Combined nerve transfers for C5 and C6 brachial plexus avulsion injury

Neurotization of the axillary nerve using a motor branch of the triceps brachii: Outcomes after a 3-to-15-year follow-up

PURPOSE

Axillary nerve neurotization using a motor branch of the triceps brachii has become a therapeutic option in the management of deltoid paralysis. The purpose of this study was to report the medium to long-term outcomes of this procedure.

MATERIAL AND METHODS

Twenty patients with a median age of 31 years (interquartile range - IQR, 29-53) were included in a single-operator retrospective study. A clinical evaluation was conducted, including the assessment of deltoid muscle strength using the British Medical Research Council grading system and a dynamometer with comparisons made between preoperative and postoperative outcomes.

RESULTS

The median follow-up period was 6 years (IQR, 5-11). At last follow-up, the median active abduction was 160° (IQR 60-160), and 85% of patients recovered at least M3 abduction force. No donor site deficits were identified.

DISCUSSION

The medium to long-term outcomes of the neurotization of a triceps brachii motor branch on the axillary nerve are comparable to the short-term outcomes.

LEVEL OF EVIDENCE

IV.

Functional outcomes following nerve transfers for shoulder and elbow reanimation in brachial plexus injuries: a 10-year retrospective study

Brachial plexus injuries are rare but highly disabling, with major implications for upper limb function and quality of life. Nerve transfers have emerged as a key reconstructive technique, particularly valuable in cases where primary repair or grafting is unfeasible or delayed. This retrospective study analysed functional outcomes following nerve transfers in 37 patients with brachial plexus injury. Motor recovery was assessed using the Medical Research Council scale. Patients were stratified by age, timing of surgery, injury severity, and type of nerve transfer performed. The majority of our cohort consisted of male adults, predominantly injured in motorcycle accidents, while pediatric cases were mostly due to obstetrical trauma. For shoulder reanimation, all patients received spinal accessory to suprascapular nerve transfer, with a subset also undergoing medial triceps branch of the radial nerve to axillary nerve transfer. These techniques resulted in 85.3% of patients achieving shoulder function recovery with M3 or M4 muscle strength, with combined procedures leading exclusively to M3 or M4 muscle strength. For elbow flexion restoration, surgical approaches included intercostal to musculocutaneous nerve transfer, ulnar and median fascicles to musculocutaneous nerve transfer, contralateral C7 to musculocutaneous nerve transfer with ulnar graft, and spinal accessory to musculocutaneous nerve transfer with sural nerve graft. Root grafting procedures using sural nerve grafts or nerve conduits were employed in three pediatric patients. Overall, 84.38% of patients achieved elbow flexion recovery with M3 or M4 muscle strength. These findings reinforce the utility of nerve transfers as a cornerstone in the surgical management of brachial plexus injury.

Impact of Surgery Timing on Outcomes After Nerve Transfer to Restore Elbow Flexion

Background

Nerve reconstruction following brachial plexus injury (BPI) is a time-sensitive procedure, and surgical delay may negatively impact muscle reinnervation and outcomes. This study investigated the impact of surgical timing on elbow flexion strength in patients with BPI undergoing nerve transfer to restore elbow flexion.

Methods

Following PRISMA guidelines, MEDLINE, Embase, and the Cochrane Library databases were systematically searched. English-language studies investigating the single fascicular transfer (SFT) or double fascicular transfer (DFT) to restore elbow flexion in BPI were included. Data were analyzed to identify the predictors of elbow flexion strength: surgery timing, age, injury level, and SFT versus DFT.

Results

The literature search identified 1051 articles. Studies (n = 31) reporting data of individual patients who underwent SFT (n = 341) or DFT (n = 67) were included; the mean age was 29.6 ± 11.2 years, time from injury to surgery was 6.5 ± 5.0 months, and follow-up was 27.1 ± 24.3 months. Good elbow flexion strength was found: Medical Research Council grade greater than or equal to 3 in 352 (86.3%) and Medical Research Council grade greater than or equal to 4 in 288 (70.6%). In the adjusted analysis, poorer motor recovery was associated with increased age (P = 0.02), surgical delay (P < 0.0001), C5-7 injuries (P < 0.01), and pan-plexus injuries (P < 0.0001). A 32% reduction in the odds of favorable motor recovery was observed with a 3-month delay to surgery. Patients who had a nerve transfer 6 months or earlier from injury had 2.4 times the odds of favorable motor recovery (P < 0.001).

Conclusions

SFT and DFT provide excellent elbow flexion strength in the majority of patients. Following nerve transfers in individuals with BPI, poorer motor recovery was observed with each 3-month delay to surgery.

Outcomes of Oberlin Transfer in Elderly Patients: A Case Series

OBJECTIVE

A case series analysis was performed of upper brachial plexus injuries (BPIs) from low-impact trauma in patients ≥60 years old to assess the effectiveness of nerve transfers, particularly the Oberlin technique, in restoring elbow flexion and to refine clinical decision making for managing traumatic BPIs in this age group.

METHODS

Between 2013 and 2024, 11 patients aged 60-72 with traumatic upper BPIs underwent Oberlin technique for elbow flexion; all were evaluated with consistent postsurgical criteria.

RESULTS

Trauma mechanisms included falls (55%), direct trauma (27%), knife wounds (9%), and stretching (9%), with no high-impact trauma cases. Injuries predominantly affected the right side (55%). Elbow flexion strength was assessed using the British Medical Research Council scale. Positive Tinel sign was present in 73% of patients, all reporting pain ranging from mild to severe. At 1 year postsurgery, 64% achieved M4 elbow flexion, 27% achieved M3, and 9% achieved M1 after 4 months. Patients >65 who received surgery within 6 months of injury showed better outcomes except for 1 case. No ulnar nerve deficits were observed. Following surgery, 36% experienced no pain, whereas 64% reported mild pain. Additionally, 64% underwent further nerve transfers to restore shoulder function (spinal accessory nerve to suprascapular nerve), and 18% underwent the Somsakprocedure for deltoid function.

CONCLUSIONS

Positive outcomes were achieved with the Oberlin technique in patients >60 with upper BPIs from low-energy trauma. However, delayed surgery, significant atrophy, and low testosterone levels may affect results. Evaluation of each patient's medical history is crucial before performing this procedure.

Results of the Nerve Transfers and Secondary Procedures to Restore Shoulder and Elbow Function in Traumatic Upper Brachial Plexus Palsy

Background: Damage to the upper trunk of the brachial plexus, often caused by high-energy trauma, leads to significant functional impairment of the upper limb. This injury primarily affects the C5 and C6 roots, resulting in paralysis of muscles critical for shoulder and elbow function. If spontaneous nerve regeneration does not occur within 3-6 months post-injury, surgical intervention, including nerve transfers, is recommended to restore function. Methods: This study evaluates long-term outcomes of nerve transfer surgeries performed between 2013 and 2023 on 16 adult patients with post-traumatic brachial plexus injuries. The most common cause of injury was motorcycle accidents. Nerve transfers targeted shoulder and elbow function restoration, including transfer of the accessory nerve to the suprascapular nerve, the radial nerve branch to the long or medial head of the triceps brachii to the axillary nerve, or the transfer of motor fascicles of the ulnar and median nerves (double Oberlin) to the brachialis and biceps brachii motor nerves. Results: Postoperative results showed varying degrees of functional recovery. In the shoulder, most patients achieved stabilization and partial restoration of active movement, with average flexion up to 92° and abduction up to 78°. In the elbow, full flexion with M4 strength was achieved in 64% of patients. In both the shoulder and the elbow, double nerve transfers yield better long-term outcomes than single transfers. Secondary procedures, such as tendon transfers, were required in some cases to improve limb strength. Conclusions: The study concludes that nerve transfers offer reliable outcomes in restoring upper limb function, although additional surgeries may be necessary in certain cases.

Transfer of Motor Fascicle From the Ulnar Nerve to the Axillary Nerve by Posterior Access. New Approach

ABSTRACT

We describe a new technique of transferring the motor branch ulnar nerve (UN) to the axillary nerve (AN) by posterior approach. Three patients with C5, C6, and C7 brachial plexus injury were operated. By supraclavicular approach, the spinal accessory was transferred to the suprascapular nerve. By posterior approach in the arm, the AN was identified within the quadrilateral space, and the UN was identified medially with intrafascicular dissection of a motor fascicle, which is lifted to 4 cm in length and transferred to AN. By medial approach, a motor branch from the median nerve is transferred to the biceps nerve. At a follow-up minimum of 10 months, the maximum abduction was 160 and the minimum 90 degrees. This technique, neurotization of the AN with fascicles of the UN, spinal accessory to suprascapular nerve, and median nerve branch to biceps nerve are indicated in C5-C7 avulsion when there is no radial nerve available.

