Muscle transpositions in the shoulder and upper arm for sequelae of brachial plexus palsy

Assessment, management, and rehabilitation of traumatic peripheral nerve injuries for non-surgeons

Electrodiagnostic evaluation is often requested for persons with peripheral nerve injuries and plays an important role in their diagnosis, prognosis, and management. Peripheral nerve injuries are common and can have devastating effects on patients' physical, psychological, and socioeconomic well-being; alongside surgeons, electrodiagnostic medicine specialists serve a central function in ensuring patients receive optimal treatment for these injuries. Surgical intervention-nerve grafting, nerve transfers, and tendon transfers-often plays a critical role in the management of these injuries and the restoration of patients' function. Increasingly, nerve transfers are becoming the standard of care for some types of peripheral nerve injury due to two significant advantages: first, they shorten the time to reinnervation of denervated muscles; and second, they confer greater specificity in directing motor and sensory axons toward their respective targets. As the indications for, and use of, nerve transfers expand, so too does the role of the electrodiagnostic medicine specialist in establishing or confirming the diagnosis, determining the injury's prognosis, recommending treatment, aiding in surgical planning, and supporting rehabilitation. Having a working knowledge of nerve and/or tendon transfer options allows the electrodiagnostic medicine specialist to not only arrive at the diagnosis and prognosticate, but also to clarify which nerves and/or muscles might be suitable donors, such as confirming whether the branch to supinator could be a nerve transfer donor to restore distal posterior interosseous nerve function. Moreover, post-operative testing can determine if nerve transfer reinnervation is occurring and progress patients' rehabilitation and/or direct surgeons to consider tendon transfers.

Functional Evaluation of Levator Scapulae Tendon to Supraspinatus in Adult Brachial Plexus Injuries

Introduction  Brachial plexus injuries are severe life-altering injuries. The surgical method to restore shoulder abduction in adult upper brachial plexus injuries involves the usage of nerve grafts and nerve transfers targeting the suprascapular and/or the axillary nerve. When the primary nerve surgery has been unsuccessful or recovery has been incomplete or with a late presentation, muscle transfer procedures are needed to provide or improve shoulder abduction. Levator scapulae to supraspinatus is a transfer to improve shoulder abduction in posttraumatic brachial plexus injuries.

Material and Methods  The study included 13 patients with the age ranging from 17 to 47 years with a mean age of 30 years. All these patients had preop shoulder abduction of Medical Research Council (MRC) grade ≤3. All had a minimum of MRC grade 4 of active elbow flexion. Eleven patients had primary surgery. Only patients with a minimum of 1 year postoperative follow-up were included. All 13 patients underwent levator scapulae transfer only.

Results  All patients had a stable shoulder postoperatively. The average increase in active shoulder abduction was from 6.15°(median: 0°) preoperatively to 61.92°(median: 60°), with an average gain in shoulder abduction of 49.61°(median: 50°).

Conclusions  Transfer of levator scapulae tendon to the supraspinatus is an option to improve shoulder abduction in posttraumatic brachial plexus. In conditions where supraspinatus alone is not functioning, levator scapulae is the best available transfer, considering its strength and maintaining the form of the shoulder unlike trapezius transfer. In patients with previous surgery where supraspinatus has recovered partially but not functionally significant, this tendon transfer can be considered for the augmentation of the existing shoulder abduction.

Obstetric Paralysis: Evaluation of the Sever-L'Episcopo Technique Modified by Hoffer

Evaluate the results of a series of 28 cases of high obstetric paralysis treated with the Sever-L'Episcopo technique modified by Hoffer, between 2003 and 2016. Children (mean age, four years and seven months) with adduction contracture and internal rotation of the shoulder without secondary bone deformities (Mallet class II) underwent lengthening of the pectoralis major muscle and tenotomy of the subscapularis muscle associated with transfer of the latissimus dorsi and teres major muscle to the infraspinatus muscle, moving to the function of external rotators and elevators. The mean follow-up was three years and 10 months. At the end of the study, 24 patients achieved excellent functional assessment scores, mainly of the abduction and external rotation, passing from Mallet class II to class IV. Four patients still demonstrated some degree of global movement limitation, passing from class II to class III. Regardless of the final functional gain, all patients were able to perform tasks that were previously difficult. The data from this study suggest that Hoffer's surgery is an effective method in the treatment of the sequelae of high obstetric paralysis without secondary bone deformities.

