Introductory Chapter: Treatment of Brachial Plexus Lesions - A New Transdisciplinary Approach

1. Introduction

A discipline is defined as a group of experts sharing the same body of knowledge.

There are several medical and also surgical and other disciplines involved in peripheral nerve reconstruction, such as neuro-, plastic, orthopaedic or hand surgeons, physio- and occupational therapists, neuropathologists, and bio-engineers.

The neurosurgeon is considered an expert in surgical treatment of pathologies within the central and peripheral nervous system and has particular knowledge in nerve anatomy, the physiology of nerve de- and regeneration, direct nerve repair techniques, microsurgery.

The orthopedic surgeon has specialized in bones and joints static and dynamic corrections and functional surgery of the lower limb, whereas the plastic surgeon deals with soft tissue and microsurgery and performs muscle and tendon transfers as well as small vessel and nerve microsurgery—hand and peripheral nerve surgery.

These attributions are of course country/continent dependent.

Giving an image to possible interactions between disciplines, a multidisciplinary approach assembles several disciplines in parallel, like several fruits placed in a basket. The routine interaction is interdisciplinary, like fruit pieces in a fruit salad. A transdisciplinary approach raises totally new issues, like in the creation of a smoothie.

2. The concept of transdisciplinarity

Already in 1970, Jean Piaget stated that “ a child is not a small adult.”

In 1996, the French-Romanian physicist Basarab Nicolescu published a “manifest” about transdisciplinarity, where he developed it as a strong concept, but open and tolerant, transgressing frontiers between disciplines. He cited quantic physics, where the quantum (M. Planck: discontinuity of energy) may be seen as a particle or wave. There is also the time–space indeterminism (Heisenberg) and thus different levels of reality. Facing complex issues, one observes multiplication of disciplines.

Stephane Lupasco, a French-Romanian philosopher, introduced the “ included third”: Extending the concept of “ A and non A” known in classic physics with the addition of a third status (being neither A nor “ non A”) in quantic physics.

Transdisciplinary approaches are actually seen in science, like physics; in medicine, like for general practitioners [1], in psychiatry-psychoanalysis, for example, in the treatment of psychopathy [2], emergency care of polytraumatized [3], oncology [4], and geriatrics [5].

It has to be distinguished from translational medicine (“from bench to bed”).

We also find it in nursing, overall in palliative care [6] and even politics—like in Bhutan, the concept of “gross national happiness.”

3. Examples in reconstructive brachial plexus surgery

1. think beyond the nerve repair one to one

Some target nerves are more important than others for functional recovery. In obstetric brachial plexus palsy, the re-innervation of the suprascapular nerve is mandatory for a dynamic rotational equilibrium of the glenohumeral joint, a condition allowing congruent development of the joint partners and preventing dysplasia [7]. Thus, in specific conditions, this nerve must be targeted separately by a good motor donor nerve, like the distal/caudal branch of the spinal accessory nerve [8].

1. think beyond the nerve alone: transfers of one or two motor intercostal nerves onto the thoracodorsalis and thoracicus longus nerve allow to re-innervate during primary surgery such major target muscles than the latissimus dorsi (transferable for elbow flexion or extension later on if needed) and the serratus anterior (stabilizing the scapula, mandatory in case of a later glenohumeral arthrodesis in adult patients).

2. think global: Glenohumeral arthrodesis may be a late option to recreate a stable, and basically mobile shoulder.

3. think life quality: consider the specific treatment of neuropathic pain, the rare indications for amputation of a flail limb.

4. integrate all aspects and tissues in your strategy, beyond your own basic specialty/discipline!