Transference of thoracodorsal nerve to musculocutaneous or axillary nerve in old traumatic injury

Elbow flexion reconstruction with nerve transfer or grafting in patients with brachial plexus injuries: A systematic review and comparison study

INTRODUCTION

Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury.

METHODS

PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed.

RESULTS

In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5-C6 injuries and total BP injuries, p = 0.018 for C5-C6-C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022).

CONCLUSIONS

Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5-C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery.

LEVEL OF EVIDENCE

Level II.

Multiple nerve transfers for the reanimation of shoulder and elbow functions in irreparable C5, C6 and upper truncal lesions of the brachial plexus

In irreparable C5, C6 spinal nerve and upper truncal injuries the proximal root stumps are not available for grafting, hence repair is based on nerve transfer or neurotization. Between Feb 2004 and May 2006, 23 patients with irreparable C5, C6 or upper truncal injuries of the Brachial Plexus underwent multiple nerve transfers to restore the shoulder and elbow functions. Most of them (16 patients) sustained injury following motor cycle accidents. The average denervation period was 5.3 months. Shoulder function was restored by transfer of distal part of spinal accessory nerve to suprascapular nerve, and transfer of radial nerve branch to long head of triceps to the anterior branch of axillary nerve. Elbow function was restored by transfers of ulnar and median nerve fascicles to the biceps and brachialis motor branches of musculocutaneous nerve. All patients recovered shoulder abduction and external rotation; 7 scored M4 and 16 scored M3. Range of abduction averaged 1230(range, 800-1700). Full elbow flexion was restored in all 23 patients; 15 scored M4 and 8 scored M3. Patients with excellent results could lift 5 kgs of weight. Selective nerve transfers close to the target muscle provide an early and good return of functions. There is negligible morbidity in donor nerves. These intraplexal transfers are suitable in all cases of upper brachial plexus injuries.

Thoracodorsal nerve transfer for elbow flexion reconstruction in infraclavicular brachial plexus injuries

PURPOSE

To report the clinical results of thoracodorsal nerve (TDN) transfer to the biceps nerve for elbow flexion restoration in infraclavicular brachial plexus injuries.

METHODS

Five male patients, mean age 33 years and affected with infraclavicular brachial plexus injuries, underwent a direct coaptation of the TDN to the nerve to the biceps an average of 8 months after injury. The procedure included the transfer of a branch of the TDN to the musculocutaneous nerve in 2 patients.

RESULTS

All patients achieved M4 elbow flexion strength according to the British Medical Research Council scale at a mean follow-up of 22 months.

CONCLUSIONS

Direct TDN transfer seems to be a useful surgical procedure for restoring elbow flexion in patients with infraclavicular brachial plexus injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

Nerve transfers in cases of directly irreparable or high-level extensive brachial plexus traction injuries have been done using a variety of donor nerves with various success, but an ideal method has not been established. The purpose of this study is to analyze the results of nerve transfers using the thoracodorsal and medial pectoral nerves as donors in patients with upper palsy.

METHODS

This retrospective study included 40 patients with 29 procedures using the thoracodorsal nerve and 33 procedures using the medial pectoral nerve as donors for reinnervation of the musculocutaneous or axillary nerve. Both nerves were used simultaneously in 22 of these patients. The thoracodorsal nerve was transferred in 13 patients to the musculocutaneous nerve and in nine patients to the axillary nerve. The medial pectoral nerve was transferred in nine patients to the musculocutaneous nerve and in 13 patients to the axillary nerve. The results were analyzed according to the donor nerve, the age of the patient, and the timing of surgery.

RESULTS

The total rate of recovery for elbow flexion was 94.1%, for shoulder abduction 89.3%, and for shoulder external rotation 64.3%. The corresponding rates of recovery using the thoracodorsal nerve were 100, 93.7, and 68.7%, respectively. The rates of recovery with medial pectoral nerve transfers were 90.5, 83.3, and 58.3%, respectively. Despite the obvious differences in the rates of recovery, statistical significance was found only between the rates and quality of recovery for the musculocutaneous and axillary nerve using the thoracodorsal nerve as donor.

CONCLUSIONS

According to our findings, nerve transfers using collateral branches of the brachial plexus in cases with upper palsy offer several advantages and yield high rate and good quality of recovery.

Shoulder reanimation in posttraumatic brachial plexus paralysis

INTRODUCTION

Posttraumatic brachial plexus paralysis invariably involves the upper roots leading to paralysis of the shoulder region musculature. Early neurotisation of the suprascapular and the axillary nerve should be one of the priorities in plexus reconstruction in order to reanimate the shoulder.

