Triceps brachii reinnervation in primary reconstruction of the adult brachial plexus: experience in 25 cases

Intercostal nerve transfer in management of biceps and triceps co-contraction in brachial plexus birth palsy

OBJECTIVE

Brachial plexus birth palsy (BPBP) is often caused by traction during birth. In some cases, reinnervation occurs during spontaneous recovery and it causes involuntary co-contraction between antagonistic muscles. When it comes up between the biceps and triceps muscles, smooth active motion of the elbow joint is impaired. We are presenting outcomes of intercostal nerve (ICN) to radial nerve transfer to minimize elbow motion abnormality due to co-contraction.

METHODS

We present five cases (two males and three females) of biceps and triceps co-contraction in BPBP patients treated from 2005 to 2018. The mean age at surgery was 9.36 years (range, 4.8-16.4 years). They were treated by ICNs transfer to motor branch of the radial nerve to the triceps muscle. Preoperative electromyography was done in all cases to confirm biceps and triceps co-contraction and to assess the contractile status of both muscles. A 10-s flexion extension test was done pre and postoperatively to assess the efficacy of our procedure.

RESULTS

The postop course was uneventful. No donor site morbidity or respiratory complications were recorded in any patient. The mean postoperative follow-up period was 83.9 months (range, 53.6-135.5 months). At the final follow-up, elbow flexion was M4 in the Medical Research Council (MRC) grading scale in all five patients and elbow extension was graded M4 or M4- in all five patients. There was significant increase in the 10 s flexion extension test results delineating the effectiveness of the procedure.

CONCLUSIONS

ICNs transfer to motor branch of the radial nerve to the triceps muscle for management of biceps and triceps co-contraction in BPBP is a good option with minimal morbidity and good success rate.

The Intercostal Nerves Transfer to the Radial Nerve Branch to the Long Head Triceps Muscle: Influencing Factor and Outcome of 55 Cases

PURPOSE

The objective of this study was to report the functional outcomes and factors affecting the result of intercostal nerves transfer to the radial nerve branch to the long head triceps muscle for restoration of elbow extension in patients with total brachial plexus palsy or C5 to C7 palsy with the loss of triceps muscle function.

METHODS

Fifty-five patients with total brachial plexus palsy or C5 to C7 palsy with no triceps muscle function had a reconstruction of elbow extension by transferring the third to fifth intercostal nerves to the radial nerve branch to the long head triceps muscle. The functional outcomes determined by the Medical Research Council grading were evaluated. Factors influencing the outcomes were determined using logistic regression analysis.

RESULTS

At the follow-up of at least 2 years, 36 patients (65%) had antigravity motor function (Medical Research Council grade, ≥3). Multivariable logistic regression analysis showed that the body mass index, time to surgery, and injury of the dominant limb were associated with the outcome.

CONCLUSIONS

The third to fifth intercostal nerves transfer to the radial nerve branch to the long head triceps muscle is an effective procedure to restore elbow extension. We would recommend using 3 intercostal nerves without grafts; in cases of nerve root avulsion in which there is no chance of spontaneous recovery, early surgery should be considered.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Comparative Study of Intercostal Nerve and Contralateral C7 Nerve Transfers for Elbow Extension After Global Brachial Plexus Avulsion

INTRODUCTION

Elbow extensive reconstruction was essential for the patients with brachial plexus avulsion. Nerve transfer was applied to repair elbow extension, but the ultimate recovery was quite different. The purpose of this study was to compare the effects of elbow extension in patients with global brachial plexus avulsion after repaired by intercostal nerve (ICN) and contralateral cervical 7 (cC7) nerve transfer to the long head branch of triceps and to analyze the possible influencing factors.

MATERIALS AND METHODS

A retrospective review of 24 patients treated with ICN and cC7 nerve transfer for elbow extension in posttraumatic global brachial plexus avulsion was carried out. Two ICNs were used as donors in 17 patients, and cC7 nerve was used in the other 7 patients. We evaluated the recovery of elbow extension by the British Medical Research Council grading system and electromyography. The correlation between age, preoperative interval, and prognosis was analyzed in this study.

