Transfer of fascicles from the ulnar nerve to the nerve to the biceps in the treatment of upper brachial plexus palsy

Results of ulnar nerve neurotization to biceps brachii muscle in brachial plexus injury

OBJECTIVE

To evaluate the factors influencing the results of ulnar nerve neurotization at the motor branch of the brachii biceps muscle, aiming at the restoration of elbow flexion in patients with brachial plexus injury.

METHODS

19 patients, with 18 men and 1 woman, mean age 28.7 years. Eight patients had injury to roots C5-C6 and 11, to roots C5-C6-C7. The average time interval between injury and surgery was 7.5 months. Four patients had cervical fractures associated with brachial plexus injury. The postoperative follow-up was 15.7 months.

RESULTS

Eight patients recovered elbow flexion strength MRC grade 4; two, MRC grade 3 and nine, MRC <3. There was no impairment of the previous ulnar nerve function.

CONCLUSION

The surgical results of ulnar nerve neurotization at the motor branch of brachii biceps muscle are dependent on the interval between brachial plexus injury and surgical treatment, the presence of associated fractures of the cervical spine and occipital condyle, residual function of the C8-T1 roots after the injury and the involvement of the C7 root. Signs of reinnervation manifested up to 3 months after surgery showed better results in the long term.

LEVEL OF EVIDENCE

IV, Case Series.

Emerging issues in peripheral nerve repair

It is today widely acknowledged that nerve repair is now more than a matter of perfect microsurgical reconstruction only and that, to further improve clinical outcome, the involvement of different scientific disciplines is required. This evolving reconstructive/regenerative approach is based on the interdisciplinary and integrated pillars of tissue engineering such as reconstructive microsurgery, transplantation and biomaterials. In this paper, some of the most promising innovations for the tissue engineering of nerves, emerging from basic science investigation, are critically overviewed with special focus on those approaches that appear today to be more suitable for clinical translation.

Efficacy and Safety of Oberlin's Procedure in the Treatment of Brachial Plexus Birth Palsy

BACKGROUND:

In brachial plexus injuries, when there are no available roots to use as a source for graft reconstruction, nerve transfers emerge as an elective technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. Despite the high rate of good to excellent results in adults, this technique is seldom used in children.

OBJECTIVE:

To evaluate the efficacy and safety of Oberlin's procedure in the surgical treatment of brachial plexus birth palsy.

METHODS:

Striving to restore elbow flexion, we performed Oberlin's procedure in 17 infants with brachial plexus birth palsy. After follow-up of at least 19 months, primary outcomes were the strength of elbow flexion (modified British Medical Research Council Scale), hand function measured using Al-Qattan's Scale, and comparative x-rays of both hands to detect altered growth.

RESULTS:

Good to excellent results related to biceps contraction were obtained in 14 patients (82.3%) (3/MRC3, 11/MRC4). The preoperative Al-Qattan Scale score for the hand was maintained at final follow-up. Comparing the treated and normal limb, no difference was observed in hand development by x-ray.

CONCLUSION:

Oberlin's procedure is an effective and safe option for the surgical treatment of upper brachial plexus birth palsy.

Health-related quality of life and functional outcomes following nerve transfers for traumatic upper brachial plexus injuries

We report the patient-scored Health-Related Quality of Life (HRQoL) and functional outcomes of a cohort of 21 consecutive patients undergoing nerve transfer surgery for traumatic upper brachial plexus injuries. Outcomes were assessed using the British Medical Research Council power grading system, Short-Form 36, Disability of Arm, Shoulder and Hand questionnaire, and Pain Visual Analogue Scale (PVAS). The mean age of our cohort was 29.8 years (range 18-53 years), with a mean follow-up period of 42.9 months. At follow-up, elbow flexion ≥ M3 strength was achieved in 17/21 patients. Shoulder abduction ≥ M3 was achieved in 14/19 patients. External rotation ≥ M3 strength was achieved in 11/15 patients. Delayed surgical repair correlated negatively with HRQoL outcomes. Higher injury severity scores and smoking were associated with higher PVAS scores. These findings provide key prognostic information for patients and peripheral nerve surgeons embarking upon this intensive pathway to potential recovery.

Methodologically rigorous clinical research

BACKGROUND

Rigorous methodology increases the quality of clinical research by encouraging freedom from the biases inherent in clinical studies. As randomized controlled studies (clinical trial design) are rarely applicable to surgical research, the authors address the commonly used observational study designs and methodologies by presenting guidelines for rigor.

METHODS

The authors performed a review of study designs, including cohort, case-control, and cross-sectional studies and case series/reports, and biases and confounders of study design.

RESULTS

Details about biases and confounders at each study stage, study characteristics, rigor checklists, and published literature examples for each study design are summarized and presented in this report.

CONCLUSIONS

For those surgeons interested in pursuing clinical research, mastery of the principles of methodologic rigor is imperative in the context of evidence-based medicine and widespread publication of clinical studies. Knowledge of the study designs and their appropriate application, and strict adherence to study design methods can provide high-quality evidence to serve as the basis for rational clinical decision-making.

Nerve transfers for the upper extremity: new horizons in nerve reconstruction

Nerve transfers are key components of the surgeon's armamentarium in brachial plexus and complex nerve reconstruction. Advantages of nerve transfers are that nerve regeneration distances are shortened, pure motor or sensory nerve fascicles can be selected as donors, and nerve grafts are generally not required. Similar to the principle of tendon transfers, expendable donor nerves are transferred to denervated nerves with the goal of functional recovery. Transfers may be subdivided into intraplexal, extraplexal, and distal types; each has a unique role in the reconstructive process. A thorough diagnostic workup and intraoperative assessment help guide the surgeon in their use. Nerve transfers have made a positive impact on the outcomes of nerve surgery and are essential tools in complex nerve reconstruction.

