 bulan. Penyembuhan akan sempurna tanpa ada masalah motorik dan sensorik.

1. Tingkat 2 (axonotmesis)

Pada axonotmesis (axon cutting) erjadi diskotinuitas myelin dan aksonal, tidak melibatkan jaringan encapsulating, epineurium, dan perineurium, juga akan sembuh sempurna. Bagaimanapun, penyembuhan akan terjadi lebih lambat daripada cedera tingkat pertama.

2. Tingkat 3

Cedera ini melibatkan kerusakan myelin, akson, dan endoneurium. Cedera juga akan sembuh dengan lambat, tetapi penyembuhannya hanya sebagian.penyembuhan akan tergantung pada beberapa faktor, sepertisemakin rusak saraf, semakin lama pula penyembuhan terjadi.

3. Tingkat 4

Cedera ini melibatkan kerusakan myelin, akson, endoneurium, dan perineurium. Cedera derajat ini terjadi bila terdapat skar pada jaringan saraf, yang menghalangi penyembuhan.

4. Tingkat 5 (neurotmesis)

Cedera pada neurotmesis (nerve cutting) melibatkan pemisahan sempurna dari saraf, seperti nerve avulsion. Cedera saraf tingkat 4 dan 5 memerlukan tindakan operasi untuk sembuh.[15][16][17][18]

 

Tabel 8. Klasifikasi cedera saraf.

Sumber: Solomon L, Warwick DJ, Selvadurai N. Apley’s System of Orthopaedics and Fractures. United of Kingdom: Hodder Arnold; 2010.

Derajat cedera saraf

Myelin

Akson

Endoneurium

Perineurium

Epineurium

I (Neuropraksia)

+/-

Tidak

Tidak

Tidak

Tidak

II (Axonotmesis)

Ya

Ya

Tidak

Tidak

Tidak

III

Ya

Ya

Ya

Tidak

Tidak

IV

Ya

Ya

Ya

Ya

Tidak

V (Neurotmesis)

Ya

Ya

Ya

Ya

Ya

 Tabel 9.Tabel perbedaan cedera saraf.

Sumber: Solomon L, Warwick DJ, Selvadurai N. Apley’s System of Orthopaedics and Fractures. United of Kingdom: Hodder Arnold; 2010.

Derajat

Sembuh spontan

Waktu penyembuhan

Pembedahan

I (Neuropraxia)

Penuh

Dalam hitungan hari sampai 4 bulan setelah cedera

Tidak

II (Axonotmesis)

Penuh

Regenerasi kira-kira 1 inci per bulan

Tidak

III

Parsial

Regenerasi kira-kira 1 inci per bulan

Ya

IV

Tidak ada

Setelah tindakan bedah, regenerasi terjadi kira-kira 1 inci per bulan

Ya

V (Neurotmesis)

Tidak ada

Setelah tindakan bedah, regenerasi terjadi kira-kira 1 inci per bulan.

Ya

Untuk menentukan derajat cedera, diperlukan:

  • Anamnesis

Low energy injury seringkali menyebabkan neuropraxia; pasien sebaiknya diobservasi.High energy injury lebih sering menyebabkan axonal dan endoneurial disruption (derajat 3 dan 4 klasifikasi Sunderland), sedangkan very high energy closed injury dapat menyebabkan nerve avulsion.

  • Tinel’s Sign

Tinel’s sign positif ditandai oleh munculnya peripheral tingling atau dysaesthesia yang diprovokasi oleh perkusi saraf. Pada neuropraxia, Tinel’ sign negatif. Pada axonotmesis, Tinel’s sign postitif pada lokasi cedera karena sensitivitas regenerasi axon. Rata-rata regenerasi axon sekitar 1 mm setiap hari sepanjang Schwann-cell.

  • EMG (Electromyography)

Apabila otot kehilangan suplai sarafnya, EMG akan menunjukkan loss of nerve supply pada minggu ke-3. Dari pemeriksaan EMG, cedera neuropraxia dapat dieksklusi, tetapi axonotmesis dan neurotmesis tidak dapat dibedakan.[19][20]

 

3.6     Lesi Pre-ganglionik dan Post-Ganglionik

Plexus brachialis dibentuk oleh pertemuan nerve roots dari C5 sampai T1. Plexus berasal dari vertebra yang melewati otot-otot leher dan di bawah clavicle yang berjalan ke arah lengan.Karena letak anatomisnya, maka daerah ini rentan terhadap cedera. Cedera plexus brachialis dibagi menjadi supraclavicular (65%), infraclavicular (25%), dan kombinasi (10%)(Gambar 17).Lesi supraclavicular umumnya terjadi akibat kecelakaan motor.Pada kasus berat, terjadi avulsi dari trunkus dengan rupture pada a. subclavia. Lesi infraclavicular biasanya berhubungan dengan fracture atau dislokasi bahu, pada seperempat kasus, a. axillaris ikut robek.[18][21]

 

Gambar 17.Persarafan plexus brachialis.

Sumber:Tortora GJ, Derrickson B. Principles of Anatomy and Physiology. Unites States of America: Wiley; 2009.

Cedera dapat mempengaruhi setiap tingkat plexus, bahkan seringkali melibatkan cedera roots, trunks, dan nervussecara bersamaan. Penting untuk membedakan antara lesi yang berasal dari pre-ganglion atau post-ganglion untuk mengetahui seberapa dekat jarak lesi dengan spinal cord.Nerve root avulsion dari spinal cord termasuk dalam lesi pre-ganglion, misalnya gangguan proksimal hingga dorsal root ganglion; ini tidak dapat disembuhkan sekalipun dengan operasi. Rupture of nerve root distal ke arah ganglion, atau rupture trunkus, atau rupture saraf perifer, termasuk dalam lesi post-ganglion yang masih dapat disembuhkan dan diperbaiki dengan operasi.[18][22]

Ciri-ciri root avulsion adalah: (1) crushing atau burningpain pada anaesthetic hand; (2) paralisis m. scapularis atau diafragma; (3) adanya Horner’s syndrome, yang terdiri dari: ptosis, miosis, enoftalmos, dan anhidrosis; (4) cedera vaskular berat; (5) berhubungan dengan fracture tulang servikal; dan (6) disfungsi spinal cord (hiperefleks pada lower limbs).

Lesi derajat 1-4 umumnya mempunyai prognosis yang lebih baik dibandingkan dengan lesi derajat 5 (complete ruptures).[18]

Untuk membedakan lesi pre-ganglion atau post-ganglion dapat dilakukan pemeriksaan:

Histamine test

Injeksi histamine intradermal biasanya menyebabkan 3 reaksi di sekitar kulit: (1) dilatasi central capillary; (2) wheal (munculnya reaksi alergi); (3) surrounding flare. Jika flare reaction pada anaesthetic area, lokasi lesi pasti berada di bagian proksimal dari posterior root ganglion, dengan kata lain, kemungkinannya adalah root avulsion.Pada lesi post-ganglion, histamine test negatif karena saraf antara kulit dan dorsal root ganglion mengalami gangguan.

  1. CT myelography atau MRI :Hasil yang mungkin ditemukan adalah pseudomeningoceles yang diproduksi oleh root avulsion, tetapi hasil yang positif tidak selalu dapat diandalkan karena dura dapat robek tanpa adanya root avulsion.
  2. Electrophysiology

Electromyography (EMG) dan Nerve Conduction Studies (NCS) sangat berguna untuk mengkonfirmasi diagnosis, melokalisasi letak lesi, dan menentukan derajat axonal loss.Pemeriksaan ini dilakukan 3-4 minggu setelah cedera. Perubahan denervasi dapat terjadi 10-14 hari setelah trauma, ketika wallerian degeneration pada lesi post-ganglionik akan memblok konduksi saraf. Respon motorik terganggu lebih dulu dibanding respon sensorik; karena itu, tanda awal kerusakan dapat terlihat sebagai reduksi pada aksi potensial otot. Jika terdapat konduksi sensorik dari anaesthetic dermatome, berarti lokasi lesi pre-ganglionik.[2][18]

 

3.7     Manifestasi Klinis

3.7.1            Total Plexus Injury

General brachial plexus injury umumnya bersifat unilateral, tetapi kadang-kadang bersifat bilateral, seperti cedera akibat diffuse polyneuropathy, inflammatory demyelinating neuropathy, danmultifocal motor neuropathy.Banyak hal yang menjadi penyebab, tetapi inflitrasi tumor, radiation plexitis, dan idiopathic plexitis adalah yang paling sering.MRI dengan kontras dapat mengkonfirmasi ada atau tidaknya lesi ini.Penyebab lain adalah cedera selama persalinan.[18][23]

Jika seluruh plexus cedera, maka keseluruhan anggota gerak atas paralisis dan mati rasa, terkadang ditemukan unilateral Horner’s syndrome, yaitu tanda ptosis, miosis, dan anhidrosisyang timbul akibat kerusakan saraf di bagian servikal spinalis.[18]

 

3.7.2            Root and Trunk Injury

3.7.2.1        Upper Radicular Syndrome (Erb-Duchenne Palsy)

Upper radicular syndrome (Erb-Duchenne palsy) adalah akibat dari cedera pada upper roots (C4, C5, atau C6) atau upper trunk.Lesi ini paling sering disebabkan oleh cedera selama persalinan akibat sulitnya bayi keluar dari birth canalketika bahu bayi tertinggal pada birth canal yang disebut denganshoulder dystocia(ilustrasi Gambar 18).Penyebab lain adalah penggunaan forceps dan bayi besar dengan berat >4,5 kg.[18][24]

Kelainan ini mengakibatkan paralisis m. deltoid, m. biceps brachii, m. brachioradialis, m. pectoralis mayor, m. supraspinatus, m. infraspinatus, m. subscapularis, dan m. teres major.Jika lesi berada di dekat akar (roots), m. serratus, m. rhomboideus, dan m. levator scapulae juga dapat mengalami paralisis.[23][25]

 

Gambar 18.Cedera plexus brachialis saat persalinan.

Sumber: http://www.erbspalsyonline.com/shoudlerdystocia2.jpg

 

Secara klinis, akan ditemukan kelemahan fleksi pada cubiti, kelemahan abduksi, kelemahan endorotasi dan eksorotasibrachii. Selain itu, juga ditemukan paralisis aposisi gerakan skapula dan paralisis abduksi dan adduksi brachii.Sensory loss inkomplit yang terdiri dari hipestesia di superficialis brachii dan antebrachii.Refleks bisep tidak ada. Jika tidak dilatih dengan latihan gerakan pasif, gejala dapat berkembang menjadi kontraktur kronik dengan lengan menyamping, posisi adduksi, tangan pronasi (dapat dilihat pada Gambar 19), sampai dengan munculnya waiter’s tip position.[18][23][26]

 

Gambar 19.Cedera persalinan yang menyebabkanErb’s palsy.

Sumber: Solomon L, Warwick DJ, Selvadurai N. Apley’s System of Orthopaedics and Fractures. United of Kingdom: Hodder Arnold; 2010.

