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

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.

The Intercostal Nerves Transfer to the Radial Nerve Branch to the Long Head Triceps Muscle: Influencing Factor and Outcome of 55 Cases

PURPOSE

The objective of this study was to report the functional outcomes and factors affecting the result of intercostal nerves transfer to the radial nerve branch to the long head triceps muscle for restoration of elbow extension in patients with total brachial plexus palsy or C5 to C7 palsy with the loss of triceps muscle function.

METHODS

Fifty-five patients with total brachial plexus palsy or C5 to C7 palsy with no triceps muscle function had a reconstruction of elbow extension by transferring the third to fifth intercostal nerves to the radial nerve branch to the long head triceps muscle. The functional outcomes determined by the Medical Research Council grading were evaluated. Factors influencing the outcomes were determined using logistic regression analysis.

RESULTS

At the follow-up of at least 2 years, 36 patients (65%) had antigravity motor function (Medical Research Council grade, ≥3). Multivariable logistic regression analysis showed that the body mass index, time to surgery, and injury of the dominant limb were associated with the outcome.

CONCLUSIONS

The third to fifth intercostal nerves transfer to the radial nerve branch to the long head triceps muscle is an effective procedure to restore elbow extension. We would recommend using 3 intercostal nerves without grafts; in cases of nerve root avulsion in which there is no chance of spontaneous recovery, early surgery should be considered.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Hand Surgery in Thailand

Modern hand surgery in Thailand started after the end of World War II. It is divided into 4 phases. In the initial phase (1950-1965), the surgery of the hand was mainly performed by general surgeons. In 1965-1975, which was the second phase, many plastic surgeons and orthopaedic surgeons graduated from foreign countries and came back to Thailand. They played a vital role in the treatment of the surgery of the hand and set up hand units in many centers. They also contributed to the establishment of the "Thai Society for Surgery of the Hand," which still continues to operate. In the third phase (1975-2000), there was a dramatic development of microsurgery because of the rapid economic expansion. There were many replantation, free tissue transfers, and brachial plexus surgeries in traffic and factory-related accidents. The first hand-fellow training program began in 1993. In the fourth phase (since 2000), the number of hand injuries from factory-related accidents began declining. But the injury from traffic accidents had been increasing both in severity and number. Moreover, the diseases of hand that relate to aging and degeneration had been on the rise. Thai hand surgeons have been using several state-of-the-art technologies such as arthroscopic and endoscopic surgery. They are continuing to invent innovations, generating international publications, and frequently being invited as speakers in foreign countries.

Physical therapeutic treatment for traumatic brachial plexus injury in adults: A scoping review

Traumatic brachial plexus injury (BPI) is one of the most disabling injuries of the upper extremity, often requiring specialized treatment and a prolonged rehabilitation period. This scoping review was carried out to identify and describe the physical therapy modalities applied in the rehabilitation of adult individuals with BPI. Electronic databases, gray literature, and reference lists were searched, and studies meeting the following eligibility criteria were included: (a) interventions including any physical therapy modality; (b) individuals age ≥18 years old; and (c) a clinical diagnosis of BPI. The literature search yielded 681 articles of which 49 met the inclusion criteria and had their outcomes, treatment parameters, and the differences between conservative and pre- and postoperative treatment phases analyzed. The most commonly used physical therapy interventions were in the subfields of kinesiotherapy (ie, involving range of motion exercises, muscle stretching, and strengthening), electrothermal and phototherapy, manual therapy, and sensory re-education strategies. Although several physical therapy modalities were identified for the treatment of BPI in this scoping review, the combination of low levels of evidence and the identified gaps regarding the treatment parameters challenge the reproducibility of such treatments in clinical practice. Therefore, future controlled clinical trials with clearer treatment protocols for individuals with BPI are needed.

Intercostal to musculocutaneous nerve transfer in patients with complete traumatic brachial plexus injuries: case series

BACKGROUND

To recover biceps strength in patients with complete brachial plexus injuries, the intercostal nerve can be transferred to the musculocutaneous nerve. The surgical results are very controversial, and most of the studies with good outcomes and large samples were carried out in Asiatic countries. The objective of the study was to evaluate biceps strength after intercostal nerve transfer in patients undergoing this procedure in a Western country hospital.