Free functional muscle transfer for the upper extremity

Free functional muscle transfers are an excellent treatment option in patients when significant time has passed after a nerve injury. In addition, they are the treatment of choice for reconstruction of established Volkmann's ischemic contracture, muscle loss from trauma, or tumor resection, and in congenital muscle absence. In cases where there is both soft tissue and functional muscle loss, free functional muscle transfers can address these problems together. This article focuses on the key principles for functional reconstruction of the upper extremity with free functional muscle transfers.

Outcome after delayed Oberlin transfer in brachial plexus injury

BACKGROUND

Nerve transfers following traumatic brachial plexus injuries are infrequently operated on after 6 months of injury because myoneural degeneration may set in before nerve regeneration can occur. An exception may lie in transferring healthy donor nerve fascicles directly onto an injured recipient nerve close to the motor point. This is especially true of the Oberlin transfer in which ulnar nerve fascicle(s) are transferred onto the damaged nerve to the biceps.

OBJECTIVE

This retrospective observational study evaluated the outcome of the Oberlin transfer on bicipital power in patients with upper trunk/C5,6,7 root level injuries operated on after 6 months of injury.

METHODS

Using a standard infraclavicular exposure, the musculocutaneous nerve was followed to its branch to the biceps. Distal to this, the ulnar nerve was skeletonized and a constituent motor fascicle was transferred onto the nerve to biceps. Medical Research Council (MRC) motor power grading was assessed every 3 months following surgery. Patients with a follow-up less than 12 months were excluded.

RESULTS

Nine patients operated on after an average of 12.2 months (range, 7-24 months) following injury qualified for the study. At an average follow-up of 26.7 months (range, 12-41 months), all patients had ≥ 2/5 biceps power. Seven patients (77.8%) had useful biceps function ≥ 3/5 MRC score. A single patient operated on 24 months after injury gained 4/5 MRC biceps power.

CONCLUSION

The Oberlin transfer is a useful salvage procedure in patients presenting after 6 months of a brachial plexus injury.

Free Gracilis muscle transfer to restore elbow flexion in brachial plexus injuries

INTRODUCTION

Restoration of elbow flexion is an important step in managing brachial plexus injuries. After more than one year of functional denervation, the muscle atrophy is significant enough that transferring a free muscle to act as a new effector becomes a treatment option. The goal of this study was to evaluate the effectiveness of transferring a gracilis free muscle, innervated by three intercostal nerves, to restore elbow flexion.

MATERIAL AND METHODS

This was a retrospective study of a series of gracilis transfer procedures in 12 men having an average age of 25.6 years (23-37) and average follow-up of 112 months (28-260). The patients were operated on average at 42 months (14-153) following their motor vehicle accident; five had a partial paralysis (C5C6C7) and seven had a complete paralysis (C5-T1). The surgical technique and rehabilitation protocol were the same for all the patients.

RESULTS

There were two cases of acute arterial thrombosis (17%) that led to functional failure. When these two cases were excluded from the analysis, all the remaining patients had a useful result (British Medical Research Council score ≥ M4) and 2.5 kg of elbow flexion strength measured on a dynamometer. The strength was 3.8 kg (2.7 to 55) for partial plexus injuries and 1.6 kg (0.3 to 1.5) for complete plexus injuries. For partial injuries, active elbow flexion was 128° and extension -38°, versus 103° and -23° for complete injuries. The average DASH score was 42 for partial injuries and 32 for complete injuries.

DISCUSSION

Free Gracilis muscle transfer is a challenging technique that leads to reproducible and encouraging results, but has vascular failure rate that cannot be ignored. When compared to published results, our series provides similar results to primary suturing performed within 6 months for cases of complete paralysis and within 12 months for cases of C5C6C7 partial paralysis; our series was better for cases beyond 12 months.

Fascicular selection for nerve transfers: the role of the nerve stimulator when restoring elbow flexion in brachial plexus injuries

PURPOSE

Restoration of elbow flexion is an important goal in brachial plexus injuries. Double nerve transfers using fascicles from ulnar and median nerves have consistently produced good results without causing functional compromise to the donor nerve. According to conventional practice, these double nerve transfers are dependent on the careful isolation of ulnar and median nerve fascicles, which are responsible for wrist flexion, using a handheld nerve stimulator. Here we suggest that fascicular selection by nerve stimulation might not be a necessity when executing double nerve transfers for restoration of elbow flexion in brachial plexus injuries.

METHODS

This is a retrospective case control study in 26 patients with C5, C6 brachial plexus injuries that were managed with double nerve transfers between March 2005 and January 2008. Our technique consisted of transferring 2 fascicles, one each from the ulnar and the median nerve, directly onto the biceps and brachialis motor branches. Contrary to the standard practice, the ulnar or median nerve fascicles were selected without using a handheld nerve stimulator. Results were compared to 21 cases (control group) in which a nerve stimulator was used for fascicular selection. The denervation period ranged from 3 to 9 months.

RESULTS

Twenty-four patients of the study group experienced full restoration of elbow flexion, and 2 had an antigravity flexion of 120° and 110°. The EMG revealed the first sign of reinnervation of biceps and brachialis muscle at 9 ± 2 weeks and 11 ± 2 weeks, as compared to 9 ± 2 weeks and 12 ± 4 weeks in the control group. After surgery, the appearance of initial evidence of elbow flexion, the range and mean of elbow flexion strength, and the difference between preoperative and postoperative grip and pinch strengths were comparable in both groups. At 24 to 28 months follow-up, 19 patients of the study group had M4 power and 7 had M3, compared to 18 and 3 cases, respectively, in the control group. The P values for Medical Research Council grade, strength of elbow flexion, and range of elbow flexion between the 2 groups did not reveal any significant statistical difference.