3.7.2.2        Middle Radicular Syndrome

Middle radicular syndrome timbul akibat cedera cervical root C7 atau middle trunk.Lesi tersebut menyebabkan paralisis terutama otot yang disuplai oleh n. radialis, kecuali brachioradialis.Sensory loss dapat bervariasi. Jika ada, akan terbatas pada hipestesi di antebrachii dorsal superficialis dan manus dorsal superficialis externa.[23]

 

3.7.2.3        Lower Radicular Syndrome (Klumpke’s Palsy)

Lower radicular syndrome (Klumpke palsy) timbul akibat cedera lower roots (C7-T1) atau lower trunk, yang menyebabkan paralisis m. flexor carpi ulnaris, m. flexor digitorum, m. interossei, m. thenar, dan m. hypothenar.Sindrom ini merupakan lesi kombinasi n. medianusdan n. ulnaris.Secara klinis, akan terlihat clawlike deformity of the hand (Gambar 20), kelemahan distal fleksicubiti, ekstensi carpi, hiperekstensi pada articulatio metacarpophalangeal. Refleks triseps hilang.Sensory loss di bagian brachii medialis,brachii inferior, dan manus ulnaris. Jika cabang ganglion servikal inferior ikut cedera, maka terjadi paralisis nervus simpatetik yang menyebabkan Horner’s syndrome, yaitu tanda yang timbul akibat kerusakan saraf di bagian servikal spinalis dengan karakteristik ptosis, miosis, dan anhidrosis.[18][23][27]

 

Gambar 20.Clawlike hand deformity pada Klumpke palsy.

Sumber: http://www.glowm.com/resources/glowm/graphics/figures/v3/0630/006f.jpg

 

 

3.7.2.4        Nervus Thoracicus Longus Injury

N. thoracicus longus berasal dari C5, C6, dan C7 yang mensuplai m. serratus anterior.Cedera nervus ini paling sering disebabkan oleh tekanan yang kuat pada bahu sehingga terjadi kompresi nervus (biasanya axonotmesis). Biasanya tekanan tersebut disebabkan membawa beban terlalu berat di bahu, misalnya karung beras, ransel pada satu bahu, dsb.[8][23][28]

Cedera pada nervus menyebabkan instabilitas skapula dan kesulitan gerakan abduksi lengan 90-180° ke arah atas, kelemahan pergerakan elevasi lengan di atas garis horizontal.Gambaran utamanya adalah winging scapula, yaitu penonjolan sisi medial scapula dilihat dari punggung akibat paralisis m. serratus anterior.Tes klasik untuk winging scapula dengan mengarahkan pasien ke dinding kemudian pasine mengangkat kedua telapak tangannya menempel pada dinding (Gambar 21).[18][29]

Kecuali setelah cedera secara langsung, saraf biasanya membaik secara spontan, sekalipun membutuhkan waktu 1 tahun atau lebih.Persisten winging of the scapula biasanya membutuhkan operasi stabilisasi dengan cara mentransfer m. pectoralis mayor atau minor di bagian bawah dari scapula.[18][23][30]

 

Gambar 21.Winging scapula.

Sumber: http://www.wheelessonline.com/userfiles/2010-07-19%2015_44_46.jpg

 

3.7.2.5        Nervus Suprascapularis Injury

N. suprascapularis merupakan cabang dari upper trunk yang berasal dari C5-C6.Fungsi utamanya untuk pergerakan motorik dan menginervasi supraspinatus dan infraspinatus plexus.Saraf ini biasanya cedera pada fracturescapula, dislokasi bahu, trauma bahu akibat membawa beban berat pada bahu dan diffuse injury pada plexus brachialis.[23][33]

Dari anamnesis akan ditemukan riwayat cedera, tetapi terkadang pasien datang dengan keluhan nyeri di bagian suprascapularis dan kesulitan pergerakan abduksi lengan 15-30° dan kesulitan eksorotasi pada bahu.Jika tidak ada riwayat trauma, mungkin terjadi nerve entrapment syndrome.Gejala ini terkadang sulit dibedakan dengan rotator cuff syndrome.Pemeriksaan EMG dapat membantu penegakkan diagnosis.[23][34]

Cedera ini biasanya berupa axonotmesis yang akan sembuh spontan setelah 3 bulan. Pada persistent n. scapularis injury, dilakukan operasi melalui insisi posterior atas dan paralel dari spine of the scapula.[23][35]

3.7.3            Cord Injury

Lesi pada kord menyebabkan hilangnya aktivitas motorik dan sensorik yang terlihat setelah cedera pada dua atau lebih nervus perifer.Lateral cord injury menyebabkan kelemahan pada distribusi n. musculocutaneouss dan n. medianus, termasuk kelemahan pada m. pronator teres, m. flexor carpi radialis, m. flexor pollicis dan m. opponens. Posterior cord injury menyebabkan kelemahan paralel yang mengakibatkan cedera kombinasi pada n. radialis dan n. axillaris. Medial cord injury mengakibatkan cedera kombinasi pada n. ulnaris dan n. medianus (finger-flexion weakness).[23]

3.7.3.1        Brachial Cutaneous dan Antebrachial Cutaneous Nerve Injury

Brachial dan antebrachial cutaneous nervusyang merupakan cabang dari plexus C8-T1 memperlengkapi sensasi pada barchii medialis dan 2/3 bagian anterior antebrachii.Nervus ini biasanya cedera bersamaan dengan medial cord dari plexus brachialis dan jarang cedera pada satu nervus saja. Ketika cedera, akan terjadi loss sensation pada antebrachii medialis dan posterior.[23]

3.7.4            Terminal Branches Injury

3.7.4.1        Nervus Musculocutaneous Injury

N. musculocutaneous berasal dari C5 dan C6 yang merupakan cabang utama dari upper trunk plexus brachialis.Nervus ini memperlengkapi inervasi m. coracobrachialis, m. biceps brachii,m. brachialis, dan sensorik pada ventrolateral foream dan antebrachii dorsolateral superficialis. Cedera nervus ini jarang terjadi.[23][34]

Jika cedera, gejala klinis yang muncul adalah kelemahan fleksi dan supinasi antebrachii akibat paralisis biceps brachii dan m. brachialis.Sensory loss pada musculocutaneous myotomes (antebrachii lateral superficialis)dan hilangnya refleks bisep.Pergerakan fleksi antebrachii mungkin saja masih dapat dilakukan oleh m. brachioradialis, yang diinervasi oleh n. radialis. Tetapi, untuk refleks biceps dapat dipastikan paralisis karena m. biceps brachii tidak diinervasi oleh nervus lain.[4][23][35]

3.7.4.2        Nervus Axillaris Injury

Nervus axillaris adalah cabang terakhir dari kord posterior plexus brachialis sebelum menjadi n. radialis.Nervus axillaris berasal dari C5 dan C6 yang mensuplai m. deltoideus dan mentransmisikan sensasi kutaneus pada area kecil di permukaan lateral bahu. Lesi n. axillaris biasanya disebabkan oleh trauma, fracture leher humerus, dislokasi pada kepala humerus, maupun brachial plexitis.[18][23]

Lesi pada n. axillaris memiliki karakteristik utama kelemahan abduksi pada lengan bahu setelah 15-30° pergerakan tangan yang menjauhi pinggul.Pergerakan adduksi, fleksi, dan ekstensi juga terjadi kelemahan.Sensory loss sangat terbatas dan biasanya hanya terjadi pada brachii lateralis.[4][23]

N. axillary injury biasanya berhubungan dengan fracture atau dislokasi yang sembuh spontan pada 80% kasus. Jika deltoid tidak menunjukkan tanda-tanda perbaikan setelah 8 minggu, dilakukan pemeriksaan EMG. Jika tes menunjukkan tanda denervasi, biasanya dibutuhkan eksisi nerve ends dan grafting yang pada umumnya hasil dapat terlihat dalam 3 bulan setelahnya. Jika operasi gagal dan bahu masih nyeri, dilakukan arthrodesis untuk stabilitas dan memperbaiki fungsi abduksi.[18]

3.7.4.3        Nervus Medianus Injury

N. medianus injury biasanya disebabkan oleh cedera di bagian carpi (low lesions) dan di bagian antebrachii superior (high lesions).

  1. Low lesions

Sindrom yang paling sering terjadi adalah carpal tunnel syndrome (Gambar 22) akibat terjepitnya n. medianus saat melewati celah antara os.carpalis dan ligamentum transversus.[23]

 

Gambar 22.Carpal tunnel syndrome.

Sumber: Baehr M, Frotscher M. DUUS’ Topical Diagnosis in Neurology. Germany: Thieme; 2005.

 

Akibatnya, timbul nyeri dan sensory loss pada distribusi n. medianus (manus palmaris superficialis, digiti I, II, III, dan setengah digiti IV),kelemahan pada median myotomes di tangan dan bagian thenar. Hal ini dapat disebabkan karena cedera akibat gerakan fleksi pergelangan tangan yang terlalu lama, seperti mengetik dan merajut.[23]

Dari pemeriksaan khusus, Tinel’s sign positif pada carpal tunnel syndrome. Diagnosisnya didapatkan melalui gejala klinis, tetapi tes elektrofisiologis, seperti segmental nerve conductions dapat mengkonfirmasi lesi dan melokalisasi letak kompresi. Pengobatan konservatif menggunakan wrist splint, tetapi pada kasus berat, dilakukan tindakan operatif. [23]

 

1. High lesions

High lesions dapat disebabkan oleh fracture di bagian antebrachii, dislokasi bagian cubiti, luka tusukan, luka tembakan, trauma, iskemik, maupun kompresi anatomi, seperti terjepitnya m. pronator teres, sehingga menyebabkan kelemahan dan sensory loss.[18][23]

Lesi pada n. medianus menyebabkan kelemahan dan sensory loss, tetapi hanya pada beberapa pergerakan yang benar-benar paralisis karena adanya kontribusi sinergik otot yang masih diinervasi oleh nervus lain.[23]

Gejala yang timbul sama dengan low lesions, dengan tambahan  ketidakmampuan pergerakan fleksi articulatio interphalangeal proximalis 1-3 dan articulatio interphalangeal distalis 2-3 disebabkan oleh paralisis m. flexor digitorum superficialis dan m. flexor digitorum profundus. Tambahan lain, ditemukan paralisis pergerakan radial wrist flexion dan m. pronator teres, pergerakan fleksi articulatio metacarpophalangeal 2-3 juga tidak dapat dilakukan karena paralsis dari m. lumcbricalis 1-2. Oleh karena itu, pasien dengan n. medianus injury tidak dapat mengepalkan tangan karena digiti II dan III yang mengalami ekstensi parsial. Tanda ini disebut dengan sign of benediction (Gambar 28c).[18][23]

Cedera pada n. interosseous anterior yang disebut dengan anterior interosseous syndromejarang terjadi.Gejala motorik yang timbul mirip dengan high lesions dari n. medianus injury, tetapi tanpa adanya defisit sensorik.Kelemahan tersebut adalah kelemahan pada m. flexor pollicis longus (kelemahan motorik digiti I), m. flexor digitorum profundus I dan II, dan m. pronator quadratus. Penyebab yang paling sering adalah brachial neuritis (Parsonage-Turner syndrome) yang berhubungan dengan shoulder girdle pain setelah imunisasi atau penyakit virus.[18][23]

 

Jika terjadi avulsi saraf, sebaiknya dilakukan nerve grafting. Post operasi, dilakukan splint pada pergelangan tangan. Jika fungsi sensorik membaik, tetapi fungsi motorik oposisi pada digiti I tidak membaik, dilakukan transfer m. extensor indicis proprius atau m. abductor digiti minimi ke m. abductor pollicis brevis.M. extensor carpi radialis longus dapat ditransfer ke m. flexor digitorum profundus, m. brachioradialis ke m. flexor pollicis longus, dan m. extensor indicis ke m. abductor pollicis brevis.[18][23]

 

3.7.4.4        Nervus Radialis Injury

Radial neuropati adalah kondisi yang disebabkan oleh kompresi saraf radial pada posterior humerus.Temuan klinis trauma padan. radialis tergantung pada tingkat lesi.Nervus radialis injury biasanya terjadi di bagian cubiti (low lesions), upper arm (high lesions), dan axilla (very high lesions).[4][18]

2.  Low lesions

Gejala klinis low lesions biasanya disebabkan oleh fracture atau dislokasi cubiti atau karena luka yang sifatnya lokal. Pasien tidak dapat melakukan pergerakan ekstensi pada articulatio metacarpophalengeal, kelemahan pergerakan ekstensi dan retroposisi pada digiti V.[18]

1. High lesions

High lesions biasanya terjadi akibat fracturehumerus dan kompresi intrinsik. Cedera pada spiral groove yang disebabkan oleh fracturehumerus (Gambar 23) dan kompresi ekstrinsik (contohnya, kebiasaan tidur dengan kepala yang menekan lengan posterior) menyebabkan kelemahan pada radial myotome di bawah cubiti, dengan wrist drop akibat dari paralisis radial ekstensor cubiti(Gambar 28b), kelemahan pada gerakan ekstensi articulatio metacarpophalangeal jari-jari, dan sensory loss pada distribusi n. radialis superfisial (permukaan manus dorsalis dan digiti I, II, III dan setengah digiti IV), tetapi gerakan ekstensi cubiti masih baik. Kelemahan gerakan fleksi cubiti dapat ditemukan sebagai akibat dari keterlibatan brachioradialis.[4][18][23]

 

Gambar 23. Cedera n. radialis akibat fracturehumerus pada spiral groove.