LEVEL OF EVIDENCE

Level IV.

The prerequisites and clinical outcomes of ipsilateral C7 nerve root transfer to the upper trunk for adult C5-C6 brachial plexus injuries

PURPOSE

Although ipsilateral C7 nerve transfer is used for the treatment of C5-C6 brachial plexus injuries, accurately evaluating the functional quality of the donor nerve (ipsilateral C7 nerve root) is difficult, especially when the C7 nerve root is slightly injured. The purpose of this study was to determine the indicators to evaluate the quality of the ipsilateral C7 nerve and assess the clinical outcomes of this procedure.

METHODS

This study employed the following three indicators to assess the quality of the ipsilateral C7 nerve: (1) the muscle strength and electrophysiological status of the latissimus dorsi, triceps brachii, and extensor digitorum communis; (2) the sensibility of the radial three digits, especially the index finger; and (3) the intraoperative appearance, feel and electrophysiological status of the ipsilateral C7 nerve root. Transfer of the ipsilateral C7 nerve root to the upper trunk was implemented only when the following three tests were conducted, the criteria were met, and the clinical outcomes were assessed in eight patients with C5-C6 brachial plexus injuries.

RESULTS

Patients were followed-up for an average of 90 ± 42 months. At the final follow-up, all eight patients achieved recovery of elbow flexion, with five and three patients scoring M4 and M3, respectively, according to the Medical Research Council scoring. The shoulder abduction range of motor recovery averaged 86 ± 47° (range, 30°-170°), whereas the shoulder external rotation averaged 51 ± 26° (range, 15°-90°).

CONCLUSION

Ipsilateral C7 nerve transfer is a reliable and effective option for the functional reconstruction of the shoulder and elbow after C5-C6 brachial plexus injuries when the three prerequisites are met.

Phrenic Nerve as an Alternative Donor for Nerve Transfer to Restore Shoulder Abduction in Severe Multiple Root Injuries of the Adult Brachial Plexus

PURPOSE

Nerve transfer is the gold standard to restore shoulder abduction in acute brachial plexus injuries. The aim of this study was to compare the phrenic nerve (Ph) to the spinal accessory nerve (XI) as the donor nerve for this purpose.

METHODS

A retrospective chart review was performed on 136 patients with acute brachial plexus injuries who received a nerve transfer of the shoulder with either the Ph (94 patients) or XI (42 patients). Each group was divided into 3 subgroups based on the recipient nerve. The maximum degree of shoulder abduction was recorded after 2 years of postoperative follow-up. A generalized estimating equation model was performed to examine the variables affecting shoulder abduction over time.

RESULTS

The maximum degrees of shoulder abduction achieved were 61.9° ± 38.7° in patients with Ph and 51.1° ± 37.3° in patients with XI. More than M3 shoulder abduction was achieved by 67% of patients with Ph versus 59% of patients with XI. The regression analysis showed that the age at the time of surgery correlated more with the functional outcome over time than the choice of donor nerve.

CONCLUSIONS

In multiple root brachial plexus injuries, the Ph exhibited similar outcomes to the XI for shoulder abduction. Our routine exploration of the supraclavicular plexus exposes the Ph conveniently for nerve transfer. The phrenic nerve should be considered as an alternative when the XI is not available or is reserved for secondary reconstruction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Long-term functional recovery in C5-C6 avulsions treated with distal nerve transfers

BACKGROUND

In patients suffering from traction lesions of the brachial plexus, complete C5 and/or C6 root avulsion patients with C7 root preservation are relatively uncommon occurrences, but represent excellent candidates for surgical treatment, with satisfactory results. Shoulder abduction and extra-rotation, elbow flexion and forearm supination are lost functions restorable with surgical treatment.

METHODS

This single-center, prospective observational study involved a series of 27 young adults with C5 and/or C6 root complete avulsion and C7 preservation, which underwent surgical repair with double or triple nerve transfer.

RESULTS

Patients recovered a useful elbow flexion. Electromyographic and clinical signs of biceps reinnervation were observed in each UN-MC nerve transfer. The abduction strength recovery was M5 in 10 patients, M4 in 14 patients and M3 in 3 patients. The external rotation strength recovery was M5 in 4 patients, M4 in 18 patients, M3 in 3 patients and M2 in 2 patients. The elbow flection strength was M5 in 5 patients, M4 in 15 patients and M3 in 7 patients. Elbow extension was preserved in all cases.

CONCLUSIONS

The concept of 'peripheral rewiring procedures' represents an advance in the repair of the peripheral nerve injuries. Triple nerve transfer can be nowadays considered a standard treatment for isolated C5-C6 avulsions. We report our experience with the second-biggest casuistry in the literature on patients treated with this technique. We consider our outcome concerning functional recovery to be satisfying and comparable to data reported in the literature.

Nerve Transfer Is Superior to Nerve Grafting for Suprascapular Nerve Reconstruction in Obstetrical Brachial Plexus Birth Injury: A Meta-Analysis

BACKGROUND

Restoration of shoulder function in obstetrical brachial plexus injury is paramount. There remains debate as to the optimal method of upper trunk reconstruction. The purpose of this study was to test the hypothesis that spinal accessory nerve to suprascapular nerve transfer leads to improved shoulder external rotation relative to sural nerve grafting.

METHODS

A systematic review of Medline, EMBASE, EBSCO CINAHL, SCOPUS, Cochrane Library, and TRIP Pro from inception was conducted. Our primary outcome was shoulder external rotation.

RESULTS

Four studies were included. Nerve transfer was associated with greater shoulder external rotation relative to nerve grafting (mean difference: 0.82 AMS 95% confidence interval [CI]: 0.27-1.36, P < .005). Patients undergoing nerve grafting were more likely to undergo a secondary shoulder stabilizing procedure (odds ratio [OR]: 1.27, 95% CI: 0.8376-1.9268).

CONCLUSION

In obstetrical brachial plexus injury, nerve transfer is associated with improved shoulder external rotation and a lower rate of secondary shoulder surgery.

LEVEL OF EVIDENCE

Level III; Therapeutic.

Is there any difference between anterior and posterior approach for the spinal accessory to suprascapular nerve transfer? A systematic review and meta-analysis

Dual nerve transfer of the spinal accessory nerve to the suprascapular nerve (SAN-SSN) and the radial nerve to the axillary nerve is considered to be the most feasible method of restoration of shoulder abduction in brachial plexus injuries. Supraspinatus muscle plays an important role in the initiation of abduction and its functional restoration is crucial for shoulder movements. There are two possible approaches for the SAN-SSN transfer: the more conventional anterior approach and the posterior approach in the area of scapular spine, which allows more distal neurotization. Although the dual nerve transfer is a widely used method, it is unclear which approach for the SAN-SSN transfer results in better outcomes. We conducted a search of English literature from January 2001 to December 2021 using the PRISMA guidelines. Twelve studies with a total 142 patients met our inclusion criteria. Patients were divided into two groups depending on the approach used: Group A included patients who underwent the anterior approach, and Group B included patients who underwent the posterior approach. Abduction strength using the Medical Research Scale (MRC) and range of motion (ROM) were assessed. The average MRC grade was 3.57 ± 1.08 in Group A and 4.0 ± 0.65 (p = 0.65) in Group B. The average ROM was 114.6 ± 36.7 degrees in Group A and 103.4 ± 37.2 degrees in Group B (p = 0.247). In conclusion, we did not find statistically significant differences between SAN-SSN transfers performed from the anterior or posterior approach in patients undergoing dual neurotization technique for restoration of shoulder abduction.

Recent Advances in the Treatment of Brachial Plexus Birth Injury

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation.

SUMMARY

Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales.

Nerve Transfers for Brachial Plexus Reconstruction in Patients over 60 Years

Negative expectations regarding nerve reconstruction in the elderly prevail in the literature, but little is known about the effectiveness of nerve transfers in patients with brachial plexus injuries aged over 60 years. We present a series of five patients (1 female, 4 male) aged between 60 and 81 years (median 62.0 years) who underwent nerve reconstruction using multiple nerve transfers in brachial plexopathies. The etiology of brachial plexus injury was trauma (n = 2), or iatrogenic, secondary to spinal surgical laminectomy, tumor excision and radiation for breast cancer (n = 3). All but one patient underwent a one-stage reconstruction including neurolysis and extra-anatomical nerve transfer alone (n = 2) or combined with anatomical reconstruction by sural nerve grafts (n = 2). One patient underwent a two-stage reconstruction, which involved a first stage anatomical brachial plexus reconstruction followed by a second stage nerve transfer. Neurotizations were performed as double (n = 3), triple (n = 1) or quadruple (n = 1) nerve or fascicular transfers. Overall, at least one year postoperatively, successful results, characterized by a muscle strength of M3 or more, were restored in all cases, two patients even achieving M4 grading in the elbow flexion. This patient series challenges the widely held dogma that brachial plexus reconstruction in older patients will produce poor outcomes. Distal nerve transfers are advantageous as they shorten the reinnervation distance. Healthy, more elderly patients should be judiciously offered the whole spectrum of reconstructive methods and postoperative rehabilitation concepts to regain useful arm and hand function and thus preserve independence after a traumatic or nontraumatic brachial plexus injury.