CONCLUSIONS

Double nerve transfer is a reliable technique for restoring elbow flexion in brachial plexus injuries. There is no advantage of using a nerve stimulator in selecting fascicles before performing the nerve transfer.

Brachial plexus surgery: the role of the surgical technique for improvement of the functional outcome

OBJECTIVE: The study aims to demonstrate the techniques employed in surgery of the brachial plexus that are associated to evidence-based improvement of the functional outcome of these patients. METHOD: A retrospective study of one hundred cases of traumatic brachial plexus injuries. Comparison between the postoperative outcomes associated to some different surgical techniques was demonstrated. RESULTS: The technique of proximal nerve roots grafting was associated to good results in about 70% of the cases. Significantly better outcomes were associated to the Oberlin's procedure and the Sansak's procedure, while the improvement of outcomes associated to phrenic to musculocutaneous nerve and the accessory to suprascapular nerve transfer did not reach statistical significance. Reinnervation of the hand was observed in less than 30% of the cases. CONCLUSION: Brachial plexus surgery renders satisfactory results for reinnervation of the proximal musculature of the upper limb, however the same good outcomes are not usually associated to the reinnervation of the hand.

Transfer of a Motor Fascicle From the Ulnar Nerve to the Branch of the Radial Nerve Destined to the Long Head of the Triceps for Restoration of Elbow Extension in Brachial Plexus Surgery

BACKGROUND AND IMPORTANCE:

Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks.

CLINICAL PRESENTATION:

Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases.

CONCLUSION:

The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.

Double fascicular nerve transfer to the biceps and brachialis muscles after brachial plexus injury: clinical outcomes in a series of 29 cases

Object

The clinical outcomes of patients with brachial plexus injuries who underwent double fascicular transfer (DFT) using fascicles from the median and ulnar nerves to reinnervate the biceps and brachialis muscles were evaluated.

Methods

The authors conducted a retrospective chart review of 29 patients with brachial plexus injuries that were treated with DFT for restoration of elbow flexion. All patients underwent pre- and postoperative clinical evaluation using the Medical Research Council grading system.

Results

The mean patient age was 37 years (range 17–68 years), and there was a mean follow-up of 19 ± 12 months (range 8–68 months). At the most recent follow-up, all but 1 patient (97%) had regained elbow flexion. Eight patients recovered Grade M5, 15 patients recovered Grade M4, and 4 patients recovered Grade M3 elbow flexion strength. There was no evidence of functional deficit in the donor nerve distributions.

Conclusions

Study results demonstrated the reliable restoration of M4–M5 elbow flexion following double fascicular transfer in patients with brachial plexus injuries.

Femoral branch to obturator nerve transfer for restoration of thigh adduction following iatrogenic injury

Obturator nerve injury is a rare complication of pelvic surgery. A variety of management strategies have been reported, with conservative measures being the preferred treatment in most cases. While nerve transfer has become more commonly used for restoring brachial plexus injuries, it has rarely been applied to the lower extremities. To the authors' knowledge, this is the first report of an obturator nerve neurotization. A patient presented 7 months after an iatrogenic right obturator nerve palsy due to pelvic surgery for gynecological malignancy. She underwent a femoral branch to obturator nerve transfer to restore right thigh adduction. Ten months after the neurotization procedure, there was electromyographic evidence of almost complete obturator nerve reinnervation. At 1 year postoperatively, the patient had regained full muscle strength on thigh adduction and a normal gait. Nerve transfer could therefore be a good option in patients with obturator nerve injury whose symptoms fail to respond to conservative medical therapy.

Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy: a systematic review and analysis

BACKGROUND

In treating patients with brachial plexus injury, there are no comparative data on the outcomes of nerve grafts or nerve transfers for isolated upper trunk or C5-C6-C7 root injuries. The purpose of our study was to compare, with systematic review, the outcomes for modern intraplexal nerve transfers for shoulder and elbow function with autogenous nerve grafting for upper brachial plexus traumatic injuries.

METHODS

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies in which patients had surgery for traumatic upper brachial plexus palsy within one year of injury and with a minimum follow-up of twelve months. Strength and shoulder and elbow motion were assessed as outcome measures. The Fisher exact test and Mann-Whitney U test were used to compare outcomes, with an alpha level of 0.05.

RESULTS

Thirty-one studies met the inclusion criteria. Two hundred and forty-seven (83%) and 286 (96%) of 299 patients with nerve transfers achieved elbow flexion strength of grade M4 or greater and M3 or greater, respectively, compared with thirty-two (56%) and forty-seven (82%) of fifty-seven patients with nerve grafts (p < 0.05). Forty (74%) of fifty-four patients with dual nerve transfers for shoulder function had shoulder abduction strength of grade M4 or greater compared with twenty (35%) of fifty-seven patients with nerve transfer to a single nerve and thirteen (46%) of twenty-eight patients with nerve grafts (p < 0.05). The average shoulder abduction and external rotation was 122° (range, 45° to 170°) and 108° (range, 60° to 140°) after dual nerve transfers and 50° (range, 0° to 100°) and 45° (range, 0° to 140°) in patients with nerve transfers to a single nerve.

CONCLUSIONS

In patients with demonstrated complete traumatic upper brachial plexus injuries of C5-C6, the pooled international data strongly favors dual nerve transfer over traditional nerve grafting for restoration of improved shoulder and elbow function. These data may be helpful to surgeons considering intraoperative options, particularly in cases in which the native nerve root or trunk may appear less than optimal, or when long nerve grafts are contemplated.

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.

