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Vyas AK, Gupta A, Dhanjani B, Batajoo S, Misra S. Functional Outcome following Phrenic Nerve Transfer in Brachial Plexus Injury. J Hand Microsurg 2024; 16:100029. [PMID: 38855508 PMCID: PMC11144632 DOI: 10.1055/s-0043-1764162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Background Brachial plexus injuries are debilitating injuries resulting in paralyzed shoulder to global paralysis of the upper extremity. Treatment strategies have evolved over the years with nerve transfer forming the mainstay of surgical management. Phrenic nerve provides certain advantages as donor over other options but has been less preferred due to fear of pulmonary complications. In this study, we assess the functional outcomes of phrenic nerve transfer in brachial plexus injuries. Materials and Methods A retrospective study was performed on 18 patients operated between 2012 and 2017. The mean duration of injury to surgery was 4.56 months and mean follow-up was for 3.66 years. Phrenic nerve was used as donor to neurotize either biceps and brachialis branch of musculocutaneous nerve or suprascapular nerve. Assessment was done through Waikakul score for elbow flexion and Medical Research Council grading for shoulder abduction. Respiratory function assessment was done through questionnaire. Results Twelve (80%) patients recovered grade 3 and above elbow flexion with 6 patients having a positive endurance test according to Waikakul and a "very good" result. In phrenic to suprascapular transfer group (3 patients), all patients had more than grade 3 recovery of shoulder abduction. No patient complained of respiratory problems. Conclusion Phrenic nerve can be used as a reliable donor with suitable patient selection with good results in regaining muscle power without any anticipated effects on respiratory function.
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Affiliation(s)
- Amit Kumar Vyas
- Hand and Microsurgery Orthopedic Specialty Services, Durgapura, Fortis Escorts Hospital, Jaipur, Rajasthan, India
| | - Aviral Gupta
- Department of Hand and Microsurgery, Rukhmani Birla Hospital, Jaipur, Rajasthan, India
| | - Bharat Dhanjani
- Department of Orthopedic Surgery, Rungta Hospital, Jaipur, Rajasthan, India
| | - Santosh Batajoo
- Department of Orthopedic Surgery, Hand and Microsurgery Specialty Services, Jaipur, Rajasthan
| | - Sayantani Misra
- Department of Pediatric Orthopedic Surgery, National Centre for Child Health and Development (NCCHD), Tokyo, Japan
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Li YW, Hsueh YH, Tu YY, Tu YK. Surgical reconstructions for adult brachial plexus injuries. Part II: Treatments for total arm type. Injury 2024; 55:111012. [PMID: 38041925 DOI: 10.1016/j.injury.2023.111012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
Brachial plexus injuries (BPI) contribute not only to physical dysfunction but also to socioeconomic aspects and psychological disability. Patients with total arm-type BPI will lose not only the shoulder and elbow function but also the hand function, making reconstruction particularly challenging. Reconstructive procedures commonly include nerve repair, grafting, neurotization (nerve transfer), tendon transfer and free functional muscle transfer (FFMT). Although it is difficult to achieve prehensile hand function, most of patients with total arm-type BPI can be treated with satisfied outcomes. In addition to surgical techniques, comprehensive rehabilitation is another important factor for successful outcomes, and efficient communication can help to boost patient morale and eliminate uncertainty.
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Affiliation(s)
- Yen-Wei Li
- Department of Orthopedics, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Huan Hsueh
- Department of Orthopedics, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yung-Yi Tu
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
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Abdelmalek G, Mina GE, Pant K, Zheng Z, Mahajan J, Srinivasan N, Gupta S, Shafei J, Levidy MF, McGrath A, Chu A. Intercostal Nerve Transfer for Biceps Reinnervation in Obstetrical Brachial Plexus Palsy: A Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Individual Patient Data Systematic Review using Individualized Fusion and Comparison to Supraclavicular Exploration and Nerve Grafting. J Child Orthop 2024; 18:54-63. [PMID: 38348437 PMCID: PMC10859120 DOI: 10.1177/18632521231211644] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Introduction The objective of this study was to search existing literature on nerve reconstruction surgery in patients with obstetric brachial plexus palsy to determine whether treatment with supraclavicular exploration and nerve grafting produced better elbow flexion outcomes compared to intercostal nerve transfer. Methods This study was a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Individual Patient Data guidelines. A systematic search was conducted using multiple databases. An ordinal regression model was used to analyze the effect of using supraclavicular exploration and nerve grafting or intercostal nerve on elbow flexion with the two scores measured: elbow flexion Medical Research Council scores and Toronto active movements scale scores for elbow flexion. Results A final patient database from 6 published articles consisted of 83 supraclavicular exploration and nerve grafting patients (73 patients with Medical Research Council and 10 patients with Toronto score) and 7 published articles which consisted of 131 intercostal nerve patients (84 patients with Medical Research Council and 47 patients with Toronto scores). Patients who underwent supraclavicular exploration and nerve grafting presented with an average Medical Research Council score of 3.9 ± 0.72 and an average Toronto score of 6.2 ± 2.2. Patients who underwent intercostal nerve transfer presented with an average Medical Research Council score of 3.9 ± 0.71 and an average Toronto score of 6.4 ± 1.2. There was no statistical difference between supraclavicular exploration and nerve grafting and intercostal nerve transfer when utilizing Medical Research Council elbow flexion scores (ordinal regression: 0.3821, standard error: 0.4590, p = 0.2551) or Toronto Active Movement Scale score for elbow flexion (ordinal regression: 0.7154, standard error: 0.8487, p = 0.2188). Conclusion Regardless of surgical intervention utilized (supraclavicular exploration and nerve grafting or intercostal nerve transfers), patients had excellent outcomes for elbow flexion following obstetric brachial plexus palsy when utilizing Medical Research Council or Toronto scores for elbow flexion. The difference between these scores was not statistically significant. Type of study/Level of evidence Therapeutic Study: Investigating the Result of Treatment/level III.