The Effectiveness of Different Nerve Transfers in the Restoration of Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis

PURPOSE

Restoration of elbow flexion is an important goal in the treatment of patients with traumatic brachial plexus injury. Numerous studies have described various nerve transfers for neurotization of the musculocutaneous nerve (or its motor branches); however, there is uncertainty over the effectiveness of each method. The aim of this study was to summarize the published evidence in adults with traumatic brachial plexus injury.

METHODS

Medline, Embase, medRxiv, and bioRxiv were systematically searched from inception to April 12, 2021. We included studies that reported the outcomes of nerve transfers for the restoration of elbow flexion in adults. The primary outcome was elbow flexion of grade 4 (M4) or higher on the British Medical Research Council scale. Data were pooled using random-effects meta-analyses, and heterogeneity was explored using metaregression. Confidence intervals (CIs) were generated to the 95% level.

RESULTS

We included 64 articles, which described 13 different nerve transfers. There were 1,335 adults, of whom 813 (61%) had partial and 522 (39%) had pan-plexus injuries. Overall, 75% of the patients with partial brachial plexus injuries achieved ≥M4 (CI, 69%-80%), and the choice of donor nerve was associated with clinically meaningful differences in the outcome. Of the patients with pan-plexus injuries, 45% achieved ≥M4 (CI, 31%-60%), and overall, each month delay from the time of injury to reconstruction reduced the probability of achieving ≥M4 by 7% (CI, 1%-12%).

CONCLUSIONS

The choice of donor nerve affects the chance of attaining a British Medical Research Council score of ≥4 in upper-trunk reconstruction. For patients with pan-plexus injuries, delay in neurotization may be detrimental to motor outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Posterior division of ipsilateral C7 transfer to C5 for shoulder abduction limitation

Background

Reparation of C5 by proximal selective ipsilateral C7 transfer has been reported for the treatment of neurogenic shoulder abduction limitation as an alternative to the reparation of the suprascapular nerve (SSN) and the axillary nerve (AXN) by distal nerve transfers. However, there is a lack of evidence to support either strategy leading to better outcomes based on long-term follow-up.

Objective

The purpose of the study was to investigate the safety and long-term outcomes of the posterior division of ipsilateral C7 (PDIC7) transfer to C5 in treating neurogenic shoulder abduction limitation.

Methods

A total of 27 cases with limited shoulder abduction caused by C5 injury (24 cases of trauma, 2 cases of neuritis, and 1 case of iatrogenic injury) underwent PDIC7 transfer to the C5 root. A total of 12 cases (11 cases of trauma and 1 case of neuritis) of C5 injury underwent spinal accessory nerve (SAN) transfer to SSN plus the triceps muscular branch of the radial nerve (TMBRN) transfer to AXN. The patients were followed up for at least 12 months for muscle strength and shoulder abduction range of motion (ROM).

Results

In cases that underwent PDIC7 transfer, the average shoulder abduction was 105.9° at the 12-month follow-up. In total, 26 of 27 patients recovered at least M3 (13 reached M4) (Medical Research Council Grading) of the deltoid. In cases that underwent SAN transfer to SSN plus TMBRN to AXN, the average shoulder abduction was 84.6° at the 12-month follow-up. In total, 11 of 12 patients recovered at least M3 (4 reached M4) of the deltoid.

Conclusion

Posterior division of ipsilateral C7 transfer is a one-stage, safe, and effective surgical procedure for patients with neurogenic shoulder abduction limitation.

Elevated Body Mass Index Negatively Impacts Recovery of Shoulder Abduction Strength in Triceps Motor Branch to Axillary Nerve Transfers

BACKGROUND

The purpose of this work was to evaluate the clinical outcomes of triceps motor branch to axillary nerve transfers and to identify prognostic factors which may influence these outcomes.

METHODS

A retrospective cohort included all patients who underwent a triceps motor branch to axillary nerve transfer (2010-2019) with at least 12 months of follow-up. The primary outcome measure was shoulder abduction strength assessed with British Medical Research Council (MRC) grade.

RESULTS

Ten patients were included with a mean follow-up of 19.1 (SD 5.9) months. Compared with preoperative MRC shoulder abduction strength (0.2 SD 0.4), patients significantly improved postoperatively (2.8 SD 1.6; P = .005). Increased body mass index (BMI) was significantly associated with worse postoperative MRC (P = .014).

CONCLUSION

Triceps motor branch to axillary nerve transfer is a beneficial procedure for restoring shoulder function in patients presenting with either isolated axillary nerve or brachial plexus pathology. Patients with elevated BMI may not have as robust strength recovery and should be counseled carefully regarding prognosis.

Trends in Brachial Plexus Surgery: Characterizing Contemporary Practices for Exploration of Supraclavicular Plexus

BACKGROUND

There is variability in treatment strategies for patients with brachial plexus injury (BPI). We used qualitative research methods to better understand surgeons' rationale for treatment approaches. We hypothesized that distal nerve transfers would be preferred over exploration and nerve grafting of the brachial plexus.

METHODS

We conducted semi-structured interviews with BPI surgeons to discuss 3 case vignettes: pan-plexus injury, upper trunk injury, and lower trunk injury. The interview guide included questions regarding overall treatment strategy, indications and utility of brachial plexus exploration, and the role of nerve grafting and/or nerve transfers. Interview transcripts were coded by 2 researchers. We performed inductive thematic analysis to collate these codes into themes, focusing on the role of brachial plexus exploration in the treatment of BPI.

RESULTS

Most surgeons routinely explore the supraclavicular brachial plexus in situations of pan-plexus and upper trunk injuries. Reasons to explore included the importance of obtaining a definitive root level diagnosis, perceived availability of donor nerve roots, timing of anticipated recovery, plans for distal reconstruction, and the potential for neurolysis. Very few explore lower trunk injuries, citing concern with technical difficulty and unfavorable risk-benefit profile.

CONCLUSIONS

Our analysis suggests that supraclavicular exploration remains a foundational component of surgical management of BPI, despite increasing utilization of distal nerve transfers. Availability of abundant donor axons and establishing an accurate diagnosis were cited as primary reasons in support of exploration. This analysis of surgeon interviews characterizes contemporary practices regarding the role of brachial plexus exploration in the treatment of BPI.

Factors Associated with Poorer Outcomes from Triceps Motor Branch to Anterior Axillary Nerve Transfer: A Case-Control Study

INTRODUCTION

We sought to identify predictors of failed triceps motor branch transfer to the anterior division of the axillary nerve (AN) for shoulder abduction reconstruction after a brachial plexus injury (BPI).

METHODS

A case-control study of adult AN or brachial plexus patients treated with a triceps motor branch transfer to the anterior division of the AN with a minimum 18 months of follow-up was performed. The failure group (case group) was defined as modified British Medical Research Council muscle scale (mBMRC) postoperative deltoid grade ≤2 and was compared to the successful outcome group (control group), defined as mBMRC postoperative deltoid grade ≥3. Clinical variables, injury mechanism, time from injury to surgery, root avulsion status, electrodiagnostic studies, rotator cuff injuries, scapula fracture, Disabilities of the Arm Shoulder and Hand scores, and preoperative triceps strength were analyzed. Subgroup analysis was performed for patients with isolated AN injuries and those with BPI.

RESULTS

A total of 69 patients met inclusion/exclusion criteria, of whom 23 regained ≥M3 deltoid muscle strength and 52° ± 69° of shoulder abduction (successful outcome group) and 46 regained ≤M2 deltoid muscle strength and 27° ± 30° of shoulder abduction (failure group). Preoperative triceps weakness (M ≤4) was significantly more common in the failure group (63% vs. 30%, P = 0.032); preoperative triceps muscle fibrillations were significantly more common in the failure group (61% vs. 30%, P = 0.02). Isolated AN injuries presented better preoperative motion and postoperative outcomes results compared to BPI.

CONCLUSIONS

Use of triceps motor branch associated with fibrillations or weakness resulted in statistically poorer outcomes compared to the use of a normal triceps motor branch in the restoration of anterior AN function after nerve transfer.