Sumber: http://www.e-radiography.net/articles/ortho/Image11.jpg

 

  1. Very high lesions

Very high lesions disebabkan oleh trauma atau operasi di sekitar bahu. Trauma yang paling sering adalah kompresi kronik axilla akibat penggunaan kruk terlalu lama (crutch pasly)atau Saturday night palsy pada pecandu alkohol dan obat-obat yang tidak sadar dan tidur dalam keadaan lengan menggelantung di bagian belakang kursi (Gambar 24). Hal ini menyebabkan kelemahan carpi dan manus, kelemahan m. triceps, kelemahan radial myotome, kelamahan radial dermatomes, dan hilangnya refleks triceps.[18][23]

 

Gambar 24.Saturday night palsy.

Sumber:http://saturdaynightpalsy.com/wp-content/uploads/2011/05/Saturday-Night-Palsy-300x188.jpg

 

Jika terjadi persistent injury, sebaiknya dilakukan pemeriksaan EMG.Jika hasil menunjukkan denervasi saraf, maka neuropraxia telah tereksklusi. Fungsi motorik n. radialis dapat dikembalikan dengan quite long grafts. Jika kesembuhan tidak terjadi, dapat dilakukan tendon transfers, yaitu pronator teres ke short radial extensor of the wrist, flexor carpi radialis ke long finger extensors, dan palmaris longus ke long thumb abductor.[18][23]

 

3.7.4.5        Nervus Ulnaris Injury

Lesi komplit pada n. ulnaris menimbulkan gejala kelemahan pada gerakan fleksi dan adduksi carpi dan kelemahan gerakan fleksi pada jari kelingking, paralisis gerakan abduksi dan oposisi digiti I, paralisis gerakan adduksi digiti I, dan paralisis gerakan adduksi dan abduksi digiti, bersamaan dengan atrofi hypothenar dan interossei.Atrofi interossous terutama terlihat jelas di bagian manus dorsum, antara digiti I dan digiti II.Sensory loss terutama pada bagian permukaan palmar dan dorsal digiti V dan setengah digiti IV. Lesi kronis akan menyebabkan claw hand. Cedera n. ulnaris dapat disebabkan oleh trauma, iskemik, dan kompresi anatomis.[4][18][23]

Lesi n. ulnaris dapat terjadi pada 2 lokasi utama, yaitu lesi dekat cubiti(high lesions) dan lesi dekat carpi (low lesions):[23]

  1. High lesions

Lesi terjepitnya nervus yang paling sering adalah di bagianCubital tunnelyang disebut dengan Cubital tunnel syndrome(Gambar 25).Kompresi atau nerve entrapment di bagian epicondylaris medialis (cubital tunnel) sering menyebabkan ulnar neuritis.Hal ini berbeda dengan penyebab cedera akibat fracture ataupun dislokasi.[23]

Gejala yang timbul adalah kelemahan ulnar myotomes di bagian manus, termasuk m. flexor carpi ulnaris dan m. flexor digitorum profundus III dan IVsehingga terjadi less clawed (the high ulnar paradox). Fungsi motorik dan sensorik juga hilang sesuai dengan distribusi ulnar.[23]

 

Gambar 25.Kompresi n. ulnaris pada cubital tunnel.

Sumber:http://www.handsurgery.com.sg/wordpress/wp-content/uploads/2011/03/Cubital-Tunnel-Syndrome_ds.jpg

 

  1. Low lesions

Lesi terjepitnya nervus juga dapat terjadi di bagian Guyon canal yang disebut dengan Guyon cannal syndrome. Guyon canal adalah celah yang dibentuk oleh ossapisiforme-hamatum dan ligamen yang menghubungkan keduanya (Gambar 26).[23]

 

Gambar 26.Kompresi n. ulnaris pada guyon tunnel.

Sumber:http://www.bedfordsackvillephysio.com/media/img/424/hand_guyon_canal_anat03.jpg

 

Lesi ini seringkali disebabkan oleh perlukaan pergelangan tangan oleh benda tajam yang biasanya dilakukan saat usaha bunuh diri. Penyebab lain adalah deep carpal ganglion dan a. ulnaris aneurysm. Gejala yang timbul adalah numbness pada distribusi ulnaris(Gambar 27) dan ditemukan karakteristik khas, yaitu claw hand(Gambar 28d) akibat kelemahan dan atrofi otot intrinsik. M. flexor carpi ulnaris dan m. flexor digitorum profundus normal pada pemeriksaan elektrofisiologik.[18][23]

 

Gambar 27.Tipikal sensory loss area pada Guyon canal syndrome.

Sumber: Solomon L, Warwick DJ, Selvadurai N. Apley’s System of Orthopaedics and Fractures. United of Kingdom: Hodder Arnold; 2010.

 

Metacarpophalangeal flexion dapat diperbaiki dengan transfer m. extensor carpi radialis longus ke intrinsic tendon.

 

Ilustrasi cedera nervus plexus brachialis dapat dilihat pada Gambar 28di bawah ini:

 

Gambar 28.Nervus injury pada cederaplexus brachialis.

Sumber: Tortora GJ, Derrickson B. Principles of Anatomy and Physiology. Unites States of America: Wiley; 2009.

Distribusi persarafan pada cabang terminal dapat dilihat pada Gambar 29 Adan B di bawah:

Gambar 29.Terminal branches distribution.(A) Distribusi n. musculocutaneous, n. medianus, n. ulnaris. (B) Distribusi n. radialis, n. axillaris.

Sumber: http://antranik.org/peripheral-nervous-system-spinal-nervus-and-plexuses/

 

3.8     Pemeriksaan Fisik

Tujuan pemeriksaan fisik untuk menentukan tipe dan lokasi brachial plexus injury.Pemeriksaan fisik tersebut, meliputi:

  1. Pemeriksaan fungsi motorik (Tabel 11) sesuai dengan distribusinya (Gambar 31), yang dinilai dari skala 0 hingga 5 disesuaikan dengan Medical Research Council Scale for Assessment of Muscle Power.(Tabel 10).
  2. Pemeriksaan fungsi sensorik (Gambar 30)

Pemeriksaan sensorik dilakukan pada setiap dermatom, propioceptive, temperatur, taktil, perabaan, vibrasi dengan turning fork 30 dan 256 cycles per second, dan ninhydrin test.

  1. Pemeriksaan khusus, meliputi Tinel’s sign dan Horner’s syndrome.[35][36]

 

Gambar 30.Brachial plexus sensibility assessment chart.

Sumber: Gilbert A. Brachial Plexus Injuries. United of Kingdom: Martin Dunitz Ltd; 2001.

Gambar 31.Brachial plexus muscle test chart.

Sumber: Gilbert A. Brachial Plexus Injuries. United of Kingdom: Martin Dunitz Ltd; 2001.

Tabel 10.Medical Research Council scale for assessment of muscle power.

Sumber: Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. United States of America: Lipincott Williams and Wilkins; 2011.

Grade

Assessment

0

no movement 

1

flicker is perceptible in the muscle 

2

movement only if gravity eliminated 

3

can move limb against gravity 

4

can move against gravity & some resistance exerted by examiner 

5

normal power

Pemeriksaan untuk otot dan inervasi brachial plexus dapat dilihat pada Tabel 11.

Tabel 11.Pemeriksaan motorik muskulus padaplexus brachialis.

Sumber: Gilbert A. Brachial Plexus Injuries. United of Kingdom: Martin Dunitz Ltd; 2001.

   

  

Pemeriksaan khusus lain, meliputi

  1. Tinel’s sign(Gambar 32)

Tinel’s sign positif jika muncul peripheral tingling atau dysaesthesia perkusi saraf.Proksimal Tinel’s sign yang positif pada leher saat tes disto-proksimal nerves perifer biasanya mengindikasikan adanya proksimal neuroma dan tanda prognosis yang baik. Jika Tinel’s sign pada leher negatif, mengindikasikan adanya total plexus avulsion.

Gambar 32.Tinel’s sign.

Sumber: Baehr M, Frotscher M. DUUS’ Topical Diagnosis in Neurology. Germany: Thieme; 2005.

 

  1. Horner’s syndrome(Gambar 33)

Horner’s syndrome, yaitu tanda yang timbul akibat kerusakan saraf di bagian servikal spinalis dengan karakteristik ptosis, miosis, dan anhidrosis.Horner’s syndrome terjadi akibat avulsi C8-T1 atau lesi dekat vertebral column pada saraf spinal sehingga membahayakan fiber preganglion simpatetik pada sisi yang sama dengan lesi, yang kemudian timbul tanda-tanda vasodilatasi, enoftalmos, anhidrosis, miosis, dan ptosis. Horner’s syndromeyang negatif merupakan tanda prognosis yang baik.[35]

 

Gambar 33.Horner’s syndrome positif pada mata kiri.

Sumber: http://www.frca.co.uk/images/horners.jpg

 

3.9     Diagnosis

Untuk menegakkan diagnosis pada pasien dengan brachial plexus injury, anamnesis dan pemeriksaan fisik sangat penting untuk dilakukan:

Anamnesis

Anamnesis yang penting untuk ditanyakan adalah riwayat trauma sebelumnya, kronologi kejadian, dan gejala klinis yang dirasakan oleh pasien.

Pada pasien dengan lesi plexus brakhialis akibat trauma lahir, perlu diketahui riwayat kehamilan, kelahiran, usia kehamilan, berat badan lahir, presentasi bayi, riwayat penggunaan forcep, distosia bahu, apgar skor dan kebutuhan akan resusitasi saat kelahiran.

Pemeriksaan fisik

Dari hasil pemeriksaan fisik, akan ditemukan adanya perubahan anatomi dan fisiologis di bagian ekstremitas atas, kelemahan pergerakan motorik, parestesia atau anestesia pada daerah tertentu.

Pemeriksaan fisik untuk lesi plexus brachialis dilakukan dengan inspeksi, yaitu melihat posisi lengan terutama saat istirahat.Avulsi pada radiks saraf dapat diketahui dengan adanya sindroma Horner dan kelemahan pada otot-otot paraspinal.Sisi kontralateral dan ekstremitas bawah perlu juga dinilai untuk menyingkirkan adanya lesi di medula.