Nerve transfer to the triceps after brachial plexus injury: report of four cases

These case reports review the clinical outcomes of 4 patients who underwent nerve transfer to a triceps motor branch of the radial nerve. Mean follow-up was 26 ± 15 months. Two patients had a transfer using an ulnar nerve fascicle to the flexor carpi ulnaris muscle, yielding a motor recovery of grade M5 elbow extension strength in one case and M4+ in the other. In 1 patient, a thoracodorsal nerve branch was used as the donor; this patient recovered M4 strength. One patient had a transfer using a radial nerve fascicle to the extensor carpi radialis longus muscle and recovered M5 strength. These outcomes indicate that expendable fascicles of the ulnar, thoracodorsal, and radial nerves are viable donors in the surgical reconstruction of elbow extension.

Use of quantitative intra-operative electrodiagnosis during partial ulnar nerve transfer to restore elbow flexion

The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level.

Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss.

Nerve transfers for traumatic brachial plexus injury: advantages and problems

In recent years nerve transfers have been increasingly used to broaden reconstructive options for brachial plexus reconstruction. Nerve transfer is a procedure where an expendable nerve is connected to a more important nerve in order to reinnervate that nerve. This article outlines the experience of the Scottish National Brachial Plexus Injury Service as our use of nerve transfers has increased. Outcomes have improved for reconstruction of the paralysed shoulder using transfer of the accessory nerve to the suprascapular nerve. Medial pectoral to musculocutaneous nerve transfer has proved reliable for restoration of elbow flexion for patients with C5,6 and C5,6,7 injuries. Problems with nerve transfers include morbidity in the donor nerve territory, co-contraction, and pre-existing injury to the donor nerve. There is a balance of risks in these procedures which should be weighed up in individual cases.

Avaliação do ganho funcional do cotovelo com a cirurgia de Steindler na lesão do plexo braquial

OBJETIVO: Avaliar ganho de força e amplitude de movimento do cotovelo após cirurgia de Steindler Modificada em pacientes com lesão do tronco superior do plexo braquial. MÉTODO: Foram acompanhados de 1998 a 2007 onze pacientes com lesão traumática fechada do tronco superior do plexo braquial. Todos apresentavam evolução de pelo menos 1 ano da lesão e grau de força de flexão do cotovelo que variou de M1 a M3. Os pacientes foram submetidos à cirurgia de Steindler modificada e seguidos por período mínimo de 6 meses. Realizadas avaliações pré e pós-operatórias do ganho de força muscular, amplitude de movimento do cotovelo e pontuação conforme escala DASH. RESULTADOS: Dos onze pacientes analisados, nove (82%) atingiram nível de força igual ou maior a M3 (MRC). Dois (18%) chegaram ao nível de força M2(MRC). Observamos que os pacientes apresentaram ganho médio de amplitude de movimento do cotovelo pós-operatória de 43,45 graus. A média de flexão do cotovelo pós-operatória foi de 88 graus. Houve melhora da função do cotovelo demonstrada na Escala DASH em 81% dos pacientes do estudo. CONCLUSÃO: A cirurgia de Steindler Modificada mostrou-se eficaz no tratamento dos pacientes com lesão de tronco superior de plexo braquial, com ganho estatisticamente significativo de amplitude de movimento. Em todos os casos algum grau de ganho de força e amplitude de flexão do cotovelo, sendo tanto maior quanto maior a força muscular inicial. Nível de Evidência: Nível II, ensaio clínico prospective.

A comparison of intercostal and partial ulnar nerve transfers in restoring elbow flexion following upper brachial plexus injury (C5-C6+/-C7)

PURPOSE

Restoring active elbow flexion is essential in the surgical management of C5-C6 +/- C7 brachial plexus palsies. This study compares the clinical results of 2 techniques to restore elbow flexion: the partial ulnar nerve transfer and the intercostal nerve transfer.

METHODS

Partial ulnar nerve transfer was performed in 23 patients, and intercostal nerve transfer was performed in 17 patients. For both techniques, the transfer to the musculocutaneous nerve was made at the same anatomical point. Age and preoperative delay were comparable between groups of patients.

RESULTS

Biceps reinnervation time was significantly earlier (p = .001) in the ulnar nerve technique (mean, 5.1 mo) than the intercostal nerve technique (mean 9.9 mo). Ten of 17 patients recovered useful elbow flexion force (British Medical Research Council grade >M3) in the intercostal nerve transfer group, compared with 20 of 23 patients in the ulnar nerve transfer group. No patient who had surgery more than 6 months after the injury recovered useful elbow flexion force in the intercostal nerve transfer. Elbow flexion strength was better in patients less than 30 years old in the intercostal nerve group. No complications were observed in either group.

CONCLUSIONS

This study shows that transferring fascicles of the ulnar nerve yields better results than intercostals nerve transfer for restoring elbow flexion. Moreover, preoperative delay and age are important preoperative prognostic factors for the intercostal nerves transfers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Nerve root grafting and distal nerve transfers for C5-C6 brachial plexus injuries

PURPOSE

To investigate the results of distal nerve transfer, with and without nerve root grafting, in C5-C6 palsy of the brachial plexus.

METHODS

We prospectively studied 37 young adults with C5-C6 brachial plexus palsy who underwent surgical repair an average of 6.3 months after trauma. In 7 patients, no nerve roots were available for grafting, so reconstruction was achieved by transferring the accessory nerve to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps branches to the axillary nerve (a triple nerve transfer). In 24 patients, C5 nerve root grafting to the anterior division of the upper trunk was combined with triple nerve transfer. In 6 patients, the C5+C6 nerve roots were grafted to the anterior and posterior divisions of the upper trunk, the accessory nerve was transferred to the suprascapular nerve, and ulnar nerve fascicles were connected to the biceps motor branch. The range of shoulder abduction/external rotation recovery and elbow flexion strength were evaluated between 24 and 26 months after surgery.