Nerve Transfers for Elbow Reconstruction in Upper and Extended Upper-Type Brachial Plexus Injuries: A Case Series

BACKGROUND

Nerve transfers for elbow flexion in brachial plexus injuries have been used with increasing frequency because of the higher rate of success and acceptable morbidity. This is especially true in upper and extended upper-type brachial plexus injuries.

OBJECTIVE

To present the clinical outcomes of nerve transfers for elbow flexion in patients with upper and extended upper-type brachial plexus injuries.

METHODS

A retrospective cohort review was done on all patients with upper and extended upper-type brachial plexus injuries from 2006 to 2017, who underwent nerve transfers for the restoration of elbow flexion. Outcome variables include Filipino version of the disability of the arm, shoulder, and hand (FIL-DASH) score, elbow flexion strength and range of motion, and pain. All statistical significance was set at P &lt; .05.

RESULTS

Fifty-six patients with nerve transfers to restore elbow flexion were included. There was a significant improvement in FIL-DASH scores in 28 patients after the nerve transfer procedure. Patients with C56 nerve root injuries and those with more than 2 years' follow-up have a higher percentage of regaining ≥M4 elbow flexion strength. Those with double nerve transfers had a higher percentage of ≥M4 elbow flexion strength, greater range of elbow flexion, and better FIL-DASH scores compared with single nerve transfers, but this did not reach statistical significance.

CONCLUSION

Nerve transfer procedures improve FIL-DASH scores in upper and upper-type brachial plexus injuries. After nerve transfer, stronger elbow flexion can be expected in patients with C56 injuries, and those with longer follow-up.

Upper limb joint coordination preserves hand kinematics after a traumatic brachial plexus injury

Background

Traumatic brachial plexus injury (TBPI) causes a sensorimotor deficit in upper limb (UL) movements.

Objective

Our aim was to investigate the arm–forearm coordination of both the injured and uninjured UL of TBPI subjects.

Methods

TBPI participants (n = 13) and controls (n = 10) matched in age, gender, and anthropometric characteristics were recruited. Kinematics from the shoulder, elbow, wrist, and index finger markers were collected, while upstanding participants transported a cup to their mouth and returned the UL to a starting position. The UL coordination was measured through the relative phase (RP) between arm and forearm phase angles and analyzed as a function of the hand kinematics.

Results

For all participants, the hand transport had a shorter time to peak velocity (p &lt; 0.01) compared to the return. Also, for the control and the uninjured TBPI UL, the RP showed a coordination pattern that favored forearm movements in the peak velocity of the transport phase (p &lt; 0.001). TBPI participants' injured UL showed a longer movement duration in comparison to controls (p &lt; 0.05), but no differences in peak velocity, time to peak velocity, and trajectory length, indicating preserved hand kinematics. The RP of the injured UL revealed altered coordination in favor of arm movements compared to controls and the uninjured UL (p &lt; 0.001). Finally, TBPI participants' uninjured UL showed altered control of arm and forearm phase angles during the deceleration of hand movements compared to controls (p &lt; 0.05).

Conclusion

These results suggest that UL coordination is reorganized after a TBPI so as to preserve hand kinematics.

Optimal timing of referral for nerve transfer surgery for postoperative C5 palsy

OBJECTIVE

Cervical nerve 5 palsy can occur following surgery for cervical spine pathology. The prognosis of C5 palsy is generally favorable, and most patients recover useful function. However, some patients do not recover useful strength. Nerve transfers are a potential effective treatment of postoperative severe C5 palsy. This study aimed to further delineate the natural history of recovery from postoperative C5 palsy, determine whether lack of recovery at specific time points predicts poor recovery prognosis, and thereby determine a reasonable time point for referral to a complex peripheral nerve specialist.

METHODS

The authors conducted a retrospective review of 72 patients who underwent surgery for cervical spondylosis and stenosis complicated by C5 palsy. Medical Research Council (MRC) motor strength grades were recorded preoperatively; immediately postoperatively; at discharge; and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Univariate and multivariate logistic regression models were used to identify demographic and clinical risk factors associated with recovery of useful strength after severe C5 palsy.

RESULTS

The mean patient age was 62.5 years, and 36.1% of patients were female. Thirty patients (41.7%) experienced severe C5 palsy with less than antigravity strength (MRC grade 2 or less) at discharge. Twenty-one (70%) of these patients recovered useful strength (MRC grade 3 or greater) at 12 months postoperatively, and 9 patients (30%) did not recover useful strength at 12 months. Of those patients with persistent severe C5 palsy at 3 months postoperatively, 50% recovered useful strength at 12 months. Of those patients with persistent severe C5 palsy at 6 months postoperatively, 25% recovered useful strength at 12 months. No patient with MRC grade 0 or 1 strength at 6 months postoperatively recovered useful strength. A history of diabetes was associated with the occurrence of severe C5 palsy. On multivariate analysis, female sex was associated with recovery of useful strength.

CONCLUSIONS

Most patients with severe C5 palsy recover useful strength in their C5 myotome within 12 months of onset. However, at 3 months postoperatively, patients with persistent severe C5 palsy had only a 50% chance of recovering useful strength by 12 months. Lack of recovery of useful strength at 3 months postoperatively is a reasonable time point for referral to a complex peripheral nerve center to establish care and to determine candidacy for nerve transfer surgery if severe C5 palsy persists.

Clinical Assessment of Functional Recovery Following Nerve Transfer for Traumatic Brachial Plexus Injuries

Surgical reconstruction and postoperative rehabilitation are both important for restoring function in patients with traumatic brachial plexus injuries (BPIs). The current study aimed to understand variations in recovery progression among patients with different injury levels after receiving the nerve transfer methods. A total of 26 patients with BPIs participated in a rehabilitation training program over 6 months after nerve reconstruction. The differences between the first and second evaluations and between C5-C6 and C5-C7 BPIs were compared. Results showed significant improvements in elbow flexion range (p = 0.001), British Medical Research Council's score of shoulder flexion (p = 0.046), shoulder abduction (p = 0.013), shoulder external rotation (p = 0.020), quantitative muscle strength, and grip strength at the second evaluation for both groups. C5-C6 BPIs patients showed a larger shoulder flexion range (p = 0.022) and greater strength of the shoulder rotator (p = 0.004), elbow flexor (p = 0.028), elbow extensor (p = 0.041), wrist extensor (p = 0.001), and grip force (p = 0.045) than C5-C7 BPIs patients at the second evaluation. Our results indicated different improvements among patients according to injury levels, with quantitative values assisting in establishing goals for interventions.

Nerve transfers for brachial plexus injuries: grading of volitional control

OBJECTIVE

After brachial plexus injuries (BPIs), nerve transfers are used to restore lost muscle function. Brain plasticity underlies the process of regaining volitional control, which encompasses disconnection of the original donor nerve-related programs and reconnection to acceptor nerve programs. To the authors' knowledge, the levels of disconnection and reconnection have never been studied systematically. In this study, the authors developed a novel 4-point plasticity grading scale (PGS) and assessed the degree of volitional control achieved, identifying clinical correlations with this score.

METHODS

Patients with BPI who underwent a phrenic, spinal accessory, median, and/or ulnar fascicle nerve transfer to restore biceps and deltoid function were asked to maximally contract their target muscle as follows: 1) by using only the donor nerve program, and 2) by activating the target muscle while consciously trying to avoid using the donor nerve, with assessment each time of the Medical Research Council (MRC) scale grade for muscle strength. The authors' PGS was used to rate the level of volitional control achieved. PGS grade 1 represented the lowest independent volitional control, with MRC grade 4 obtained in response to the donor command and MRC grade 0 in response to the acceptor command (minimum brain plasticity), whereas PGS grade 4 was no noticeable contraction in response to the donor command and MRC grade 4 in response to the acceptor command (maximum brain plasticity).

RESULTS

In total, 153 patients were studied. For biceps restoration, the phrenic nerve was used as a donor in 44 patients, the spinal accessory nerve in 40 patients, and the median and/or ulnar fascicles in 44 patients. A triceps branch was used to restore deltoid function in 25 patients. The level of volitional control achieved was PGS grade 1 in 1 patient (0.6%), grade 2 in 21 patients (13.7%), grade 3 in 103 patients (67.3%), and grade 4 in 28 patients (18.3%). The median PGS grade did not differ significantly between the four donor nerves. No correlations were observed between age, time from BPI to surgery, duration of follow-up, or compliance with rehabilitation and PGS grade.

CONCLUSIONS

Just around 20% of the authors' patients developed a complete disconnection of the donor program along with complete independent control over the reinnervated muscle. Incomplete disconnection was present in the vast majority of the patients, and the level of disconnection and control was poor in approximately 15% of patients. Brain plasticity underlies patient ability to regain volitional control after a nerve transfer, but this capacity is limited.