Pada pasien trauma, palpasi clavicula, costae dan humerus disertai foto sendi bahu jika dicurugai adanya fracture atau dislokasi.Mengevaluasi otot-otot pada punggung termasuk m. trapezius, m. rhomboideus, m. supraspinatus, m. infraspinatus, m. latissimus dorsi, m. teres mayor, dan m. teres minor.Lebih lanjut, nilai fungsi motorik m. deltoideus, m. biceps, m. triceps, juga pergelangan tangan, muskulus fleksor, dan ekstensor.Nilai pergerakan sendi, seperti abduksi pada sendi bahu, adduksi, rotasi interna dan eksterna, juga fleksi dan ekstensi pada sendi siku, pergelangan tangan dan sendi pada jari-jari.Adanya kontraktur pada m. pectoralis mayor dapat dinilai dengan palpasi pada regio axillaris anterior pada saat rotasi eksterna.Demikian pula kontraktur pada m. subscapularis dinilai pada palpasi regio aksillaris posterior saat abduksi bahu.

Pemeriksaan penunjang

Beratnya lesi saraf yang ditemukan dapat berupa neuropraxia, axonotmesis ataupun neurotmesis. Beberapa pemeriksaan tersebut juga akan membantu menentukan penanganan selanjutnya dan perlu tidaknya prosedur bedah dilakukan

  • X-Ray (tergantung kebutuhan)
    • Foto vertebra servikal untuk mengetahui apakah ada fracture pada vertebra cervical.
    • Foto bahu untuk mengetahui apakah ada fracturescapula, clavicula, atau humerus.
    • Foto thorak untuk melihat disosiasi scapulothoracic (depresi scapula dengan lateral displacement), fracturecostae, massa tumor pulmonari, dan untuk kepentingan extraplexus (n. intercostalis) nerve transfer.
    • MRI atau CT Scan

MRI atau CT Scan (sesuai dengan kebutuhan) untuk melihat detail struktur anatomi dan jaringan lunak saraf perifer, deformitas sendi, kapsul yang robek, atrofi otot, dan untuk melihat adanya avulsi saraf, juga mendiagnosa adanya pseudomeningocele. MRI merupakan pemeriksaan utama untuk menilai adanya rootlet avulsion pada lesi plexus brachialis

  • CT Myelography

Hasil yang mungkin ditemukan adalah pseudomeningoceles yang diproduksi oleh root avulsion, tetapi hasil yang positif tidak selalu dapat diandalkan karena dura dapat robek tanpa adanya root avulsion. CT myelography lebih sering dikerjakan pada pasien yang akan melakukan operasi. Kesimpulan hasil CT myelography:

-          Dorsal dan ventral rootlets yang intak tanpa adanya meningocele mengeksklusi kemungkinan avulsi.

-          Adanya meningocele tidak selalu menyatakan adanya avulsi.

-          Jika meningocele meluas hingga keluar foramen, kemungkinan adanya avulsi sangat besar.

  • Angiography

Angiography seringkali sudah digantikan oleh MRA (Magnetic Resonance Angiography).Pada beberapa kasus dapat dilakukan pemeriksaan angiografi untuk menilai kerusakan pada pembuluh darah akibat trauma yang juga menyebabkan lesi pada plexus brachialis. Angiografi dapat membantu menentukan tingkat lesi pada saraf oleh karena arteri dan plexus sering mengalami trauma pada tingkat yang sama. Angiography juga sering dikerjakan setelah vaskular rekonstruksi.

  • Electrophysiology
    • EMG (Electromyography)

Pemeriksaan EMG dapat membantu menentukan letak lesi dan fungsi inervasi saraf.

  • NCV (Nerve-Conduction Velocity)

Pemeriksaan NCV untuk mengetahui sistem motorik dan sensorik, kecepatan hantar saraf, serta latensi distal.

  • SNAPs (Sensory Nerve Action Potentials)

SNAPs berguna untuk membedakan lesi preganglionik atau lesi postganglionik.Pada lesi postganglionik, SNAPs tidak didapatkan tetapi positif pada lesi preganglionik.

  • SSEP (Somato-Sensory Evoked Potensials)

SSEP berguna untuk membedakan lesi proksimal misalnya pada root avulsion.[18][35]

 

3.10  Guideline Penanganan Obstetrical Brachial Plexus Injury

Langkah-langkah yang harus dilakukan pada neonatal brachial plexus palsy:

  1. Menegakkan diagnosis
  • Riwayat kehamilan dan persalinan: lama kehamilan, jumlah persalinan, presentasi normal janin atau sunsang, berat janin.
  • Kesulitan persalinan: shoulder dystocia.
  • Apgar score
  1. Pemeriksaan neurologik
  • Pemeriksaan motorik
  • Pemeriksaan sensorik
  • Pemeriksaan khusus lain: Tinel’s sign, Horner’s syndrome
  1. Tes
  • EMG pada hari pertama jika dicurgai adanya lesi intra-uterine
  • Pemeriksaan radiologi thoraks, clavicle, humerus jika dicurigai adanya paralisis n. phrenicus, dan/atau fracture.
  1. Terapi
  • Posisi istirahat selama 3 minggu dengan lengan di depan dada.[35]

 

Kriteria untuk neurosurgical treatment

  • Fungsi biceps M0 setelah 3 bulan
  • Bukti adanya severe lesion: Horner’s syndrome, persisting hypotonic paralysis, persisting phrenic paralysis, gangguan sensorik berat.
  • Hasil EMG menunjukkan persisting denervation
  • Hasil CT-myelography menunjukkan adanya meningocele di luar foramen vertebralis.[35][37][38][39]

 

Waktu yang tepat dilakukannya neurosurgical intervention umumnya, saat usia 3-4 bulan. Pada kasus berat, seperti total avulsions, dilakukan operasi sesegera mungkin. Diagram penanganan obstetrical brachial plexus injury dapat dilihat pada Skema 1 di bawah.[35]

Skema 1.Guideline penanganan obstetric brachial plexus injury.

Sumber: Gilbert A. Brachial Plexus Injuries. United of Kingdom: Martin Dunitz Ltd; 2001.

 

3.11  Pengobatan

Pembedahan adalah pilihan untuk adultbrachial plexus injury, baik pada closed maupun open injury. Setidaknya ada 4 hal yang mempengaruhi dalam pengambilan keputusan pembedahan:

  1. Donor saraf yang digunakan (supraclavicular, infraclavicular dissection, dan donor nerve dissection)
  2. Strategi rekonstruktif (fungsi pergerakan yang menjadi prioritas rekonstruktif)
  3. Teknik pembedahan

Setidaknya terdapat 5 teknik pembedahan untuk brachial plexus injury:

  • Nerve transfer

Nerve transfer mengambil saraf lain atau cabang saraf yang kurang penting untuk ditransfer pada saraf krusial yang mengalami kerusakan dengan tujuan mengembalikan fungsinya dengan caradirect suturingatau nerve grafting pada sisi distal. Nerve transfer dapat diambil dari saraf proksimal (extraplexus dan intraplexus nerve transfer) atau saraf distal (closed-target nerve transfer).

  • Functioning free muscle transplantation

Functioning free muscle transplantation adalah transfer otot menggunakan microvascular anastomoses untuk revaskularisasi dan penyambungan microneural pada recipient motor nerve dengan tujuan reinervasi.

  • Neurolysis

Neurolysis merupakan suatu prosedur melepaskan neuroma (constrictive scar tissue) di sekitar saraf. Bila neuroma besar, harus dieksisi dan saraf dilekatkan kembali dengan teknik end-to-end atau nerve grafts.

Neurolysis diindikasi pada kasus neuropraxia atau konduksi blok yang tidak membaik secara spontan. Kondisi ini biasanya disebabkan oleh perineural fibrosis yang dipicu oleh hematoma post-traumatik maupun stretch injuries. Saraf terdiri dari banyak fiber (axon).Ketika terjadi cedera saraf, fiber-fiber ini berusaha menyebar keluar supaya tersambung, kadang-kadang, fiber ini dapat membentuk gumpalan sehingga terjadi jaringan parut pada saraf.

  • Nerve repair

Prosedur nerve repair berarti menjahit antara ujung dan ujung saraf yang terputus yang dikerjakan di bawah mikroskop. Saraf tidak akan pernah kembali secara sempurna jika telah terpotong. Kesembuhan maksimal hanya terjadi sekitar 80%.Pertumbuhan saraf sekitar 1 mm setiap harinya.

  • Nerve grafting

Bila gap antara saraf terlalu besar, sehingga tidak mungkin dilakukan tarikan.Saraf yang sering dipakai adalah n. suralis, n. cutaneous antebrachial lateralis dan medialis, dan cabang terminal sensoris n. interosseus posterior.

  1. Waktu pembedahan yang tepat (primary atau secondary repair)
  • Immediate atau early surgery

Pada kasus open injury di bagian leher oleh pisau atau benda tajam lainnya menyebabkan defisit motorik maupun sensorik dan kecurigaan adanya avulsi saraf. Eksplorasi dan immediately nerve repair beberapa hari setelah trauma sangat diindikasikan. Golden time untuk supraclavicular penetrating lesions adalah 1 minggu, sedangkan infraclavicular penetrating lesions selama 2 minggu. Setelah golden time, biasanya dibutuhkan nerve grafts setelah neuroma resection.

  • Secondary nerve repair: delayed repair

Terdapat 3 tipe secondary repair:

  • Early delayed repair (nerve repair dalam waktu 1 bulan untuk diagnosis open injury atau 5 bulan untuk closed injury).

Untuk kasus closed brachial plexus injury, tujuan utama delayed repair untuk menegakkan diagnosis, termasuk mencari derajat, letak, dan luas lesi. Managemen untuk kasus ini terdiri dari 3 tahap:

-          Stage 1            : stabilization stage selama 1 bulan pertama, temasuk stabilisasi tanda-tanda vital, fracture tulang, dan dislokasi sendi.

-          Stage 2            : diagnostic stage pada bulan ke-2, termasuk pemeriksaan klinis dan investigasi untuk menegakkan diagnosis, mulainya fisioterapi dengan stimulasi elektrik untuk mencegah soft tissue swelling, kekuan sendi, dan atrofi otot. Selain itu, pada tahap ini juga dilakukan psychological education sebelum operasi.

-          Stage 3            : pada bulan ke-3 hingga ke-5 perawatan. Jika tidak ada tanda-tanda perbaikan fungsi saraf pada 3 bulan pertama, maka diindikasikan operasi.

  • Late delayed repair (nerve repair lebih dari 6 bulan setelah trauma)

Dalam waktu 6 bulan setelah trauma, telah terjadi denervasi saraf sehingga disarankan nerve repair yang diikuti oleh local muscle transfer atau functioning free muscle transplantation.

