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Kim SJ, Bang JH, Yang HJ, Moon SH, Choi YR, Lee HY. Anatomical considerations for nerve transfer in axillary nerve injury. Sci Rep 2024; 14:1262. [PMID: 38218996 PMCID: PMC10787799 DOI: 10.1038/s41598-024-51923-w] [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: 08/04/2023] [Accepted: 01/11/2024] [Indexed: 01/15/2024] Open
Abstract
This study investigated the anatomical details of the axillary and radial nerves in 50 upper limbs from 29 adult formalin-embalmed cadavers, and ten fresh upper limbs. The focus was on understanding the course, division, and ramifications of these nerves to improve treatment of shoulder dysfunction caused by axillary nerve damage. The axillary nerve divided anteriorly and posteriorly before passing the quadrangular space in all specimens, with specific distances to the first ramifications. It was found that the deltoid muscle's clavicular and acromial parts were always innervated by the anterior division of the axillary nerve, whereas the spinous part was variably innervated. The longest and thickest branches of the radial nerve to the triceps muscles were identified, with no statistically significant differences in fiber numbers among triceps branches. The study concludes that nerve transfer to the anterior division of the axillary nerve can restore the deltoid muscle in about 86% of shoulders, and the teres minor muscle can be restored by nerve transfer to the posterior division. The medial head branch and long head branch of radial nerve were identified as the best donor options.
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Affiliation(s)
- Soo-Jung Kim
- Department of Anatomy, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Department of Medicine, The Graduate School Yonsei University, Seoul, Republic of Korea
| | - Jong-Ho Bang
- Surgical Anatomy Education Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee-Jun Yang
- Department of Anatomy, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- The Youth Clinic, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Seong-Hwan Moon
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun-Rak Choi
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye-Yeon Lee
- Department of Anatomy, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Jerome JTJ. Deltopectoral Approach Overcomes All Blind Spots for Axillary Nerve Transfers in Brachial Plexus Injuries and Isolated Axillary Nerve Injuries. J Hand Microsurg 2021; 13:121-122. [PMID: 34456529 DOI: 10.1055/s-0041-1732769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- J Terrence Jose Jerome
- Department of Orthopedics, Hand, and Reconstructive Microsurgery, Olympia Hospital and Research Centre, Trichy, Tamil Nadu, India
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Segal D, Cornwall R, Little KJ. Outcomes of Spinal Accessory-to-Suprascapular Nerve Transfers for Brachial Plexus Birth Injury. J Hand Surg Am 2019; 44:578-587. [PMID: 30898464 DOI: 10.1016/j.jhsa.2019.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 12/29/2018] [Accepted: 02/06/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The results of a spinal accessory nerve-to-suprascapular (SAN-SSN) nerve transfer for brachial plexus birth injuries (BPBIs) have thus far been presented only in limited case series. Our study evaluates the recovery of shoulder function of patients who underwent an SAN-SSN for BPBI as an isolated procedure or as part of a multinerve reconstruction (MNR) surgery. METHODS We retrospectively reviewed the medical records of patients at a single institution who underwent an SAN-SSN after BPBI. Inclusion criteria were patients with both preoperative and a minimum 12-months postoperative active movement scale (AMS) scores. Patients for whom the primary surgery involved tendon transfers were excluded. The primary outcome measures were AMS scores for shoulder abduction, forward flexion, and external rotation and secondary outcomes included the need for further shoulder surgery to improve function. RESULTS Seventy-three patients met the inclusion criteria. Forty-three patients (58.9%) obtained functional shoulder motion (AMS ≥ 6) of at least 1 of 3 planes (abduction/flexion/external rotation) following surgery, with 13 patients (17.8%) achieving full recovery of 1 of these shoulder motions against gravity (AMS = 7). Fifty-six patients (76.7%) did not undergo subsequent tendon transfers or corrective osteotomies to augment shoulder function. The MNR procedures were performed in 46 patients (63%), of whom 45.7% gained a functional recovery. In 27 patients for whom SAN-SSN nerve transfer was conducted in isolation, 81.5% gained functional shoulder motion. However, isolated SAN-SSNs were conducted at a later age than MNR procedures (13.2 vs 4.8 months) and had higher preoperative AMS scores. The anterior and posterior approaches for SAN-SSN were both found to be effective when used for SAN-SSN in BPBI. When the follow-up duration cutoff was set to 3 years, the outcomes were found to be superior. CONCLUSIONS In 76.7% of the patients, SAN-SSN was able to recover function that was sufficient to prevent tendon transfers and corrective osteotomies. A cutoff of 3 postoperative years should be used as a benchmark for analyzing the results of this procedure. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- David Segal
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, affiliated with Cincinnati University, Cincinnati, OH; Department of Orthopaedic Surgery, Meir Medical Center, Kfar Saba, affiliated with Tel Aviv University, Tel Aviv, Israel.