PATIENTS AND METHODS

From 1998 to 2007, 78 patients with posttraumatic brachial plexus palsy were operated in our department. Forty-three patients presented with supraclavicular lesions with involvement of C5 and C6 roots in all cases. Reconstruction of the shoulder function was achieved with neurotisation of the suprascapular nerve in 41 patients. Extraplexus donors were utilised in 34 patients, while intraplexus donors via nerve grafts in 7 patients. Neurotisation of the axillary nerve was performed in 25 patients, utilising intraplexus donors in 16 patients, extraplexus donors in 4, and combination of intraplexus and extraplexus donors in 5 patients.

RESULTS

Suprascapular nerve neurotisation gave good or excellent results (supraspinatus>M3+ or shoulder abduction>40 degrees) in 35 patients. Intraplexus donors regained good or excellent function in 5 out of 6 patients (83%), while extraplexus neurotisations achieved good or excellent function of the supraspinatus in 30 out of 34 patients (88%). Axillary nerve neurotisation offered good or excellent results (deltoid>M3+ or shoulder abduction>60 degrees) in 14 patients (58%). Direct neurotisation of the axillary nerve via the motor branch for the long head of the triceps gave shoulder abduction of >110 degrees, as well as external rotation of >30 degrees in 3 out of 5 patients. Combined neurotisation of suprascapular and axillary nerves gave the best outcome achieving shoulder abduction of >60 degrees as well as external rotation of >30 degrees.

CONCLUSIONS

Shoulder reanimation should be one of the first priorities in brachial plexus reconstruction. Early neurotisation of the suprascapular, and if possible the axillary nerve offers the best outcome.

TRANSFER OF A FASCICLE FROM THE POSTERIOR CORD TO THE SUPRASCAPULAR NERVE AFTER INJURY OF THE UPPER ROOTS OF THE BRACHIAL PLEXUS

OBJECTIVE

A new nerve transfer technique using a healthy fascicle of the posterior cord for suprascapular nerve reconstruction is presented. This technique was used in a patient with posttraumatic brachial plexopathy resulting in upper trunk injury with proximal root stumps that were unavailable for grafting associated with multiple nerve dysfunction.

CLINICAL PRESENTATION

A 45-year-old man sustained a right brachial plexus injury after a bicycle accident. Clinical evaluation and electromyography indicated upper trunk involvement. Trapezius muscle function and triceps strength were normal on physical examination.

INTERVENTION

The patient underwent a combined supra- and infraclavicular approach to the brachial plexus. A neuroma-in-continuity of the upper trunk and fibrotic C5 and C6 roots were identified. Electrical stimulation of the phrenic and spinal accessory nerves produced no response. The suprascapular nerve was dissected from the upper trunk, transected, and rerouted to the infraclavicular fossa. A healthy fascicle of the posterior cord to the triceps muscle was transferred to the suprascapular nerve. At the time of the 1-year follow-up evaluation, arm abduction against gravity and external rotation reached 40 and 34 degrees, respectively.

CONCLUSION

The posterior cord can be used as a source of donor fascicle to the suprascapular nerve after its infraclavicular relocation. This new intraplexal nerve transfer could be applied in patients with isolated injury of the upper trunk and concomitant lesion of the extraplexal nerve donors usually used for reinnervation of the suprascapular nerve.

Surgical outcomes following nerve transfers in upper brachial plexus injuries

BACKGROUND

Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury.

MATERIALS AND METHODS

We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient).

RESULTS

Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).

Measuring outcomes in adult brachial plexus reconstruction

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

Electromyographic comparison of various exercises to improve elbow flexion following intercostal nerve transfer

We compared the quantitative electromyographic activity of the elbow flexors during four exercises (forced inspiration, forced expiration, trunk flexion and attempted elbow flexion), following intercostal nerve transfer to the musculocutaneous nerve in 32 patients who had sustained root avulsion brachial plexus injuries. Quantitative electromyographic evaluation of the mean and maximum amplitude was repeated three times for each exercise. We found that mean and maximum elbow flexor activity was highest during trunk flexion, followed by attempted elbow flexion, forced inspiration and finally forced expiration. The difference between each group was significant (p < 0.001), with the exception of the difference between trunk flexion and attempted elbow flexion. Consequently, we recommend trunk flexion exercises to aid rehabilitation following intercostal nerve transfer.