RESULTS

Both full abduction and full external rotation of the shoulder were restored in one of the 7 patients in the C5 and C6 nerve root avulsion group, in 14 of 21 patients who received C5 nerve root grafting, and in 2 of 6 patients in the C5+C6 nerve root graft group. The average percentages of elbow flexion strength recovery, relative to the normal, contralateral side, were 27%, 43%, and 59% for the C5-C6 nerve root avulsion, C5 nerve root graft, and C5+C6 nerve root graft groups, respectively.

CONCLUSIONS

We repaired C5-C6 brachial plexus palsies using a combination of strategies depending on the site of root injury (ie, intradural vs extradural). Patients with injuries that were able to be reconstructed with both root grafting and nerve transfers had the best function. These results suggest that the combined use of nerve transfers and root grafting may enhance outcomes in the reconstruction of C5-C6 injuries of the brachial plexus.

Treatment of acute peripheral nerve injuries: current concepts

Although clinical outcomes of peripheral nerve injuries are often suboptimal, an adherence to well-established basic principles of evaluation and repair can optimize results of even the most complex injuries. Proper assessment of injury patterns both preoperatively and intraoperatively can guide treatment, and multiple repair techniques including strategies for overcoming both small and large gaps offer different advantages and disadvantages. New technologies and ideas address some unsolved problems, but more experience and research is necessary to elucidate fully their roles in the treatment algorithm.

Nerve transfers: indications, techniques, and outcomes

This article provides an update of the current strategies of motor and sensory nerve transfers for peripheral nerve lesions of the upper extremity. Indications, techniques, and outcomes are summarized for both well-established transfers used in the management of proximal and brachial plexus injuries as well as those more recently developed for more distal and isolated nerve injuries in the forearm and hand.

Comparison between partial ulnar and intercostal nerve transfers for reconstructing elbow flexion in patients with upper brachial plexus injuries

BACKGROUND

There have been several reports that partial ulnar transfer (PUNT) is preferable for reconstructing elbow flexion in patients with upper brachial plexus injuries (BPIs) compared with intercostal nerve transfer (ICNT). The purpose of this study was to compare the recovery of elbow flexion between patients subjected to PUNT and patients subjected to ICNT.

METHODS

Sixteen patients (13 men and three women) with BPIs for whom PUNT (eight patients) or ICNT (eight patients) had been performed to restore elbow flexion function were studied. The time required in obtaining M1, M3 (Medical Research Council scale grades recovery) for elbow flexion and a full range of elbow joint movement against gravity with the wrist and fingers extended maximally and the outcomes of a manual muscle test (MMT) for elbow flexion were examined in both groups.

RESULTS

There were no significant differences between the PUNT and ICNT groups in terms of the age of patients at the time of surgery or the interval between injury and surgery. There were significantly more injured nerve roots in the ICNT group (mean 3.6) than in the PUNT group (mean 2.1) (P = 0.0006). The times required to obtain grades M1 and M3 in elbow flexion were significantly shorter in the PUNT group than in the ICNT group (P = 0.04 for M1 and P = 0.002 for M3). However, there was no significant difference between the two groups in the time required to obtain full flexion of the elbow joint with maximally extended fingers and wrist or in the final MMT scores for elbow flexion.

CONCLUSIONS

PUNT is technically easy, not associated with significant complications, and provides rapid recovery of the elbow flexion. However, separation of elbow flexion from finger and wrist motions needed more time in the PUNT group than in the ICNT group. Although the final mean MMT score for elbow flexion in the PUNT group was greater than in the ICNT group, no statistically significant difference was found between the two groups.

Medial pectoral nerve to musculocutaneous nerve neurotization for the treatment of persistent birth-related brachial plexus palsy: an 11-year institutional experience

OBJECT

Medial pectoral nerve (MPN) to musculocutaneous nerve (MCN) neurotization for recovery of elbow flexion by biceps reinnervation is a valid option following traumatic injury to the upper brachial plexus. A major criticism of the application of this technique in infants is the smaller size of the MPN and mismatch of viable axons. We describe our institutional experience utilizing this procedure and critically examine functional outcomes.

METHODS

Office charts and hospital records of children from over an 11-year period beginning January 1997 were reviewed. Of the 53 children of various ages undergoing brachial plexus exploration for traumatic injury of any nature, 20 underwent MPN to MCN neurotization as a part of an overall procedure in the first year of life to treat birth-related brachial plexus palsy and had at least 9 months' follow-up. Medial pectoral nerve to MCN neurotization was chosen if the results of clinical examination and intraoperative electrophysiological evidence were consistent with medial cord function. Functional recovery was defined as the ability of the child to bring their hand to their mouth.

RESULTS

Sixteen patients (80%) gained functional recovery. The median age at surgery was 7 months. Median time to first clinic visit documenting recovery was 11.5 months and median overall follow up was 21.5 months. Preoperative hand function was a useful predictor of recovery of elbow flexion.

CONCLUSIONS

Medial pectoral nerve to MCN neurotization is a valid surgical option for the reinnervation of the biceps muscle for birth-related brachial plexus palsy when the hand is functional preoperatively. Useful elbow flexion can be expected in the majority of these children.

Partial ulnar nerve transfer to the nerve to the biceps for the treatment of brachial plexopathy in metastatic breast carcinoma: case report

Brachial plexus neuropathy can cause progressive pain and disability in patients with breast cancer. Metastatic spread and radiation injury are the most common causes in these patients. We report a case of partial ulnar nerve transfer to the nerve to the biceps muscle to restore elbow flexion in a patient with combined radiation-induced and metastatic brachial plexopathy.