RESULTS

Efficiency of elbow extensor strength in the ICN transfer group was 47.06%, and it was 28.57% in the cC7 nerve transfer group, but there was no significant difference (P = 0.653). The effective recovery of electromyography in ICN transfer group was 82.35%, whereas in the group cC7 nerve transfer, it was 28.57%, there was a statistical difference between the 2 groups (P = 0.021). Age and interval were negatively correlated with prognosis.

CONCLUSIONS

Intercostal nerve or cC7 nerve transfer to the long head branch of triceps could reconstruct elbow extension to some extent. Compared with cC7 nerve transfer, ICN transfer had a greater result for elbow extension, but the difference in extension power was not significant, whereas there was difference in electromyography recovery. Patient's age and interval were negatively correlated with the results.

Distal Nerve Transfers to the Triceps Brachii Muscle: Surgical Technique and Clinical Outcomes

PURPOSE

To report the clinical outcomes and describe the surgical technique of triceps muscle reinnervation using 2 different distal nerve transfers: the flexor carpi ulnaris (FCU) fascicle of the ulnar nerve and the posterior branch of the axillary nerve (PBAN) to the triceps nerve branch.

METHODS

A retrospective review of patients undergoing FCU fascicle of ulnar nerve or PBAN to triceps nerve branch transfer was performed. Outcome measures included preoperative and postoperative modified British Medical Research Council (MRC) score, EMG results, and complications.

RESULTS

Between September 2003 and April 2017, 6 patients were identified. Four patients with a traumatic upper trunk and posterior cord palsy underwent ulnar nerve fascicle to triceps nerve transfer. Two patients with a recovering upper trunk following a pan-brachial plexus palsy underwent PBAN to triceps nerve branch transfer. The median age was 30.0 years (range, 18-68 years). Surgery was performed at a median of 6.9 months (range, 5.0-8.9 months) postinjury, with a median follow-up of 18.4 months (range, 7.6-176.3) months. Before surgery, 4 patients exhibited grade M0 and 2 patients exhibited grade M1 triceps strength. Four patients had M5 donor muscle strength and 2 had grade M4. Postoperatively, 4 patients regained MRC grade M4 triceps muscle strength, 1 regained M3, and 1 regained M2. There was no noticeable donor muscle weakness.

CONCLUSIONS

Nerve fascicles to the FCU and PBAN are viable options for obtaining meaningful triceps muscle recovery in a select group of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Partial ulnar nerve transfer to the branch of the long head of the triceps to recover elbow extension in C5, C6 and C7 brachial plexus palsy

Elbow flexion is the first goal in upper partial brachial plexus palsy treatment. However, elbow extension is essential for daily living activities. To recover this function, one fascicle of ulnar nerve can be transferred to the branch of the long head of the triceps, but this procedure has been previously published in only two patients. The goal of our study is to assess a larger series of transfers of one fascicle of ulnar nerve to the branch of the long head of the triceps to help patients recover elbow extension. Ten male patients with C5, C6 and C7 brachial plexus injuries underwent operation. For shoulder recovery, we transferred the spinal accessory nerve and rhomboid nerve. For elbow flexion, one fascicle of median nerve was transferred to the nerve of the biceps. For elbow extension, we transferred one fascicle of ulnar nerve to the branch of the long head of the triceps. Tendon transfers were performed for wrist and finger extension. Nine patients recovered M4 elbow flexion and extension. One patient had M3 elbow extension and flexion. Average active shoulder elevation was 85° and average active shoulder external rotation was 65° All patients recovered finger and wrist extension. The classical techniques of grafts or phrenic or intercostal nerve transfers to recover elbow extension are not always reliable, according to the literature. Because the harvested ulnar nerve motor fascicle is close to the branch of the long head of the triceps, the recovery time for this procedure is shorter than that of other described nerve transfers. The isolated recovery of the reinnervated long head of the triceps muscle excludes spontaneous recovery occasionally noted in upper root plexus injuries. The transfer of one fascicle of ulnar nerve to the branch of the long head of the triceps is reliable for active elbow extension recovery in C5, C6 and C7 brachial plexus palsies.

Outcomes of Elbow Flexion Reconstruction in Patients Older than 50 with Traumatic Brachial Plexus Injury

BACKGROUND

There is controversy regarding the effectiveness of brachial plexus reconstruction for elbow function in older patients, as reported outcomes are generally poor. The purpose of this study was to evaluate elbow function outcomes in patients older than 50.