The use of thoracodorsal nerve transfer in restoration of irreparable C5 and C6 spinal nerve lesions

There are only a few reports on the use of thoracodorsal nerve (TDN) transfer to the musculocutaneous or axillary nerves in cases of directly irreparable brachial plexus injuries. In this study, we analysed outcome and time-course of recovery in correlation with recipient nerves and type of nerve transfer (isolated or in combination with other collateral branches) for 27 patients with transfer to the musculocutaneous or axillary nerves. Using this nerve as donor, we obtained useful functional recovery in all 12 cases for the musculocutaneous nerve, and in 14 (93.3%) of 15 nerve transfers for the axillary nerve. Although, we found no significant statistical difference between analysed patients according to the percentage of recoveries and mean values, we established a better quality and shorter time of recovery for the musculocutaneous nerve. According to obtained results, we consider that transfer may be a valuable method in reconstruction after directly irreparable C5 and C6 spinal nerve lesions.

Direct plexus repair by grafts supplemented by nerve transfers

This article reviews the Louisiana State University Health Sciences Center experience with direct repair of brachial plexus lacerations, gunshot wounds, and stretch/contusive/avulsive injuries. In the stretch category, limited outcomes with direct repair have led to addition of nerve transfers rather than their exclusive use. It is important to per-form direct plexus repair in conjunction with nerve transfers in the same patient when-ever possible. The intent of such a "pants-over-vest" approach is to maximize axonal input to denervated structures.

Axillary nerve injury: diagnosis and treatment

Axillary nerve injury is infrequently diagnosed but is not a rare occurrence. Injury to the nerve may result from a traction force or blunt trauma applied to the shoulder. The most common zone of injury is just proximal to the quadrilateral space. Atraumatic causes of neuropathy include brachial neuritis and quadrilateral space syndrome. The vast majority of patients recover with non-operative treatment. Baseline electromyographic and nerve conduction studies should be obtained within 4 weeks after injury, with a follow-up evaluation at 12 weeks. If no clinical or electromyographic improvement is noted, surgery may be appropriate. The results of operative repair are best if surgery is performed within 3 to 6 months from the injury. Surgical options include neurolysis, nerve grafting, and neurotization. The results of repair of axillary nerve injuries have been good compared with treatment of other peripheral nerve lesions, due to the monofascicular composition of the nerve and the relatively short distance between the zone of injury and the motor end-plate.

Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature

We report the results of 15 patients who underwent nerve transfer for restoration of shoulder and elbow function at our institution for traumatic brachial plexus palsy. We present these results in the context of a meta-analysis of the English literature, designed to quantitatively assess the efficacy of individual nerve transfers for restoration of elbow and shoulder function in a large number of patients. One thousand eighty-eight nerve transfers from 27 studies met the inclusion criteria of the analysis. Seventy-two percent of direct intercostal to musculocutaneous transfers (without interposition nerve grafts) achieved biceps strength > or =M3 versus 47% using interposition grafts. Direct intercostal transfers to the musculocutaneous nerve had a better ability to achieve > or =M4 elbow strength than transfers from the spinal accessory nerve (41% vs 29%). The suprascapular nerve fared significantly better than the axillary nerve in obtaining > or =M3 shoulder abduction (92% vs 69%). At our institution 90% of intercostal to musculocutaneous transfers (n = 10) achieved > or =M3 bicep strength and 70% achieved > or =M4 strength. Four of seven patients achieved > or =M3 shoulder abduction with a single nerve transfer and 6 of 7 regained > or =M3 strength with a dual nerve transfer. This study suggests that interposition nerve grafts should be avoided when possible when performing nerve transfers. Better results for restoration of elbow flexion have been attained with intercostal to musculocutaneous transfers than with spinal accessory nerve transfers and spinal accessory to suprascapular transfers appear to have the best outcomes for return of shoulder abduction. We conclude that nerve transfer is an effective means to restore elbow and shoulder function in brachial plexus paralysis.

Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery

OBJECT

Direct coaptation of intercostal nerves (ICNs) to the musculocutaneous (MC) nerve was performed to restore elbow flexion in 25 patients with brachial plexus root avulsions.

METHODS

Seventy-five ICNs were transected as close as possible to the sternum to obtain sufficient length and then tunneled to the axilla and coapted to the MC nerve. Direct coaptation was achieved in 95% of ICNs, and functional elbow flexion was regained in 64% of the patients. The results were compared with several reported transfer techniques in which either an ICN or other donor nerves were used.

CONCLUSIONS

Direct coaptation was equally effective and more straightforward than transfers involving interposition of grafts. The use of alternative donors such as the accessory nerve carries inherent disadvantages compared with the use of ICNs, and the results are not substantially better. Direct ICN-MC nerve transfer is a valuable reconstructive procedure.