Morbidity of long head of the triceps motor branch neurotization to the axillary nerve: Retrospective subjective and objective assessment of triceps brachii strength after transfer

INTRODUCTION

Morbidity is considered to be negligible in Leechavengvongs transfer (LT) of the long head of the triceps onto the axillary nerve, but the assessment methods used may lack reproducibility. We assessed triceps strength after LT objectively by the isokinetic technique, addressing the following questions: Is strength lowered after LT compared to the healthy limb? And 2) is there a good correlation between isokinetic dynamometry and subjective assessment?

HYPOTHESIS

Isokinetic measurement shows a decrease in triceps strength at peak torque after LT compared to the healthy limb, and this morbidity is underestimated on subjective assessment.

MATERIAL AND METHODS

This single-center retrospective study included patients undergoing LT for axillary nerve trunk palsy between 2008 and 2020, with M5 triceps preoperatively on the British Medical Research Council (BMRC) scale. Twenty patients, with a mean age of 25±9years (range, 15-48years) were assessed at a mean 58±47months (range, 6-174months). Elbow extension strength was assessed on a standardized questionnaire, BMRC isometric test and isokinetic test on an angular course of 90° at 60°/sec and 180°/sec concentrically and 30°/sec excentrically.

RESULTS

Strength at 60°/sec and 180°/sec concentrically and 30°/sec excentrically was significantly lower than in the healthy limb: respectively, -17Nm, -15Nm, and -16Nm, (p<0.001) for a mean -23%. Loss of strength was mainly severe on isokinetic testing and mild on isometric testing. Seven patients reported contracture (35%), 12 fatigue (60%), and 3 weakness (15%). Satisfaction with extension strength was excellent or good for respectively 12 (60%) and 8 patients (40%). Triceps strength was graded BMRC M4 in 9 triceps (11%) and M5 in 11 (55%).

DISCUSSION

After LT, isokinetic measurement found generally severe loss of triceps strength, but without subjective impact on everyday life.

LEVEL OF EVIDENCE

IV; retrospective study.

Outcome Analysis of Medial Triceps Motor Nerve Transfer to Axillary Nerve in Isolated and Brachial Plexus-Associated Axillary Nerve Palsy

BACKGROUND

Since 2007, the authors have performed the triceps-to-axillary nerve transfer using the medial triceps branch to reconstruct axillary nerve function in brachial plexus and isolated axillary nerve palsies.

METHODS

A retrospective chart review was undertaken of patients reconstructed with this transfer, recording patient and injury demographics and time to surgery. Preoperative and postoperative function was graded using the Medical Research Council scale and the Disabilities of the Arm, Shoulder, and Hand questionnaire.

RESULTS

Postoperatively, 31 patients (64.6 percent) reached Medical Research Council grade 3 or higher at final follow-up. The median Disabilities of the Arm, Shoulder, and Hand score was 59.9 (interquartile range, 38.8 to 70.5) preoperatively and 25.0 (interquartile range, 11.3 to 61.4) at final follow-up. Sixteen patients (33 percent) had isolated axillary nerve injury; the median Medical Research Council grade was 4.25 (interquartile range, 3 to 4.25), with 14 patients (87.6 percent) achieving grade 3 or higher. Thirty-two patients (77 percent) had brachial plexus-associated injury; median Medical Research Council grade was 3 (interquartile range, 2 to 3), with 17 patients (53.1 percent) achieving grade 3 or higher.

CONCLUSION

Medial triceps nerve branch is a strong donor for triceps-to-axillary nerve transfer; however, injury factors may limit the motor recovery in this complex patient population, particularly in axillary nerve palsy associated with brachial plexus injury.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcomes of Spinal Accessory Nerve and Intercostal Nerve Transfers for Shoulder Stabilisation and Elbow Extension in Patients with C5,6,7 Root Avulsion Injury

Background: Upper arm type brachial plexus palsy results in decreased shoulder and elbow function. Reanimation of shoulder and elbow function is beneficial in these patients. The aim of this study is to report the results of restoring the shoulder abduction and elbow extension in patients with C5,6,7 root avulsion injury by simultaneous transfer of the spinal accessory nerve for the supraspinatus muscle combined with the transferring of the sixth and seventh intercostal nerves for the serratus anterior muscle along with the third to fifth intercostal nerves to the triceps muscle.

Methods: All patients who underwent the above set of nerve transfers and had at least 2 years of follow-up were included in the study. The outcome measures included the Medical Research Council (MRC) grading of motor strength of shoulder abduction and elbow extension and range of motion of shoulder abduction and shoulder external rotation.

Results: The study included 10 patients with an average age of 27. The mean time from injury to surgery was 6 months and the mean follow-up period was 35 months. M4 grade shoulder abduction was restored in five patients, M3 grade in three patients and M2 grade in two. M4 grade elbow extension was achieved in four patients, M3 grade in four patients and M2 grade in two patients. The average arc of shoulder abduction and external rotation was 71° and −21°, respectively.

Conclusions: The spinal accessory nerve and the sixth and seventh intercostal nerves transfer to the supraspinatus muscle and serratus anterior muscle with the third to fifth intercostal nerves transfer to the triceps muscle provided satisfactory results for both shoulder abduction and elbow extension in C5,6,7 root avulsion injury.

Level of Evidence: Level IV (Therapeutic)

The Terminal Anatomy of Phrenic Nerve: a Deeper Look at Diaphragm Innervation Patterns

BACKGROUND

Traumatic brachial plexus injuries are devastating lesions and neurotization is an usually elected surgical therapy. The phrenic nerve has been harvested as motor fibers donor in brachial plexus neurotization, showing great results in terms of motor reinnervation. Unfortunately, these interventions lack solid evidence regarding long-term safety and possible late respiratory function sequelae, raising crescent concerns after the COVID-19 pandemic onset and possibly resulting in reduced propensity to use this technique. The study of the distal anatomy of the phrenic nerves may lead to a better understanding of their branching patterns, and thus the proposition of surgical approaches that better preserve patient respiratory function.

METHODS

Twenty-one phrenic nerves in ten formalized cadavers were scrutinized. Pre-diaphragmatic branching patterns were inspected through analysis of the distance between the piercing site of the nerve at the diaphragm and the cardiac structures, number of divisions, and length from the point where the main trunk emits its branches to the diaphragm.

RESULTS

The main trunk of the right phrenic nerve reaches the diaphragm near the inferior vena cava and branches into three major divisions. The left phrenic nerve reaches the diaphragm in variable locations near the heart, branching into two to five main trunks. Moreover, we noticed a specimen presenting two ipsilateral parallel phrenic nerves.

CONCLUSION

The right phrenic nerve presented greater consistency concerning insertion site, terminal branching point distance to this muscle, and number of rami than the left phrenic nerve.

Possible donor nerves for axillary nerve reconstruction in dual neurotization for restoring shoulder abduction in brachial plexus injuries: a systematic review and meta-analysis

Restoring shoulder abduction is one of the main priorities in the surgical treatment of brachial plexus injuries. Double nerve transfer to the axillary nerve and suprascapular nerve is widely used and considered the best option. The most common donor nerve for the suprascapular nerve is the spinal accessory nerve. However, donor nerves for axillary nerve reconstructions vary and it is still unclear which donor nerve has the best outcome. The aim of this study was to perform a systematic review on reconstructions of suprascapular and axillary nerves and to perform a meta-analysis investigating the outcomes of different donor nerves on axillary nerve reconstructions. We conducted a systematic search of English literature from March 2001 to December 2020 following PRISMA guidelines. Two outcomes were assessed, abduction strength using the Medical Research Council (MRC) scale and range of motion (ROM). Twenty-two studies describing the use of donor nerves met the inclusion criteria for the systematic review. Donor nerves investigated included the radial nerve, intercostal nerves, medial pectoral nerve, ulnar nerve fascicle, median nerve fascicle and the lower subscapular nerve. Fifteen studies that investigated the radial and intercostal nerves met the inclusion criteria for a meta-analysis. We found no statistically significant difference between either of these nerves in the abduction strength according to MRC score (radial nerve 3.66 ± 1.02 vs intercostal nerves 3.48 ± 0.64, p = 0.086). However, the difference in ROM was statistically significant (radial nerve 106.33 ± 39.01 vs. intercostal nerve 80.42 ± 24.9, p < 0.001). Our findings support using a branch of the radial nerve for the triceps muscle as a donor for axillary nerve reconstruction when possible. Intercostal nerves can be used in cases of total brachial plexus injury or involvement of the C7 root or posterior fascicle. Other promising methods need to be studied more thoroughly in order to validate and compare their results with the more commonly used methods.