METHODS

We retrospectively analyzed 39 patients from 2011 to 2016 with traumatic brachial plexus injuries receiving intercostal to musculocutaneous nerve transfer in a rehabilitation hospital. The biceps strength was graded using the British Medical Research Council (BMRC) scale. The variables reported and analyzed were age, the time between trauma and surgery, surgeon experience, body mass index, nerve receptor (biceps motor branch or musculocutaneous nerve), and the number of intercostal nerves transferred. Statistical tests, with a significance level of 5%, were used.

RESULTS

Biceps strength recovery was graded ≥M3 in 19 patients (48.8%) and M4 in 15 patients (38.5%). There was no statistical association between biceps strength and the variables. The most frequent complication was a pleural rupture.

CONCLUSIONS

Intercostal to musculocutaneous nerve transfer is a safe procedure. Still, biceps strength after surgery was ≥M3 in only 48.8% of the patients. Other donor nerve options should be considered, e.g., the phrenic or spinal accessory nerves.

Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus

PURPOSE

To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis.

METHODS

Twenty-four male patients were reoperated upon an average of 45 months (SD, ± 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle belly was sutured to the biceps distal tendon. Vascular repair was performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus.

RESULTS

Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110° (95% confidence interval [95% CI], 100°-120°) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94° (95% CI, 86°-102°). There was, on average, a 10° (95% CI, 4.4°-15.6°). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in 12.

CONCLUSIONS

In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Simultaneous Phrenic and Intercostal Nerves Transfer for Elbow Flexion and Extension in Total Brachial Plexus Root Avulsion Injury

BACKGROUND

To report the results of restoring the elbow flexion and extension in patients with total brachial root avulsion injuries by simultaneous transfer of the phrenic nerve to the nerve to the biceps and three intercostal nerves to the nerve of the long head of the triceps.

METHODS

Ten patients with total brachial root avulsion injuries underwent the spinal accessory nerve transfer to the suprascapular nerve for shoulder reconstruction. Simultaneous transfer of the phrenic nerve to the nerve to the biceps via the sural nerve graft and three intercostal nerves to the nerve of the long head of the triceps was done for restoration of the elbow flexion and extension. Trunk flexion exercise program was used for all patients postoperatively. The mean follow up period was 36 months.

RESULTS

For elbow flexion, there were two M4, seven M3, and one M1. For elbow extension, there were three M4, four M3, two M2, and one M1. No patient demonstrated a respiratory problem clinically postoperatively. The average FVC% decreased to 61% of the predicted value at 24 months after surgery.

CONCLUSIONS

The simultaneous nerve transfer using the phrenic nerve to the nerve to the biceps and 3 intercostal nerves to the nerve of the long head of the triceps with postoperative trunk flexion exercise provide a comparable result for restoration of elbow function in total brachial plexus root avulsion injury. The patients who appear to have a respiratory problem and are unable to comply with the post-operative respiratory muscles training should be contraindicated for this simultaneous transfer.

Timing of surgery in traumatic brachial plexus injury: a systematic review

OBJECTIVEIdeal timeframes for operating on traumatic stretch and blunt brachial plexus injuries remain a topic of debate. Whereas on the one hand spontaneous recovery might occur, on the other hand, long delays are believed to result in poorer functional outcomes. The goal of this review is to assess the optimal timeframe for surgical intervention for traumatic brachial plexus injuries.METHODSA systematic search was performed in January 2017 in PubMed and Embase databases according to the PRISMA guidelines. Search terms related to "brachial plexus injury" and "timing" were used. Obstetric plexus palsies were excluded. Qualitative synthesis was performed on all studies. Timing of operation and motor outcome were collected from individual patient data. Patients were categorized into 5 delay groups (0-3, 3-6, 6-9, 9-12, and > 12 months). Median delays were calculated for Medical Research Council (MRC) muscle grade ≥ 3 and ≥ 4 recoveries.RESULTSForty-three studies were included after full-text screening. Most articles showed significantly better motor outcome with delays to surgery less than 6 months, with some studies specifying even shorter delays. Pain and quality of life scores were also significantly better with shorter delays. Nerve reconstructions performed after long time intervals, even more than 12 months, can still be useful. All papers reporting individual-level patient data described a combined total of 569 patients; 65.5% of all patients underwent operations within 6 months and 27.4% within 3 months. The highest percentage of ≥ MRC grade 3 (89.7%) was observed in the group operated on within 3 months. These percentages decreased with longer delays, with only 35.7% ≥ MRC grade 3 with delays > 12 months. A median delay of 4 months (IQR 3-6 months) was observed for a recovery of ≥ MRC grade 3, compared with a median delay of 7 months (IQR 5-11 months) for ≤ MRC grade 3 recovery.CONCLUSIONSThe results of this systematic review show that in stretch and blunt injury of the brachial plexus, the optimal time to surgery is shorter than 6 months. In general, a 3-month delay appears to be appropriate because while recovery is better in those operated on earlier, this must be considered given the potential for spontaneous recovery.