METHODS

Fifty-eight patients older than 50 years underwent nerve grafting, transfers, or free functioning muscle transfer to improve elbow function after traumatic brachial plexus injury. Patients were evaluated preoperatively and postoperatively for elbow flexion strength and range of motion; Disabilities of the Arm, Shoulder and Hand scores; pain; concomitant trauma; severity of trauma; and type of reconstruction.

RESULTS

The average age of the patients was 57.8 years, and the average follow-up was 24.0 months. The average modified British Medical Research Council elbow flexion grade improved significantly from 0.26 to 2.63. Thirty-three patients (60 percent) achieved functional flexion greater than or equal to M3 postoperatively, compared to zero patients preoperatively. There was no correlation between age and modified British Medical Research Council grade. Active elbow range of motion improved significantly postoperatively, with no effect of age on flexion motion. More patients achieved greater than or equal to M3 flexion with nerve transfers (69 percent) compared to free functioning muscle transfer (43 percent). Patients had worse outcomes with high-energy injuries. The mean Disabilities of the Arm, Shoulder and Hand score decreased from 51.5 to 49.6 postoperatively, and the average pain score decreased from 5.0 to 4.3.

CONCLUSION

Brachial plexus reconstruction for elbow function in patients older than 50 can yield useful flexion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcomes of shoulder abduction after nerve surgery in patients over 50 years following traumatic brachial plexus injury

PURPOSE

There is controversy regarding the effectiveness of brachial plexus reconstruction in older patients, as outcomes are thought to be poor. The aim of this study is to determine the outcomes of shoulder abduction obtained after nerve reconstruction in patients over the age of 50 years and factors related to success.

METHODS

Forty patients over the age of 50 years underwent nerve surgery to improve shoulder function after a traumatic brachial plexus injury. Patients were evaluated pre- and postoperatively for shoulder abduction strength and range of motion (ROM); Disability of the Arm, Shoulder and Hand (DASH) scores; pain; age bracket; gender; body mass index (BMI); delay from injury to operation; concomitant trauma; severity of trauma; and type of reconstruction.

RESULTS

The average age was 58.2 years (range 50-77 years) with an average follow-up of 18.8 months. The average modified British Medical Research Council (BMRC) shoulder abduction grade improved significantly from 0.23 to 2.03 (p < 0.005). Fourteen patients achieved functional shoulder abduction of ≥ M3 postoperatively. There was no correlation between age or age range stratification and BMRC grade or those obtaining useful shoulder abduction ≥ M3. Active shoulder abduction improved significantly from 18.25° to 40.64°, with no difference on the basis of age or age stratification. There were improved modified BMRC grades with nerve transfers versus nerve grafts. Less patients achieved ≥ M3 function if surgery was delayed > 6 months. The mean DASH score decreased from 45.3 to 40.7 postoperatively, and the average pain score decreased from 3.7 to 3.0. Patients with a higher postoperative BMRC grade for shoulder abduction had improved postoperative DASH scores and VAS for pain (p = 0.011 and 0.005, respectively).

CONCLUSION

Brachial plexus nerve reconstruction for shoulder abduction in patients over the age of 50 years can yield useful BMRC scores and ROM, and age should not be used to exclude nerve reconstruction in these patients.

Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord

OBJECTIVE Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord. METHODS The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients' average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength). RESULTS After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6. CONCLUSIONS The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.

Surgical strategy in extensive proximal brachial plexus palsies

PURPOSE

To describe and assess an overall surgical strategy addressing extensive proximal brachial plexus injuries (BPI).

METHODS

Forty-five consecutive patients' charts with C5-C6-C7 and C5-C6-C7-C8 BPI were reviewed. Primary procedures were nerve transfers to restore elbow function and grafts to restore shoulder function when a cervical root was available; when nerve surgery was not possible or had failed, tendon transfers were conducted at the elbow while addressing shoulder function with glenohumeral arthrodesis or humeral osteotomy. Tendon transfers were used to restore finger extension.