Optimal Donor Nerve to Restore Elbow Flexion After Traumatic Brachial Plexus Injury: A Systematic Review and Meta-Analysis

BACKGROUND

Traumatic brachial plexus injuries (BPIs) often lead to devastating upper extremity deficits. Treatment frequently prioritizes restoring elbow flexion through transfer of various donor nerves; however, no consensus identifies optimal donor nerve sources.

OBJECTIVE

To complete a meta-analysis to assess donor nerves for restoring elbow flexion after partial and total BPI (TBPI).

METHODS

Original English language articles on nerve transfers to restore elbow flexion after BPI were included. Using a random-effects model, we calculated pooled, weighted effect size of the patients achieving a composite motor score of ≥M3, with subgroup analyses for patients achieving M4 strength and with TBPI. Meta-regression was performed to assess comparative efficacy of each donor nerve for these outcomes.

RESULTS

Comparison of the overall effect size of the 61 included articles demonstrated that intercostal nerves and phrenic nerves were statistically superior to contralateral C7 (cC7; P = .025, <.001, respectively) in achieving ≥M3 strength. After stratification by TBPI, the phrenic nerve was still superior to cC7 in achieving ≥M3 strength (P = .009). There were no statistical differences among ulnar, double fascicle, or medial pectoral nerves in achieving ≥M3 strength. Regarding M4 strength, the phrenic nerve was superior to cC7 (P = .01) in patients with TBPI and the ulnar nerve was superior to the medial pectoral nerve (P = .036) for partial BPI.

CONCLUSION

Neurotization of partial BPI or TBPI through the intercostal nerve or phrenic nerve may result in functional advantage over cC7. In patients with upper trunk injuries, neurotization using ulnar, median, or double fascicle nerve transfers has similarly excellent functional recovery.

Defining the Reliability of Deltoid Reanimation by Nerve Transfer When Using Abnormal but Variably Recovered Triceps Donor Nerves

Upper brachial plexus injuries to the C5/6 roots or axillary nerve can result in severe deficits in upper limb function. Current techniques to reinnervate the deltoid muscle utilise the well-described transfer of radial nerve branches to triceps to the axillary nerve. However, in around 25% of patients, there is a failure of sufficient deltoid reinnervation. It is unclear in the literature if deltoid reanimation should be attempted with a nerve transfer from a weak but functioning triceps nerve. The authors present the largest series of triceps to axillary nerve transfers for deltoid reanimation in order to answer this clinical question. Seventy-seven consecutive patients of a single surgeon were stratified and analysed in four groups: (1) normal triceps at presentation, (2) abnormal triceps at presentation recovering to clinically normal function preoperatively, (3) abnormal triceps at presentation remaining abnormal preoperatively, and lastly (4) where pre-operative triceps function was deemed insufficient for use, requiring alternative reconstruction for deltoid reanimation. The authors considered deltoid re-animation of ≥ M4 as successful for the purpose of this study. Median Medical Research Council (MRC) values demonstrate group 1 achieves this successfully (M5), while median values for groups 2-4 result in M4 power (albeit with decreasing interquartile ranges). Median post-operative shoulder abduction active range of motion (AROM) values were represented by 170° (85-180) in group 1, 117.5° (97.5-140) in group 2, 90° (35-150) in group 3, and 60° (40-155) in group 4. For both post-operative assessments, subgroup analyses demonstrated statistically significant differences when comparing group 1 with groups 3 and 4 (p < 0.05), while all the other group to group pairwise comparisons did not reach significance. The authors postulated that triceps deficiency can act as a surrogate marker of a more extensive plexus injury and may predict poorer outcomes if the weakness persists representing the trending differences between groups 2 and 3. However, given no statistical differences were demonstrated between groups 3 and 4, the authors conclude that utilising an abnormal triceps nerve that demonstrates sufficient strength and redundancy intraoperatively is preferable to alternative transfers for deltoid reanimation. Lastly, in group 4 patients where triceps nerves are damaged and unusable for nerve transfer, alternative operations can also achieve sufficient outcomes and should be considered for restoration of shoulder abduction.

Shoulder abduction reconstruction for C5-7 avulsion brachial plexus injury by dual nerve transfers: spinal accessory to suprascapular nerve and partial median or ulnar to axillary nerve

Results of shoulder abduction reconstruction in partial upper-type brachial plexus avulsion injuries are better when a triceps nerve is transferred to the axillary nerve in addition to the spinal accessory to suprascapular nerve transfer. However, in C5-7 avulsion injuries, the triceps nerve may be unavailable as a donor nerve. We report the results of an alternative neurotization to the axillary nerve using either a partial median or ulnar nerve. Patients with C5, 6 ± 7 avulsion injuries and weak triceps who underwent dual nerve transfers for shoulder abduction reconstruction were recruited for the study. The second neurotization to the axillary nerve was from either a partial median or ulnar nerve that had an expandable muscle innervation of ≥ M4 motor power. Patients were assessed for recovery of shoulder abduction and external rotation. Nine patients (median age = 23 years) underwent these dual neurotizations from March 2005 to April 2013. The median time to surgery was 4.5 months. Recovery of shoulder abduction averaged 114.4° (range 90°-180°) and external rotation averaged 136.3° (range 135°-140°). Final shoulder abduction power was > M3 in all 9 patients and ≥ M4 in 6 patients. One patient with partial median nerve transfer had transient hypoaesthesia in his thumb and index finger and another had a residual M4 power in his thumb and index finger flexors. In C5-7 avulsion injuries, dual nerve transfers of the spinal accessory to suprascapular nerve and partial median or ulnar nerve to axillary nerve are good options for shoulder abduction reconstruction with minimal morbidity. Level of evidence is level IV.

Transfer of Motor Fascicle From the Median to the Axillary Nerve for Upper Brachial Plexus Injury: A Surgical Technique and Case Report

Upper brachial plexus injury or isolated lesions of the axillary nerve (AN) compromise shoulder functionality significantly. Different surgical techniques have been described for selective reconstruction of the AN, with good results especially in association with repair of the suprascapular nerve. The objective of this study is to describe the transfer of motor fascicles of the median nerve to the AN by an axillary approach in cadavers and the clinical results in 2 patients. Dissections were performed on 5 cadavers, followed by identification and dissection of the AN and its divisions before entering the quadrangular space. We standardized the surgical technique in which the median nerve was first identified and then an intrafascicular dissection was performed. Then we harvested a fascicle and transferred it to the anterolateral branch of the AN. Two patients underwent an operation; at 2 years of follow-up, average abduction of 125 degrees and external rotation of 95 degrees were observed. In conclusion, the transfer of motor fascicles of the median nerve to the AN by an axillary approach could be an alternative technique for the deltoid reinnervation in upper brachial plexus injury. Some advantages are the proximity of the donor nerve to the receptor nerve and the low morbidity of the target muscles of the donor nerve. Studies with a larger number of patients are required to establish its effectiveness compared with other techniques already described.

Nerve transfers in the upper extremity: A review

Injury of the brachial plexus and peripheral nerve often result in significant upper extremity dysfunction and disability. Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries. These transfers require an intimate knowledge of nerve topography, a technically demanding Intraneural dissection and require extensive physical therapy for retraining. In this review, we present a summary of the most widely accepted nerve transfers in the upper extremity described in the current literature.

Radial to Axillary Nerve Transfer Outcomes in Shoulder Abduction: A Systematic Review

Background

Brachial plexus and axillary nerve injuries often result in paralysis of the deltoid muscle. This can be functionally debilitating for patients and have a negative impact on their activities of daily living. In these settings, transferring the branch of the radial nerve innervating the triceps to the axillary nerve is a viable treatment option. Additional nerve transfers may be warranted. This study sought to determine the efficacy of nerve transfer procedures in the setting of brachial plexus and axillary nerve injuries and factors affecting clinical outcomes.

Methods

The U.S. National Library of Medicine's website "PubMed" was queried for "radial to axillary nerve transfer" and "brachial plexus nerve transfer." An initial review by two authors was performed to identify relevant articles followed by a third author validation utilizing inclusion and exclusion criteria. Individual patient outcomes were recorded and pooled for final analysis.

Results

Of the 80 patients, 66 (82.5%) had clinical improvement after surgical nerve transfer procedures. Significant difference in clinical improvement following nerve transfer procedures was correlated with patient age, mechanism of injury, brachial plexus vs isolated axillary nerve injuries, multiple nerve transfers vs single nerve transfers, and surgery within the first 7 months of injury. The branch of the radial nerve supplying the triceps long head showed improved clinical results compared with the branch of the radial nerve supplying the triceps medial head and anconeus.

Conclusion

Nerve transfers have been shown to be effective in restoring shoulder abduction in both isolated axillary nerve injuries and brachial plexus injuries.