Rehabilitation, Using Guided Cerebral Plasticity, of a Brachial Plexus Injury Treated with Intercostal and Phrenic Nerve Transfers

Recovery after surgical reconstruction of a brachial plexus injury using nerve grafting and nerve transfer procedures is a function of peripheral nerve regeneration and cerebral reorganization. A 15-year-old boy, with traumatic avulsion of nerve roots C5–C7 and a non-rupture of C8–T1, was operated 3 weeks after the injury with nerve transfers: (a) terminal part of the accessory nerve to the suprascapular nerve, (b) the second and third intercostal nerves to the axillary nerve, and (c) the fourth to sixth intercostal nerves to the musculocutaneous nerve. A second operation—free contralateral gracilis muscle transfer directly innervated by the phrenic nerve—was done after 2 years due to insufficient recovery of the biceps muscle function. One year later, electromyography showed activation of the biceps muscle essentially with coughing through the intercostal nerves, and of the transferred gracilis muscle by deep breathing through the phrenic nerve. Voluntary flexion of the elbow elicited clear activity in the biceps/gracilis muscles with decreasing activity in intercostal muscles distal to the transferred intercostal nerves (i.e., corresponding to eighth intercostal), indicating cerebral plasticity, where neural control of elbow flexion is gradually separated from control of breathing. To restore voluntary elbow function after nerve transfers, the rehabilitation of patients operated with intercostal nerve transfers should concentrate on transferring coughing function, while patients with phrenic nerve transfers should focus on transferring deep breathing function.

Free Flap Functional Muscle Transfers

Free functional muscle transfers remain a powerful reconstructive tool to restore upper extremity function when other options such as tendon or nerve transfers are not available. This reconstructive technique is commonly used for patients following trauma, ischemic contractures, and brachial plexopathies. Variable outcomes have been reported following free functional muscle transfers that are related to motor nerve availability and reinnervation. This article highlights considerations around donor motor nerve selection, dissection, and use of the gracilis muscle, and the surgical approach to performing a free functional muscle transfer to restore elbow flexion and/or digit flexion.

Nerve Transfers to Restore Shoulder Function

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.

Donor Activation Focused Rehabilitation Approach: Maximizing Outcomes After Nerve Transfers

As nerve transfers become the mainstay in treatment of brachial plexus and isolated nerve injuries, the preoperative and postoperative therapy performed to restore motor function requires continued dedication and appreciation. Through the understanding of the general principles of muscle activation and patient education, the therapist has a unique impact on the return of function in patients with nerve injuries. As surgeons continue to develop novel nerve transfers, the perioperative training, education, and implementation of the donor activation focused rehabilitation approach model is critical to ensure successful outcomes.

Use of long autologous nerve grafts in brachial plexus reconstruction: factors that affect the outcome

BACKGROUND

Using grafts directed to distal targets in brachial plexus reconstruction has the advantage over proximal targets of avoiding axonal dispersion. A long graft (more than 10 cm) is needed to reach most distal targets. The objective of this article is to identify factors associated with good versus poor outcomes in a clinical series of long grafts used for distal brachial plexus reconstruction.

METHODS

In 34 patients with a flail arm, 47 sural grafts >10 cm long were followed for ≥2 years postoperatively. Surgical technique included standard supraclavicular exposure of the proximal brachial plexus and its branches, the phrenic nerve and spinal accessory nerve. Distal target nerves were exposed via an incision starting at the axilla, following the gap between the biceps and triceps. Cases achieving a good result were statistically compared against those with a poor result as to the donor nerve/root, target nerve, patient age and weight, time from trauma to surgery, graft length and long-term rehabilitation quality.

FINDINGS

A good outcome was observed with 23 grafts (48.9%), but 66.7% of the 30 long grafts done within 6 months of trauma yielded a good result. Only 1 of 15 patients with the lowest quality rehabilitation score experienced a good result (6.6%) versus all 12 patients with the highest rating (p < 0.001). Trauma-to-surgery time was roughly half as long in those with a good result (4.7 vs. 9.0 months, p < 0.001). No other inter-group differences were observed.