RESULTS

Forty-one patients underwent elbow flexion reanimation: thirty-eight had nerve transfers and eight received tendon transfers, including five cases secondary to nerve surgery failure; grade-3 strength or greater was reached in thirty-seven cases (90%). Twenty-nine patients had nerve transfers to restore elbow extension: twenty-five recovered grade-3 or grade-4 strength (86%). Forty-one patients underwent shoulder surgery: fourteen had nerve surgery and thirty-one received palliative procedures, including four cases secondary to nerve surgery failure; thirty patients recovered at least 60° of abduction and rotation (73%). Distal reconstruction was performed in thirty-seven patients, providing finger full extension in all cases but two (95%).

CONCLUSIONS

A standardized strategy may be used in extensive proximal BPI, providing overall satisfactory outcomes.

Outcomes of Transferring a Healthy Motor Fascicle From the Radial Nerve to a Branch for the Triceps to Recover Elbow Extension in Partial Brachial Plexus Palsy

BACKGROUND: Triceps reinnervation is an important objective to pursue when repairing the brachial plexus for cases with upper roots injuries, and a number of different techniques have been developed in order to restore elbow extension in such cases.

OBJECTIVE: To demonstrate the surgical outcomes associated with the technique of transferring a single healthy motor fascicle from the radial nerve of the affected arm to a branch innervating 1 of the 3 heads of the triceps.

METHODS: A retrospective study of 13 adult patients sustaining an upper trunk syndrome associated with total elbow extension palsy who underwent the proposed technique as part of the surgical planning for reconstruction of the brachial plexus.

RESULTS: Outcomes scored as M4 for elbow extension were noted in 9 cases (70%), M3 in 3 (23%), and M1 in 1 subject (7%). No patient considered the postoperative strength for carpal or finger extension as impaired. There were no differences in outcomes by using a fascicle activating carpal or finger extension as donor, as well as regarding the use of the branch to the medial or lateral head of the triceps as the recipient.

CONCLUSION: The technique of transferring a healthy motor fascicle from the radial nerve of the affected side to one of its nonfunctional motor branches to the triceps is an effective and safe procedure for recovering elbow extension function in patients sustaining partial injuries of the brachial plexus.

Nerve Transfers to Restore Elbow Function

The purpose of this article is to provide an overview of the various nerve transfer options for restoration of elbow function. This article describes nerve transfer strategies for elbow flexion and extension including the indications, limitations, and expected outcomes based on current literature.

Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord

OBJECT

Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord.

METHODS

The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients’ average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength).

RESULTS

After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6.

CONCLUSIONS

The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.

Transfer of a Terminal Motor Branch Nerve to the Flexor Carpi Ulnaris for Triceps Reinnervation: Anatomical Study and Clinical Cases

PURPOSE

To analyze the anatomical feasibility of transferring a motor branch nerve to the flexor carpi ulnaris (FCU) to the triceps upper medial head motor branch (UMHM) and to report the resultant outcome of the restoration of elbow extension in 5 patients with extensive brachial plexus injury.

METHODS

The ulnar and radial nerves were dissected in 10 cadavers. We measured the length and diameter of the branches to the FCU and the UMHM branch and counted the axons. Then, 5 male patients, mean age 30 years, underwent FCU nerve branch transfer for reconstruction of elbow extension. Elbow flexion was restored via a median nerve branch to biceps transfer.

RESULTS

Mean UMHM nerve length and diameter were 86 and 1.5 mm, respectively. Mean number of branches to the FCU muscle was 2.9. Mean FCU nerve length and diameter were 50 and 1.0 mm, respectively. Mean number of myelinated fibers was 818 and 743 for the UMHM and the longest branch to the FCU, respectively. Coaptation between nerves was possible without tension. All patients recovered functional active elbow extension at a mean follow-up of 19 months with a British Medical Research Council score of M4. After surgery, all patients retained a functional FCU with a British Medical Research Council score of M4.

CONCLUSIONS

Nonselective ulnar nerve fascicles at the root of the limb might not be adequate to restore elbow extension when combined with a median nerve branch transfer for elbow flexion. A selective distal ulnar motor fascicle such as a FCU motor branch could be harvested and connected to a triceps branch to restore elbow extension. Such a nerve transfer would also allow for later transfer of the still functional FCU tendon to the digital extensors.