Clinical and functional outcome of modified Quad surgery in adult obstetric brachial plexus injury patients: Case reports

Untreated adult obstetric brachial plexus injury (OBPI) patients, in general, use compensatory strategies to achieve their lost upper extremity functions; they cause some adverse effects. Our present study is a case series of 3 female adult OBPI patients, aged 46, 23 and 21 years old. They all had a modified Quad surgical procedure. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized upper extremity movements using the modified Mallet scale. The average postoperative follow-up was 4.3 months (1 to 9 months). Total Mallet score significantly improved from 15 and 18 to 21 in two patients. Supination angle measured from active movement of these 3 patients improved from 40°, 0° and -60° to 80°, 40° and -40°, respectively. The modified Quad surgical procedure significantly improves active abduction and other shoulder functions not only in young pediatric and adolescent patients, as we have previously reported, but also in adult patients with muscle imbalance secondary to brachial plexus injury sustained at birth.

Restoration of Shoulder Function

Restoration of shoulder function in patients with brachial plexus injury can be challenging. Initial reported efforts were focused on stabilizing the shoulder, improving inferior subluxation and restoring abduction and flexion of the joint. Recent advancements and improved understanding of coordinated shoulder motion and the biomechanical properties of the muscles around the shoulder applicable to tendon transfer have expanded available surgical options to improve shoulder function, specifically external rotation. Despite the advances in reconstructive options, brachial plexus injury remains a serious problem that requires complex surgical solutions, prolonged recovery, and acceptance of functional loss.

Development of a set of activities to evaluate the arm and hand function in children with obstetric brachial plexus lesion

Objective: To develop an observational instrument that can be used to evaluate the quality of arm and hand skills in daily functional activities in children with obstetric brachial plexus lesion (OBPL). A set of functional activities was constructed and standardized, and the intra-observer reliability of the assessment of this set of activities was studied.

Setting: Department of Occupational Therapy and Department of Rehabilitation Medicine, VU University Medical Centre.

Subjects: Twenty-six children with OBPL in the age range of 4 -6 years.

Interventions: The children were asked to perform 47 bimanual activities, which were recorded on videotape.

Main measures: The videotapes were scored twice by the same occupational therapist.

Results: The percentage of agreement in scoring ‘hand-use’, ‘speed’ and ‘assistance’ was over 80% for a substantial number of activities, indicating a strong agreement. However, in scoring ‘deviations in movements and body posture’ the percentage of agreement was insufficient in most activities.

Conclusions: This set of activities has good potential for assessment of the performance of functional activities in children with OBPL. This study, however, showed a number of difficulties in observing and scoring the activities that have to be considered when developing a standardized video observation.

Vascularized Thoracodorsal to Suprascapular Nerve Transfer, a Novel Technique to Restore Shoulder Function in Partial Brachial Plexopathy

We describe the clinical outcome of a novel nerve transfer to restore active shoulder motion in upper brachial plexus injury. The thoracodorsal nerve (TDN) was successfully used as a vascularized donor nerve to neurotize to the suprascapular nerve (SSN) in a patient with limited donor nerve availability. At 4 years follow-up, he had regained useful external rotation of the injured limb, with no significant donor site morbidity. Shoulder abduction return was less impressive, however, and reasons for this are discussed. We provide a comprehensive review of the literature on this topic and a subsequent discussion on the details of this novel technique. This is the first reported case of TDN to SSN transfer, and also the first reported case of a vascularized TDN transfer in the English language literature. We advocate direct thoracodorsal to SSN transfer as a valid surgical option for the restoration of shoulder function in patients with partial brachial plexus avulsion, when conventional nerve donors are unavailable.

EVALUATION OF UPPER-LIMB FUNCTION IN PATIENTS WITH OBSTETRIC PALSY AFTER MODIFIED SEVER-L'EPISCOPO PROCEDURE

Objective: To evaluate upper-limb function by means of the Mallet score, in patients with medial rotation contracture of the shoulder who underwent the modified Sever-L'Episcopo procedure, and to correlate evolution with age and length of postoperative follow-up. Methods: Sixteen patients were assessed by comparing the pre and postoperative Mallet scores and correlating the differences between these scores with age at the time of surgery and length of follow-up. Results: A statistically significant improvement in the postoperative Mallet score was observed. The correlations of the differences in scores with age and length of follow-up were not statistically significant. Conclusion: The modified Sever-L'Episcopo procedure led to improved upper-limb function according to the Mallet score. Limb function did not present correlations with age or length of follow-up.