  • Late repair (nerve repair lebih dari 1 tahun setelah trauma)

Pada kasus kronik, 1 tahun setelah trauma, otot telah sangat lama mengalami denervasi sehingga atrofi dan telah digantikan oleh jaringan konektif dan lemak.Sekalipun dilakukan operasi, hasilnya tetap buruk dan sia-sia.Fisioterapi hanya mencegah terjadinya atrofi otot lebih jauh tetapi tidak memperbaiki otot yang telah rusak. Operasi pilihan untuk kasus kronik seperti ini adalah functioning free muscle transplantation atau banked nerve grafts dari ipsilateral atau contralateral nerve transfer, yang diikuti oleh secondary functioning free muscle transplantation.[35][40][41]

 

Perbedaan derajat dan perbedaan level cedera membutuhkan strategi rekonstruksi yang berbeda. Hampir 70% cederaplexus brachialis termasuk dalamclosed injury yang menyebabkan avulsi saraf spinal. Ini adalah lesi yang tidak dapat diperbaiki.Nerve transfer dan functioning free muscle transplantation menjadi satu-satunya pilihan jika terjadi avulsi pada cederaplexus brachialis.[42][43]

Pilihan rekonstruktif untuk cedera level 1 adalah nerve transfer dan functioning free muscle transplantation. Palliative surgerydikerjakan untuk lesi level 1 sampai dengan 4.Functioning free muscle transplantation termasuk dalam palliative surgery dan dapat dikerjakan pada lesi selain lesi level 1.Neurolysis, nerve repair, nerve graft (free nerve graft atau vascularized ulnar nerve graft), nerve transfer dikerjakan pada lesi level 2. Clavicle osteotomy seringkali dibutuhkan pada lesi level 3. Nerve grafts juga sering dikerjakan pada lesi level 4.[42][44]

 

Agar lebih mengerti tentang strategi rekonstruktif, David Chuang membagi lesi plexus brachialis menjadi 4 level cedera yang dapat dilihat pada Gambar 34:

  1. Level 1     : pre-ganglionic root injury, termasuk: spinal cord, rootlets, dan root injuries.
  2. Level 2     : post-ganglionic spinal nerve injury yang terbatas pada lesi interscalene space/interscalene groove (celah antara anterior dan m. scaleneus medius) ke arah proksimal dari n. suprascapularis.
  3. Level 3     : preclavicular dan retroclavicularcederaplexus brachialis termasuk trunks dan divisions.
  4. Level 4     : infraclavicular cederaplexus brachialis termasuk cords dan terminal branches proximal sampai ke axillary fossa.[42]

 

Gambar 34.Level BPI menurut pembagian Chuang. (BPI = Brachial Plexus Injury)

Sumber: Chuang DC. Brachial Plexus Injury: Nerve Reconstruction and Functioning Muscle Transplantation. Seminars in Plastic Surgery.2010; 24: 57-66.

 

David Chuang juga membagi 2 tipe lesi pada cederaplexus brachialis(Gambar 35) yang dibedakan untuk tujuan perbedaan pengobatannya.

  1. Avulsion   : mengacu pada saraf yang robek dari perlekatannya (disebut avulsi proksimal jika perlekatannya terlepas dari spinal cord, disebut avulsi distal jika perlekatannya terlepas dari otot).
  2. Rupture   : adalah cedera saraf yang diakibatkan oleh trauma traksi yang terbelah secara inkomplit sehingga menyebabkan bentuk akhir iregular proksimal dan distal.[42]

 

 

Gambar 35.Perbedaan preganglionic avulsion dan postganglionic rupture.

Sumber: Chuang DC. Brachial Plexus Injury: Nerve Reconstruction and Functioning Muscle Transplantation. Seminars in Plastic Surgery.2010; 24: 57-66.

 

Cedera level 1 pada konteks ini adalah avulsion injury, sedangkan level 2, 3, dan 4 adalah rupture injury. Perbedaan avulsion dan rupture dapat dilihat pada Tabel 12.[42]

 

Tabel 12. Perbedaan avulsion dan rupture.

Sumber: Chuang DC. Brachial Plexus Injury: Nerve Reconstruction and Functioning Muscle Transplantation. Seminars in Plastic Surgery.2010; 24: 57-66.

 

3.11.1         Level1 Injury (Preganglionic Injury: Spinal Cord, Rootlets, and Roots)

Sayangnya, insiden nerve injury yang paling sering terjadi adalah lesi level 1 yang ditemukan sebesar 70%. Avulsi dapat terjadi pada satu hingga lima akar yang terlibat. Strategi rekonstruktif yang dapat dikerjakan, antara lain: nerve transfer, functioning free muscle transplantation, dan palliative surgery.

1.        Nerve Transfer (Gambar 36)

Prosedur ini baik dikerjakan dalam rentang waktu golden periodyang tidak lebih dari 5 bulan sejak trauma.Tujuan operasi ini setidaknya dapat memperbaiki kekuatan otot hingga power4disesuaikan dengan Medical Research Council Scale for Assessment of Muscle Power.Nerve transfer diklasifikasikan menjadi:

Extraplexus nerve transfer

Extraplexus nerve transfer melibatkan transfer dari saraf tetangga (dari saraf leher ipsilateral atau kontralateral) untuk neurotisasi saraf yang paralisis pada avulsi plexus brachialis. Saraf tersebut termasuk n. phrenicus, n. accesorius spinalis (XI), n. hypoglossus (XII), dan saraf C7 kontralateral.Extraplexus sensory nerve transfer, seperti n. supraclavicularis sensoryuntuk transfer n. medianus, terkadang digunakan untuk memperbaiki paralitik sensorik.

Intraplexus nerve transfer

Intraplexus nerve transfer dapat dikerjakan pada kasus non-global root avulsion dimana sekurangnya satu dari saraf spinal terjadi rupture injury dan masih dapat di-transfer. Contohnya, pada kasus C5 rupture dan C6 avulsion, dimana ujung C5 lebih sehat dibanding ujung C6.Fiber C5 ditransfer secara sengaja pada C6 (atau anterior division of the upper trunk) untuk memperbaiki pergerakan fleksi cubiti.C5 distal (atau posterior division of the upper trunk dan n. suprascapularis) kemudian diinervasi oleh partially injured C6. Strategi ini menyatakan bahwa pergerakan fleksi cubiti memiliki prioritas lebih dibanding rekonstruksi bahu.Intraplexus nerve transfer bersifat individual, tergantung dari penemuan intraoperative, kondisi pasien, dan persyaratan. Extraplexus dan intraplexus nerve transfers dikerjakan untuk neurotisasi saraf proksimal.

Close-target nerve transfer

Close-target nerve transfer adalah prosedur transfer untuk saraf bagian distal, lebih dekat pada neuromuscular junction, sehingga dapat dicapai perbaikan motorik yang lebih cepat. Saraf donor yang diambil untuk close-target nerve transfer adalah saraf yang letaknya di dekat target atau saraf yang berada di luar fossa supraclavicularis dan infraclavicularis, seperti:

-          n. accessorius spinalis ditransfer ke n. suprascapularis

-          partial n. ulnaris ditransfer ke n. biceps brachii

-          part of n. medianus ditransfer ke n. brachialis

-          caput longus dari n. triceps brachii ditransfer ke n. axillaris

-          n. intercostalis ditransfer ke n. biceps brachii atau ke n. musculocutaneous, atau ke caput longus dari n. triceps brachii

-          n. interosseus anterior ditransfer ke n. interosseus radialis atau posterior

-          cabang n. interosseus anterior ditransfer ke deep motor branch dari n. ulnaris pada antebrachii.[42][45]

 

 

Gambar 36.Nerve transfer: cabang brachialis dari n. musculocutaneous ditransfer ke posterior fascicle dari n. medianus.

Sumber: Brown JM, Mackinnon SE. Nerve Transfers in the Forearm and Hand. 2008. The Journal of Hand Surgery. 2008; 24:319-40.

 

Pilihan proksimal atau distal nerve transfer sebagai operasi rekonstruktif masih diperdebatkan (Tabel 13). Proximal nerve transfer (extraplexus dan intraplexus nerve transfer) masih merupakan prosedur operatif rekonstruktif utama.[42]

 

Tabel 13.Perbedaan proksimal dan distal nerve transfer.

Sumber: Chuang DC. Brachial Plexus Injury: Nerve Reconstruction and Functioning Muscle Transplantation. Seminars in Plastic Surgery.2010; 24: 57-66.

 

 

Induction or motivation exercise adalah latihan otot yang sangat penting untuk pasien yang menjalani nerve transfer. Latihan ini adalah latihan otot yang diinervasi oleh transferred nerve, diindikasikan untuk semua kasus nerve transfer. Induction exercise dimulai ketika gerakan otot inervasi sudah dapat teraba (M1). Aksi ini sebanding dengan internal electric stimulator. Nerve transfer yang berbeda maka induction exercises yang diperlukan juga berbeda (Tabel 14).[42]

 

Tabel 14.Induction excersice pada nerve transfer.

Sumber: Chuang DC. Brachial Plexus Injury: Nerve Reconstruction and Functioning Muscle Transplantation. Seminars in Plastic Surgery.2010; 24: 57-66.

 

Shoulder

Rekonstruksi untuk pergerakan abduksi bahu pada lesi level 1 harus diprioritaskan dibanding pergerakan adduksi bahu.Jika m. supraspinatus, m. infraspinatus, dan m. deltoideus diinervasi secara bersamaan, tentu saja hasilnya lebih baik.Nervus phrenicus dan n. XI adalah donor utama untuk abduksi bahu.Nervus XII,cervical motor branches, part of C5 atau C6, n. thoracicus longus, cabang dari caput longus triceps, n. pectoralis medialis, n. intercostalis, dan contralateral C7 juga dilaporkan sebagai saraf donor untuk abduksi bahu. Saraf resipien untuk abduksi bahu dalam urutan prioritas adalah distal C5, n. suprascapularis, divisioner dorsalis dari trunkus superior, kemudian n. axillaris.[42][46]

 

Cubiti

Pada cedera level 1, prioritas rekonstruksi adalah pergerakan fleksi cubiti. Donor saraf untuk fleksi cubiti termasuk n. intercostalis, nervus XI dengan nerve graft, n. phrenicus dengan atau tanpa nerve graft, partial n. ulnaris, partial n. medialis, n. pectoralis, n. thoracodorsal, dan contralateral C7. Saraf resipien termasuk n. musculocutaneous, cabang dari n. biceps, atau cabang n. brachialis.

Rekonstruksi pergerakan ekstensi cubiti bukanlah prioritas utama.Transfer n. phrenicus ke distal C5 atau posterior division of the upper trunk atau n. radialis dengan nerve graft seringkali baru dapat menghasilkan pergerakan ekstensi pada tahun ke-3 rehabilitasi. Beberapa ahli menggunakan 2 atau 3 n. intercostalis untuk ditransferkan ke caput longus triceps dengan tujuan rekonstruksi pergerakan ekstensi cubiti.[42][47]

 

Digiti

Pada cedera global (C5-T1) level 1, prioritas rekonstruksi untuk fungsi jari tergantung dari prosedur yang digunakan, yaitunerve transfer atau functioning free muscle transplantation.Secara tradisional, prioritas rekonstruktif adalah pergerakan fleksi jari.Pada rupture C5 dengan C6-T1 four-root avulsion, seringkali dilakukantransfer C5 ke n. medianus, sedangkan padatotal root (C5-T1) avulsionseringkali dilakukan transfer contralateral C7 ke n. medianus untuk perbaikan pergerakan fleksi jari dan cubiti. Salah satu prosedur membutuhkan vascularized ulnar nerve graft untuk mencapai one-stafe full reconstruction jika kerusakan disertai dengan nerve transfer untuk fungsi bahu dan cubiti. Pada total root avulsion fase akut, one-stage full reconstruction dapat dicapai dengan multiple nerve transfer termasuk contralateral C7.[42]

Functioning free muscle transplantation diutamakan sebagai terapi rekonstruktif paliatif untuk mencapai hasil yang lebih baik pada fase lanjut. Pendekatan alternatif untuk functioning free muscle transplantation, antara lain: a longfunctioning free muscle transplantation from the clavicle down to the extensor digitorumcommunis, innervated by the XI nerve,dilakukan pada fase awal, diikuti dengan second long functioning free muscle transplantation from the second rib to the flexor digitorum profundus, inervasi oleh n. intercostalis pada fase kedua.[42]

Arthrodesis cubiti dan digiti I biasanya dibutuhkan untuk stabilitas. Untuk proximal to distal reconstructive strategy (nerve reconstruction pada fase awal, selanjutnya free functioning muscle transplantion) dibandingkan dengan distal to proximal (free functioning muscle transplantation pada fase awal, selanjutnya nerve reconstruction) pada cedera level 1 diilustrasikan pada Tabel 15.[42]

 

Tabel 15.Perbedaan antara proksimal-distal dan distal-proksimal rekonstruktif.