| | - Roger Cornwall
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, affiliated with Cincinnati University, Cincinnati, OH
| | - Kevin J Little
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, affiliated with Cincinnati University, Cincinnati, OH
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Prasad GL. An All-Anterior Approach for Quadruple Nerve Transfer for Upper Trunk Brachial Plexus Injuries. World Neurosurg 2018; 120:e651-e659. [PMID: 30165220 DOI: 10.1016/j.wneu.2018.08.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The most commonly performed nerve transfers in upper trunk (UT) or partial brachial plexus injuries (BPIs) include the spinal accessory nerve to suprascapular nerve, Oberlin, and, lately, radial nerve (RN) (branch to triceps) to axillary nerve (AN) transfers. Routinely, the former 3 procedures are performed through an anterior approach (supraclavicular plus infraclavicular), while the triceps branch of the RN-AN transfer has been performed through a posterior approach with the patient in either the prone or semilateral position, which requires a separate incision in the posterior arm. The aim of the present study was to report the outcomes for 4 cases of quadruple nerve transfers performed for UT BPI using an all-anterior approach. METHODS The functional outcomes of 4 consecutive cases of UT BPI treated using an all-anterior approach were analyzed in terms of improvement in motor power and range of motion at the shoulder and elbow joints. RESULTS The mean age was 27.5 years (range, 16-40). All had sustained injuries from road traffic accidents. The mean injury to surgery interval was 4.5 months (range, 3-6). Of the 4 patients, 2 each had pre- and postganglionic injuries. All 4 patients had 0 of M0 power in shoulder abduction and external rotation, and elbow flexion. At a mean follow-up of 28.6 months, the average shoulder abduction was 157°, with an average of 82° of external rotation. The mean elbow flexion was 104°. CONCLUSIONS This technique appears to be feasible, with good-to-excellent outcomes achieved without requiring a separate posterior arm incision for the RN-AN transfer.
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Affiliation(s)
- G Lakshmi Prasad
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India.
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Manouvakhova OV, Macchi V, Fries FN, Loukas M, De Caro R, Oskouian RJ, Spinner RJ, Tubbs RS. Landmarks for Identifying the Suprascapular Foramen Anteriorly: Application to Anterior Neurotization and Decompressive Procedures. Oper Neurosurg (Hagerstown) 2018; 14:166-170. [PMID: 29351679 DOI: 10.1093/ons/opx096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/27/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Additional landmarks for identifying the suprascapular nerve at its entrance into the suprascapular foramen from an anterior approach would be useful to the surgeon. OBJECTIVE To identify landmarks for the identification of this hidden site within an anterior approach. METHODS In 8 adult cadavers (16 sides), lines were used to connect the superior angle of the scapula, the acromion, and the coracoid process tip thus creating an anatomic triangle. The suprascapular nerve's entrance into the suprascapular foramen was documented regarding its position within this anatomical triangle. Depths from the skin surface and specifically from the medial-most point of the clavicular attachment of the trapezius to the suprascapular nerve's entrance into the suprascapular foramen were measured using calipers and a ruler. The clavicle was then fractured and retracted superiorly to verify the position of the nerve's entrance into the suprascapular foramen. RESULTS From the trapezius, the nerve's entrance into the foramen was 3 to 4.2 cm deep (mean, 3.5 cm). The mean distance from the tip of the corocoid process to the suprascapular foramen was 3.8 cm. The angle best used to approach the suprascapular foramen from the surface was 15° to 20°. CONCLUSION Based on our study, an anterior suprascapular approach to the suprascapular nerve as it enters the suprascapular foramen can identify the most medial fibers of the trapezius attachment onto the clavicle and insert a finger at an angle of 15° to 20° laterally and advanced to an average depth of 3.5 cm.
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Affiliation(s)
| | - Veronica Macchi
- Institute of Human Anatomy, Department of Molecular Medicine, University of Padova, Padua, Italy
| | - Fabian N Fries
- Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, Grenada
| | - Raffaele De Caro
- Institute of Human Anatomy, Department of Molecular Medicine, University of Padova, Padua, Italy
| | | | | | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, Grenada.,Seattle Science Foundation, Seattle, Washington
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Abstract
The restoration of shoulder function after brachial plexus injury represents a significant challenge facing the peripheral nerve surgeons. This is owing to a combination of the complex biomechanics of the shoulder girdle, the multitude of muscles and nerves that could be potentially injured, and a limited number of donor options. In general, nerve transfer is favored over tendon transfer, because the biomechanics of the musculotendinous units are not altered. This article summarizes the surgical techniques and clinical results of nerve transfers for restoration of shoulder function.