The role of elective amputation in patients with traumatic brachial plexus injury

BACKGROUND AND AIM

Despite undergoing complex brachial plexus, surgical reconstructions, and rehabilitation, some patients request an elective amputation. This study evaluates the role of elective amputation after brachial plexus injury.

METHODS

A retrospective chart review was performed for all the 2140 patients with brachial plexus injuries treated with elective amputation between 1999 and 2012 at a single institution. Analysis was conducted on the potential predisposing factors for amputation, amputation level, and postamputation complications. Patients were evaluated using pre- and postamputation Disabilities of the Shoulder, Arm, and hand scores in addition to visual analog pain scores.

RESULTS

The following three conditions were observed in all nine patients who requested an elective amputation: (1) Pan-plexus injury; (2) non-recovery (mid-humeral amputation) or elbow flexion recovery only (forearm amputation) 1 year after all other surgical options were performed; and (3) at least one chronic complication (chronic infection, nonunion fractures, full-thickness burns, chronic neck pain with arm weight, etc.). Pain improvement was found in five patients. Subjective patient assessments and visual analog pain scores before and after amputation did not show a statistically significant improvement in Disabilities of the Shoulder, Arm, and Hand Scores. However, four patients reported that their shoulder pain felt "better" than it did before the amputation, and two patients indicated they were completely cured of chronic pain after surgery.

CONCLUSIONS

Elective amputation after brachial plexus injury should be considered as an option in the above circumstances. When the informed and educated decision is made, patients can have satisfactory outcomes regarding amputation.

Significant improvement in nerve conduction, arm length, and upper extremity function after intraoperative electrical stimulation, neurolysis, and biceps tendon lengthening in obstetric brachial plexus patients

Background

Progressive loss of extension and concomitant bony deformity of the elbow are results of persistent biceps contracture in obstetric brachial plexus injury (OBPI) patients, if they do not fully recover. This adversely affects the growth and development and functions of the upper extremity.

Patients and method

We have performed biceps tendon lengthening (BTL) using a Z-plasty technique on OBPI patients aged 4 years to adulthood, who had been diagnosed with biceps tendon fixed flexion contractures. Ulnar, radial, and median nerve decompression was also performed at the same sitting. Somatosensory evoked potential (SSEP) monitoring was performed by stimulating the median and ulnar nerves at the wrist and the radial nerve over the dorsum of the hand and recording the peripheral, cervical, and cortical responses.

Seven children with obstetric brachial plexus palsy with an average age of 11 years (8.7–14.2 years) were included in this report. Mean follow-up time was 7.4 months (4–11 months). All the patients in this report had the elbow flexion contractures greater than 30°.

Results

Mean flexion contracture was 35° (30°–45°) preoperatively, which was improved to 0°–10° postoperatively with an average follow-up of 7 (4–11) months. This surgical procedure corrected the elbow flexion contractures, about an average of 25° and an improved length almost to normal, and improved the upper extremity functions. Neurophysiological data showed significant improvement in conduction of all three nerves tested after neurolysis. Further, median and radial nerve amplitude increase was statistically significant.

Conclusion

Statistically significant improvement in biceps length as well as nerve conduction was observed after the surgery. None of the children in our study lost biceps function, although weakness of the biceps is both a short- and long-term risk associated with biceps lengthening.

Modified Quad surgery significantly improves the median nerve conduction and functional outcomes in obstetric brachial plexus nerve injury

Background

Nerve conduction studies or somatosensory evoked potentials (SSEPs) have become an important tool in the investigation of peripheral nerve lesions, and is sensitive in detecting brachial plexus nerve injury, and other nerve injuries.

To investigate whether the modified Quad surgical procedure improves nerve conductivity and functional outcomes in obstetric brachial plexus nerve injury (OBPI) patients.

Methods

All nerves were tested with direct functional electrical stimulation. A Prass probe was used to stimulate the nerves, and recording the response, the compound motor action potential (CMAP) in the muscle. SSEP monitoring was performed pre- and post modified Quad surgery, stimulating the median and ulnar nerves at the wrist, the radial nerve over the dorsum of the hand, recording the peripheral, cervical and cortical responses. All patients have had the modified Quad surgery (n = 19). The modified Quad surgery is a muscle release and transfer surgery with nerve decompressions. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized movements, the modified Mallet scale to index active shoulder movements.