Sumber: Chuang DC. Brachial Plexus Injury: Nerve Reconstruction and Functioning Muscle Transplantation. Seminars in Plastic Surgery.2010; 24: 57-66.

 

2.        Functioning Free Muscle Transplantation

Penggunaan functioning free muscle transplantation pada rekonstruksi plexus brachialis adalah salah satu contoh aplikasi nerve transfer (termasuk extraplexus, intraplexus, dan close target nerve transfer).[42]

Gracilis myocutaneous functioning free muscle transplantation(Gambar 37)adalah pilihan terbaik yang paling sering dilakukan pada donor muscle pada brachial plexus reconstruction.Extraplexus donor nervusyang paling sering digunakan adalah nervus IX, n. intracostalis, n. phrenicus, dan n. contralateral C7. Intraplexus donor nervusyang paling sering digunakan adalahpart of the n. ulnaris, part of the n. medianus, n. infraclavicularis atau n. supraclavicularis yang membutuhkan perpanjangan saraf (dengan nerve graft) dan functioning free muscle transplantation pada prosedur selanjutnya.[42]

 

Gambar 37.Gracilis functional free muscle transfer surgery.

Sumber:http://4.bp.blogspot.com/_Xa2VrB26aXU/TJ0HYYZX2JI/AAAAAAAAALk/VmNXQlo8odE/s1600/Gracilis.jpg

Hasil functioning free muscle transplantation lebih memuaskan dibanding local muscle transfer.Functioning free muscle transplantation terutama digunakan untuk cubiti dan perbaikan fungsi manus pada kasus global plexopathy.

Indikasi functioning free muscle transplantation pada cederaplexus brachialis termasuk akut dan kronik root avulsion, root injury with failed nerve transfer (muscle strength <M3) atau cederaplexus brachialis dengan Volkmann’s contracture pada antebrachii.[42]

3.11.2         Level 2 Injury (Postganglionic Spinal Nerve Injury Limiting the Lesion in the Interscalene Space and Proximal to the Nervus Suprascapularis)

Diagnosis banding antara preganglionic root (level 1) dan postganglionic spinal nerve injury (level 2) sangat penting dibedakan karena berkaitan dengan pendekatan bedah dan prognosisnya.[42]

Cedera level 2 didefinisikan sebagai cedera distal ke dorsal root ganglion (atau di luar intervertebral foramen) di antara m. scaleneus dan proksimal ke n. suprascapularis.Insidennya sekitar 8% kasus.[42][47][48]

Jika n. suprascapularis intak, lesi dapat berasal dari level 3-4 dan tidak berada di level 2.Adanya neuroma pada spinal nerve (khususnya m. scleneus medius) adalah penyebab tersering cedera tipe ini.Rupture dapat terjadi pada satu atau lebih spinal nerve.[42]

Rekonstruksi untuk cedera level ini meliputi neurolysis, nerve repair, nerve grafts (free nerve graft atau vascularized ulnar nerve graft).[42][49][50]

1.        Neurolysis

Lesi saraf yang masih tersambung, biasanya menunjukkan neuroma-in continuity, menyatakan bahwa beberapa fungsi saraf masih tersisa.Neurolysis (Gambar 38) kadang membantu.

Teknik operasi sebaiknya epifascicular epineurotomy/epineurotommy (external neurolysis) atau interfascicular epineurectomy (internal neurolysis).Pada lesi plexus brachialis, biasanya dilakukan external neurolysis.[42]

 

Gambar 38.Prosedur neurolysis yang dilanjutkan dengan nerve graft.

Sumber:http://www.highimpact.com/uploads/exhibits/images/legal-exhibits/medical-illustrations/large/MDI00400.jpg

 

2.        Nerve Repair

Direct nerve repair (Gambar 39) biasanya dilakukan pada cedera penetrasi.[42]

Gambar 39.Nerve repair under microscope.

Sumber: http://www.pncl.co.uk/~belcher/information/Nerve%20repair.pdf

 3.        Nerve Graft

Nerve grafting adalah teknik yang paling sering dilakukan pada perbaikan plexus brachialis level 2, 3, atau 4. Ada 2 teknik nerve grafts yang popular yang biasa dikerjakan pada rekonstruksi plexus brachialis: (1) free nerve graft; dan (2) vascularized ulnar nerve graft.

Nervus suralis adalah nervus yang paling sering digunakan pada free nerve grafts(Gambar 39). Nervus cutaneous medialis pada brachii atauantebrachii dan n. saphenus kadang-kadang juga digunakan. Hasil pengerjaan dipengaruhi oleh panjangnya nerve graft, ada tidaknya jaringan parut (neuroma) pada daerah luka, jumlah nerve graft yang digunakan, dan ada tidaknya proximal stump untuk grafting.

Gambar 40.Suralis free nerve graft.

Sumber:http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/581-3-iline_default.gif

Pada kasus total root avulsion atau lower plexus root avulsion (C8-T1±C7), seluruh n. ulnaris dari axilla ke cubiti dapat digunakan sebagai vascularized nerve graft, baik untuk kepentingan pedicle atau sebagai free tissue transfer. Nerve grafting penting untuk dilakukan pada cedera level 2. Hal ini seringkali berkaitan dengan cedera level 3 pada spinal nerve yang samaatau seringkali berkaitan dengan cedera level 1 pada spinal nerve yang berbeda. Jika kombinasi cedera level 1 dan level 2 pada spinal nerve yang berbeda dipersatukan, nerve grafts dan nerve transfers adalah prosedur utama untuk rekonstruksi cedera ini.

Contohnya, rupture C5 dan C6 dengan root avulsion C7-T1 adalah yang paling sering terjadi.C5 nerve grafting pada n. suprascapularis dan divisi posterior dari upper trunk untuk shoulder elevation, C6 nerve grafts ke bagian distal C8 spinal nerve atau n. medianus sering digunakan untuk vascularized ulnar nerve graft untuk fungsi manus, dan n. intercostalis transfer hingga n. musculocutaneous untuk fungsi cubiti  adalah pilihan yang baik untuk full one-stage reconstruction.

Jika dikombinasikan dengan cedera level 2 dan 3 pada spinal nerve yang sama, long nerve grafts (dengan panjang >10 cm) biasanya digunakan untuk menutup jarak dari spinal nerve ke cabang terminal pada fossa infraclavicularis. Clavicle dapat ditinggikan melalui pendekatan Chuang’s triangle tanpa memerlukan osteotomi.[42]

3.11.3         Level 3

Cedera level 3 melibatkan trunk dan divisions.Insidennya sekitar 5% dari 1600 kasus dengan penyebab tersering adalah neuroma.Bypass nerve grafting diperlukan untuk membangun kembali koneksi antara supraclavicular dan infraclavicular brachial plexus. Clavicle osteotomy diperlukan khususnya untuk cedera yang melibatkan lower trunk, untuk memenuhi grafting atau direct neurolysis. Multiple nerve grafts seringkali dibutuhkan dan seringkali diambil dari lokasi lain. C-loop vascularized ulnar nerve graft kadang-kadang dibutuhkan untuk mengurangi jumlah nerve grafts, khususnya pada kasus cedera yang luas.[42][51]

3.11.4         Level 4

Level 4 cederaplexus brachialis melibatkan cords dan terminal branches. Insidennya cukup tinggi, yaitu sekitar 17%. Cedera ini berhubungan dengan nerve ruptures, tetapi kadang-kadang dapat disebabkan oleh nerve avulsion. Pada beberapa kasus, distal avulsion terjadi pada bone margin (seperti avulsi n. musculocutaneous dari permukaan m. biceps brachii).

Pada lesi level 4 tertutup, nerve damage bervariasi, berkisar dari simple isolated nerve injury hingga lesi pada seluruh cords atau seluruh cabang terminal. Pada cedera level 4 seringkali dilakukan nerve graft dengan prognosis yang pada umumnya baik.Angka kejadian tertinggi disebabkan oleh vascular injury, rupture, dan oklusi segmental pada a. subclavia atau a. axillaris. Pada kasus penetrating injuries, vascular dan nerve repairs biasanya dilakukan secara bersamaan. Golden time untuk primary direct repair pada pembuluh darah level 4 yang terbelah pada kasus penetrating injury tanpa nerve grafts berkisar 2 minggu, berbeda dengan cedera level 2 atau 3 yang hanya berkisar 1 minggu. Traction injury level 4 biasanya berhubungan dengan fracture pada proximal humerus atau pada scapula glenoideus.Biasanya dibutuhkan long nerve grafts dengan panjang lebih dari 8 cm. Kadang-kadangC-loop vascularized ulnar nerve grafts diambil dari paralytic antebrachii dan digunakan untuk rekonstruksi n. medianus dan n. radialis. Pada umumnya, hasilnya baik. Pada avulsi saraf dari otot seringkali dilakukan nerve grafting dari proximal nerve stump dan direct implantation ke dalam otot (nerve to muscle neurotization) dengan hasil kekuatan otot rata-rata berkisar M3. Pilihan rekonstruksi yang lain adalah functioning muscle transplantation.[42][52][53]

3.11.5         Strategi Rekonstruksi untuk Perbedaan Tipe Lesi

3.11.5.1     Single-Root Avulsion

Pada kasus isolated C5 root injury, dilakukan mass nerve transfer, termasuk spinal accessorius, phrenicus, dan cabang motorik cervicalis yang ditransfer secara langsung ke C5 spinal nerve untuk memperbaiki kekuatan m. supraspinatus, m. infraspinatus, dan m. deltoideus dan untuk mendapatkan kekuatan pegerakan abduksi bahu lebih dari 90°.

Single C6 root avulsion biasanya berhubungan dengan C5 rupture. Nerve grafts dari ujung proksimal C5 ke divisi anterior upper trunk biasanya menghasilkan pergerakan fleksi cubiti yang lebih baik dibanding transfer n. intercostalis ke n. musculocutaneous. Pergerakan abduksi dapat diperbaiki melalui transfer n. accesorius ke n. suprascapularis dan transfer n. phrenicus ke divisi posterior upper trunk.[42]

Single C7 root avulsion biasanya berhubungan dengan rupture of the upper trunk.Hanya dibutuhkan perbaikan upper trunk saja. Reinervasi C7 spinal nerve tidak dibutuhkan.[42]

3.11.5.2     Two-Root Avulsion

Pada kombinasi C5 dan C6 two-root avulsion, dilakukan nerve transfers. Untuk pergerakan elevasi bahu, direkomendasikan transfer n. XI ke n. suprascapularis, dikombinasikan dengan n. phrenicus transfer ke divisi posterior upper trunk. Untuk restorasi pergerakan fleksi cubiti, dilakukan n. intercostalis transfers ke n. musculocutaneous.

Pada kasus C6 dan C7 two-root avulsions, biasanya C5 ikut ruptured. Ujung proksimal C5 yang masih sehat ditransferkan pada divisi anterior upper trunk untuk pergerakan fleksi cubiti.Fungsi bahu didapat dari n. XI dan n. phrenicus transfer seperti yang telah dijelaskan sebelumnya. Jika transfer proksimal C5 tidak dapat dilakukan, direkomendasikan untuk ditransfer ke divisi posterior upper trunk sebagai tambahan transfer n. XI dan n. suprascapularis untuk mendapatkan fungsi bahu yang maksimal. Pergerakan fleksi cubiti dapat diperoleh dari transfer n. intercostalis ke n. musculocutaneous.