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Zuckerman SL, Allen LA, Broome C, Bradley N, Law C, Shannon C, Wellons JC. Functional outcomes of infants with Narakas grade 1 birth-related brachial plexus palsy undergoing neurotization compared with infants who did not require surgery. Childs Nerv Syst 2016; 32:791-800. [PMID: 26906477 DOI: 10.1007/s00381-016-3039-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 02/08/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aimed to investigate the functional outcomes of infants who underwent neurotization for shoulder abduction and elbow flexion in Narakas grade 1 birth-related brachial plexus palsy (BRBPP) and compare this cohort to children who progressed past the point of needing intervention. METHODS A cohort study was conducted at a single center between 1999 and 2010. Two-hundred and eight infants were identified with BRBPP that presented for neurosurgical care as infants. Of those, 38 (18 %) received neurosurgical intervention with approximate 2-year follow-up. Only infants undergoing cranial nerve XI to suprascapular nerve neurotization for shoulder abduction (SA) weakness and medial pectoral nerve to musculocutaneous nerve neurotization for elbow flexion (EF) weakness were included. In addition, 30 infants who improved past the need for surgical intervention and had been followed for close to 24 months were identified for comparison. Descriptive statistics and exploratory analysis were performed using SAS 9.2 and JMP 9.0.2. RESULTS Shoulder abduction For SA, there were no differences in age at presentation between the operative (6-9 months) and non-operative (5-9 months) groups (p = 0.99). Infants in the operative cohort had significantly worse initial function (p = 0.008). At 2-year follow-up, the two groups had become similar (p = 1.0). Elbow flexion For EF, there were no differences in age at presentation between the operative (6-8 months) and non-operative (5-8.5 months) groups (p = 0.98). Infants in the operative cohort had significantly worse initial function (p = 0.002). At 2-year follow-up, those two groups had become similar (p = 0.26). CONCLUSIONS Infants undergoing neurotization for Narakas grade 1 brachial plexus injury had similar long-term function to those who had improved and never required surgery. The preoperative exam findings were significantly different between the intervened and non-intervened groups, while the postoperative exam findings were not.
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Affiliation(s)
- Scott L Zuckerman
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, USA.
| | - Laura A Allen
- Department of General Surgery, University of Alabama Birmingham, Birmingham, AL, USA
| | - Camille Broome
- Department of Thoracic Surgery, Oschner Medical Center, New Orleans, LA, USA
| | - Nadine Bradley
- Pediatric Neurosurgery, Children's Hospital of Alabama, University of Alabama Birmingham, Birmingham, AL, USA
| | - Charlie Law
- United Cerebral Palsy of Greater Birmingham, Birmingham, AL, USA
| | - Chevis Shannon
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, USA
| | - John C Wellons
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, USA
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Moore AM, Novak CB. Advances in nerve transfer surgery. J Hand Ther 2014; 27:96-104; quiz 105. [PMID: 24513183 DOI: 10.1016/j.jht.2013.12.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 12/15/2013] [Accepted: 12/15/2013] [Indexed: 02/09/2023]
Abstract
Peripheral nerve injuries are devastating injuries and can result in physical impairments, poor functional outcomes and high levels of disability. Advances in our understanding of peripheral nerve regeneration and nerve topography have lead to the development of nerve transfers to restore function. Over the past two decades, nerve transfers have been performed and modified. With the advancements in surgical management and recognition of importance of cortical plasticity, motor-reeducation and perioperative rehabilitation, nerve transfers are producing improved functional outcomes in patients with nerve injuries. This manuscript explores the recent literature as it relates to current nerve transfer techniques and advances in post-operative rehabilitation protocols, with a focus on indications, techniques and outcomes.
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Affiliation(s)
- Amy M Moore
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Christine B Novak
- Hand & Upper Extremity Program, Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada.
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Zuckerman SL, Eli IM, Shah MN, Bradley N, Stutz CM, Park TS, Wellons JC. Radial to axillary nerve neurotization for brachial plexus injury in children: a combined case series. J Neurosurg Pediatr 2014; 14:518-26. [PMID: 25192235 DOI: 10.3171/2014.7.peds13435] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Axillary nerve palsy, isolated or as part of a more complex brachial plexus injury, can have profound effects on upper-extremity function. Radial to axillary nerve neurotization is a useful technique for regaining shoulder abduction with little compromise of other neurological function. A combined experience of this procedure used in children is reviewed. METHODS A retrospective review of the authors' experience across 3 tertiary care centers with brachial plexus and peripheral nerve injury in children (younger than 18 years) revealed 7 cases involving patients with axillary nerve injury as part of an overall brachial plexus injury with persistent shoulder abduction deficits. Two surgical approaches to the region were used. RESULTS Four infants (ages 0.6, 0.8, 0.8, and 0.6 years) and 3 older children (ages 8, 15, and 17 years) underwent surgical intervention. No patient had significant shoulder abduction past 15° preoperatively. In 3 cases, additional neurotization was performed in conjunction with the procedure of interest. Two surgical approaches were used: posterior and transaxillary. All patients displayed improvement in shoulder abduction. All were able to activate their deltoid muscle to raise their arm against gravity and 4 of 7 were able to abduct against resistance. The median duration of follow-up was 15 months (range 8 months to 5.9 years). CONCLUSIONS Radial to axillary nerve neurotization improved shoulder abduction in this series of patients treated at 3 institutions. While rarely used in children, this neurotization procedure is an excellent option to restore deltoid function in children with brachial plexus injury due to birth or accidental trauma.
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