CONCLUSIONS

The results of a series of distal brachial plexus target reinnervations with long grafts is presented and analyzed. According to them, time from trauma to surgery and an adequate postoperative rehabilitation are important predictors of outcome.

Electrophysiological study of the dominant motor innervation to the extensor digitorum communis muscle and long head of triceps brachii at posterior divisions of brachial plexus

BACKGROUND

Restoration of elbow and finger extension function is still challenging in management of complete brachial plexus avulsion injury, mainly because of fewer available donor nerves for transfer to the radial nerve. Selective neurotization could be a potentially alternative for overcoming this dilemma. This study was designed to identify the innervation dominance of the extensor digitorum communis muscle (EDCM) and long head of the triceps brachii (LTB) at the level of division of brachial plexus.

METHODS

From February 2008 to October 2009, 17 patients with complete brachial plexus avulsion injury underwent the procedure of contralateral C7 nerve root transfer. The posterior divisions of brachial plexus on the healthy donor side were intraoperatively stimulated and the compound muscle action potentials (CMAPs) from the extensor digitorum communis muscle and long head of triceps brachii were recorded by an electrophysiological device.

RESULTS

In 13 out of 17 patients (76.5%), the maximal amplitude of CMAP from EDCM was induced by stimulation of the posterior division of lower trunk (PDLT). The mean amplitudes of CMAP from EDCM with stimulation of the posterior division of upper trunk (PDUT), middle trunk (PDMT), and PDLT were 0.64 ± 0.95, 1.64 ± 1.56, and 5.32 ± 4.67 mV (P < 0.05), respectively. The maximal amplitude of CMAP from LTB was induced mainly by stimulation of the PDMT) and PDLT (6 out of 11 and 5 out of 11 patients). The mean amplitudes of CMAP from LTB with stimulation of the PDUT, PDMT, and PDLT were 0.15 ± 0.24, 5.20 ± 4.27, and 7.48 ± 9.90 mV, respectively. The differences of CMAPs between stimulation of PDUT and other two divisions were significant (P < 0.05).

CONCLUSIONS

From the electrophysiological point of view, this study showed that the PDLT was the major motor division innervating EDCM, and the PDMT and PDLT shared the similar proportion of LTB innervation.

Rehabilitation following motor nerve transfers

Cortical mapping and relearning are key factors in optimizing patient outcome following motor nerve transfers. To maximize function following nerve transfers, the rehabilitation program must include motor reeducation to initiate recruitment of the weak reinnervated muscles and to establish new motor patterns and cortical mapping. Patient education and a home program are essential to obtain the optimal functional result.

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.

Hand prehension recovery after brachial plexus avulsion injury by performing a full-length phrenic nerve transfer via endoscopic thoracic surgery

Object

The functional recovery of hand prehension after complete brachial plexus avulsion injury (BPAI) remains an unsolved problem. The authors conducted a prospective study to elucidate a new method of resolving this injury.

Methods

Three patients with BPAI underwent a new procedure during which the full-length phrenic nerve was transferred to the medial root of the median nerve via endoscopic thoracic surgery support. All 3 patients were followed up for a postoperative period of > 3 years.

Results

The power of the palmaris longus, flexor pollicis longus, and the flexor digitorum muscles of all 4 fingers reached Grade 3–4/5, and no symptoms of respiratory insufficiency occurred.

Conclusions

Neurotization of the phrenic nerve to the medial root of the median nerve via endoscopic thoracic surgery is a feasible means of early hand prehension recovery after complete BPAI.

Technique of intercostal nerve harvest and transfer for various neurotization procedures in brachial plexus injuries

Brachial plexus palsy caused by traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Neurotization is the only possibility for repair in cases of spinal nerve-root avulsion. Intercostal neurotization is a well-established technique in the treatment of some severe brachial plexus lesions in adults. In this article, we describe our experience and technique of intercostal nerve harvest for transfer in various neurotization strategies in posttraumatic brachial plexus reconstruction. Intercostal nerve harvest is a technique requiring meticulous technique and careful dissection along with proper hemostasis. It is also very important to preserve the serratus anterior muscle insertion and keep soft tissue stripping to a minimal. We do not osteotomize the ribs and believe that this adds to the morbidity and length of the procedure. Neurotization using intercostal nerves is a very viable procedure in avulsion injuries of the brachial plexus; however, there is some concern that in the presence of ipsilateral phrenic nerve palsy, it may lead to a significant compromise of respiratory function. In our experience, this is negligible with good long-term results.