Neuroprotection in the Acute Stage Enables Functional Recovery Following Repair of Chronic Cervical Root Transection After a 3-Week Delay

BACKGROUND

Preganglionic cervical root transection (PCRT) is the most severe type of brachial plexus injury. In some cases, surgical procedures must be postponed for ≥3 wk until electromyographic confirmation. However, research works have previously shown that treating PCRT after a 3-wk delay fails to result in functional recovery.

OBJECTIVE

To assess whether the immunosuppressive drug sirolimus, by promoting neuroprotection in the acute phase of PCRT, could enable functional recovery in cases of delayed repair.

METHODS

First, rats received a left 6th to 8th cervical root transection, after which half were administered sirolimus for 1 wk. Markers of microglia, astrocytes, neurons, and autophagy were assessed at days 7 and 21. Second, animals with the same injury received nerve grafts, along with acidic fibroblast growth factor and fibrin glue, 3 wk postinjury. Sirolimus was administered to half of them for the first week. Mechanical sensation, grasping power, spinal cord morphology, functional neuron survival, nerve fiber regeneration, and somatosensory-evoked potentials (SSEPs) were assessed 1 and 23 wk postinjury.

RESULTS

Sirolimus was shown to attenuate microglial and astrocytic proliferation and enhance neuronal autophagy and survival; only rats treated with sirolimus underwent significant sensory and motor function recovery. In addition, rats who achieved functional recovery were shown to have abundant nerve fibers and neurons in the dorsal root entry zone, dorsal root ganglion, and ventral horn, as well as to have SSEPs reappearance.

CONCLUSION

Sirolimus-induced neuroprotection in the acute stage of PCRT enables functional recovery, even if surgical repair is performed after a 3-wk delay.

Double-Nerve Transfer to the Axillary Nerve in Traumatic Upper Trunk Brachial Plexus Injuries Using an Axillary Approach: Anatomical Description and Preliminary Case Series

BACKGROUND

Restoration of shoulder external rotation remains challenging in patients with C5/C6 brachial plexus injuries (BPI).

OBJECTIVE

To describe a double-nerve transfer to the axillary nerve (AN), targeting both its anterior and posterior motor branches, through an axillary route.

METHODS

A total of 10 fresh-frozen cadaveric brachial plexuses were dissected. Using an axillary approach, the infraclavicular brachial plexus terminal branches were exposed, including the axillary, ulnar, and radial nerves. Under microscopic magnification, the triceps long head motor branch (TLHMB), anteromedial fascicles of the ulnar nerve (UF), the anterior motor branch of the axillary nerve (AAMB), and the teres minor motor branch (TMMB) were dissected and transected to simulate 2 nerve transfers, THLMB-AAMB and UF-TMMB. Several anatomical criteria were assessed, including the overlaps between fascicles when placed side-by-side. Six patients with C5/C6 BPI were then operated on using this technique.

RESULTS

TLHMB-AAMB and UF-TMMB transfers could be simulated in all specimens, with mean overlaps of 37.1 mm and 6.5 mm, respectively. After a mean follow-up of 23 mo, all patients had recovered grade-3 strength or more in the deltoid and teres minor muscles. Mean active shoulder flexion, abduction, and external rotation with the arm 90° abducted were of 128°, 117°, and 51°, respectively. No postoperative motor deficit was found in the UF territory.

CONCLUSION

A double-nerve transfer, based on radial and ulnar fascicles, appears to be an adequate option to reanimate both motor branches of the AN, providing satisfactory shoulder active elevations and external rotation in C5/C6 BPI patients.

Isolated Axillary Nerve Rupture due to Closed Nondislocating Injury of the Shoulder in Contact Sports: A Report of 2 Cases

CASE

Axillary nerve rupture without shoulder joint fracture or dislocation in contact sports is very rare. To date, there has been no detailed report on such cases. We present 2 rare cases of axillary nerve rupture in contact sports who were successfully treated with free nerve grafting.

CONCLUSION

In contact sports, the deltoid muscle is sometimes paralyzed temporarily after a collision. However, similar to our cases, the axillary nerve can be lacerated without fracture or dislocation. It is necessary to watch the course of paralysis carefully and consider nerve reconstruction if it does not recover.

Characterising cellular and molecular features of human peripheral nerve degeneration

Nerve regeneration is a key biological process in those recovering from neural trauma. From animal models it is known that the regenerative capacity of the peripheral nervous system (PNS) relies heavily on the remarkable ability of Schwann cells to undergo a phenotypic shift from a myelinating phenotype to one that is supportive of neural regeneration. In rodents, a great deal is known about the molecules that control this process, such as the transcription factors c-Jun and early growth response protein 2 (EGR2/KROX20), or mark the cells and cellular changes involved, including SOX10 and P75 neurotrophin receptor (p75NTR). However, ethical and practical challenges associated with studying human nerve injury have meant that little is known about human nerve regeneration.The present study addresses this issue, analysing 34 denervated and five healthy nerve samples from 27 patients retrieved during reconstructive nerve procedures. Using immunohistochemistry and Real-Time quantitative Polymerase Chain Reaction (RT-qPCR), the expression of SOX10, c-Jun, p75NTR and EGR2 was assessed in denervated samples and compared to healthy nerve. Nonparametric smoothing linear regression was implemented to better visualise trends in the expression of these markers across denervated samples.It was found, first, that two major genes associated with repair Schwann cells in rodents, c-Jun and p75NTR, are also up-regulated in acutely injured human nerves, while the myelin associated transcription factor EGR2 is down-regulated, observations that encourage the view that rodent models are relevant for learning about human nerve injury. Second, as in rodents, the expression of c-Jun and p75NTR declines during long-term denervation. In rodents, diminishing c-Jun and p75NTR levels mark the general deterioration of repair cells during chronic denervation, a process thought to be a major obstacle to effective nerve repair. The down-regulation of c-Jun and p75NTR reported here provides the first molecular evidence that also in humans, repair cells deteriorate during chronic denervation.

Transfers of the Ipsilateral C7 Plus the Spinal Accessory Nerve Versus Triple Nerve Transfers for Treatment of C5-C6 Avulsion of the Brachial Plexus

PURPOSE

To compare the long-term results of transfers of the ipsilateral C7 (IC7) plus spinal accessory nerve (SAN) with those of triple nerve transfers (TNT) using one fascicle of the ulnar nerve to the biceps motor branch (Oberlin's procedure), SAN transferred to the suprascapular nerve, and transfer of the long head of triceps nerve branch to the anterior branch of axillary nerve to treat C5-C6 avulsion of the brachial plexus.

METHODS

The IC7 group included 9 patients undergoing transfers of IC7 to the upper trunk and SAN to the suprascapular nerve. Median age at surgery was 26 years and interval between injury and surgery was 2.8 months. Patients were observed for a median of 118 months. The TNT group contained 13 patients, median age 33 years; interval between injury and surgery was 3.1 months. Patients were observed for a median of 103 months.

RESULTS

In the IC7 group, median shoulder abduction was 105° and median external rotation of the shoulder was 64°, which was similar to that of the TNT group (89° abduction and 58° external rotation). Eight of nine patients recovered at least M3 (Modified Narakas scale) strength of deltoid in the IC7 group, which was similar to that in the TNT group (11 of 13 patients). Six of nine patients achieved at least Medical Research Council grade 3 (MRC3) strength of biceps in the IC7 group, which was similar to that in the TNT group (11 of 13 patients). Of 4 patients in the IC7 group with a preoperative latissimus dorsi strength of MRC3 or less, 3 gained a deltoid strength of M3 or less, and 3 a biceps strength of MRC2 or less.

CONCLUSIONS

Transfers of IC7 plus SAN provide results comparable to those of TNT for treatment of C5-C6 avulsion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Evaluation of Triple Neurotization Technique as a Single Procedure in Adult Traumatic Brachial Plexus Injury

INTRODUCTION

Brachial plexus injuries are common and result in significant disabilities. This study evaluated the outcome of triple neurotization as a single procedure for upper trunk brachial plexus injury.

PATIENTS AND METHODS

Some 25 adult consecutive patients with injured upper trunk brachial plexus who underwent microscopic reconstructive surgery using triple neurotization technique in the authors' institute were recruited in this study. Data on operative and functional outcomes were captured. Modified Narkas scale was used to evaluate the shoulder function in addition to Waikakul scale which was used to evaluate the elbow function. Data were analyzed with respect to short and long term with a median follow-up duration of two years.