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Affiliation(s)
| | | | | | - Zheshi Zheng
- Department of Statistics, Rutgers University, Piscataway, NJ, USA
| | | | | | | | | | | | - Aleksandra McGrath
- Department of Hand Surgery, Norrland’s University Hospital, Umea, Sweden
- Department of Anatomy, Umea University, Umea, Sweden
| | - Alice Chu
- Division of Pediatric Orthopedics, Department of Orthopedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
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Vernon Lee CY, Cochrane E, Chew M, Bains RD, Bourke G, Wade RG. The Effectiveness of Different Nerve Transfers in the Restoration of Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis. J Hand Surg Am 2023; 48:236-244. [PMID: 36623945 DOI: 10.1016/j.jhsa.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Chung Yan Vernon Lee
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Elliott Cochrane
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Misha Chew
- James Cook University Hospital, South Tees Hospitals NHS Trust, Middlesbrough, United Kingdom
| | - Robert D Bains
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Gráinne Bourke
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
| | - Ryckie G Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom.
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Kim RB, Bounajem M, Hamrick F, Mahan MA. Optimal Donor Nerve to Restore Elbow Flexion After Traumatic Brachial Plexus Injury: A Systematic Review and Meta-Analysis. Neurosurgery 2022; 90:39-50. [PMID: 34982869 DOI: 10.1227/neu.0000000000001737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/18/2021] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Robert B Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Forrest Hamrick
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Mark A Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Emamhadi M, Behzadnia H, Golsefid HN, Emamhadi A, Andalib S. Reanimation of triceps muscle using ulnar nerve fascicle transfer to the nerve to long head of the triceps muscle. Acta Neurochir (Wien) 2020; 162:1899-1905. [PMID: 32318932 DOI: 10.1007/s00701-020-04346-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/09/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Triceps muscle serves an important role in extension of the elbow. Its action is required for reaching out objects without using the trunk. Elbow extension is an important function for natural stabilization of the elbow. The aim of this study was to evaluate restoration of elbow extension in adults suffering triceps muscle palsy with various causes, by using transfer of a fascicle of ulnar nerve to the long head of triceps branch of the radial nerve. MATERIALS AND METHODS In the present case series, 7 patients with partial brachial plexus injury or posterior cord injury, where triceps muscle was involved, were subjected to motor fascicle of ulnar nerve transfer to the nerve to long head of triceps for restoration of elbow extension. Follow-ups, including EMG-NCV (electromyography-nerve conduction velocity) 6 and 12 months after surgery and elbow extension muscle strength using MRC grading, were carried out. RESULTS Six patients (85.71%) achieved a functional muscle strength of M4 for their elbow extension. In all of the patients, re-innervation was discovered using EMG-NCV. CONCLUSION This surgical technique (ulnar nerve fascicle transfer to long head of the triceps) for improving elbow extension is promising in patients with brachial plexus injury.
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Affiliation(s)
- Mohammadreza Emamhadi
- Brachial Plexus and Peripheral Nerve Injury Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Hamid Behzadnia
- Department of Neurosurgery, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Hadi Nozari Golsefid
- Department of Neurosurgery, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Amirreza Emamhadi
- School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Sasan Andalib
- Neuroscience Research Center, Department of Neurosurgery, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran.
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark.
- Research Unit of Clinical Physiology and Nuclear Medicine, Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
- BRIDGE-Brain Research-Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Research Unit of Psychiatry, Department of Psychiatry, Psychiatry in the Region of Southern Denmark, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
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Surgical reconstructions for adult brachial plexus injuries. Part I: Treatments for combined C5 and C6 injuries, with or without C7 injuries. Injury 2020; 51:787-803. [PMID: 32156416 DOI: 10.1016/j.injury.2020.02.076] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 02/15/2020] [Indexed: 02/02/2023]
Abstract
Brachial plexus injuries will cause a significantly decreased quality of life. Patients with upper arm type brachial plexus injuries, which means C5 and C6 roots injury, will lose their shoulder elevation/abduction/external rotation, and elbow flexion function. Additional elbow, wrist, and hand extension function deficit will occur in patients with C7 root injury. With the advances of reconstructive procedures, the upper arm brachial plexus injuries can be successfully restored through nerve repair, nerve grafting, nerve transfer, muscle / tendon transfer and free functioning muscle transfer. In this review article, we summarized the various reconstructive procedures to restore the function of shoulder and elbow. Nowadays, the upper arm type BPI can be treat with satisfied outcomes (80-90% successful rate).
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