Nerve transfers using collateral branches of the brachial plexus as donors in patients with upper palsy--thirty years' experience

A Brief History of Peripheral Nerve Surgery in Serbia

Peripheral nerve surgery in Serbia has become the most fruitful subsection of national neurosurgery, with international recognition of Serbian surgeons and institutions. We chronicle landmark events in the history of the field in Serbia, highlighting the development of the field over time and outlining future prospects. This manuscript provides an example of the development of peripheral nerve surgery and associated training in a challenging social, political, and economic context and may guide the development of peripheral nerve surgery care and training in other settings.

Age correlation in upper brachial plexus injury patients undergoing nerve transfer surgeries

•A patient's age can be a critical factor influencing the outcome following upper brachial plexus injury (BPI) reconstruction.•The favorable factor being younger patients with short denervation period.•In older patients early and more aggressive management for an optimal outcome.•This study supports the various correlation of age with the outcomes of upper brachial plexus reconstruction surgery.

Diffusion tensor imaging of the roots of the brachial plexus: a systematic review and meta-analysis of normative values

Purpose

Diffusion tensor magnetic resonance imaging (DTI) characterises tissue microstructure and provides proxy measures of myelination, axon diameter, fibre density and organisation. This may be valuable in the assessment of the roots of the brachial plexus in health and disease. Therefore, there is a need to define the normal DTI values.

Methods

The literature was systematically searched for studies of asymptomatic adults who underwent DTI of the brachial plexus. Participant characteristics, scanning protocols, and measurements of the fractional anisotropy (FA) and mean diffusivity (MD) of each spinal root were extracted by two independent review authors. Generalised linear modelling was used to estimate the effect of experimental conditions on the FA and MD. Meta-analysis of root-level estimates was performed using Cohen's method with random effects.

Results

Nine articles, describing 316 adults (1:1 male:female) of mean age 35 years (SD 6) were included. Increments of ten diffusion sensitising gradient directions reduced the mean FA by 0.01 (95% CI 0.01, 0.03). Each year of life reduced the mean MD by 0.03 × 10^-3 mm²/s (95% CI 0.01, 0.04). At 3-T, the pooled mean FA of the roots was 0.36 (95% CI 0.34, 0.38; I ² 98%). The pooled mean MD of the roots was 1.51 × 10^-3 mm²/s (95% CI 1.45, 1.56; I ² 99%).

Conclusions

The FA and MD of the roots of the brachial plexus vary according to experimental conditions and participant factors. We provide summary estimates of the normative values in different conditions which may be valuable to researchers and clinicians alike.

Lower subscapular nerve transfer for axillary nerve repair in upper brachial plexus palsy

BACKGROUND

The potential to utilize the lower subscapular nerve for brachial plexus surgery has been suggested in many anatomical studies. However, we know of no studies in the literature describing the use of the lower subscapular nerve for axillary nerve reconstruction to date. This study aimed to examine the effectiveness of this nerve transfer in patients with upper brachial plexus palsy.

METHODS

Of 1340 nerve reconstructions in 568 patients with brachial plexus injury performed by the senior author (P.H.), a subset of 18 patients underwent axillary nerve reconstruction using the lower subscapular nerve and constitutes the patient group for this study. The median age was 48 years, and the median time between trauma and surgery was 6 months. A concomitant radial nerve injury was found in 8 patients.

RESULTS

Thirteen patients completed a minimum follow-up period of 24 months. Successful deltoid recovery was defined as (1) muscle strength MRC grade ≥ 3, (2) electromyographic signs of reinnervation, and (3) increase in deltoid muscle mass. Axillary nerve reconstruction was successful in 9 of 13 patients, which represents a success rate of 69.2%. No significant postoperative weakness of shoulder internal rotation or adduction was observed after transecting the lower subscapular nerve.

CONCLUSIONS

The lower subscapular nerve can be used as a safe and effective neurotization tool for upper brachial plexus injury, having a success rate of 69.2% for axillary nerve repair. Our technique presents a suitable alternative for patients with concomitant radial nerve injury.

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.

Unusual and Unique Variant Branches of Lateral Cord of Brachial Plexus and its Clinical Implications- A Cadaveric Study

INTRODUCTION

Adequate knowledge on variant morphology of brachial plexus and its branches are important in clinical applications pertaining to trauma and surgical procedures of the upper extremity.

AIM

Current study was aimed to report variations of the branches of the lateral cord of brachial plexus in the axilla and their possible clinical complications.

MATERIALS AND METHODS

Total number of 82 upper limbs from 41 formalin embalmed cadavers was dissected. Careful observation was made to note the formation and branching pattern of lateral cord. Meticulous inspection for absence of branches, presence of additional or variant branches and presence of abnormal communications between its branches or with branches of other cords was carried out.