Nerve transfers in brachial plexus birth palsies: indications, techniques, and outcomes

The advent of nerve transfers has greatly increased surgical options for children who have brachial plexus birth palsies. Nerve transfers have considerable advantages, including easier surgical techniques, avoidance of neuroma resection, and direct motor and sensory reinnervation. Therefore, any functioning nerve fibers within the neuroma are preserved. Furthermore, a carefully selected donor nerve results in little or no clinical deficit. However, some disadvantages and unanswered questions remain. Because of a lack of head-to-head comparison between nerve transfers and nerve grafting, the window of opportunity for nerve grafting may be missed, which may degrade the ultimate outcome. Time will tell the ultimate role of nerve transfer or nerve grafting.

Measuring outcomes in adult brachial plexus reconstruction

The focus of this article is on evaluating the various outcome measures of surgical interventions for adult brachial plexus injuries. From a surgeon's perspective, the goals of surgery have largely focused on the return of motor function and restoration of protective sensation. From a patient's perspective, alleviation of pain, cosmesis, return to work, and emotional state are also important. The ideal outcome measure should be valid, reliable, responsive, unbiased, appropriate, and easy. The author outlines pitfalls and benefits of current outcome measures and offers thoughts on possible future measures.

Results of grafting the anterior and posterior divisions of the upper trunk in complete palsies of the brachial plexus

PURPOSE

In most complete brachial plexus injuries, at least 1 root still is available for grafting. We report on the results obtained with reconstruction of the brachial plexus using short sural nerve grafts that connect nonavulsed roots to the anterior, posterior, or both divisions of the upper trunk.

METHODS

We prospectively studied 22 young adults with complete brachial plexus palsy who had surgical repair an average of 5 months after trauma. Sural nerve grafts connected the C5 root to the anterior division and the C6 root to the posterior division of the upper trunk. When the C6 root was not available, the posterior division of the upper trunk was repaired by means of a nerve transfer. In all cases except one, the suprascapular nerve was repaired via a nerve transfer. Outcomes were assessed an average of 35 months after surgery, focusing on recovery of muscle strength, categorized using the Medical Research Council scale. We compared the results obtained after a single root graft, either C5 (n = 11) or C6 (n = 1), with those observed after double root grafting (i.e., C5 + C6; n = 9). The single case of 3 roots available for grafting was excluded for this comparative study.

RESULTS

With grafting of the anterior division of the upper trunk, 17 of the 22 patients (n = 15) regained useful pectoralis major and biceps function of at least M3. Grafting the anterior and the posterior divisions of the upper trunk resulted in 18 of the 22 patients (n = 18) recovering shoulder abduction-adduction and either elbow flexion or extension. In only 5 cases (5 of 22 patients), however, was shoulder abduction-adduction achieved with concomitant recovery of both elbow flexion and extension. Grafting the posterior division of the upper trunk did not enhance the recovery of shoulder abduction, but it did restore elbow extension in approximately 6 of the 9 patients. In terms of muscle strength, an average of 2.3 muscles scored M3 or M4 in the single-root group, compared with 3.1 in the C5/C6 group (p < .05). The relative probability of recovering elbow flexion and shoulder adduction did not differ between patients with 1 versus 2 root grafts. The results of nerve transfers to the posterior division and of forearm muscle reinnervation were poor.

CONCLUSIONS

Grafting the divisions of the brachial plexus ensured multiple function reconstruction in 18 of the 22 patients (n = 18). However, only 5 of 22 patients (n = 4) experienced restoration of elbow flexion and extension.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Management of obstetrical brachial plexus palsy with early plexus microreconstruction and late muscle transfers

Birth brachial plexus injury usually affects the upper roots. In most cases, spontaneous reinnervation occurs in a variable degree. This aberrant reinnervation leaves characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are the internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Nowadays, the strategy in the management of obstetrical brachial plexus palsy focuses in close follow-up of the baby up to 3-6 months and if there are no signs of recovery, microsurgical repair is indicated. Nonetheless, palliative surgery consisting of an ensemble of secondary procedures is used to further improve the overall function of the upper extremity in patients who present late or fail to improve after primary management. These secondary procedures include transfers of free vascularized and neurotized muscles. We present and discuss our experience in treating early and/or late obstetrical palsies utilizing the above-mentioned microsurgical strategy and review the literature on the management of brachial plexus birth palsy.

TRAUMATIC LESIONS OF THE BRACHIAL PLEXUS

OBJECTIVE

To analyze retrospectively the outcomes of primary as well as secondary functional reconstructions in 49 patients with traumatic brachial plexus lesions from a single service. Guidelines for treatment might be extracted from this analysis.

METHODS

Among 152 cases of traumatic lesion of the brachial plexus presented to our clinic, 58 underwent primary brachial plexus reconstructive surgery. On exploration, all patients showed stretching and scarring of plexus elements; root avulsions were found in 28 patients (48%). Outcome evaluation was carried out in 49 of these patients with a follow-up period of 1 year or longer (mean follow-up, 27.9 mo; range, 12–72 mo). A total of 43 secondary reconstructive procedures to improve functionality of the involved arm were performed at a later stage in 25 of 58 patients. Outcomes of the secondary functional restorative procedures were evaluated (mean follow-up, 11.5 mo; range, 3–60 mo in 43 procedures).

RESULTS

Patients with neurolysis as a stand-alone procedure (11 patients) showed an outcome grade of 4 or 5. The average outcome of the 19 patients with C5, C6, and C7 grafting was Grade 3, the same as in patients with nerve transfers to the upper plexus elements (C5–C6 root avulsions, 13 patients). Patients with multiple root avulsions (five cases) showed an overall poor outcome (Grades 0–2). Secondary functional restorative surgery was performed in 43% of the patients and helped improve individual outcomes, providing a favorable effect on the general functionality of the arm. Among the restorative operations performed, the Steindler procedure, wrist extension restoration, claw hand correction, and free functional muscle flap transfer to the arm and forearm were the most rewarding.