Results

The cervical responses were significantly lower in amplitude in the affected arm than the un-affected arm. The median nerve conduction was significantly improved from 8.04 to 9.26 (P < 0.022) post-operatively. The shoulder abduction was also significantly improved (pre-op 30° ± 23.3 to 143° ± 33.7, p < 0.0001), with a mean follow-up of 43 months after the modified Quad surgery in these patients.

Conclusion

Median nerve conduction, and shoulder abduction were significantly improved in OBPI children, who have undergone the modified Quad procedure with neuroplasty, internal microneurolysis and tetanic stimulation of the median nerve.

Nerve reconstruction in the hand and upper extremity

In the management of traumatic peripheral nerve injuries, the severity or degree of injury dictates the decision making between surgical management versus conservative management and serial examination. This review explores some of the recent literature, specifically addressing recent basic science advances in end-to-side and reverse end-to-side recovery, Schwann cell migration, and neuropathic pain. The management of nerve gaps, including the use of nerve conduits and acellularized nerve allografts, is examined. Current commonly performed nerve transfers are detailed with focus on both motor and sensory nerve transfers, their indications, and a basic overview of selected surgical techniques.

Treatment of shoulder sequelae in brachial plexus birth injury

BACKGROUND

Many children with permanent brachial plexus birth injury (BPBI) develop shoulder problems, with subsequent joint deformity without treatment. We assessed the indications and outcome of shoulder operations for BPBI.

PATIENTS AND METHODS

31 BPBI patients who had undergone a shoulder operation in our hospital between March 2002 and December 2005 were included in the study. Relocation of the humeral head had been performed in 13 patients, external rotation osteotomy of the humerus in 5 patients, subscapular tendon lengthening in 5 patients, and teres major transposition in 8 patients. Subjective results were registered. Shoulder range of motion was measured, and function assessed according to the Mallet scale. Magnetic resonance imaging (MRI) was performed pre- and postoperatively. Glenoscapular angle (GSA) and percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) were measured. Congruency of the glenohumeral joint (GHJ) was estimated. The mean follow-up time was 3.8 (1.7-6.8) years.

RESULTS

At follow-up, the subjective result was satisfactory in 30 of the 31 patients. There were 4 failures, which in retrospect were due to wrong choice of surgical method in 3 of these 4 patients. Mean increase in Mallet score was 5.5 after successful relocation, 1.4 after rotation osteotomy, 2.2 after subscapular tendon lengthening, and 3.1 after teres major transposition. Congruency of the shoulder joint improved in 10 of 13 patients who had undergone a relocation operation, with mean improvement in GSA of 33º and mean increase in PHHA of 25%. There were no substantial changes in congruency of the glenohumeral joint in patients treated with other operation types.

INTERPRETATION

Restriction of the range of motion and malposition of the glenohumeral joint can be improved surgically in brachial plexus birth injury. Remodeling of the joint takes place after successful relocation of the humeral head in young patients.

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.

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.

Free muscle transfer in posttraumatic plexopathies: part 1: the shoulder

Microsurgical restoration of shoulder abduction with free muscle transfers is one of the most challenging reconstructions. The purpose of this study was to analyze retrospectively the outcomes of free muscle transfer for shoulder abduction. Since 1981, 22 muscles have been transferred for shoulder abduction in posttraumatic brachial plexopathy. Two techniques have been used: a double muscle transfer of adductor longus and gracilis was used for shoulder abduction and elbow flexion, respectively (n = 18), and latissimus dorsi transfer for shoulder abduction (n = 4). For the double muscle transfer, the mean range of motion of shoulder abduction was found postoperatively to be 30 +/- 24 degrees and the mean muscle grade was to be 2.61 +/- 0.76 (P < 0.001). For latissimus transfer, the mean postoperative muscle grade of the transferred muscle was 3.25 +/- 0.73, and the shoulder abduction was 40 +/- 32 degrees. Free muscle transfer can enhance shoulder abduction after inadequate results from primary reconstruction or in late cases. In this study, all patients achieved a stable shoulder, 53% yielded shoulder abduction against gravity, and 9% achieved abduction to the horizontal level.

Reinnervation of thenar muscle after repair of total brachial plexus avulsion injury with contralateral C7 root transfer: report of five cases

OBJECTIVE

In this report, we present the findings of reinnervation of the thenar muscle in five patients who underwent the contralateral C7 nerve root transfers for repair of total brachial plexus root avulsions.