CLINICAL RELEVANCE

For patients with extensive brachial plexus injury and a preserved medial cord, transferring a motor branch nerve to the FCU is an effective technique for the reconstruction of elbow extension.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Motor Nerve Transfers

Brachial plexus and peripheral nerve injuries are exceedingly common. Traditional nerve grafting reconstruction strategies and techniques have not changed significantly over the last 3 decades. Increased experience and wider adoption of nerve transfers as part of the reconstructive strategy have resulted in a marked improvement in clinical outcomes. We review the options, outcomes, and indications for nerve transfers to treat brachial plexus and upper- and lower-extremity peripheral nerve injuries, and we explore the increasing use of nerve transfers for facial nerve and spinal cord injuries. Each section provides an overview of donor and recipient options for nerve transfer and of the relevant anatomy specific to the desired function.

Transplantation of human amniotic epithelial cells repairs brachial plexus injury: pathological and biomechanical analyses

A brachial plexus injury model was established in rabbits by stretching the C₆ nerve root. Immediately after the stretching, a suspension of human amniotic epithelial cells was injected into the injured brachial plexus. The results of tensile mechanical testing of the brachial plexus showed that the tensile elastic limit strain, elastic limit stress, maximum stress, and maximum strain of the injured brachial plexuses were significantly increased at 24 weeks after the injection. The treatment clearly improved the pathological morphology of the injured brachial plexus nerve, as seen by hematoxylin eosin staining, and the functions of the rabbit forepaw were restored. These data indicate that the injection of human amniotic epithelial cells contributed to the repair of brachial plexus injury, and that this technique may transform into current clinical treatment strategies.

Thoracodorsal nerve transfer for triceps reinnervation in partial brachial plexus injuries

PURPOSE

To report the clinical outcomes of thoracodorsal nerve (TDN) transfers to the triceps motor branches for elbow extension restoration in patients with partial brachial plexus injuries (BPI).

METHODS

Eight male patients of mean age 23 years and suffering from a partial BPI underwent direct coaptation of the TDN to the nerve of the upper medial and long heads of the triceps, an average 6 months after their accident.

RESULTS

Seven patients achieved M4 elbow extension strength and one patient M3, according to the BMRC scale, after a mean follow-up of 21 months.

DISCUSSION

Direct TDN transfer might be a valid surgical procedure for the restoration of elbow extension in patients with partial BPI.

Results of surgical techniques for re-innervation of the triceps as additional procedures for patients with upper root injuries

Patients with injuries restricted to the upper and middle trunks of the brachial plexus may obtain recovery of elbow extension via the lower trunk, which makes it difficult to assess the real effect of interventions to restore the triceps function in such cases. This study aimed to determine the impact of surgical strategies for re-innervation of the triceps in individuals with partial injuries of the brachial plexus. Patients were divided into two groups. Group 1 consisted of 21 participants in whom the surgery included one technique for re-innervation of elbow extension. In this group, six different extra- or intra-plexal donors were targeted to one of the motor branches of the triceps muscle. Group 2 was composed of 24 controls in which the reconstruction did not include any intervention for recovering triceps function. The individuals who underwent intervention for re-innervation of the triceps obtained significantly better outcomes for elbow extension than the controls.

Transfer of median and ulnar nerve fascicles for lesions of the posterior cord in infraclavicular brachial plexus injury: report of 2 cases

In infraclavicular lesions of brachial plexus, severe lesions of the posterior cord often occur when medial and lateral cord function is preserved to a greater or lesser extent. In these cases, shoulder function may be preserved by activity of the muscles innervated by the suprascapular nerve, but complete paralysis exists in the deltoid, triceps, and brachioradialis, and all wrist and finger extensors. Classical reconstruction procedures consist of nerve grafts, but their results in adults are disappointing. We report an approach transferring: (1) an ulnar nerve fascicle to the motor branch of the long portion of the triceps brachii muscle, (2) a median nerve branch from the pronator teres to the motor branch of the extensor carpi radialis longus, and (3) a median nerve branch from the flexor carpi radialis to the posterior interosseous nerve. We describe the procedure and report 2 clinical cases showing the effectiveness of this technique for restoring extension of the elbow, wrist, and fingers in the common infraclavicular lesions of the brachial plexus affecting the posterior cord.