RESULTS

In the present study, we noted varied branching pattern of lateral cord in 6 out of 82 limbs (7%). In one of the limb, the median nerve was formed by three roots; two from lateral cord and one from medial cord. Two limbs had absence of lateral pectoral nerve supplemented by medial pectoral nerves. One of which had an atypical ansa pectoralis. In 2 upper limbs, musculocutaneous nerve was absent and in both cases it was supplemented by median nerve. In one of the limb, coracobrachialis had dual nerve supply by musculocutaneous nerve and by an additional branch from the lateral cord.

CONCLUSION

Variations of brachial plexus and its branches could pose both intraoperative and postoperative complications which eventually affect the normal sensory and motor functions of the upper limb.

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.

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.

Advances in nerve transfer surgery

Peripheral nerve injuries are devastating injuries and can result in physical impairments, poor functional outcomes and high levels of disability. Advances in our understanding of peripheral nerve regeneration and nerve topography have lead to the development of nerve transfers to restore function. Over the past two decades, nerve transfers have been performed and modified. With the advancements in surgical management and recognition of importance of cortical plasticity, motor-reeducation and perioperative rehabilitation, nerve transfers are producing improved functional outcomes in patients with nerve injuries. This manuscript explores the recent literature as it relates to current nerve transfer techniques and advances in post-operative rehabilitation protocols, with a focus on indications, techniques and outcomes.

Multiple unilateral variations in medial and lateral cords of brachial plexus and their branches

During routine dissection of the upper extremity of an adult male cadaver, multiple variations in branches of medial and lateral cords of brachial plexus were encountered. Three unique findings were observed. First, intercordal neural communications between the lateral and medial cords were observed. Second, two lateral pectoral nerves and one medial pectoral nerve were seen to arise from the lateral and medial cord respectively. The musculocutaneous nerve did not pierce the coracobrachialis. Finally, the ulnar nerve arose by two roots from the medial cord. Knowledge of such variations is of interest to anatomists, radiologists, neurologists, anesthesiologists, and surgeons. The aim of our study is to provide additional information about abnormal brachial plexus and its clinical implications.

The Clinic of Neurosurgery at the Clinical Center of Serbia in Belgrade--building on the past

Neurosurgery as an independent discipline in Serbia has a distinguished history, beginning in 1938 when Dr. Milivoje Kostic, Professor and Chairman of Surgery, opened the Department of Neurosurgery within the Clinic of Surgery in Belgrade. Since then, thanks to the founding fathers' efforts and their successors' work, the Clinic for Neurosurgery in Belgrade has become a highly specialized health, scientific, and educational institution that is part of the University of Belgrade and is a referral center for all neurosurgical clinics in Serbia. Currently, the Clinic for Neurosurgery, with 160 patient beds, is one of the largest European institutions of its kind. Neurosurgery at the Clinical Center of Serbia (CCS) involves a wide range of patients and resources, with an average daily inpatient census of 15 to 20 patients. Each year, there are more than 3000 admissions at the neurosurgical service. Approximately 3500 operations per year are performed in the main campus neurosurgical operating rooms of CCS, while approximately 15,000 patients alone are evaluated in emergency room or inpatient consultations. Despite economic restraints, the department continues to grow in strength, and we remain optimistic of exciting times ahead for neurosurgery at the CCS.

Upper brachial plexus injuries: grafts vs ulnar fascicle transfer to restore biceps muscle function

BACKGROUND

Nerve transfers or graft repairs in upper brachial plexus palsies are 2 available options for elbow flexion recovery.

OBJECTIVE

To assess outcomes of biceps muscle strength when treated either by grafts or nerve transfer.

METHODS

A standard supraclavicular approach was performed in all patients. When roots were available, grafts were used directed to proximal targets. Otherwise, a distal ulnar nerve fascicle was transferred to the biceps branch. Elbow flexion strength was measured with a dynamometer, and an index comparing the healthy arm and the operated-on side was developed. Statistical analysis to compare both techniques was performed.

RESULTS

Thirty-five patients (34 men) were included in this series. Mean age was 28.7 years (standard deviation, 8.7). Twenty-two patients (62.8%) presented with a C5-C6 injury, whereas 13 patients (37.2%) had a C5-C6-C7 lesion. Seventeen patients received reconstruction with grafts, and 18 patients were treated with a nerve transfer from the ulnar nerve to the biceps. The trauma to surgery interval (mean, 7.6 months in both groups), strength in the healthy arm, and follow-up duration were not statistically different. On the British Medical Research Council muscle strength scale, 8 of 17 (47%) patients with a graft achieved ≥ M3 biceps flexion postoperatively, vs 16 of 18 (88%) post nerve transfers (P = .024). This difference persisted when a muscle strength index assessing improvement relative to the healthy limb was used (P = .031).

CONCLUSION

The results obtained from ulnar nerve fascicle transfer to the biceps branch were superior to those achieved through reconstruction with grafts.