PATIENTS AND METHODS

Five (2 children and 3 adults) of 32 patients who received two-staged procedures of the contralateral C7 nerve root transfers to the median nerves showed reinnervation of thenar muscle were evaluated. The patients also received other procedures including the intercostal nerve transfer to the musculocutaneous nerve, the spinal accessory nerve to the suprascapular nerve, and the ipsilateral phrenic nerve to the musculocutaneous nerve before the contralateral C7 nerve root transfers. The patients were followed up from 24 to 118 months after surgery.

RESULTS

Varied degrees of functional restorations were achieved after different procedures. The strength of abductor pollicis brevis (APB) muscle with Grade M2 was found in four patients. The incomplete interference pattern in the APB muscle was detected by electromyogram (EMG) in two patients, and the minority motor unit potential (MUP) was detected in other two patients. The strength of APB muscle was found with Grade M1 in one patient with EMG showing MUP.

CONCLUSION

The findings from our series show reinnervation of thenar muscles after repair of the median nerve with the contralateral C7 nerve root transfer, which provides evidence for further investigation of reconstruction of the brachial plexus root avulsion injury with this procedure.

Shoulder tendon transfer options for adult patients with brachial plexus injury

Enhancement of upper-extremity function, specifically shoulder function, after brachial plexus injury requires a good understanding of nerve repair and transfer, with their expected outcome, as well as shoulder anatomy and biomechanics enabling the treating surgeon to use available functioning muscles around the shoulder for transfer, to improve shoulder function. Surgical treatment should address painful shoulder subluxation in addition to improvement of function. The literature focuses on improving shoulder abduction, but improving shoulder external rotation should take priority because this function, even if isolated, will allow patients to position their hand in front of their body. With a functional elbow and hand, patients will be able to do most activities of daily living. The lower trapezius has been shown to be a good transfer to restore external rotation of the shoulder. Other parts of the trapezius, levator scapulae, rhomboids, and, when available, the latissimus dorsi, pectoralis major, teres major, biceps, triceps, and serratus anterior muscles can all be used to replace the rotator cuff and deltoid muscle function. To optimize the results, a close working relationship is required between surgeons reconstructing brachial plexus injury and shoulder specialists.

Shoulder function and anatomy in complete obstetric brachial plexus palsy: long-term improvement after triangle tilt surgery

PURPOSE

Untreated complete obstetric brachial plexus injury (COBPI) usually results in limited spontaneous recovery of shoulder function. Older methods used to treat COBPI have had questionable success, with very few studies being published. The purpose of the current study was to examine the results of triangle tilt surgery on shoulder function and development in COBPI individuals.

METHODS

This study was conducted as a retrospective chart review. Inclusion criteria were COBPI patients that had undergone the triangle tilt procedure from 2005 to 2009 and were between the ages of 9 months and 12 years. COBPI was defined as permanent injury to all five nerve roots (C5-T1), with significant degradation in development and function of the hand. Twenty-five patients with a mean age of 5 (0.75-12) years were followed up clinically for more than 2 years.

RESULTS

The triangle tilt procedure resulted in demonstrable clinical enhancements with appreciable improvements in shoulder function, glenoid version, and humeral head congruity. There was a significant increase in the overall Mallet score (2.4 points, p < 0.0001) following surgical correction in patients that were followed up for more than 2 years.

CONCLUSIONS

The results of this study demonstrate that COBPI patients who develop SHEAR and medial rotation contracture deformities can benefit from the triangle tilt surgery, which improves shoulder function and anatomy across a range of pediatric ages. Despite these patients presenting late for surgery in general (5 years), significant improvements were observed in their glenohumeral (GH) dysplasia and their ability to perform shoulder and arm movements following surgery.

Lower trapezius muscle transfer for reconstruction of elbow extension in brachial plexus injuries

Elbow extension is a prerequisite for adequate hand position. Muscle transfers are often employed in partial injuries of the brachial plexus, when neurological surgery is unlikely to achieve desired results. The posterior deltoid and latissimus dorsi are the two muscles most commonly used for transfer but there are few alternatives when these two muscles are paralysed. We now report on the successful transfer of the lower trapezius muscle to reconstruct triceps function in three patients with longstanding lesions of the brachial plexus that had not been previously treated surgically.

A simple effective design for a thermoplastic shoulder spica following secondary surgery for obstetrical brachial plexus palsy

Secondary shoulder surgery is frequently needed to improve shoulder contracture and movement after obstetrical brachial plexus palsy. This surgery comprises subscapularis release coupled in half the cases with tendon transfers, and is generally performed from ages three to nine years. Postoperatively, a shoulder splint is used to immobilize the shoulder in a position that maintains the released position and prevents tension on the tendon transfer, if performed. A thermoplastic splint design that is light and effective is presented.