RESULTS

Assessment of the recovered shoulder abduction was excellent in 48% (n=12), good in 24% (n=6), fair in 16% (n=4), and poor in 12% of cases (n=3). Shoulder external rotation recovery was excellent in 48% (n=12), good in 12% (n=3), fair in 12% (n=3), and poor in 28% of cases (n=7). Recovery of elbow flexion was excellent in 60% (n=15), good in 12% (n=3), fair in 12% (n=3), and poor in 16% of cases (n=4). The mean value of recovered shoulder abduction was 111.26 degrees (range: 70-150). The mean value of restored shoulder external rotation was 57.5 degrees (range: 45-70). The mean value of restored elbow flexion was 75 degrees (range: 55-120).

CONCLUSION

Triple neurotization technique can be effective to restore elbow flexion, shoulder abduction, and external rotation in adult patients with upper trunk brachial plexus injury.

Cost-Effectiveness Analysis of Combined Dual Motor Nerve Transfers versus Alternative Surgical and Nonsurgical Management Strategies to Restore Shoulder Function Following Upper Brachial Plexus Injury

BACKGROUND

Restoration of shoulder function is an important treatment goal in upper brachial plexus injury (UBPI). Combined dual motor nerve transfer (CDNT) of spinal accessory to suprascapular and radial to axillary nerves demonstrates good functional recovery with minimal risk of perioperative complications.

OBJECTIVE

To evaluate the cost-effectiveness of CDNT vs alternative operative and nonoperative treatments for UBPI.

METHODS

A decision model was constructed to evaluate costs ($, third-party payer) and effectiveness (quality-adjusted life years [QALYs]) of CDNT compared to glenohumeral arthrodesis (GA), conservative management, and nontreatment strategies. Estimates for branch probabilities, costs, and QALYs were derived from published studies. Incremental cost-effectiveness ratios (ICER, $/QALY) were calculated to compare the competing strategies. One-way, 2-way, and probabilistic sensitivity analyses with 100 000 iterations were performed to account for effects of uncertainty in model inputs.

RESULTS

Base case model demonstrated CDNT effectiveness, yielding an expected 21.04 lifetime QALYs, compared to 20.89 QALYs with GA, 19.68 QALYs with conservative management, and 19.15 QALYs with no treatment. The ICERs for CDNT, GA, and conservative management vs nontreatment were $5776.73/QALY, $10 483.52/QALY, and $882.47/QALY, respectively. Adjusting for potential income associated with increased likelihood of returning to work after clinical recovery demonstrated CDNT as the dominant strategy, with ICER = -$56 459.54/QALY relative to nontreatment. Probabilistic sensitivity analysis showed CDNT cost-effectiveness at a willingness-to-pay threshold of $50 000/QALY in 78.47% and 81.97% of trials with and without income adjustment, respectively. Conservative management dominated in <1% of iterations.

CONCLUSION

CDNT and GA are cost-effective interventions to restore shoulder function in patients with UBPI.

Traumatic Brachial Plexopathy in Athletes: Current Concepts for Diagnosis and Management of Stingers

Traumatic upper trunk brachial plexopathy, also known as a stinger or burner, is the most common upper extremity neurologic injury among athletes and most commonly involves the upper trunk. Recent studies have shown the incidence of both acute and recurrent injuries to be higher in patients with certain anatomic changes in the cervical spine. In addition, despite modern awareness, tackling techniques, and protective equipment, some think the incidence to be slowly on the rise in contact athletes. The severity of neurologic injury varies widely but usually does not result in significant loss of playing time or permanent neurologic deficits if appropriate management is undertaken. Timely diagnosis allows implementation of means to minimize the risk of recurrent injury. It is important for treating physicians to understand the pathogenesis, evaluation, and acute and long-term management of stingers to improve recovery and minimize chronic sequela.

Isolated Axillary Nerve Injury in an Elite High School American Football Player: A Case Report

An elite high school American football athlete sustained a traumatic, isolated, axillary nerve injury. Axillary nerve injuries are uncommon, but serious injuries in American football. With the advent of nerve transfers and grafts, these injuries, if diagnosed in a timely manner, are treatable. This case report discusses the multidisciplinary approach necessary for the diagnosis and treatment of an elite high school American football player who presented with marked deltoid atrophy. The athlete's injury was diagnosed via electrodiagnostic testing and he underwent a medial triceps nerve to axillary nerve transfer. After appropriate postsurgical therapy, the athlete was able to return to American football the subsequent season and continue performing at an elite level. This case report reviews the evaluation and modern treatment for axillary nerve injuries in the athlete, including nerve transfers, nerve grafts, and return to play.

Combined flexor carpi ulnaris and flexor carpi radialis transfer for restoring elbow function after brachial plexus injury

The result of combined agonist and antagonist muscle innervation in traumatic brachial plexus injury through the intraplexal fascicle nerve transfers with the same donor function has not yet been reported. We describe a patient with a C5-C7 traumatic brachial plexus injury who had a combined transfer of the flexor carpi radialis (FCR) fascicle to the musculocutaneous nerve and the flexor carpi ulnaris (FCU) fascicle to the radial nerve of the triceps. The patient returned for his follow-up visit 2 years after his surgery. The muscle strengths of his triceps and biceps were Medical Research Council grade 2 and 0, respectively. Compared with his uninjured side, his grip strength was 9.8%, and his pinch strength was 14.2%. Our case report provides insights on result of combined agonist and antagonist muscle innervation through combining the motor fascicle of the FCR and FCU to restore the elbow flexor and extensor. The result may not be promising.

Development of a core outcome set for traumatic brachial plexus injuries (COMBINE): study protocol

INTRODUCTION

Traumatic brachial plexus injury (TBPI) involves major trauma to the large nerves of the arm which control the movement and sensation. Fifty per cent of injuries result in complete paralysis of the arm with many other individuals having little movement, sensation loss and unremitting pain. The injury often causes severe and permanent disability affecting work and social life, with an estimated cost to the National Health Service and the economy of £35 million per annum. Advances in microsurgery have resulted in an increase in interventions aimed at reconstructing these injuries. However, data to guide evidence-based decisions is lacking. Different outcomes are used across studies to assess the effectiveness of treatments. This has impeded our ability to synthesise results to determine which treatments work best. Studies frequently report short-term clinical outcomes but rarely report longer term outcomes and those focused on quality of life. This project aims to produce a core outcome set (COS) for surgical and conservative management of TBPI. The TBPI COS will contain a minimum set of outcomes to be reported and measured in effectiveness studies and collected through routine clinical care.

METHODS AND ANALYSIS

This mixed-methods project will be conducted in two phases. In phase 1 a long list of patient-reported and clinical outcomes will be identified through a systematic review. Interviews will then explore outcomes important to patients. In phase 2, the outcomes identified across the systematic review, and the interviews will be included in a three-round online Delphi exercise aiming to reach consensus on the COS. The Delphi process will include patient and healthcare participants. A consensus meeting will be held to achieve the final COS.

ETHICS AND DISSEMINATION

The use of a COS in TBPI will increase the relevance of research and clinical care to all stakeholders, facilitate evidence synthesis and evidence-based decision making. The study has ethical approval.

TRIAL REGISTRATION NUMBERS

CRD42018109843.

Combined Radial to Axillary and Spinal Accessory Nerve (SAN) to Suprascapular Nerve (SSN) Transfers May Confer Superior Shoulder Abduction Compared with Single SA to SSN Transfer

BACKGROUND

The restoration of shoulder function after brachial plexus injury is a high priority. Shoulder abduction and stabilization can be achieved by nerve transfer procedures including spinal accessory nerve (SAN) to suprascapular nerve (SSN) and radial to axillary nerve transfer. The objective of this study is to compare functional outcomes after SAN to SSN transfer versus the combined radial to axillary and SA to SSN transfer.

METHODS

This retrospective chart review included 14 consecutive patients with brachial plexus injury who underwent SAN to SSN transfer, 4 of whom had both SA to SSN and radial to axillary nerve transfer.

RESULTS

SAN to SSN transfer achieved successful shoulder abduction (≥M3) in 64.3% of this cohort (9/14). During the long-term follow-up, patients achieved an average increase of 67.5° in shoulder abduction. There was no association between motor recovery and time from injury to surgery, age, body mass index (BMI), sex, or smoking status. The 4 patients who had SAN to SSN combined with radial to axillary nerve transfer demonstrated a statistically significant increase in the range of abduction (median, 90° vs. 42.5°, respectively; P = 0.022) compared with those who had SAN to SSN transfer alone; however, the difference in Medical Research Council (MRC) grades (MRC > M3) did not reach statistical significance (P = 0.07).

CONCLUSIONS

Patients with brachial plexus injury and an intact C7 root could benefit from radial to axillary transfer in addition to SAN to SSN transfer. There was no association between recovery of shoulder abduction and time interval from injury to surgery, age, sex, smoking, and BMI.