CONCLUSION

A combination of primary brachial plexus reconstruction and carefully evaluated, selected, and planned function-restorative secondary procedures might offer favorable outcomes in patients with partial or total brachial plexus lesions.

Anatomy of branches of the musculocutaneous nerve to the biceps and brachialis in human fetuses

Forty upper limbs (20 right and 20 left) of spontaneously aborted human fetuses were examined to determine the branching patterns of the musculocutaneous nerve. The mean age of the fetuses was 21.3 weeks. We identified three branching patterns of the musculocutaneous nerve to the biceps muscle. Type I with a single primary branch occurred in 47.5% of cases. Type II with two primary branches each to a separate head of the biceps muscle was observed in 42.5% of cases. Type III consisted of two primary branches, the proximal dividing into two branches, each to a different head of the biceps, and the distal branch supplying the common belly. Type III was present in 10% of cases. We found only one branching pattern for the brachialis muscle, a single primary branch. In our material communicating branches between the median and musculocutaneous nerves were found in 20% of specimens. We measured the distances between the acromion and the exit points of the first and second branch to the biceps, which averaged 36.3% for the first branch regardless of the type of branching pattern, 54.2% for the second branch in Type II, 60.7% for the second branch in Type III and 60.9% for the branch to brachialis, expressed as a percentage of the distance between the acromion and the lateral epicondyle.

RESULTS OF END-TO-SIDE NERVE COAPTATION IN SEVERE OBSTETRIC BRACHIAL PLEXUS LESIONS

OBJECTIVE

Options for nerve repair are limited in brachial plexus lesions with multiple root avulsions because an insufficient number of proximal nerve stumps are available to serve as lead-out for nerve grafts. End-to-side nerve repair might be an alternative surgical technique for repair of such severe lesions. In this technique, an epineurial window is created in a healthy nerve, and the distal stump of the injured nerve is coapted to this site. Inconsistent results of end-to-side nerve repairs in traumatic nerve lesions in adults have been reported in small series. This article evaluates the results of end-to-side nerve repair in obstetric brachial plexus lesions and reviews the literature.

METHODS

A retrospective analysis was performed of 20 end-to-side repairs in 12 infants. Evaluation of functional recovery of the target muscle was performed after at least 2 years of follow up (mean, 33 mo).

RESULTS

Five repairs failed (25%). Seven times (35%) good function (Medical Research Council at least 3) of the target muscle occurred in addition to eight partial recoveries (40%). In the majority of patients, however, the observed recovery cannot be exclusively attributed to the end-to-side repair. The reinnervation may be based on axonal outgrowth through grafted or neurolyzed adjacent nerves. It seems likely that recovery was solely based on the end-to-side repair in only two patients. No deficits occurred in donor nerve function.

CONCLUSION

This study does not convincingly show that the end-to-side nerve repair in infants with an obstetric brachial plexus lesion is effective. Its use cannot be recommended as standard therapy.

Median to radial nerve transfer for treatment of radial nerve palsy. Case report

The purpose of this study is to report a surgical technique of nerve transfer to restore radial nerve function after a complete palsy due to a proximal injury to the radial nerve. The authors report the case of a patient who underwent direct nerve transfer of redundant or expendable motor branches of the median nerve in the proximal forearm to the extensor carpi radialis brevis and the posterior interosseous branches of the radial nerve. Assessment included degree of recovery of wrist and finger extension, and median nerve function including pinch and grip strength. Clinical evidence of reinnervation was noted at 6 months postoperatively. The follow-up period was 18 months. Recovery of finger and wrist extension was almost complete with Grade 4/5 strength. Pinch and grip strength were improved postoperatively. No motor or sensory deficits related to the median nerve were noted, and the patient is very satisfied with her degree of functional restoration. Transfer of redundant synergistic motor branches of the median nerve can successfully reinnervate the finger and wrist extensor muscles to restore radial nerve function. This median to radial nerve transfer offers an alternative to nerve repair, graft, or tendon transfer for the treatment of radial nerve palsy.

The Surgical Treatment of Brachial Plexus Injuries in Adults

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Evaluate clinically a patient with brachial plexus paralysis and define the appropriate electrophysiologic and radiographic studies. 2. Differentiate between preganglionic (root) avulsion and postganglionic lesions and identify appropriate motor donors and nerve grafts. 3. Describe various nerve reconstructive strategies and make appropriate selection of secondary procedures for shoulder stability, elbow flexion, and hand reanimation. 4. Anticipate the possible functional outcome.

Technique of the double nerve transfer to recover elbow flexion in C5, C6, or C5 to C7 brachial plexus palsy

In C5, C6, or C5-to-C7 root injuries, many surgical procedures have been proposed to restore active elbow flexion. Nerve grafts or nerve transfers are the main techniques being carried out. The transfer of ulnar nerve fascicles to the biceps branch of the musculocutaneous nerve is currently proposed to restore active elbow flexion. Recovery of biceps muscle function is generally sufficient to obtain elbow flexion. However, the strength of elbow flexion is sometimes weak because the brachialis muscle is not reinnervated. Therefore, the transfer of 1 fascicle of the median nerve to the brachialis branch of the musculocutaneous nerve may be proposed to improve strength of the elbow flexion. We describe the technique of this double transfer to restore elbow flexion. The results concerning 5 patients are presented.