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.

Restoration of elbow function in severe brachial plexus paralysis via muscle transfers

Reconstruction of elbow function in severe or late brachial plexus injuries represents a challenge to the reconstructive microsurgeons. The current sophisticated techniques of nerve reconstruction in combination with secondary local or free functional muscle transfers, may offer satisfactory outcome. Latissimus dorsi can be transferred as a pedicled or free muscle to restore elbow function. We present our experience with elbow reanimation in late cases of brachial plexus paralysis utilising latissimus dorsi muscle transfer. From 1998 to 2006 we operated 103 patients with brachial plexus paralysis. Amongst these patients, 21 were late cases and underwent latissimus dorsi muscle transfer for elbow reanimation. Ten patients had free latissimus dorsi transfer for elbow flexion. Free latissimus dorsi muscle was neurotised either directly via three intercostals in three patients or with a nerve transfer procedure using the contralateral seventh cervical nerve root in seven patients. Care was taken to maintain the proper tension to the muscle, which must hold the elbow in static flexion of about 120 degrees at the end of the procedure. Powerful elbow flexion (M4-M4+) or extension (M4) was obtained after the first 3 months in all patients who had an ipsilateral pedicled latissimus dorsi transfer. In the group of free muscle transfers, elbow flexion was seen after 6-8 months. After the initiation of muscle contraction, eight of the patients regained elbow flexion of M3-M4+. Latissimus dorsi muscle transfer is a reliable method for elbow reanimation. Appropriate postoperative management is also an important factor to obtain better outcome.

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.

Pectoralis major inverse plasty for functional reconstruction in patients with anterolateral deltoid deficiency

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°.

The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved.

Secondary reanimation procedures in late obstetrical brachial plexus palsy patients

The varying degrees of spontaneous reinnervation that occur in untreated obstetrical brachial plexus palsy leave characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Early microsurgical reconstruction of the affected plexus leads to a more rewarding overall function of the upper arm, but residual deformities might appear later which are similar, although less serious, than those observed in untreated cases. Secondary procedures of the shoulder, elbow, forearm, and hand will improve the appearance and function of the upper extremity in late cases of obstetrical brachial plexus. Careful preoperative planning is mandatory and a multistage approach should be applied, depending on the type of palsy and the age of the patient.

Surgical treatment of brachial plexus injuries in adults

We carried out a retrospective review of 32 consecutive patients (30 adults and two children) with total or partial lesions of the brachial plexus who had surgical repair using nerve grafting, neurotisation, and neurolysis between January 1991 and December 2003. The outcome measures of muscular strength were correlated with the type of lesion, age, preoperative time, length and number of grafts, and time to reinnervation of the biceps. The function of the upper limb was also evaluated. There was a significant correlation between muscular strength after surgical repair and both the preoperative time and the length of the nerve graft. There was also a significant correlation between muscular strength and the number of grafts. Muscular strength was better when the neurolysis was done before six months. When neurosurgical repair and reconstructive procedures were performed, the function of the upper limb was improved.

Trapezius transfer in brachial plexus palsy

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Saha’s technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique.

The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6° (0 to 45) to 34° (5 to 90) at the last review. The mean forward flexion increased from 12° (0 to 85) to 30° (5 to 90).

Abduction (41°) and especially forward flexion (43°) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42° of abduction and 56° of forward flexion. Active abduction (28°) and forward flexion (19°) were much less in completely flail shoulders (n = 34).

Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished.

The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.

[The brachial plexus lesion. Management, consequences of palsy and reconstructive operations]

The treatment of traumatic brachial plexus lesions follows sequential steps. After acute therapy (phase I), neurological diagnostics (phase II), neurosurgery and postoperative treatment (phase III/IV), reconstructive operations (phase V) can be indicated and performed. In most cases an insufficient grade of muscle power remains. Within 6 months after injury, neurosurgery must be performed in patients with brachial plexus palsy. After malfunction of the muscles, taking into account the individual neuromuscular defects, passive joint function and bony deformities, different procedures such as muscle transposition, arthrodesis and corrective osteotomy can be performed to improve the function of the upper extremity. The treatment of patients suffering from brachial plexus lesion requires interdisciplinary teamwork.

Glenohumeral deformity in children with internal rotation contractures secondary to brachial plexus birth palsy: intraoperative arthrographic classification

PURPOSE

To evaluate, with intraoperative arthrography, joint morphology in children undergoing surgical treatment of residual paralysis of the shoulder resulting in brachial plexus birth palsy and to correlate the morphology with the degree of passive external rotation.