Kombinasi C8 dan T1 root avulsions biasanya disertai dengan C5 dan C7 ruptures. Pergerakan elevasi bahu didapat melalui nerve grafts dari C5 ke n. suprascapularis dan divisi posterior upper trunk. C6 nerve fibers ditransfer ke n. medianus untuk memperbaiki fungsi motorik dan sensorik manus.Pergerakan fleksi cubiti diperbaiki dengan transfer n. intercostalis.

Kasus C8 dan T1 root injury tanpa ruptures C5 hingga C7 sangat jarang terjadi. Pada fase lanjut, dilakukan tendon transfer dengan 2 prosedur yang terpisah.[42]

3.11.5.3     Three-Root Avulsion

Kombinasi C5-C7 root avulsion tanpa cedera C8-T1 adalah trauma yang sering terjadi. Direkomendasikan transfer n. phrenicus dan n. XI untuk perbaikan fungsi abduksi bahu dan transfer n. intercostalis untuk fleksi cubiti. Nervus phrenicus ditransfer ke divisi posterior upper trunk untuk muscle neurotization dari deltoid, triceps, dan ekstensi carpi (m. extensor carpi radialis longus).Jika n. phrenicus juga mengalami avulsi, dapat dilakukan transfer n. XII ke n. axillaris dengan nerve graft.

Kombinasi C7-T1 three-root aculsion biasanya disertai dengan rupture dari upper trunk. Direkomendasikan nerve grafts, transfer C5 fibers ke n. suprascapularis dan divisi posterior upper trunk untuk pergerakan elevasi bahu. Ujung proksimal C6 ditransfer ke distal C8 n. spinalis atau n. medianus untuk fungsi manus.Untuk pergerakan fleksi cubiti, dilakukan transfer n. intercostalis ke n. musculocutaneous.[42]

3.11.5.4     Four-Root Avulsion

C6-T1 four root avulsion biasanya berhubungan dengan rupture C5. Cedera ini termasuk trauma yang jarang terjadi.Jika proksimal C5 fibers masih sehat, dilakukan transfer ke divisi anterior upper trunk untuk memperbaiki pergerakan fleksi cubiti. Jika transfer C5 fibers tidak dapat dikerjakan, dilakukan transfer divisi posterior upper trunk dan transfer n. XI ke n. suprascapularis untuk perbaikan fungsi bahu. Transfer contralateral C7 ke n. medianus dengan pedicle atau free vascularized ulnar nerve graft untuk perbaikan fungsi manus (fleksi digiti dan sensorik) dapat dilakukan secara bersamaan untuk kepentingan total rekonstruksi dengan sekali prosedur.[42]

3.11.5.5     Five-Root Avulsion or Total Avulsion

Total root avulsion adalah brachial plexus injury yang paling sering terjadi. Transfer contralateral C7 ke n. medianus menggunakan free vascularized ulnar nerve graft untuk perbaikan fungsi manus dapat dilakukan untuk kepentingan total rekonstruksi dengan sekali prosedur. Sebagai tambahan, transfer n. intercostalis ke n. musculocutaneous untuk pergerakan fleksi cubiti dan transfer n. phrenicus atau n. XI untuk pergerakan elevasi bahu dapat dilakukan secara bersamaan.[42]

3.12  Rehabilitasi Paska Trauma Plexus brachialis(Palliative Surgery)

Palliative reconstruction procedures termasuk muscle transfer, tendon transfer, functioning muscle transplantation, tenodesis, dan arthrodesis. Alternatif lain adalah orthotics dan prosthetics. Local pedicled muscle transfer, sekalipun merupakan pilihan alternatif untuk restorasi, tetapi seringkali bukan pilihan yang terpercaya karena adanya partial nerve injury.[42]

Contohnya, menggunakan lokal m. latissimus dorsi transfer untuk fleksi cubiti C5 dan C6 ± C7 avulsion injury biasanya menghasilkan kekuatan otot M3, dibandingkan dengan m. latissimus dorsi transfer untuk traumatic loss of biceps and brachialis yang selalu menghasilkan kekuatan otot M4.Alasan perbedaan tersebut karena n. thoracodorsalis berasal dari C6-C8.Pada kasus pertama, terjadi nerve injury, sedangkan pada kasus yang terakhir, bukanlah suatu kasus cedera.Palliative reconstruction dapat dipertimbangkan ketika cedera melibatkan level C8 dan T1, yang disebut dengan Klumpke’s palsy pada orang dewasa, atau ketika deformitas tetap ada setelah penyebuhan maksimal, dengan atau tanpa nerve reconstruction.[42]

Post-Operasi Nerve Repair dan Nerve Grafting

Setelah pembedahan immobilisasi bahu dilakukan selama 3-4 minggu.Terapi rehabilitasi dilakukan setelah 4 minggu paska operasi dengan gerakan pasif pada semua sendi anggota gerak atas untuk mempertahankan luas gerak sendi.Stimulasi elektrik diberikan pada minggu ketiga sampai ada perbaikan motorik.Pasien secara terus menerus diobservasi dan apabila terdapat tanda-tanda perbaikan motorik, latihan aktif bisa segera dimulai. Latihan biofeedback bermanfaat bagi pasien agar otot-otot yang mengalami reinnervasi bisa mempunyai kontrol yang lebih baik.[42]

Post-Operasi Free Functioning Muscle Transplantation

Setelah transfer otot, ekstremitas atas diimobilisasi dengan bahu abduksi 30°, fleksi 60° dan rotasi internal, siku fleksi 100°. Pergelangan tangan posisi neutral, jari-jari dalam posisi fleksi atau ekstensi tergantung jenis rekonstruksinya.[42]

Ekstremitas dibantu dengan arm brace dan cast selama 8 minggu, selanjutnya dengan sling untuk mencegah subluksasi sendi glenohumeral sampai pulihnya otot gelang bahu.
Statik splint pada pergelangan tangan dengan posisi netral dan ketiga sendi-sendi dalam posisi intrinsik plus untuk mencegah deformitas intrinsik minus selama rehabilitasi. Dilakukan juga latihan gerak sendi gentle pasif pada sendi bahu, siku dan semua jari-jari, kecuali pada pergelangan tangan.[42]

Pemberian elektro stimulasi pada transfer otot dan saraf yang di repair dilakukan pada target otot yg paralisa seperti pada otot gracilis, tricep brachii, supraspinatus dan infraspinatus. Elektro stimulasi intensitas rendah diberikan mulai pada minggu ke-3 paska operasi dan tetap dilanjutkan sampai EMG menunjukkan adanya reinervasi.

Enam minggu paska operasi selama menjaga regangan berlebihan dari jahitan otot dan tendon, dilakukan ekstensi pergelangan tangan dan mulai dilatih pasif ekstensi siku. Sendi metacarpal juga digerakkan pasif untuk mencegah deformitas claw hand.[42]

Ortesa fungsional digunakan untuk mengimobilisasi ekstremitas atas.Dapat digunakan tipe airbag (nakamura brace) untuk imobilisasi sendi bahu dan siku.Sembilan minggu paska operasi, ortesa airbag dilepas dan ortesa elbow sling dipakai untuk mencegah subluksasi bahu.[42]


Setelah Reinervasi

Setelah EMG menunjukkan reinervasi pada transfer otot, biasanya 3-8 bulan paska operasi, EMG biofeedback dimulai untuk melatih transfer otot menggerakkan siku dan jari.
Teknik elektromiografi feedback di mulai untuk melatih otot yang ditransfer untuk menggerakkan siku dan jari dimana pasien biasanya kesulitan mengkontraksikan ototnya secara efektif.[42]

Pada alat biofeedback terdapat level nilai ambang yang dapat diatur oleh terapis atau pasien sendiri. Saat otot berkontraksi pada level ini, suatu nada berbunyi, layar osciloskop akan merekam respons ini. Level ini dapat diatur sesuai tujuan yang akan dicapai.
Lempeng elektroda ditempelkan pada otot, kemudian pasien diminta untuk mengkontraksikan ototnya. Pada saat permulaan biasanya EMG discharge sulit didapatkan, tetapi dengan latihan yang kontinyu, EMG discharge otot akan mulai tampak.[42]

Latihan EMG biofeedback (Gambar 40) dilakukan 4 kali seminggu dan tiap sesi selama 10-70 menit, dan latihan segera dihentikan bila ada tanda-tanda kelelahan.Efektivitas latihan biofeedback tidak dapat dicapai bila pasien tidak mempunyai motivasi dan konsentrasi yang cukup.[42]

 

 Gambar 41.EMG biofeedback.

Sumber: http://hitechtherapy.ipcoweb.com/user_images/kine/KineLive01.jpg

Reedukasi otot diindikasikan saat pasien menunjukkan kontraksi aktif minimal yang tampak pada otot dan group otot.Tujuan reedukasi otot untuk pasien adalah mengaktifkan kembali kontrol volunter otot. Ketika pasien bekerja dengan otot yang lemah, intensitas aktivitas motor unit dan frekuensi kontraksi otot akan meningkat. Waktu sesi terapi seharusnya pendek dan dihentikan saat terjadi kelelahan dengan ditandai penurunan kemampuan pasien mencapai tingkat yang diinginkan.[42]

Pemanasan, ultrasound diatermi, TENS(Transcutaneous Electrical Nerve Stimulation), interferensial stimulasi, elektro stimulasi dapat dipergunakan sesuai indikasi. Dilakukan juga penguatan otot-otot leher dan koreksi imbalance otot-otot ekstremitas atas.[42]

Terapi Okupasi

Terapi okupasi terutama diperlukan untuk:

  • Memelihara luas gerak sendi bahu, membuat ortesa yg tepat untuk membantu fungsi tangan, siku dan lengan, mengontrol edema defisit sensoris.
  • Melatih kemampuan untuk menulis, mengetik, komunikasi.
  • Menggunakan teknik-teknik untuk aktivitas sehari-hari, termasuk teknik menggunakan satu lengan, menggunakan peralatan bantu serta latihan penguatan dengan mandiri.[42]


Terapi Rekreasi

Terapi ini sebagai strategi dan aktivitas kompensasi sehingga dapat menggantikan berkurang dan hilangnya fungsi ekstremitas.[42]


Orthosis pada Post Trauma Plexus brachialis

Pada umumnya penderita dengan cedera plexus brachialisakan menggunakan lengan disisi kontralateral untuk beraktivitas. Pada beberapa kasus, penderita memerlukan kedua tangan untuk melakukan aktivitas yang lebih kompleks.Untuk itu orthosis didesain sesuai kebutuhan penderita.Orthosis (Gambar 41) untuk penderita cederaplexus brachialis dibuat terutama untuk menyokong bagian bahu dan siku.[42]

Gambar 42. Orthosis

Sumber:http://ucare.com.au/yahoo_site_admin/assets/images/85691_Fmsmall.116181507_std.jpg

Sedangkan untuk prehension tangan, umumnya terbatas pada metode kontrolnya sehingga tidak banyak didesain. Beberapa orthosis digerakkan menggunakan sistem muielektrik, sehingga penderita mampu melakukan gerakan pada pergelangan tangan dan jari-jarinya.[42]

Orthosis ini dapat membantu penderita paska trauma untuk melakukan aktivitas sehari-hari seperti makan dan minum dari gelas atau botol, menyisir rambut, menggosok gigi, menulis menggambar, membuka dan menutup pintu, membawa barang-barang.[42]

 

