ABSTRACTObjective: Missle injuries of brachial plexus are a huge and difficult problem of peripheral nerve surgery. In thisstudy, we compare the results of functional recovery of each nerve individualy, after performed surgical procedure.Material and Methods: Our series include 68 patients , with 202 nerve lesions, with 207 surgical procedures(exploration, neurolysis, and nerve grafting, or their combination) depending of intraoperative findings. The resultswere analyzed in 60 (88.2%) patients, including 173 (85.6%) of 202 nerve elements with follow-up period over twoyears.Functional reovery is used and ranged according to functional priorities in the surgery of brachial plexus andindividual nerves.The Results: Neurolysis gave 90.4% of functional recovery vs nerve grafting 85.7% of functional recoveryseparately. The results of bad functional recovery were related to neurolysis of ulnar and radial nerve, or grafting ofthe medial median, and radial nerve lesions.Conclusions: Gunshot wounds to the brachial plexus significantly produce lesions in continuity with incompletefunctional loss which may recover spotaneously,or complete loss which usually do not. Usually, the timming ofsurgery is between two and four months after injury, except when the gunshot wounds are associated withvascular injuries what is the reason for an emergency surgical treatment, and if there is a complete loss ofdistribution of nerve element(s) surgical treatment could be done after this period. Neurolysis and nerve graftinggave the similar results.Key words: Brachial plexus, missle injury, nerve grafting, neurolysis.INTRODUCTIONGunshot wounds to the brachial plexus are the second most common mechanism of the brachial plexus injuries,accounting for about 25% of them.1 They may be produced by low or high velocity missiles. Low velocity missiles(less than 700m/s) are caused by hand guns, revolvers and shell fragments (velocity around 300m/s) althoughsome authors the last type do not include. The nerve elements are damaged by small shock waves, temporarycavitation and sometimes direct impact. Majority of these lesions include the frst three degrees of nerve damageand spontaneous recovery can take place, even in those patients with severe neurologic deficit at presentation,unless the nerve is not transected by direct impact. 2,3,4,5,6,7 These lesions are characteristic for older militaryseries 8,9 and civilian practice. 3 Contrary to this, high-velocity missiles (over 700m/s, averaging 1000m/s)produced by modern rifles, machine guns, etc. cause more extensive damage. These destructive effects dependson released energy, which is determined by mass, velocity, tumble and angle of incidence of a bullet. Nerveelements are rarely injured by direct impact but are most often attributable to shock waves, and cavitation causingtheir compression and streching.7,10 This extensive injury involves also the soft tissues, blood vessels and bones.Nerve structures, all or part of them, may be damaged outside the path of the projectile, at the longer nervesegment or at the multiple levels.7,11 Furthermore, the nerve elements may be anatomically and functionallypartially injured with the first, second and third degree of nerve injuries in damaged parts. Therefore, spontaneousrecovery may sometimes occur.Brooks in 19548, and Nulsen and Slade in 19569 published the British and American experiences from the WorldWar II – 170 and 117 open wounds to the brachial plexus. The enother large series published by Kline and Judicein 19832 . Kline2 in 1989 3 analyzing injuries in civilian practice in a series of 141 patients where 90 of them wereoperated , and 75 followed up for over two years. There have been only few large series of gunshot wounds tobrachial plexus in civilian practice published during last two decades,4, 5,6 It should be mentioned, that in recentmilitary conflicts these injuries constituted 2.6% to 14% of all peripheral nerve injuries.12,13Our first experiences with missile injuries to the brachial plexus were based on 50 cases.14 In this paper wepresent experiences with 5410 gunshot injuries to the brachial plexus operated on during the civilian war in formerYugoslavia and also 14 civilian wounds operated on thereafter.MATERIALS AND METHODSIn our study there were 68 patients operated on because of missle injuries of the brachial plexus, betweenNovember 1991 and July 2015.Results were analysed for only 60 (88.2%) of 68 patients – because eight patients missed their control inspections ,including 173 (85.6%) of 202 nerve structures of brachial plexus , with follow-up period untill two years. Therewere 75 neurolysed elements, 44 grafted elements and 8 with a combination of procedures (e.g. neurolysis of theC5 and grafting of the C6 spinal nerve) available for analysis.We used Highet’s clinical scale for motor function recovery, with six grades from M0 to M5.Sensory function was classified in five grades, from S0 to S4 (anesthesia, dysesthesia, protective sensation, twopoint discrimination above and below 10 mm) according to Millesi15.Functional recovery of the median and ulnar nerves was evaluated for both motor and sensory function, and therecovery of the radial, musculocutaneous and axillary nerves was evaluated only for the motor function, since thesensory one was of no functional significance. In evaluation of the motor recovery of the median, ulnar and radialnerves, we considered the function of the proximal and distal muscles separately. Finally, the results wereclassified in three groups. Cases with lower limits M4 for proximal muscles, M3 for distal muscles, and S3 forsensory function if significant, were estimated as having good recovery. Patients with lower limits M3 for proximalmuscles and S2 for sensory function were estimated as having fair recovery, regardless of the grade of recoveryfor distal muscles. Finally, patients with functional grading below these limits were estimated as having badrecovery. Good and fair results were estimated as useful functional recovery10.Recovery following surgery of the lesions involving complex brachial plexus elements (spinal nerve to/or trunk anddivisions to/or cord) was analyzed according to the functional priorities in brachial plexus surgery that includedelbow flexion, arm abduction, wrist and fingers flexion, protective sensation in the median nerve autonomous zone,and wrist and fingers extension. Functional recovery following surgery of upper brachial plexus elements (C5 andC6 spinal nerves to/or upper trunk and C5, C6 and C7 spinal nerves to/or upper and middle trunk) was estimatedas useful if both arm abduction innervated either by the axillary or by the suprascapular nerve, or by both, andelbow flexion were at range M3 or more. In these cases recovery of the wrist and fingers flexion and extension wasof less importance. The lower limits M4 for elbow flexion and arm abduction in musculocutaneous and axillarynerve, M3 for wrist flexion and wrist and fingers extension in median and radial nerve, and S3 in the median nerveautonomous zone were classified as good recovery, whereas M3 for elbow flexion and arm abduction inmusculocutaneous and axillary nerve and S2 in the median nerve autonomous zone were classified as fairrecovery. Functional recovery following surgery of the lower brachial plexus elements (C8 and T1 spinal nervesto/or lower trunk) was estimated as useful if fingers flexion was at range M3 or more and there was at leastprotective sensation in the ulnar nerve autonomous zone. Good results in these cases included lower limits M4 forfingers flexion, M3 for intrinsic hand muscles and S3 for sensory function.The results of surgery at the cord levelwere analyzed according to their outflows, taking into consideration functional priorities in brachial plexussurgery10.