MATERIALS AND METHODS

In 64 children (age range, 7 months to 13 years 6 months), an orthopedic surgeon performed intraoperative arthrography and measured passive external rotation while the patient received a general anesthetic. The orthopedic surgeon and three radiologists reviewed arthrograms and in consensus classified glenohumeral joints in one of four categories: concentric, with the humeral head well centered on the glenoid fossa; flat, with flattening of the posterior glenoid; biconcave, with the humeral head in articulation with the posterior of two concavities, which were in the same plane; and pseudoglenoid, with the humeral head in articulation with the more posterior of two concavities, with retroversion and in a plane different from that of the anterior concavity. Kruskal-Wallis test was used to compare preoperative external rotation with four appearances of glenoid.

RESULTS

Twenty-one children had concentric glenohumeral joints; seven children, flat glenohumeral joints; 19 children, biconcave glenoid; and 17 children, pseudoglenoid. Median passive external rotation was -20 degrees for patients with pseudoglenoid, -10 degrees for those with flat or biconcave glenoids, and 0 degrees for those with concentric glenoids. Presence and type of glenoid deformity were significantly associated with severity of internal rotation contracture (P <.001).

CONCLUSION

Consistent patterns of glenohumeral joint deformity in brachial plexus birth palsy were identified and correlated with severity of internal rotation contracture.

Obstetrical brachial plexus injuries: incidence, natural course and shoulder contracture

The incidence of obstetric brachial plexus injury (OBPI) was investigated and the natural course of this disorder and the frequency of shoulder contracture described. Between 1988 and 1997 13,366 children with a gestational age of 30 weeks or more, were born at the Academic Medical Center, Amsterdam. Of these, 62 had an OBPI (4.6 per 1000). Complete neurological recovery occurred in 72.6% of cases. Half of them had a delayed recovery of more than three weeks (mean recovery time 6.2 +/- 3.1 months). Shoulder contracture occurred in at least one-third of the children with delayed recovery and in at least two-thirds of the children with incomplete recovery. The incidence of OBPI in our hospital was found to be higher and to have a less favourable natural course than is usually reported in the literature. Contracture of the shoulder joint is frequently found even in infants with complete neurological recovery.

The surgical treatment of brachial plexus injuries in adults

Posttraumatic brachial plexus palsy is a severe injury primarily affecting young individuals at the prime of their life. The devastating neurological dysfunction inflicted in those patients is usually lifelong and creates significant socioeconomic issues. During the past 30 years, the surgical repair of these injuries has become increasingly feasible. At many centers around the world, leading surgeons have introduced new microsurgical techniques and reported a variety of different philosophies for the reconstruction of the plexus. Microneurolysis, nerve grafting, recruitment of intraplexus and extraplexus donors, and local and free-muscle transfers are used to achieve optimal outcomes. However, there is yet no consensus on the priorities and final goals of reconstruction among the various centers.

Reconstructive operations for the paralyzed shoulder in brachial plexus palsy: concept of treatment

Sixty-three patients with persistent brachial plexus palsy underwent a transfer of the trapezius muscle and 14 patients a shoulder arthrodesis. Thirteen female and 64 male patients were treated with a mean age of 31 yr (17-69 yr). The average follow-up period was 14 months (6-50 months). In all cases, the trapezius transfer resulted in increased abduction from 6.1 degrees to an average of 36.4 degrees (20-80 degrees) and forward flexion from 13.8 degrees to an average of 31.9 degrees (10-90 degrees). The multidirectional shoulder instability was improved in 60 patients. Strength and functional improvement was, on average, greater following shoulder arthrodesis (abduction from 9.6 to 59.3 degrees (40-90 degrees), forward flexion from 11.4 to 50.7 degrees (30-90 degrees)). In patients with brachial plexus palsy, trapezius transfer resulted in an improvement of shoulder function and stability as well as subjectively. The increase in function was, however, less pronounced in comparison with shoulder arthrodesis. The advantages of the transfer are the regaining of normal passive function and the shorter duration of surgery. Shoulder fusion is more suitable for those patients who require the best possible extent of function and strength in the shoulder.