3.13  Prognosis

Lebih dari 70% kasus obstetric brachial plexus injury sembuh secara spontan. Hal ini dikarenakan hampir sebagian besar nervus injury pada kasus obstetrikal termasuk dalam cedera neuropraxia yang dapat pulih secara spontan.[42][54][55]

Sembuh spontan pada kasus brachial plexus injury jarang terjadi, tetapi masih mungkin pada beberapa lower plexus root injuries. Pada brachial plexus injury, setelah nerve reconstruction atau free functioning muscle transplantation, fungsi motorik dinilai kekuatannya sesuai dengan pemeriksaan British Medical Research Council grading system.[42]

Pada cedera plexus brachialis level 4 setelah nerve grafting, keberhasilan operasi ditandai dengan pergerakan elevasi bahu M4 180, pergerakan fleksi dan ekstensi cubiti M4 atau lebih, pergerakan fleksi dan ekstensi digiti M3 atau lebih. Pada post-opertive total root avulsion dengan multiple nerve transfer, keberhasilan operasi ditandai dengan pergerakan abduksi 60, pergerakan fleksi cubiti M4, dan pergerakan digiti M2 atau lebih. Keberhasilan operasi tambahan, yaitu functioning free muscle transplantation ditandai dengan pergerakan carpi M2-3 dan pergerakan ekstensi digiti.[42]

Rorabeck CH, et al meneliti 112 kasus cedera plexus brachialis dan menyimpulkan bahwa trauma upper trunk memiliki prognosis yang paling baik, trauma pada cords, upper roots, dan lower trunk umumnya memiliki prognosis yang kurang baik. Complete plexus  injuriesmemiliki prognosis yang paling buruk. Nyeri persisten yang lebih dari 6 bulan mengindikasikan tanda prognosis neurologikal yang buruk.Adanya pseudomeningocele yang terdeteksi biasanya berhubungan dengan prognosis yang buruk. Penelitian Rorabeck CH, et al dapat dilihat pada Tabel 16 di bawah.[56]

Tabel 16.Recovery in brachial plexus injury.

Sumber: Rorabeck CH, Harris WR. Factors Affecting the Prognosis of Brachial Plexus Injuries. The Journal od Bone and Joint Surgery. 1981; 63:404-7.

Injury

Total Cases

Full Recovery

Partial Recovery

No Recovery

Upper roots

13

3

5

5

Upper trunk

34

18

11

5

Lower trunk

18

3

4

11

Cords

23

6

4

13

Complete

24

0

6

18

 

Dari tabel di atas, dapat disimpulkan, full recovery pada kasus upper roots sekitar 23%, pada kasus upper trunk sekitar 53%, pada kasus lower trunk sekitar 17%, pada kasus cords trauma sekitar 26%, dan 0% pada kasus complete brachial plexus injury.[56]

 

 

BAB IV

KESIMPULAN

 

Cedera plexus brachialis adalah cedera jaringan saraf yang berasal dari C5-T1.Plexus brachialis adalah persarafan yang berjalan dari leher ke arah axilla yang dibentuk oleh ramus ventral saraf vertebra C5-T1.[8]

Insiden obstetrical brachial plexus injury di Amerika Serikat sebesar 1-2 kasus per 1000 kelahiran. Insiden Erb’s palsy sekitar 90%, total plexus injury sebesar 9%, dan Klumpke’s palsy sebesar 1%.[1][2] Menurut Office of Rare Disease of National Institutes of Health, angka kejadian brachial plexus injury kurang dari 200.000 jiwa per tahun dihitung pada populasi di Amerika Serikat. Sebagian besar korbannya adalah pria muda yang berusia 15-25 tahun.[3]

Ditemukan lebih dari 30 penyebab terjadinya cedera plexus brachialis. Tetapi etiologi yang lebih sering, antara lain: trauma, cedera persalinan, compression syndrome, dan tumor.[9][10][11]

Terdapat berbagai macam versi sistem klasifikasi brachial plexus injury, tetapi yang paling banyak digunakan adalah Leffert’s classification system.

  1. Tipe 1 termasuk brachial plexus injury yang disebabkan oleh open trauma.
  2. Tipe 2 termasuk brachial plexus injury yang disebabkan oleh closed trauma, dibagi menjadi:

-          A: Supraclavicular, dibagi menjadi: preganglionik dan postganglionik.

-          B. Infraclavicular

-          C: Kombinasi

  1. Tipe 3 termasuk brachial plexus injury yang disebabkan oleh radiotherapy induced.
  2. Tipe 4 termasuk brachial plexus injury yang disebabkan oleh cedera selama persalinan.

-          A: Erb’s palsy

-          B: Klumpke’s palsy

-          C: Kombinasi

 

Manifestasi klinis cedera plexus brachialis tergantung dari tingkat lesi yang terjadi (roots, trunks, divisions, cords, terminal branches, atau total plexus). Manifestasi klinis yang timbul adalah gangguan motorik dan sensorik sesuai dengan distribusi nervus.

Pemeriksaan fisik yang diperlukan, meliputi: (1) pemeriksaan motorik sesuai dengan distribusinya yang dinilai dari skala 0 hingga 5 disesuaikan dengan Medical Research Council Scale for Assessment of Muscle Power. (2) pemeriksaan sensorik pada setiap dermatom, propioceptive, temperatur, taktil, perabaan, vibrasi dengan turning fork 30 dan 256 cycles per second, dan ninhydrin test. (3) Pemeriksaan khusus, meliputi Tinel’s sign dan Horner’s syndrome.[35][36]

Diagnosis cedera plexus brachialis, meliputi: anamnesis, pemeriksaan fisik, dan pemeriksaan penunjang yang disesuaikan dengan kebutuhan (x-ray, CT Scan, MRI, CT myelography, angiography, electrophysiology).[18][35]

Penanganan untuk cedera plexus brachialis tergantung level cedera yang terjadi menurut pembagian David Chuang. Pilihan rekonstruktif untuk cedera level 1 adalah nerve transfer dan functioning free muscle transplantation. Palliative surgery dikerjakan untuk lesi level 1 sampai dengan 4.Functioning free muscle transplantation termasuk dalam palliative surgery dan dapat dikerjakan pada lesi selain lesi level 1. Neurolysis, nerve repair, nerve graft (free nerve graft atau vascularized ulnar nerve graft), nerve transfer dikerjakan pada lesi level 2. Clavicle osteotomy seringkali dibutuhkan pada lesi level 3. Nerve grafts juga sering dikerjakan pada lesi level 4.[42][44]

Prognosis obstetric brachial plexus injury umumnya baik, karena lebih dari 70% kasus sembuh secara spontan karenakan hampir sebagian besar nervus injury pada kasus obstetrikal termasuk dalam cedera neuropraxia yang dapat pulih secara spontan.[42][54][55]

Penelitian oleh Rorabeck CH, et al dapat disimpulkan, full recovery pada kasus upper roots sekitar 23%, pada kasus upper trunk sekitar 53%, pada kasus lower trunk sekitar 17%, pada kasus cords trauma sekitar 26%, dan 0% pada kasus complete brachial plexus injury.[56]

 

 

 

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where popular home business ideas and opportunities are tested rigorously to find
out what works and what doesn't. Sure you may have a viable service or product but are your
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you boring them away with huge volumes of printed
text. Imagine a scenario where someone on the remote side
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exe to convert a one-hour long file to a generic WMV file.
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by drag the slide bars under the play window or type values into the time-setting box.
Video production companies connect the customers with just
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I paused the movie for about 30 seconds then audio came
back.
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Article Source: the Author: Kevin Besford owns where popular home business ideas and
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If there are, then you can answer these questions by using videos.
exe to convert a one-hour long file to a generic WMV file.
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Unlike other marketing campaigns that only affect a small area, video marketing can be seen globally.
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I love the fact that you can adjust the white balance in real time with the wheel, and it goes fast with
the Canon 60d Camera.
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The Philip Andelman directed music video
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t.co | 08 Juni 2016 - 11:21:57 WIB
Meek Mill was one of the opening acts during Drake's summer tour.
This group had been performing for 30 years to capacity crowds.
I love the fact that you can adjust the white balance in real
time with the wheel, and it goes fast with the Canon 60d Camera.
t.co | 08 Juni 2016 - 13:44:48 WIB
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figured that there would have to be thousands of other questions that
could not be settled by consulting a reference book and decided to create a book
to supply answers to these types of questions. Moreover,
with the new version of High Definition satellite receivers,
it has proved to be a great success.
BokepStream | 08 Juni 2016 - 14:09:12 WIB
Open Edit window and switch to Trim, you could cut unwanted segments by
drag the slide bars under the play window or type values into the time-setting
box. He is sitting on the bed rapping while beautiful women are swimming in the water around
his bed. I paused the movie for about 30 seconds then audio came back.
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Article Source: the Author: Kevin Besford owns where popular home business ideas and opportunities are tested
rigorously to find out what works and what doesn't.
Cam - Smartz by design also provide real-time tracking data to Google Earth, which creates animated behavior maps.
Imagine a scenario where someone on the remote side of the
meeting holds up a document.
https://t.co/wxpNLa7HaP | 08 Juni 2016 - 17:53:14 WIB
Meek Mill was one of the opening acts during Drake's summer
tour. Video production companies connect the customers with just what they wish to see
without the fluff and clutter of the words.
The web is a free medium and business associations don't have to
contribute millions to purchase media space any longer.
Nicholas | 08 Juni 2016 - 22:25:19 WIB
Article Source: the Author: Kevin Besford owns where popular home business ideas
and opportunities are tested rigorously to find out what works and what doesn't.

He is sitting on the bed rapping while beautiful
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HD antennas cost in between $45-$200 depending on quality.
The burn pits are arranged together in a narrow space which is capable of
holding five times higher videos than a standard DVD disc,
so now it's possible to burn more data to single disc with ease.
The Art-A-Fair began in 1966, built an exhibition site in 1977 and exhibits juried works of 125 artists from outside the
area.
https://t.co | 08 Juni 2016 - 23:29:01 WIB
I recommend a high quality antenna because reception will be less blurry and static filled.
Your Microsoft Wireless Entertainment Keyboard 7000 can't connect.
Lawyers required in relation to theater could offer help
with rental contracts for equipment, buildings, costumes,
props, and many others.
bokep indo | 08 Juni 2016 - 23:35:48 WIB
Then there are reviews of video game stores, which are maybe even more valuable.
Gamers can play unlimited video games and save money by renting
video games. exe to convert a one-hour long file to
a generic WMV file.
Bokepstream | 08 Juni 2016 - 23:37:20 WIB
Unlike other marketing campaigns that only affect a small area, video marketing can be
seen globally. He is sitting on the bed rapping while beautiful women are swimming in the water around his bed.
If it's an instructional video a white or blue backdrop is perfect.
https://t.co/H4IRz7Huye | 09 Juni 2016 - 05:17:11 WIB
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valuable. Video production companies connect the customers
with just what they wish to see without the fluff and clutter of the words.
If it's an instructional video a white or blue backdrop is perfect.
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Currently, all Hollywood and even regional movies are released in HD
platforms. We will also understand with the help of ethical hacking course
investigator Jorge Rios why system crash is seen as a vulnerability of the these systems.
bokepStream | 09 Juni 2016 - 06:55:45 WIB
Unlike other marketing campaigns that only affect a small area, video marketing can be seen globally.
Video production companies connect the customers with just what they wish to see without the fluff and clutter of the
words. I paused the movie for about 30 seconds then audio
came back.
t.co | 09 Juni 2016 - 09:51:24 WIB
HD antennas cost in between $45-$200 depending on quality.
You simply need a TV with AV inputs and Audio
outputs, A Hi - Fi VCR or DVD player (if one is not supplied).
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