Direct repair (nerve grafting), neurotization, and end-to-side neurorrhaphy in the treatment of brachial plexus injury

Object

The authors present the long-term results of nerve grafting and neurotization procedures in their group of patients with brachial plexus injuries and compare the results of “classic” methods of nerve repair with those of end-to-side neurorrhaphy.

Methods

Between 1994 and 2006, direct repair (nerve grafting), neurotization, and end-to-side neurorrhaphy were performed in 168 patients, 95 of whom were followed up for at least 2 years after surgery. Successful results were achieved in 79% of cases after direct repair and in 56% of cases after end-to-end neurotization. The results of neurotization depended on the type of the donor nerve used. In patients who underwent neurotization of the axillary and the musculocutaneous nerves, the use of intraplexal nerves (motor branches of the brachial plexus) as donors of motor fibers was associated with a significantly higher success rate than the use of extraplexal nerves (81% compared with 49%, respectively, p = 0.003). Because of poor functional results of axillary nerve neurotization using extraplexal nerves (success rate 47.4%), the authors used end-to-side neurorrhaphy in 14 cases of incomplete avulsion. The success rate for end-to-side neurorrhaphy using the axillary nerve as a recipient was 64.3%, similar to that for neurotization using intraplexal nerves (68.4%) and better than that achieved using extraplexal nerves (47.4%, p = 0.19).

Conclusions

End-to-side neurorrhaphy offers an advantage over classic neurotization in not requiring sacrifice of any of the surrounding nerves or the fascicles of the ulnar nerve. Typical synkinesis of muscle contraction innervated by the recipient nerve with contraction of muscles innervated by the donor was observed in patients after end-to-side neurorrhaphy.

Heterotopic nerve transfers: recent trends with expanding indication

There has been increasing enthusiasm for heterotopic nerve transfers for brachial plexus palsy as well as peripheral mononeural dysfunction. The concept of nerve transfer surgery is not new; the first publications on the topic date back to the early 1900s. A wide variety of potential donor nerves are available including the intercostal nerves, the spinal accessory nerve, the phrenic nerve, the ipsilateral medial pectoral nerve, partial ulnar nerve, partial median nerve, thoracodorsal nerve, radial nerve to the triceps, and the ipsilateral C7 or the contralateral C7 nerve roots. Treatment strategies include avoidance of interposed nerve grafting, isolated motor recipient nerve, early transfer, neurorrhaphy close to target motor end plates, and similar diameter between donor nerve and recipient nerves.

Nerve transfers for adult traumatic brachial plexus palsy (brachial plexus nerve transfer)

Adult traumatic brachial plexus injuries can have devastating effects on upper extremity function. Although neurolysis, nerve repair, and nerve grafting have been used to treat injuries to the plexus, nerve transfer makes use of an undamaged nerve to supply motor input over a relatively short distance to reinnervate a denervated muscle. A review of several recent innovations in nerve transfer surgery for brachial plexus injuries is illustrated with surgical cases performed at this institution.

Preliminary Results of Double Nerve Transfer to Restore Elbow Flexion in Upper Type Brachial Plexus Palsies

BACKGROUND

Restoration of elbow flexion is the main objective in the treatment of brachial plexus palsies affecting the upper roots. Transfer of the ulnar nerve to the nerve of the biceps has given satisfactory results, but the restored biceps is often weak in cases with avulsions of the C5-C6-C7 roots, in elderly patients, and after long preoperative delays. The authors decided to investigate a double nerve transfer: one or more fascicles of the ulnar nerve to the nerve to the biceps and a fascicle of the median nerve to the motor branch to the brachialis muscle.

METHODS

The authors operated on 15 patients using this technique. The authors have follow-up of more than 6 months in 10 of them. Six had C5-C6 injuries, three had C5-C6-C7 palsies, and one had sustained an infraclavicular injury. The average age was 27.2 years. The average delay before surgery was 6.6 months. The average follow-up was 12.1 months.

RESULTS

Grade 4 elbow flexion was restored in each of the 10 patients. In 10 cases, the patients were able to lift 1 to 5 kg. There was no secondary deficit in grip strength or sensation.

CONCLUSIONS

The results of this technique compare favorably with those of other methods. The percentage of success and the strength of elbow flexion restored were increased without any morbidity. This technique will probably reduce the need for secondary procedures to augment elbow flexion. The authors propose double nerve transfer as a standard procedure in C5-C6 and C5-C6-C7 injuries.

Combined nerve transfers for C5 and C6 brachial plexus avulsion injury

PURPOSE

To report the results of combined nerve transfer in C5 and C6 brachial plexus avulsion injury.

METHODS

Fifteen patients had nerve transfers: spinal accessory nerve to the suprascapular nerve, a part of the ulnar nerve to the biceps motor branch, and the nerve to the long head of the triceps to the anterior branch of the axillary nerve. Patients were evaluated with regard to elbow flexion, shoulder abduction, and shoulder external rotation.

RESULTS

All patients had recovered full elbow flexion: 13 scored M4 and 2 scored M3. Thirteen of the 15 patients obtained good results. The weight the patients could lift ranged from 0 to 7 kg. All patients had recovery of the deltoid function: 13 scored M4 and 2 scored M3. All 15 patients achieved useful functional recovery. Ten patients experienced excellent recoveries and 5 were classified as having good results. The mean shoulder abduction was 115 degrees . Shoulder external rotation strength was scored as M4 in 9 patients, M3 in 4 patients, and M2 in 2 patients. The range of motion of external rotation that was measured from full internal rotation averaged 97 degrees . No clinical donor nerve deficits were observed.

CONCLUSIONS

We recommend combined nerve transfers for C5 and C6 avulsion root injuries. These nerve transfers have the advantage of a quick recovery time as a result of the short regeneration distance without nerve graft.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.