Glenoid deformity secondary to brachial plexus birth palsy

The association between internal rotation contracture secondary to brachial plexus birth palsy and deformity and posterior dislocation of the glenohumeral joint has been known for a long time. The precise nature of these deformities and their pathogenesis, however, remain unclear. Twenty-five children, ranging in age from 1.5 to 13.5 years, had an operation to release an internal rotation contracture secondary to brachial plexus birth palsy; eleven had a latissimus dorsi transfer to augment external rotation power as well. Arthrograms were made intraoperatively in order to clarify the pathological changes that occur in the glenohumeral joint during growth in patients who have this condition. Seven children had a concentric glenohumeral joint (the humeral head was well centered in the glenoid fossa). The remaining eighteen children (72 per cent) had a deformity of the posterior aspect of the glenoid. Five of these children had flattening of the posterior aspect of the glenoid, seven had a biconcave glenoid with the humeral head articulating with the posterior of the two concavities, and six had a so-called pseudoglenoid (the most severe deformity, in which the humeral head articulated with a distinct, retroverted, posterior articular surface). Internal rotation contracture secondary to brachial plexus birth palsy may lead to glenoid deformity that is severely advanced by the time that the child is two years old. In patients who have such a contracture, we recommend early imaging of the shoulder with arthrography or some other modality to allow visualization of the skeletally immature glenohumeral joint.

Trapezius transfer for shoulder paralysis. 6 patients with brachial plexus injuries followed for 1 year

We transferred the trapezius with its bone insertion to the proximal humerus in 6 patients for treatment of a paralytic shoulder secondary to traumatic lesions of the brachial plexus. After 1 year, the shoulder abduction was improved from average 13 degrees (0 degrees-30 degrees) preoperatively to 76 degrees (50 degrees-100 degrees) postoperatively, and the shoulder flexion from 18 degrees (0 degrees-40 degrees) to 78 degrees (45 degrees-110 degrees) postoperatively. All the patients were satisfied with the outcome. We consider that transfer of the trapezius in a paralytic shoulder after brachial plexus injury gives a better outcome than shoulder fusion.

Reinnervation of avulsed and reimplanted ventral rootlets in the cervical spinal cord of the cat

Spinal nerve root avulsions frequently occur in brachial plexus injuries caused by traction. Such lesions are considered to afflict the central nervous system (CNS) and are, therefore, believed to be beyond surgical repair. The present experimental study was initiated to challenge this hypothesis. The ventral rootlets of C-7 were avulsed from the spinal cord in 28 cats via an anterior approach and subsequently reimplanted into the cord at the site of origin. In nonoperated control cats and cats undergoing reimplantation, electrophysiological experiments were performed and horseradish peroxidase was administered to the spinal nerve on the reimplanted side after survival times ranging from 6 to 293 days. Spinal cord sections in all cats were stained for neurofilament, acetylcholinesterase (AChE), Nissl, and glial fibrillary acidic protein. Horseradish peroxidase-labeled ventral horn motoneurons were found as early as 14 days after reimplantation and their number increased with time. On Days 209 and 293, the number of labeled neurons equaled the number of labeled ventral horn neurons in the two control cats that did not undergo surgery. Starting on Day 6 after reimplantation, the appearance of the ventral horn and the white matter in the neurofilament, AChE, and Nissl-stained sections changed as a result of the CNS response to the injury. A return to their normal appearance could be observed in these stainings from Day 209 onward. Glial fibrillary acidic protein-positive astrocytic tissue was consistently found in the ventral horn and in the white matter reimplantation area. From Day 69 onward, electrophysiological stimulation of the spinal nerve C-7 on the reimplanted side elicited an electromyogram response in the spinodeltoid muscle. The latency and threshold intensity of the C-7 responses were initially increased but equalized to match the nonoperated controls between 98 and 122 days after reimplantation. The results of this study show that functional regeneration of ventral horn neurons after root avulsion and subsequent reimplantation in the cat is possible.

Brachial plexus injuries. Guidelines for management: our experience

In spite of the progress made by microneurosurgery, the treatment of brachial plexus injuries still remains a great challenge. This personal series of 49 patients with brachial plexus injuries (excluding tumours and thoracic outlet syndromes) is peculiar because the cases arose after the introduction in Italy of the law requiring all motorcyclists to wear a safety helmet. Our experience confirms that there has been a 32% increase in very severe almost irreparable injuries of the plexus in comparison with previous data reported in the literature. This is probably due to the higher rate of survival among severely-injured patients, although the possibility of a direct effect of the helmet on the plexus cannot be completely discarded. Our results confirm the good prognosis of the microsurgical repair of C5-C6 stretch injuries and infraclavicular lesions.